Although bag-valve-mask ventilation and endotracheal intubation are both widely used by EMS personnel when caring for critically ill or injured children in pre-hospital settings, a new study urges paramedics to stop using intubation to resuscitate children after finding that the simpler bag-valve-mask method is just as effective at saving children's lives as the more risky intubation procedure.

The three-year study of 830 patients, performed at Harbor-UCLA Medical Center in Los Angeles, compared how the two types of emergency respiration affected the survival and neurological outcomes, such as coma or mild-to-severe disability, of children who stopped breathing due to choking, injury or critical illness. The study found no significant difference in survival or in achieving a good neurological outcome among children receiving either procedure.

The researchers therefore question the widespread use of intubation for children because of its potentially deadly complications, such as misplacement or dislodgement of the tube. The researchers determined that the less risky BVM ventilation should be the only paramedic procedure used to keep children needing artificial respiration alive during emergency transport. If pediatric intubation is necessary, the researchers recommend that it be performed in the more controlled hospital setting.

“Intubation has been an accepted procedure for resuscitating children,” said Dr. Claude Earl Fox, administrator of the Health Resources and Services Administration's Maternal and Child Health Bureau, a funder of the study. “Now we know differently. The next step is to train pediatric medical care providers to assure kids get the lowest risk treatment that still does the job.”

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

Lead author Dr. Marianne Gausche, Harbor-UCLA Medical Center Department of Emergency Medicine, suggests that EMS medical directors who want to include pediatric ETI should look at complication rates and effectiveness of the procedure.

“Our data suggest that BVM is as effective as ETI in an urban EMS system and demonstrate increased scene time and overall time when ETI is used,” Gausche said. “Although several authors have suggested a benefit of ETI for selected subgroups, analysis of subgroups in our study failed to show favorable outcomes for ETI versus BVM and, in fact, showed a detrimental effect in survival in two subgroups and in neurological outcome in one subgroup.”

It may be more prudent for EMS policy directors to focus on effective BVM and rapid transport and to delay pediatric ETI until arrival in the emergency room, Gausche said. This delay may prevent the potentially fatal complications of ETI observed in this study and yield the same or better outcome results.

“ETI is associated with a significant rate (8%) of fatal complications for children,” Gausche said. Children are unique because of their short tracheal lengths. Therefore, once an endotracheal tube is placed, there is a greater risk of dislodgement. “Fourteen percent of our patients had a tube dislodged, because in this setting the patient is moving constantly. When unrecognized, this dislodgement complication is fatal.”

Some EMS experts wondered whether the findings of this urban study could be applied in more rural settings, where transport times tend to run longer, but Gausche said a child can be ventilated easily for 20 minutes. “In fact, we had several children who were BVM-ventilated for greater than 30 minutes.

“It is clear to me that the best way to manage a child's airway in the field who require ventilatory support is via BVM ventilation,” Gausche said. Indeed, according to her, the American Heart Association plans to change their recommendations on out-of-hospital ETI for children and put much greater emphasis on BVM ventilation in their Advanced Cardiac Life Support course.