Compression only CPR and mortality in pediatric out-of-hospital cardiac arrest during COVID-19 pandemic

Background: The COVID-19 pandemic influenced resuscitation practices worldwide, leading to a notable decline in rescue breathing cardiopulmonary resuscitation (RB-CPR), even in pediatric out-of-hospital cardiac arrest (OHCA). Understanding the impact of this decline is important to assess the role of rescue breathing in pediatric resuscitation. This study aimed to evaluate the impact of the reduced RB-CPR during the COVID-19 pandemic on mortality and neurological outcomes among pediatric OHCA patients in Japan. Methods: This retrospective cohort study utilized data from the nationwide All-Japan Utstein Registry for pediatric OHCA patients (<= 17 years) who received bystander CPR between January 2017 and December 2021. Data were compared in pre-COVID-19 (2017-2019) versus pandemic (2020-2021) periods. Bystander CPR were classified as RB-CPR or chest compression-only CPR (CO-CPR). The primary outcome was 30-day mortality, with secondary outcomes including the absence of return of spontaneous circulation and unfavorable neurological outcomes (Cerebral Performance Category scores of 3-5). Adjusted risk ratios (aRR) with 95 % confidence intervals (CI) were estimated using Poisson regression. Results: Of 7,162 pediatric OHCA cases, 3,352 (46.8 %) received bystander CPR. RB-CPR decreased from 33.0 % pre-pandemic to 21.1 % during the pandemic. CO-CPR was associated with higher 30-day mortality (aRR: 1.16; 95 % CI: 1.08-1.24) and unfavorable neurological outcomes (aRR: 1.10; 95 % CI: 1.05-1.16). These trends were consistent across age groups and arrest etiologies, particularly for non-cardiac causes. More significantly, the decrease in RB-CPR was estimated to contribute to 10.7 excess deaths annually during the pandemic. Conclusions: The findings highlight the importance of rescue breathing in pediatric OHCA. CO-CPR, while suitable for adults, may compromise outcomes in children. Emphasizing rescue breathing in pediatric resuscitation training and integrating infection control measures is essential for future public health emergencies.