Airway management in pediatric out-of-hospital cardiac arrest: A comprehensive systematic review and meta-analysis

Abstract

Airway management in pediatric out-of-hospital cardiac arrest (OHCA) is technically challenging and controversial, and the comparative effectiveness of endotracheal intubation (ETI), supraglottic airway (SGA), and bag-valve-mask (BVM) ventilation remains uncertain. We searched PubMed, Embase, Web of Science, ClinicalTrials.gov, and Scopus through December 2025 for studies comparing these strategies in pediatric OHCA and pooled the results using RStudio. Seven observational cohort studies (five retrospective and two prospective) including 10,159 pediatric patients met the inclusion criteria. Compared with ETI, BVM ventilation was associated with a significantly higher rate of favorable neurological outcome (risk ratio [RR] = 2.37, 95% confidence interval [CI]: 1.65–3.40) and survival to hospital discharge (RR = 2.00, 95% CI: 1.48–2.70), and SGA was associated with a lower rate of favorable neurological outcome than BVM (RR = 0.34, 95% CI: 0.13–0.90). There was no significant difference between SGA and ETI for return of spontaneous circulation (RR = 0.67, 95% CI: 0.42–1.07), favorable neurological outcome (RR = 1.16, 95% CI: 0.50–2.71), survival to hospital admission (RR = 1.06, 95% CI: 0.68–1.66), survival to hospital discharge (RR = 1.34, 95% CI: 0.90–2.00), or 1-month survival (RR = 1.20, 95% CI: 0.68–2.11). SGA demonstrated a higher airway success rate than ETI (94.7% vs. 65.7%) and a shorter time to airway placement, without differences in scene time or time to epinephrine. In pediatric OHCA, SGA and ETI yield comparable survival and neurological outcomes, whereas BVM is associated with higher rates of favorable neurological outcome and survival to hospital discharge than ETI.