Accepted Manuscript

Title: Effect of prehospital advanced airway management for

pediatric out-of-hospital cardiac arrest

Authors: Naoko Ohashi-Fukuda, Tatsuma Fukuda, Knet Doi,

Naoto Morimura

PII: S0300-9572(17)30100-4
DOI: http://dx.doi.org/doi:10.1016/j.resuscitation.2017.03.002
Reference: RESUS 7094

To appear in: Resuscitation

Received date: 24-11-2016

Revised date: 1-3-2017
Accepted date: 2-3-2017

Please cite this article as: Ohashi-Fukuda Naoko, Fukuda Tatsuma, Doi Knet, Morimura
Naoto.Effect of prehospital advanced airway management for pediatric out-of-hospital
cardiac arrest.Resuscitation http://dx.doi.org/10.1016/j.resuscitation.2017.03.002

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Effect of prehospital advanced airway management for pediatric out-of-hospital
cardiac arrest
Running head: Advanced vs. Basic Airway Management in Pediatric OHCA

Naoko Ohashi-Fukuda, M.D.1,2, Tatsuma Fukuda, M.D. Ph.D.

1,3*tatsumafukuda-jpn@umin.ac.jp, Knet Doi, M.D. Ph.D. 1, Naoto Morimura, M.D.,
Ph.D.1

1Department of Emergency and Critical Care Medicine, Graduate School of

Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655,
Japan
2Comprehensive perinatal medical center, Department of Obstetrics and
Gynecology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15, Kotobashi,
Sumida-ku, Tokyo, 130-8575, Japan
3Center for Resuscitation Science, Department of Emergency Medicine, Beth
Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline
Avenue, Boston, MA 02215, USA
*Corresponding author at: Department of Emergency and Critical Care
Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo,
Bunkyo-ku, Tokyo, 113-8655, Japan, Tel.: +81 3 3815 5411; fax: +81 3 3814
6446

1
Abstract
Background: Respiratory care may be important in pediatric out-of-hospital
cardiac arrest (OHCA) due to the asphyxial nature of the majority of events.
However, evidence of the effect of prehospital advanced airway management
(AAM) for pediatric OHCA is scarce.
Methods: This was a nationwide population-based study of pediatric OHCA in
Japan from 2011 to 2012 based on data from the All-Japan Utstein Registry.
We included pediatric OHCA patients aged between 1 and 17 years old. The
primary outcome was one-month neurologically favorable survival defined as a
Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2
(corresponding to a Pediatric CPC score of 1-3).
Results: A total of 2,157 patients were included in the final cohort; 365
received AAM and 1,792 received bag-valve-mask (BVM) ventilation only.
Among the 2,157 patients, 213 (9.9%) survived with favorable neurological
outcomes (CPC of 1-2) one month after OHCA. There were no significant
differences in neurologically favorable survival between the AAM and BVM
groups after adjusting for potential confounders, although there was a
tendency favoring BVM ventilation: propensity score matching, OR 0.74
(95%CI 0.35-1.59), and multivariable logistic regression modeling, ORadjusted
0.55 (95% CI 0.24-1.14). Subgroup analyses demonstrated that there were no
subgroups in which AAM was associated with neurologically favorable survival,
including the non-cardiac (primarily asphyxial) etiology group.
Conclusions: In pediatric OHCA, prehospital AAM was not associated with an
increased chance of neurologically favorable survival compared with BVM-only
ventilation. However, careful consideration is required to interpret the
findings, as there may be unmeasured residual confounders and selection bias.

Abbreviations list
AAM: advanced airway management
AED: automated external defibrillator
BVM: bag-valve-mask
CI: confidence interval

2
CPC: Glasgow-Pittsburgh cerebral performance category
CPR: cardiopulmonary resuscitation
DNR: do-not-resuscitate
ELST: emergency lifesaving technician
EMS: emergency medical service
ETI: endotracheal intubation
FDMA: Fire and Disaster Management Agency
IQR: interquartile range
OHCA: out-of-hospital cardiac arrest
OR: odds ratio
PCPC: pediatric CPC
PEA: pulseless electrical activity
RCT: randomized controlled trial
ROSC: return of spontaneous circulation
SD: standard deviation
SGA: supraglottic airway device
VF: ventricular fibrillation
VT: ventricular tachycardia

Key words: pediatrics; children; out-of-hospital cardiac arrest;

cardiopulmonary resuscitation; epidemiology

3
Word count for text: 3069 words
Word count for abstract: 250 words

1. Introduction

Although 120,000 out-of-hospital cardiac arrests (OHCA) occur annually in Japan, the

pediatric OHCA population account for only 1% of those cases [1-4]. Therefore, evidence

of cardiopulmonary resuscitation (CPR) practices for pediatric OHCA is scarce. It is

difficult to extrapolate evidence obtained from adult OHCA to pediatric OHCA, as the

etiology of OHCA in children is generally different from that in adults; non-cardiac

(especially asphyxial) etiology is predominant in children, whereas cardiac etiology is

more common in adults [5-8].

Previous adult studies have indicated that prehospital advanced airway management

(AAM) (i.e., endotracheal intubation [ETI] or supraglottic airway devices [SGA] use)

might be associated with poor outcomes in adult OHCA [9-11]. However, prehospital

AAM may have an important role in pediatric OHCA due to the respiratory (asphyxial)

nature of the majority of events. Thus far, no randomized controlled trials (RCTs) have

studied the effect of prehospital AAM in pediatric OHCA. One pseudo-RCT including

4
pediatric patients with not only OHCA but also other causes of respiratory failure indicated

prehospital ETI might not improve outcomes of pediatric patients with respiratory failure

[12]. An observational study including only pediatric OHCA patients also indicated that

ETI by EMS personnel was associated with poorer outcomes [13]. Based on these studies

on pediatric OHCA and evidence from adult OHCA studies, the current CPR guidelines

recommend Bag-valve-mask (BVM) ventilation over ETI [14-17]. Although no studies

have directly compared SGA with BVM in pediatric OHCA, BVM is recommended as a

first-choice procedure based on adult OHCA studies. Thus, the evidence of AAM for

pediatric OHCA is limited, and those previous studies were reported prior to 2010.

Considering the changes in CPR practices since then, it is also unclear whether the findings

of previous studies are applicable to current settings.

We therefore conducted a study on the effect of prehospital AAM for pediatric OHCA

using national administrative data from 2011 to 2012.

2. Materials and Methods

2.1 Study design, setting, and participants

5
The All-Japan Utstein Registry is a prospective nationwide population-based database of

patients undergoing out-of-hospital resuscitation sponsored by the Fire and Disaster

Management Agency (FDMA). This registry utilizes Utstein-style data reporting [18,19].

Previous studies have described the design of the All-Japan Utstein Registry and the

Japanese emergency medical service (EMS) system in detail [1-4,9,10,20,21]. Briefly, all

OHCA patients, including those with do-not-resuscitate (DNR) orders, are transported to an

emergency hospital as EMS personnel in Japan are not allowed to terminate resuscitation out

of hospital except in specific situations (e.g., decapitation, rigor mortis, livor mortis, and

decomposition). Data are collected from following three sources in accordance with

standardized Utstein-style templates for OHCA to facilitate uniform reporting by using

precisely defined variables and outcomes [18,19]: 1-1-9 dispatch centers, fire stations, and

receiving hospitals. The EMS personnel complete the data forms, and subsequently, the data

are integrated into the All-Japan Utstein Registry system on the FDMA database server. The

rigorous confirmation by the FDMA and the logical internal checks with standardized

software ensure the integrity, accuracy, and completeness of the data. The EMS personnel

perform airway management for OHCA patients according to a protocol fixed by each

municipality (Supplementary Materials and Methods 1, Airway management protocol in

6
Japan). Emergency lifesaving technicians (ELST) (highly trained EMS personnel) are

permitted to use SGA (laryngeal mask airway or esophageal obturator airway) for pediatric

OHCA patients under a medical control directors’ instruction in almost all municipalities.

ETI can be performed by specially trained ELST who completed an additional 62 hours of

training sessions and experienced 30 supervised successful intubations in operating rooms

[9]. However, ETI is restricted to over 8 or 15 years old in most municipalities.

This study included patients based on data submitted to the All-Japan Utstein Registry from

January 1, 2011, to December 31, 2012. We included pediatric patients aged < 18 years, but

excluded neonates and infants (< 1-year-old) due to potential differences in physiological

characteristics and etiology of cardiac arrest. No patients in the final cohort had missing,

incomplete, or inconsistent data (Figure 1).

This study was conducted according to the amended Declaration of Helsinki and was

approved by the institutional review board of the University of Tokyo with a waiver of

informed consent due to the anonymous nature of the data (ethical approval No. 10096-1).

2.2 Data collection

Data on sex, age, bystander status (i.e., witnesses, bystander CPR, and public access
7
defibrillation), first documented rhythm, etiology of cardiac arrest, availability of highly

trained ambulance crew (i.e., ELST or physician), and prehospital advanced life support (i.e.,

intravenous access, epinephrine administration, and AAM) were collected. The date and

time of onset and a series of EMS times (call receipt, contact with patient, and hospital

arrival) were also recorded. Although the etiology of cardiac arrest for hospitalized patients

was pursued during the hospital stay, for patients who died shortly after hospital arrival,

etiology was determined by the attending physicians in the emergency department in

collaboration with EMS personnel and coroners based on the witnessed situation, clinical

course, patient medical history, physical findings, laboratory examination findings, imaging,

and autopsy. In cases where evidence suggesting a non-cardiac etiology was lacking, the

etiology was presumed to be cardiac [19]. Implementation of AAM was recorded on the data

forms only in case of a successful attempt.

The data on survival and neurological status were collected by EMS personnel through a

follow-up survey one month after OHCA; the etiology of cardiac arrest was reconfirmed at

this time. The patient information was provided from the medical control director of the

admitting hospital unless the patient was transferred to another hospital within one month. If

transferred, the EMS personnel persistently conducted further investigations.

8
The primary outcome was one-month survival with favorable neurological status. The

secondary outcomes were overall one-month survival and prehospital ROSC. In the

All-Japan Utstein Registry, neurological status was assessed by the attending physician in

charge of the patient by using the Glasgow-Pittsburgh cerebral performance category

(CPC) scores as follows: 1 = good performance, 2 = moderate disability, 3 = severe

disability, 4 = vegetative state, and 5 = death. Based on the adult cardiac arrest studies, a

CPC score of 1 or 2 was defined as a favorable neurological status, and a score of 3, 4, or 5

was considered poor neurological status [19,22]. Although Pediatric CPC (PCPC) scores

were not directly collected in this registry, we regarded CPC 1-2 as equivalent to PCPC

1-3, and we also used CPC 1 (equivalent to PCPC 1) as a favorable neurological status as

well as CPC 1-2 for our analysis [3] (Supplementary Materials and Methods 2, PCPC).

2.3 Statistical analysis

Descriptive statistics were determined for the entire cohort and the propensity

score-matched cohort. We reported categorical variables as counts with proportions and

continuous variables as means with standard deviations.

Due to the lack of randomization, we used a propensity score approach to control for
9
selection bias and confounding. The propensity score for each patient to receive AAM was

estimated using a multivariable logistic regression model. The following variables were

included in the model: sex, age, bystander witness, bystander CPR, public access AED, first

documented rhythm (5 categories), etiology of cardiac arrest (7 categories), ELST presence

in ambulance, physician presence in ambulance, time from call to contact with patient,

intravenous access, epinephrine administration and calendar year. A 1:1 nearest-neighbor

matching on the propensity score was performed with a caliper of ≤ 0.2 without

replacement between patients receiving and not receiving AAM [23]. The success of the

propensity-matching procedure was confirmed by comparing the distribution of patient

characteristics in the matched cohort. We calculated standardized differences for all

variables and considered them inconsequential if they were within ± 1.96√2/362 [24]. To

account for the dependence of the matched pairs, between group differences after

propensity-score matching were tested with the McNemar’s test for outcomes. Odds ratios

(ORs) comparing the frequency of each outcome for patients receiving advanced versus

basic airway management were reported with 95% confidence intervals (CIs).

We also used multivariable logistic regression models to determine the association between

AAM and outcomes in the overall cohort, as well as propensity score-matched analyses.
10
We included all variables that could influence outcomes after OHCA in the models:

calendar year, sex, age, bystander witness, bystander CPR, public access AED, first

documented rhythm (5 categories), etiology of cardiac arrest (7 categories), ELST presence

in ambulance, physician presence in ambulance, time from call to contact with patient,

intravenous access, epinephrine administration and the type of airway management (AAM

or BVM). We reported the results of the univariable and multivariable logistic regression

analyses as crude and adjusted ORs with their 95% CIs, respectively.

Preplanned subgroup analyses were performed to further examine the association between

AAM and outcomes based on age (1–7 or ≥ 8 years), etiology of cardiac arrest (cardiac or

non-cardiac), and bystander witness (presence or absence) based on a priori hypotheses that

these subgroups could have different characteristics (Supplementary Materials and

Methods 3. Subgroup analyses). For each subgroup, the association of AAM with

neurologically favorable survival was estimated in a logistic regression model including the

same set of variables used in the regression models for the overall cohort, and adjusted

ORs and their 95% CIs were reported.

We used JMP Pro 11.2.0 software (SAS Institute Inc., Cary, NC, USA) for all statistical

analyses. The two-sided significance level for all tests was 0.05.
11
 3. Results

We identified 2,157 pediatric OHCA patients aged ≥ 1 and < 18 years during the study

period. Of these, 365 (16.9%) received AAM and 1,792 (83.1%) received only BVM

ventilation. The 346 patients (94.8%) who received AAM were matched with 346 patients

who received only BVM (Figure 1).

Table 1 summarizes the baseline characteristics of the whole cohort and the propensity

score-matched cohort. In the propensity score-matched cohort, the baseline characteristics

were well-balanced between the AAM and BVM groups. Esophageal obturator airway was

most frequently chosen as the AAM procedure (Table 1 and Supplemental Table 1).

Table 2 shows the outcomes for patients in the propensity score-matched cohort who

received either AAM or BVM. The observed frequency of each outcome was similar

between the two groups. However, there was a tendency for lower neurologically favorable

survival in the AAM group (3.5% vs. 4.6%, OR 0.74 [95%CI 0.35-1.59]), whereas the

one-month overall survival tended to be higher in the AAM group compared with the BVM

group (14.7% vs. 10.7%, OR 1.44 [95%CI 0.92-2.27]).

12
Table 3 shows the outcomes for patients in the unmatched overall cohort who received

AAM or BVM. In unadjusted analyses, the outcomes were poorer in the AAM group

compared with the BVM group. However, after adjusting for potential confounders, the

95%CI for the adjusted OR of each outcome overlapped unity. The tendency seen in the

propensity-matched analyses was also observed in multivariable regression analyses with

respect to the neurologically favorable survival and one-month overall survival.

Table 4 presents the neurologically favorable survival (CPC 1-2) for various subgroups of

patients in the overall unmatched cohort who received AAM or BVM. Although the

95%CIs for the ORs overlapped unity in all subgroups, a tendency favoring BVM was

observed.

4. Discussion

In this nationwide population-based study of pediatric OHCA patients from 2011 to 2012,

prehospital AAM was not significantly associated with an increased chance of

neurologically favorable survival compared with BVM after adjusting for potential

confounders. Rather, there was a tendency favoring BVM ventilation.

13
To our knowledge, this is the first and largest study to have compared prehospital AAM

and BVM for pediatric OHCA after 2010. The use of propensity score matching and

regression modeling to control for selection bias and potential confounders, and the

consistency in subgroup analyses, ensured the statistical robustness of the findings despite

the observational study design.

Although no RCTs have studied the effect of prehospital AAM on pediatric OHCA, several

studies on adult OHCA and one quasi-RCT on pediatric emergency patients in

out-of-hospital settings (including non-OHCA patients) indicated that AAM was not

associated with improved outcomes but might be associated with worse outcomes [9,11,12].

However, for pediatric OHCA, prehospital AAM may have an important role because the

majority of pediatric OHCA cases have a respiratory (asphyxial) etiology [5-8]. In fact, our

study demonstrated that patients with a non-cardiac etiology accounted for as many as 73%

of the entire pediatric OHCA cohort (Table 1). However, both overall analysis and the

subgroup analysis in which the overall cohort was divided into cardiac and non-cardiac

arrest etiology showed the tendency favoring BVM compared with AAM with respect to

neurologically favorable survival, although there was no statistically significant difference.

14
This finding indicates that AAM may not be effective for prehospital care for pediatric

OHCA patients, even when the etiology of cardiac arrest is respiratory. This result was

consistent with that of our previous study involving adult respiratory OHCA cases [10].

Several reasons were considered to explain the disadvantages of AAM compared to BVM.

Similar to adult cases, children could also have fatal outcomes due to the interruption of

chest compression [25,26], prolonged transportation time [9,12], hyperventilation [27,28],

and hyperoxia [29-31], associated with the AAM procedure. In addition, it has been

indicated that the AAM procedure may be more difficult in children than in adults [32], and

thus, AAM in children might result in a more prolonged interruption of chest compression

and longer transportation time. In fact, we noted that the transport time (from contact with

patient to hospital arrival) was more prolonged in the AAM group compared with the BVM

group (Supplemental Table 2). Unfortunately, the duration of chest compression

interruption was not available from the dataset we used.

Subgroup analysis by the type of airway device might be informative because there could

be great differences in the difficulty of airway management among the airway devices.

However, we did not conduct that subgroup analysis in this study because the numbers of

patients would be too small to detect statistically significant differences if the AAM group
15
was further divided into subgroups by the type of airway device.

In our study, there was a tendency for the AAM group to have a higher rate of overall

survival compared to the BVM group, in contrast to the results for neurologically favorable

survival. Prehospital AAM might be advantageous in mere cardio-pulmonary resuscitation

in pediatric OHCA, although it might not be so for cerebral resuscitation. The reason for

this remains unclear. However, these results may suggest a difference in response to

resuscitation between the brain and the heart. The heart may be more resistant to oxidative

stress than the brain, or the heart may be more resilient even after the brain has been

irreversibly injured. When interpreting this contradictory result, careful consideration may

be necessary because long-term neurological status was not assessed in our study. In

pediatric cardiac arrest, long-term neurological status might improve from short-term status

[33]. Considering that potential, the tendency favoring AAM compared with BVM with

respect to overall survival could include the possibility that an evaluation using long-term

neurological status might produce different results.

There were several limitations to our study.

16
First, differences in airway management protocols and proficiency in AAM among

municipalities could be residual confounders. In addition, protocol violation or indefinite

protocol in some municipalities could cause selection bias. In the All-Japan Utstein

registry, we could obtain only rough data on prefectures but not detailed data on

municipalities. Due to the difficulty in adjusting at a municipality level, there might be a

significant imbalance in regional variability between the AAM and BVM groups. In

addition the EMS personnel’s proficiency in AAM for pediatric OHCA could vary

significantly depending on the magnitude of involvement of regional medical control

council. Thus, we should be cautious in considering whether our findings from the

nationwide population-based study could be applicable to each region. Further study

collecting patients from the unified region where the EMS personnel perform CPR based

on the common protocol and medical direction will be required.

Second, despite our attempt to control for selection bias and potential confounders through

propensity score matching and regression modeling, it was impossible to completely rule

them out. The previously mentioned regional variability is one of the unmeasured

confounders. There may also be other unmeasured confounders that might have led to the

decision to provide AAM or BVM.

17
Third, the generalizability of our findings to other pediatric OHCA populations is

uncertain. As our analysis did not include infants, it is unclear whether our findings are

applicable to infants. It is also unclear whether the findings are applicable to other

countries. Different airway management protocols or training systems might result in

different results. In Japan, SGA, especially esophageal obturator airway, is most frequently

chosen as the AAM device. This choice may differ from other countries. In addition, the

outcomes of pediatric OHCA were relatively poor in our study cohort, which may also be

different among countries.

Fourth, we could not obtain data on the quality of the AAM. We could not assess the failed

attempts or delayed implementation of AAM. In addition, we did not conduct the subgroup

analysis by the type of airway device due to a small sample size, but it might influence the

difficulty of airway management or the outcomes themselves.

Fifth, the recorded etiologies of OHCA in this registry were less well-validated than those

in planned prospective studies. Although the most importance is attached to autopsy

records in the diagnosis of the etiology of OHCA, the autopsy rate is low in Japan. As the

diagnosed etiology was not necessarily definitive, it could be a potentially unmeasured

18
confounder. Further studies prospectively collecting data on etiology of OHCA would be

required.

Sixth, we could not collect data on in-hospital or post-resuscitation care from this registry,

although these may significantly affect the outcomes, and could thus be potential

unmeasured confounding.

Finally, although we used CPC to assess pediatric neurological status, the correlation

between CPC and PCPC is unclear; an assessment using CPC could either underestimate or

overestimate the true prognosis. In addition, there could be interrater bias in scoring the

CPC. Additionally, a study collecting long-term neurological outcomes may be required

because long-term neurological status may differ from short-term status.

5. Conclusions

The results of this nationwide population-based study of pediatric OHCA from 2011 to 2012

indicated that prehospital AAM was not associated with an increased chance of

neurologically favorable survival compared with BVM after statistical adjustments. Rather,

there was a tendency favoring BVM ventilation. However, careful consideration is required
19
in interpreting the findings as there may be unmeasured residual confounders and selection

bias.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the University of Tokyo.

Notation of prior abstract publication/presentation: Poster presentation at

AHA ReSS 2016. (Fukuda T, et al. Circulation 2016; 134(Suppl1): A12806)

20
Acknowledgments

Author Contributors: Naoko Ohashi-Fukuda and Tatsuma Fukuda had full access to all the

data in the study and take responsibility for the integrity of the data and the accuracy of the

data analysis. Naoko Ohashi-Fukuda and Tatsuma Fukuda conceived the study. All authors

contributed to the study concept and design, acquisition, analysis, or interpretation of data.

Tatsuma Fukuda and Naoko Ohashi-Fukuda contributed to the statistical analysis. Naoko

Ohashi-Fukuda and Tatsuma Fukuda contributed to drafting of the paper. All authors

contributed to critical revision of the manuscript for important intellectual content, and final

approval of the manuscript. Tatsuma Fukuda led the study.

Financial/Nonfinancial Disclosures: None reported.

Role of the sponsors: The University of Tokyo supported this study, but had no role in the

study design, data collection, analysis, or interpretation, and writing of the paper.

The FDMA collected and managed the All-Japan Utstein Registry data, oversaw data queries,

and approved manuscript submissions, but had no role in the study concept, data analysis or

interpretation, and writing of the paper. The author group had responsibility to submit for

publication.

1
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Legends to Figure and Tables

Figure 1. Patient Flow chart

7
Tables
Table 1. Baseline characteristics of the propensity score-matched cohort
Overall Propensity score-matched cohort
unmatched cohort AAM BVM Standardized
n = 2157 n = 346 n = 346 Difference, %
Calendar year
1) 2011 1097 (50.9) 177 (51.2) 190 (54.9) -7.4
2) 2012 1060 (49.1) 169 (48.8) 156 (45.1) 7.4
Sex (male) 1347 (62.4) 227 (65.6) 221 (63.9) 3.6
Age (y), mean (SD) 9.0 (5.9) 11.6 (5.2) 11.8 (5.3) -3.8
1) < 8 years 960 (44.5) 79 (22.8) 80 (23.1) -0.7
2) ≥ 8 years 1197 (55.5) 267 (77.2) 266 (76.9) 0.7
Witness 919 (42.6) 144 (41.6) 145 (41.9) -0.6
Bystander CPR 1193 (55.3) 199 (57.5) 201 (58.1) -1.2
Public access AED 57 (2.6) 12 (3.5) 10 (2.9) 3.4
First documented rhythm
Shockable rhythm 124 (5.7) 27 (7.8) 25 (7.2) 2.3
Non-shockable rhythm 2033 (94.3) 319 (92.2) 321 (92.8) -2.3

8
(continued) Table 1. Baseline characteristics of the propensity score-matched cohort
Overall Propensity score-matched cohort
unmatched cohort AAM BVM Standardized
n = 2157 n = 346 n = 346 Difference, %
First documented rhythm
- VF 117 (5.4) 27 (7.8) 25 (7.2) 2.3
- VT 7 (0.3) 0 (0.0) 0 (0.0) /
- PEA 381 (17.7) 73 (21.1) 82 (23.7) -6.2
- Asystole 1411 (65.4) 242 (69.9) 234 (67.6) 5.0
- Others (e.g., Bradycardia) 241 (11.2) 4 (1.2) 5 (1.5) -2.6
ELST present in ambulance 2107 (97.7) 345 (99.7) 346 (100.0) -7.8
Physician present in ambulance 167 (7.7) 21 (6.1) 25 (7.2) -4.4
Cardiac etiology 582 (27.0) 85 (24.6) 77 (22.3) 5.6
Noncardiac etiology 1575 (73.0) 261 (75.4) 269 (77.8) -5.6
1) Cerebrovascular disease 47 (2.2) 8 (2.3) 8 (2.3) 0.0
2) Respiratory disease 163 (7.6) 18 (5.2) 17 (4.9) 1.4
3) Malignant tumor 26 (1.2) 4 (1.2) 3 (0.9) 2.9
4) External causes (e.g., Asphyxia,
937 (43.4) 192 (55.5) 207 (59.8) -8.7
Drowning, or Trauma)
5) Others 357 (16.6) 32 (9.3) 29 (8.4) 3.2

9
 6) Unknown 45 (2.1) 7 (2.0) 5 (1.5) 3.8
(continued) Table 1. Baseline characteristics of the propensity score-matched cohort
Overall Propensity score-matched cohort
unmatched cohort AAM BVM Standardized
n = 2157 n = 346 n = 346 Difference, %
Time from call to contact with patient
10.6 (14.4) 10.1 (8.3) 11.4 (21.0) -8.1
(min), mean (SD)
Prehospital advanced life support
1) Intravenous access 235 (10.9) 95 (27.5) 91 (26.3) 2.7
2) Epinephrine administration 91 (4.2) 38 (11.0) 36 (10.4) 1.9
Type of airway management
- Bag-valve-mask 1792 (83.1) 0 (0.0) 346 (100.0) /
- Endotracheal tube 33 (1.5) 31 (9.0) 0 (0.0) /
- Supraglottic airway device
-1) Laryngeal mask airway 39 (1.8) 36 (10.4) 0 (0.0) /
-2) Esophageal obturator airway 293 (13.6) 279 (80.6) 0 (0.0) /
The data are expressed as the number (%) of patients or as the mean (SD), unless otherwise indicated.
Abbreviations: AAM, Advanced airway management; BVM, bag-valve-mask; SD, Standard deviation; CPR, Cardiopulmonary resuscitation;
AED, Automated external defibrillator; VF, Ventricular fibrillation; VT, Ventricular tachycardia; PEA, Pulseless electrical activity; ELST,
Emergency lifesaving technician

10
Table 2. Outcomes in the propensity score-matched cohort
No. (%) of Favorable Outcomes by Group
AAM BVM OR (95%CI) P Value
n = 346 n = 346
Favorable neurological outcome
12 (3.5) 16 (4.6) 0.74 (0.35-1.59) 0.43
(CPC 1 or 2)
Favorable neurological outcome
9 (2.6) 14 (4.1) 0.63 (0.27-1.48) 0.28
(CPC 1)
One-month survival 51 (14.7) 37 (10.7) 1.44 (0.92-2.27) 0.10
Pre-hospital ROSC 32 (9.3) 32 (9.3) 1.00 (0.60-1.67) 1.00
The data are expressed as the number (%) of patients, unless otherwise indicated.
Abbreviations: AAM, Advanced airway management; BVM, bag-valve-mask; OR, Odds ratio; CI, Confidence interval; CPC,
Glasgow-Pittsburgh cerebral performance category; ROSC, Return of spontaneous circulation

11
 Table 3. Multivariable logistic regression analysis in the overall unmatched cohort
No. (%) of Favorable Outcomes by Group
Crude OR Adjusted OR
AAM BVM
(95%CI) (95%CI)
n = 365 n = 1792
Favorable neurological outcome
12 (3.3) 201 (11.2) 0.23 (0.11-0.42) 0.55 (0.24-1.14)
(CPC 1 or 2)
Favorable neurological outcome
9 (2.5) 181 (10.1) 0.27 (0.14-0.47) 0.52 (0.21-1.18)
(CPC 1)
One-month survival 51 (14.0) 335 (18.7) 0.71 (0.51-0.96) 1.37 (0.93-1.99)
Pre-hospital ROSC 34 (9.3) 271 (15.1) 0.58 (0.39-0.83) 0.88 (0.54-1.38)
The data are expressed as the number (%) of patients, unless otherwise indicated.
All variables that might influence outcomes after OHCA were included in the models: calendar year, sex, age, bystander witness, bystander
CPR, public access AED, first documented rhythm (ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, asystole, or
others), etiology of cardiac arrest (cardiac etiology, respiratory disease, malignant tumor, external causes, others, or unknown), ELST presence
in ambulance, physician presence in ambulance, time from call to contact with patient, intravenous access, epinephrine administration and the
type of airway management (AAM or BVM).

Abbreviations: AAM, Advanced airway management; BVM, bag-valve-mask; OR, Odds ratio; CI, Confidence interval; CPC,
Glasgow-Pittsburgh cerebral performance category; ROSC, Return of spontaneous circulation; CPR, cardiopulmonary resuscitation; AED,
automated external defibrillator; ELST, emergency lifesaving technician

12
Table 4. Neurologically favorable survival in the subgroups of the overall unmatched cohort
Favorable Neurological Outcomes (CPC 1 or 2)
by Group No. (%) Adjusted OR
AAM BVM (95%CI)
Subgroup n = 365 n = 1792
Age
1) 1-7 years 11/149 (7.4) 139/770 (18.1) 0.61 (0.24-1.40)
2) ≥ 8 years 1/216 (0.5) 62/1022 (6.1) 0.31 (0.02-1.82)
Etiology
1) Cardiac 8/89 (9.0) 78/493 (15.8) 0.56 (0.19-1.55)
2) Non-cardiac 4/276 (1.5) 123/1299 (9.5) 0.58 (0.15-1.72)
Witness
1) Presence 1/79 (1.3) 110/881 (12.5) 0.34 (0.02-1.93)
2) Absence 11/286 (3.9) 91/911 (10.0) 0.54 (0.22-1.25)
The data are expressed as the number (%) of patients, unless otherwise indicated.
All variables that might influence outcomes after OHCA were included in the models: calendar year, sex, age, bystander witness, bystander
CPR, public access AED, first documented rhythm (ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, asystole, or
others), etiology of cardiac arrest (cardiac etiology, respiratory disease, malignant tumor, external causes, others, or unknown), ELST presence
in ambulance, physician presence in ambulance, time from call to contact with patient, intravenous access, epinephrine administration and the
type of airway management (AAM or BVM).

13
Abbreviations: CPC, Glasgow-Pittsburgh cerebral performance category; AAM, Advanced airway management; BVM, bag-valve-mask; OR,
Odds ratio; CI, Confidence interval; CPR, cardiopulmonary resuscitation; AED, automated external defibrillator; ELST, emergency
lifesaving technician

14