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AHA Addresses Questions About New PALS Guidelines

Editor’s note: In a November article emergency physician Peter Antevy, MD, raised a pair of questions about the 2020 updates to the American Heart Association’s guidelines for Pediatric Advanced Life Support. In this response members of the writing team behind those guidelines explain their reasoning.

We appreciate the opportunity to respond to the concerns of Peter Antevy, MD, regarding the changes to the Pediatric Advanced Life Support guidelines for 2020 from the American Heart Association (AHA) and American Academy of Pediatrics (AAP).1,2 We appreciate his thoughtful review and analysis of the guidelines and supporting scientific literature. Antevy raises concerns with two recommendations from the 2020 guidelines. The first focuses on the changes to the respiratory rate from 10 breaths per minute (bpm) to 20–30 bpm during CPR with an advanced airway in place. The second notes that the recommendation regarding use of epinephrine for refractory bradycardia has remained unchanged despite the addition of a new study to the literature. While we agree with certain points raised, there are significant and important considerations as to why these recommendations were adopted.

With respect to the change in the respiratory rate, there are several principles supporting ventilation rates beyond 10 breaths per minute in children. It is important to note that within the recommendation, we caution that rates above 20–30 bpm could compromise hemodynamics. The basis for the prior guideline recommendation of 10 bpm was extrapolated from adult and animal models of resuscitation that do not readily translate to heterogeneous pediatric populations.3 Due to the absence of high-quality pediatric data and a loud call from the AHA’s instructor network for educational efficiency when pediatric data did not exist, adult resuscitation data were applied to children. This creates a challenge due to the fact that healthy young children can have ventilation rates in excess of 40 bpm. While the paper by Paul Banerjee, DO, et al. does make some important points regarding pediatric out-of-hospital cardiac arrest (POHCA) care, the published results of the paper focus on the importance of facilitating on-scene management of POHCA and the reduction of the mean time to first epinephrine administration (from 16.6 minutes to 7.65 minutes).4 While there is discussion of the importance of training and avoidance of “overzealous positive-pressure ventilation delivery,” there are no objective data in the study to define that term or support any objective number. So, in essence, we would agree that “overzealous” ventilation should be avoided, but what is that in a pediatric patient? Should that number be anything above 10 bpm? The existing pediatric data we have suggest otherwise.5

To streamline educational concepts for the learner, no distinction was made between pediatric and adult cardiac arrest pathophysiology and etiology. We know the pathophysiology and etiology of pediatric cardiac arrest are distinct from adults; children have high rates of cardiac arrest secondary to respiratory causes, and adults have cardiac arrests from cardiac causes. These factors, along with direct human pediatric data, were the basis of the writing group’s decision to make a major change based on the work of Robert Sutton, MD, MSCE, et al.5 In the rigorous review process and determination of recommendations, data from children are considered as stronger evidence for change than extrapolated adult or animal data.

The concern regarding the use of epinephrine for bradycardia with poor perfusion unresponsive to interventions is more challenging in the absence of data to support or refute the change advocated for in the editorial. We agree the recent study by Mathias Holmberg, MD, et al.6 contributes to the literature in an important way. This study is based on data from the AHA’s Get With The Guidelines resuscitation registry, a quality improvement in-hospital cardiac arrest database. While its results are interesting, the study was limited by its retrospective nature, the lack of granularity with registry data, and the fact that patients could be included in both the epinephrine group and the at-risk group multiple times. This did not demonstrate causality but instead confounded associations with potentially very different patient populations, thus raising the question as to whether these cohorts were comparable. These concerns were significant enough to prevent a change in epinephrine dosing for refractory pediatric bradycardia requiring CPR. We hope if alternative strategies are being used in clinical practice that rigorous data are collected and reported in the peer-reviewed literature so advances can influence and improve future pediatric resuscitation.

We appreciate that change is difficult and data in pediatrics are often scant (or absent altogether). An overarching principle of the approach to this year’s guideline revision is that when high-quality pediatric data are available, we look to those data to guide our recommendations. To remain true to that principle, we must be ready to accept unanticipated results and make recommendations accordingly. As Antevy astutely notes, the needle has not moved in POHCA over the last decade. This is despite many of the approaches long accepted as evidence based on physiology and conditions in experimental settings.

The AHA/AAP writing group felt it was important to consider all available data and remain open to data that may challenge conventional wisdom. We are grateful to Antevy for raising these important issues and remain steadfast in our call for more research in these areas. Our EMS colleagues have long been at the “spear’s tip” in caring for pediatric patients and as innovators in care. In this sense their close adherence to and adoption of these recommendations, while a departure from historical care, could provide valuable data as we continue to find the optimal way to resuscitate pediatric patients.

Consistent with the AHA’s strict conflict-of-interest policies, members of the writing group who are authors on reviewed publications did not participate in discussions and abstained from voting on related recommendations.


1. Antevy P. Two Issues With the New PALS Guidelines. EMS World,

2. Topjian AA et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2020; 142 (16_suppl_2): S469–S523 [epub 2020 Oct 21].

3. Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med, 2004 Sep; 32(9 Suppl): S345–S351.

4. Banerjee PR, et al. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation, 2019; 135: 162–7.

5. Sutton RM, et al. Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med, 2019; 47(11): 1,627–36.

6. Holmberg MJ, et al. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation, 2020; 149: 180–90.

Alexis Topjian, MD, MSCE, is chair of the AHA’s 2020 PALS Guidelines writing group.

Tia Raymond, MD, FAAP, FAHA, is vice chair of the AHA’s 2020 PALS Guidelines writing group.

Stephen Schexnayder, MD, is a member of the AHA’s 2020 PALS Guidelines writing group.

Benny L. Joyner, Jr., MD, MPH, FAAP, is a member of the AHA’s 2020 PALS Guidelines writing group.

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