OPTImal VENTilation to Improve Pediatric Cardiac Arrest Outcomes - Project Abstract Pediatric cardiac arrest affects >15,000 children each year. Less than half of these children survive. High- quality cardiopulmonary resuscitation (CPR) can save lives, but to date, there is an imbalance in this research area with much more known about optimal chest compression techniques as compared to ventilation strategies. Given that the majority of pediatric patients have respiratory disease at the onset of cardiac arrest, the lack of rigorous investigation into optimal CPR ventilation represents a significant roadblock to progress. In 2020, the American Heart Association (AHA) increased the recommended CPR ventilation rate from 10 breaths per minute (bpm) to a range of 20 – 30 bpm, a target associated with better outcomes. Unfortunately, providers do not achieve this recommended target in actual practice. As such, innovative training strategies to this CPR parameter are potential therapeutic interventions to rescue more children from cardiac arrest. To that end, we developed an OPTImizing VENTilation (OPTI-VENT) bundle consisting of provider education and point-of-care CPR ventilation rate guidance (CPR cue cards and a ventilation rate metronome). Our bundle demonstrated efficacy to train providers to a specific ventilation rate with high compliance. In this application, we propose an adaptive, parallel-stepped-wedge hybrid cluster-randomized trial to determine if the OPTI- VENT bundle can improve cardiac arrest outcomes by training providers to the 2020 CPR ventilation rate. To achieve our objectives, we will leverage the existing infrastructure of the Pediatric Resuscitation Quality Collaborative (pediRES-Q), a network specifically designed to study in-hospital pediatric CPR. The following aims are proposed: 1) Evaluate the effectiveness of the OPTI-VENT bundle to improve survival to discharge with favorable neurological outcome among children receiving at least 1 minute of CPR; 2) Determine the association between ventilation rate and a) survival outcomes and b) intra-arrest physiologic surrogates of vital organ perfusion among children receiving at least 1 minute of CPR; and 3) Determine the association between Airway Opening Index (AOI) – a newly discovered ventilation metric – and positive end-expiratory pressure, effectiveness of ventilation during CPR, intra-arrest hemodynamics, and patient outcomes using novel multidimensional machine learning algorithms. In Aim 1, we will execute a randomized trial to determine if training to the 2020 CPR ventilation rates with the OPTI-VENT bundle can improve patient outcomes. In Aim 2, an embedded secondary observational study will determine if an alternative rate target exists. In Aim 3, we will continue our investigation into AOI – a transformative line of work that may lead to a paradigm shift in cardiac arrest algorithms. In short, even if the OPTI-VENT rate target tested in this trial is not ideal, we will have conducted the multicenter observational study to substantially advance our evidentiary support for pediatric CPR guidelines, and potentially, discover a new target that will lead to fundamental changes in pediatric CPR ventilation recommendations.
