Guidance for Cardiopulmonary Resuscitation of Children With Suspected or Confirmed COVID-19

Frontline health care providers are at risk for contracting SARS-CoV-2 when in contact with infected patients (Fig 1). Vaccination is a key strategy to protect health care workers from occupationally acquired SARS-CoV-2, but infections do occur in vaccinated individuals, and health care worker vaccination rates remain <100%.³¹  Providers should therefore always use appropriate PPE, regardless of vaccination status, during resuscitation of patients with suspected or confirmed COVID-19.³² 

SARS-CoV-2 transmission occurs primarily when an individual either inhales respiratory particles from an infectious person or these particles are deposited on a mucosal surface. Transmission therefore generally occurs when individuals are within 6 ft, though transmission through aerosolized particles can happen at greater distances, particularly in poorly ventilated spaces and when larger quantities of aerosols are generated during certain aerosol-generating procedures (AGPs).³³  There are conflicting and incomplete data regarding which components of CPR constitute AGPs.^33–38  Regardless, the overall process of CPR has the potential to generate aerosols and place providers at risk, and should thus be treated as an AGP.^39,40  Furthermore, pediatric and neonatal resuscitation algorithms include the provision of ventilations via bag–mask ventilation, regardless of COVID-19 status. As bag–mask ventilation is considered an AGP,³⁶  AGP-appropriate PPE (N95 respirator or positive pressure respirators, eye protection, gowns, and gloves)^41–43  should be used by providers in all pediatric resuscitation events involving a patient with suspected or confirmed SARS-CoV-2. High-efficiency particulate air (HEPA) filters should be used with both invasive and noninvasive ventilatory interfaces and during both manual and mechanical ventilation.

Consistent and effective use of PPE is important for the safety of resuscitation personnel. Health care organizations should continue to secure and stock appropriate PPE, ensure training regarding its appropriate application and use, monitor and reinforce its effective use, and create and maintain systems that minimize the possibility that health care professionals would have to decide whether to provide emergency care without appropriate PPE.

The combination of appropriate PPE utilization and compliance with the recommended vaccine schedule is the best way of reducing risk of SARS-CoV-2 transmission and severe COVID-19.^43–45  The AHA strongly encourages all health care providers to receive the vaccines and comply with updated recommendations for boosters.

Patients with cardiac arrest are at considerable risk for death or poor neurologic outcomes when CPR is withheld, delayed, or otherwise compromised. Resuscitation providers and systems should aim to ensure that critical elements of resuscitation care continue to be prioritized in patients with suspected or confirmed SARS-CoV-2.

Because appropriate PPE is widely available in most practice settings, health care provider exposure to SARS-CoV-2 can generally be mitigated without compromising resuscitation quality. Proactive preparation can help to both prevent health care provider exposures and avoid delays in initiating CPR. Providers should be wearing PPE appropriate for AGPs when caring for pediatric patients with suspected or confirmed SARS-CoV-2 who are at risk for requiring resuscitation or other AGPs.⁴²  Initial responders who are not already wearing appropriate PPE at the time of cardiac arrest should immediately don it and begin CPR. Pediatric resuscitation should occur according to evidence-based algorithms (Figs 2–4), regardless of SARS-CoV-2 status. Chest compressions and ventilations should be initiated as soon as possible, and defibrillation, when indicated, should occur in accordance with CPR algorithms.

Because most pediatric cardiac arrests occur in the setting of respiratory failure or respiratory insufficiency, ventilation remains a critical component of pediatric and neonatal CPR in all settings.^5,46,47  Observational studies of pediatric cardiac arrest consistently demonstrate that children who receive chest compressions with ventilations have superior survival outcomes to those who receive chest compressions only.^48,49  In neonates, delays in providing positive pressure ventilation are associated with increased risk of death and prolonged hospitalization.⁵⁰  Therefore, ventilations with rates and ratios consistent with 2020 AHA guidelines^5,51  should be provided to children and neonates with suspected or confirmed COVID-19 and cardiac arrest. Similarly, children with a pulse but abnormal or absent breathing should receive prompt rescue breathing in accordance with standard guidelines. HEPA filters should be used during ventilation. Of note, although guidance for adult resuscitation endorses the use of passive oxygenation during CPR or in the presence of agonal breathing,^4,52  there is no role for this in children and neonates because these patients should all receive assisted ventilations.

Earlier COVID-19 guidance recommended prioritization of early intubation during CPR to minimize provider risk because ventilation via a cuffed endotracheal tube may disperse less aerosols than bag–mask ventilation.²  However, endotracheal intubation itself is considered an AGP that is likely to confer a relatively high risk to unprotected providers.^36,38,53  In the absence of evidence to suggest that early intubation reduces provider risk or benefits patients, the 2020 AHA guidelines^5,54  should be followed, with decisions regarding the timing of intubation based on the overall clinical picture and per usual care standards. Considerations include both the effectiveness of bag–mask ventilation and the availability of skilled personnel for intubation. Secure placement of a supraglottic airway with a HEPA filter may help maximize chest compression fraction, but it is unclear if it limits aerosol generation before endotracheal intubation.^55,56  When actively ventilating via mask, supraglottic airway, endotracheal tube, or any other device, a HEPA filter between the airway or mask and the ventilation device or on the exhaust port of the ventilation device should be employed as soon as available to capture aerosolized particles.

• The continued use of an N95 respirator and eye protection is advised when the patient’s COVID-19 status is unknown and clinical suspicion is high or community transmission is high.

• Reduce unnecessary exposure by limiting the number of resuscitation providers to those required for providing high-quality care.

• Ensure that resuscitation providers are trained and prepared to efficiently don PPE and that PPE is appropriately stocked and optimally located to best reduce provider risk and prevent unnecessary delays.

• Additional personnel for chest compressions may be required because of increased fatigue or the potential for N95 respirator slippage while providing chest compressions.^57,58  The application of mechanical compression devices can reduce the number of health care providers required for compressions in adult CPR events. However, these devices are not available for most pediatric patients and should only be used for patients meeting manufacturer age and size specifications and in centers with appropriate experience.^59,60 

• A HEPA filter should be securely attached to the ventilation device in 1 of the following ways:

  • ∘ Manual ventilation device: on the exhaust port of the device or between the mask or airway and the ventilation device, with a low-dead space viral filter or a heat- and moisture-exchanging filter.

  • ∘ Mechanical ventilator: on the exhaust limb of the ventilator circuit or between the mask or airway and the ventilator with a low-dead space viral filter or heat- and moisture-exchanging filter.

• Before intubation, mask ventilate with a tight seal and an in-line HEPA filter, ideally using a 2-person technique. The second team member can provide support for additional procedures, such as compressions, once an advanced airway is established.

• Securing placement of a supraglottic airway with a HEPA filter can help maximize chest compression fraction and may limit aerosol generation before endotracheal intubation, though supporting data are limited.^55,56 

• Assign the airway provider and use the technique with the highest chance of first-pass intubation success while wearing appropriate PPE for AGPs. Intubate adolescents, children, and infants with a cuffed endotracheal tube to minimize aerosolization of respiratory particles after the airway is secure and to optimize delivery of ventilator pressures. For neonates, consider local practices and the patient-specific risk– benefit relationship between aerosol mitigation and cuffed endotracheal tube use.

• As in any pediatric resuscitation, maximize the chest compression fraction, pausing only to facilitate intubation if needed. Minimizing noncompression time can require team coordination surrounding pulse checks, advanced airway placement, focused ultrasound evaluation, and other potential reasons for interruptions.

• Consider the use of video laryngoscopy if equipment and experienced personnel are available because this may reduce direct exposure of the airway provider to respiratory aerosols.^61,62  There is no known evidence of a difference in transmission risk using video versus direct laryngoscopy in the setting of providers wearing appropriate PPE for AGPs.

• Minimize endotracheal administration of medications; disconnections may be a source of aerosolization because of unfiltered exhalation.

• There is inadequate evidence to recommend the use of passive barrier devices such as “intubation boxes.” The United States Food and Drug Administration has advised that health care providers should not use passive protective barrier enclosures without negative pressure and that any protective barrier enclosure (with or without negative pressure) should not substitute for appropriate PPE. Further, any protective barrier that impedes the ability to perform essential medical procedures, such as bag–mask ventilation, intubation, or CPR, should be avoided.⁶³ 

Updated algorithms for CPR for patients with suspected or confirmed COVID-19 are depicted in Figs 2, 3, and 4. As noted above, these algorithms are largely consistent with standard pediatric basic life support and pediatric advanced life support algorithms,⁵  with additional guidance on reducing provider risk. As with the standard algorithms, the pediatric advanced life support algorithm applies to infants, children, and adolescents up to 18 years of age and pediatric basic life support algorithm should be applied as follows:

• Infant guidelines apply to infants younger than ∼1 year of age.

• Child guidelines apply from ∼1 year of age until puberty.

• Adult basic life support should be followed for those with signs of puberty and beyond (not shown in this article).^4,64 

Neonatal resuscitation should be performed in accordance with 2020 AHA Neonatal Resuscitation Guidelines,⁵¹  with additional considerations as detailed below.

In patients who are known to be SARS-CoV-2–negative or in whom it is not suspected on the basis of symptoms or community prevalence, resuscitation should proceed according to standard algorithms contained in the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care.^5,51 

Guidance regarding emergency medical services and lay rescuer CPR for adults and children with out-of-hospital cardiac arrest (OHCA) is described in detail in other literature.^65,66 

• Before or upon arrival, emergency medical services providers should rapidly don PPE suited for AGPs and excuse unprotected persons from the immediate vicinity of the resuscitation as soon as possible.

• Chest compressions with ventilations should be immediately initiated for pediatric OHCA. The need for HEPA-filtered ventilation and AGP-appropriate PPE should be anticipated for all pediatric OHCAs.

• When indoors, opening windows or doors may help disperse aerosolized particles and reduce provider risk. Clear nonresponders from the vicinity.

• Closely monitor for signs and symptoms of clinical deterioration to minimize the need for emergent intubation or CPR, which places patients and providers at higher risk.

• Per routine best practice for all critically ill children, address advanced care directives and goals of care with all patients or their decision-makers on hospital arrival and with any significant change in clinical status.

• If a patient with suspected or confirmed COVID-19 is at risk for cardiac arrest, consider proactive use of N95 respirators and other AGP-appropriate PPE. Consider moving the patient to a negative-pressure room/unit, if available, to minimize risk of exposure to rescuers during a resuscitation. Regardless of the type of hospital room, close the door whenever possible to prevent contamination of adjacent spaces and ensure staff are aware of the patient’s COVID-19 status.

• Plan for PPE, HEPA filters, and other equipment for reducing risk to providers to be strategically positioned throughout the hospital to avoid unnecessary exposures or delays in CPR initiation.

• Ensure that resuscitation providers are trained and prepared to efficiently don PPE. Consider instructing resuscitation team responders to always carry N95 respirators and eye protection and don them en route or immediately upon arrival to the patient’s room or bedside.

• In addition to proactive placement in negative-pressure rooms, closing the door to the resuscitation area, when possible, may minimize contamination of adjacent indoor space.

• To avoid unnecessary provider exposure to patients with COVID-19, crowd control efforts should minimize the number of persons in the patient room or at the bedside.

• Consider assigning a PPE monitor to ensure resuscitation team members use appropriate PPE. In the event that initial responders are performing CPR without having fully donned appropriate PPE, they should be immediately relieved by responders wearing appropriate PPE.

To reduce aerosol dispersion, consider leaving patients on invasive mechanical ventilation connected to the closed ventilator circuit with a HEPA filter. As per standard resuscitation guidelines, confirm endotracheal tube position and patency.⁵  Adjust the ventilator settings to allow asynchronous ventilation with the following suggestions:

• Increase the fraction of inspired oxygen to 1.0 for children. For neonates, follow usual guidelines for oxygen titration during resuscitation.

• Use either pressure or volume control ventilation, with peak inspiratory pressure or tidal volume set to generate adequate chest rise. Initial ventilator settings should reflect patient age and size, underlying respiratory disease, prearrest ventilator settings, and local practices.

• Adjust the trigger settings to prevent the ventilator from auto triggering with chest compressions, which could result in hyperventilation and air trapping.

• Adjust the mandatory ventilation rate to 20 to 30 breaths per minute for infants and children and 30 breaths per minute for neonates.

• Assess the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return.

• Adjust ventilator settings to deliver full breaths during chest compressions.

• Ensure endotracheal tube/ tracheostomy and ventilator circuit continuity to prevent unplanned airway dislodgement or tubing disconnections.

• As with any intubated patient, end-tidal carbon dioxide monitoring should be considered to help assess endotracheal tube placement, quality of CPR, and evidence of return of spontaneous circulation.

• If return of spontaneous circulation is achieved, set ventilator settings appropriate for the patient’s clinical condition and for achievement of postarrest goals.

Anticipation and preparation are important before rotating patients to a supine position. The limited adult evidence for providing CPR in the prone position suggests that it may be a feasible alternative when a patient cannot be immediately transitioned to a supine position.⁶⁷  There are minimal data regarding prone CPR in children, but its successful use has been described.^68–70  Of note, supination of small children and infants may require less personnel and thereby be more readily achievable.

For patients in the prone position with an advanced airway, it may be reasonable to provide manual compressions in the prone position until the patient can be safely transitioned to a supine position with a trained team. The following steps for providing prone CPR and transitioning a patient to a supine position are suggested:

• Provide compressions with hands centered over the T7 to T10 vertebral bodies.

• If an advanced airway is in place, ensure that the airway is not dislodged, disconnected, or obstructed.

• Arrange for sufficient, trained, PPE-protected personnel to achieve safe supination on the first attempt, with minimal risk of ventilator disconnections or endotracheal tube dislodgment.

• Immediately resume CPR in the supine position once the patient has been rotated.

• Confirm that the airway, vascular access lines, and other devices have not been dislodged and are in working order.

This guidance primarily applies to infants during the “newly born” period from birth to the end of resuscitation and stabilization in the delivery area. However, the concepts discussed below, as with Neonatal Life Support Guidelines,⁵¹  may be applied throughout the neonatal period (birth–28 days).

Every newborn baby should have a skilled attendant prepared to resuscitate, regardless of COVID-19 status. Newborns are unlikely to be a source of SARS-CoV-2 transmission even when mothers have confirmed COVID-19, but maternal respiratory secretions and fluids may be a potential source of SARS-CoV-2 transmission for the neonatal resuscitation team and newborn. Particular attention should be paid to preparation for birth because neonatal resuscitation teams may be called to resuscitate newborns in locations where the team is less accustomed to working (eg, adult ICUs). When appropriate, mothers can be encouraged to wear a surgical mask during the delivery. For mothers with suspected or confirmed COVID-19, health care providers should don appropriate PPE for AGPs to decrease the risk of transmission to themselves and the newborn.

• Initial steps: Routine neonatal care and the initial steps of neonatal resuscitation are unlikely to be aerosol-generating and should not be delayed or altered because of COVID-19 status; they include drying, tactile stimulation, use of plastic bags or wraps to prevent hypothermia, assessment of heart rate, and placement of pulse oximetry and electrocardiographic leads.⁵¹ 

• Suction: Decision-making regarding suctioning in the newborn period should follow standard neonatal resuscitation guidelines⁵¹  and should not be based on COVID-19 status. Suction of the airway after delivery should not be performed routinely for clear or meconium-stained amniotic fluid and is not indicated for uncomplicated deliveries, regardless of COVID-19 status. Suctioning should be performed for neonates with suspected airway obstruction, noting that it is an AGP.

• Opening the airway and delivering positive-pressure ventilation via mask remains the main resuscitation strategy for newborns with apnea, ineffective breathing (gasping), and bradycardia. This should be provided without delay by providers in appropriate PPE. Chest compressions occur later in the resuscitation algorithm,⁵¹  and are indicated when the heart rate remains <60 beats per minute despite 30 seconds of adequate positive-pressure ventilation.

• Endotracheal medications: Endotracheal instillation of medications is suspected to be an AGP, especially via an uncuffed endotracheal tube. Intravascular delivery of epinephrine via a low-lying umbilical venous catheter is the preferred route of administration during neonatal resuscitation, regardless of COVID-19 status.

• Delayed cord clamping and skin-to-skin contact may be practiced with a clinically stable neonate and a mother with suspected or confirmed COVID-19, provided the mother is appropriately masked.

• Mothers with suspected or confirmed COVID-19 should practice hand and breast hygiene and wear a mask during care and feeding.

• Closed incubators: Closed incubator transfer and care (with appropriate distancing) should be used when possible, but incubators do not protect against aerosolized particles.

Maternal respiratory secretions and fluids may be sources of SARS-CoV-2 transmission for newborns and neonatal resuscitation teams. Moreover, pregnant women with symptomatic COVID-19 are at increased risk of more severe illness compared with nonpregnant peers of similar age. Although the absolute risk for severe COVID-19 is low, data indicate an increased risk of ICU admission, need for mechanical ventilation, and death in pregnant women with COVID-19.⁷¹  Given their role in newborn resuscitation, neonatal/pediatric providers should be aware of maternal cardiac arrest principles, including: prioritization of oxygenation and early intubation; provision of chest compressions with concurrent left lateral uterine displacement if the uterine fundus is at or above the level of the umbilicus; and preparation for perimortem cesarean delivery.

Health care providers wearing appropriate PPE should continue to provide postcardiac arrest care per the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care.⁵ 

CPR for patients with suspected or confirmed COVID-19 is not inherently futile, and decisions regarding the degree and duration of resuscitation care provided should be made in a manner consistent with those made for other patients. Because most children with SARS-CoV-2 do not have severe COVID-19 disease, cardiac arrest in patients who are SARS-CoV-2–positive may occur because of non-COVID-19–related disease processes. Address and follow the patient’s goals of care and commit to ethical and evidence-based organizational policies regarding the initiation and continuation of resuscitative efforts. Follow the 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care for termination of resuscitation.^5,64 

The American Heart Association Emergency Cardiovascular Committee and Get with the Guidelines-Resuscitation Pediatric Task Force writing group members include Lance B. Becker, MD, Steven M. Bradley, MD, MPH, Steven C. Brooks, MD, MHSc, Paul S. Chan, MD, MS, Brian M. Clemency, DO, MBA, Dana P. Edelson, MD, MS, Gustavo E. Flores, MD, NRP, Saket Girotra, MD, SM, Carl Hinkson, MS, RRT-ACCS, Peter J. Kudenchuk, MD, Eric J. Lavonas, MD, MS, Mary E. Mancini, RN, PhD, NE-BC, Raina M. Merchant, MD, MSHP, Vivek K. Moitra, MD, MHA, Ashish R. Panchal, MD, PhD, Mary Ann Peberdy, MD, Michael R. Sayre, MD, and David S. Wang, MD.

AGP

aerosol-generating procedure

AHA

American Heart Association

COVID-19

coronavirus disease 2019

CPR

cardiopulmonary resuscitation

HEPA

high-efficiency particulate air

OHCA

out-of-hospital cardiac arrest

PPE

personal protective equipment

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2