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Simple resuscitation method is best for children in out-of-hospital emergency settings

Researchers urged paramedics to stop using intubation to resuscitate children after finding that a simple artificial respiration method saves the lives of children who have stopped breathing as well as the more risky intubation procedure. The 3-year study of 830 patients, funded jointly by the Agency for Healthcare Research and Quality (HS09065) and the Health Resources and Services Administration's Maternal and Child Health Bureau, is published in the February 9 issue of the Journal of the American Medical Association.

Researchers at Harbor-UCLA Medical Center in Los Angeles in cooperation with the emergency medical services agencies of Los Angeles and Orange Counties conducted the study. They compared how two types of emergency breathing or respiration—bag-valve-mask ventilation (BVM) and BVM followed by endotracheal intubation (ETI)—affected the survival and neurological outcomes, such as coma or mild to severe disability, of children who stopped breathing due to injury, choking, or critical illness. BVM involves placing a mask on the face and squeezing a bag to push oxygen into the lungs. ETI involves inserting a plastic tube into the windpipe (trachea) to provide oxygen. Specially trained emergency medical providers often administer these procedures in paramedic ambulances or at emergency sites. Intubation is taught in 97 percent of paramedic training schools.

The children—ranging from infants to 12 years old or weighing less than 80 pounds—were assigned to receive either BVM or BVM followed by ETI. The study found no significant difference in survival or in achieving a good neurological outcome among children receiving either procedure. Researchers questioned the widespread use of intubation for children because of its potentially deadly complications, such as misplacement or dislodgement of the tube, which can result in no oxygen getting to the child's lungs. They determined that the less risky BVM should be the only paramedic procedure used to keep children needing artificial respiration alive on their way to the hospital. If pediatric intubation is necessary, researchers recommended that it be performed in the more controlled hospital setting.

This was the first controlled study comparing these treatments in either adults or children, even though BVM and ETI are widely used by paramedics. It also is the longest and largest controlled trial to date of treatments for children in a prehospital setting. More than 2,500 licensed paramedics in Los Angeles and Orange Counties received pediatric airway management training prior to the study.

For more details, see "Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial," by Marianne Gausche, M.D., Roger J. Lewis, M.D., Ph.D., Samuel J. Stratton, M.D., M.P.H., and others, in the January 9, 2000 JAMA 283(6), pp. 783-790.

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