Introduction: Paediatric out-of-hospital cardiac arrest survival rates remain low despite advancements in resuscitation science. Prompt restoration of oxygenation is crucial for achieving return of spontaneous circulation. Delays in airway management are associated with decreased survival rates. The primary objective of this study was to determine whether early i-gel® insertion, without prior bag-valve-mask, could enhance ventilation parameters in comparison with a bag-valve-mask-only approach.

Methods: This multicentre, randomised crossover study used a simulated paediatric out-of-hospital cardiac arrest model to compare standard American Heart Association guidelines with an intermediate airway management approach using an i-gel® device. Paramedics and emergency medical technicians from eight participating emergency medical service centres were randomised into teams and performed two 10-minute simulations. Each team employed one of the airway management strategies. Data was automatically collected by a high-fidelity manikin. The primary outcome was alveolar ventilation per minute. Secondary outcomes included metrics for ventilation quality and timing, chest compression performance and timing of adrenaline administration. Statistical analysis involved paired tests suitable for the crossover design.

Results: From 30 January 2023 to 13 June 2023, 68 participants formed 34 resuscitation teams. Minute alveolar ventilation was similar between intermediate airway management and bag-valve-mask strategies (difference: 36 ml [95% CI -28 to 99]). A sensitivity analysis showed comparable results. Intermediate airway management delivered more ventilations, but bag-valve-mask enabled quicker ventilation initiation and more ventilations within the target volume. Chest compression fraction was higher with intermediate airway management, although chest recoil was better with bag-valve-mask. Adrenaline administration rates and times were similar in both strategies. Minor protocol deviations were observed but did not introduce significant bias. The study was underpowered due to an error in the sample size calculation, limiting the robustness and generalisability of the findings.

Conclusion: In a simulated paediatric out-of-hospital cardiac arrest model, immediate use of intermediate airway management did not show relevant differences compared to bag-valve-mask. Intermediate airway management devices cannot be recommended as first-line choice but may be considered when bag-valve-mask is challenging. Whichever device is used, the focus should remain on providing high-quality ventilations.

Clinicaltrials: gov ID: NCT05498402.