2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces Free

• Passive ventilation techniques (SysRev)

• Minimizing pauses in chest compressions (SysRev)

• Cardiopulmonary resuscitation (CPR) during transport (SysRev)

• Compressions-airway-breaths (C-A-B) or airwaybreaths- compressions (A-B-C) in drowning (new topic; SysRev)

• Paddle size and placement for defibrillation (EvUp)

• Barrier devices (EvUp)

• Chest compression rate (EvUp)

• Rhythm check timing (EvUp)

• Timing of CPR cycles (2 minutes versus other; EvUp)

• Public-access automated external defibrillator (AED) programs (EvUp)

• Checking for circulation during basic life support (BLS; EvUp)

• Rescuer fatigue in compression-only CPR (EvUp)

• Harm from CPR to subjects not in cardiac arrest (EvUp)

• Harm to rescuers from CPR (EvUp)

• Hand positioning during compressions (EvUp)

• Dispatch-assisted compression-only versus conventional CPR (EvUp)

• Emergency medical services chest compression– only versus conventional CPR (EvUp)

• Compression-to-ventilation ratio (EvUp)

• CPR before defibrillation (EvUp)

• Chest compression depth (EvUp)

• Chest wall recoil (EvUp)

• Foreign body airway obstruction (EvUp)

• Firm surface for CPR (EvUp)

• In-hospital chest compression–only CPR versus conventional CPR (EvUp)

• Analysis of rhythm during chest compressions (EvUp)

• Alternative compression techniques (cough, precordial thump, fist pacing; EvUp)

• Tidal volumes and ventilation rates (EvUp)

• Lay rescuer chest compression– only versus conventional CPR (EvUp)

• Starting CPR (C-A-B versus A-C-B; EvUp)

• Dispatcher recognition of cardiac arrest (EvUp)

• Resuscitation care for suspected opioid-associated emergencies (EvUp)

• CPR before call for help (EvUp)

• Video-based dispatch (EvUp)

• Head-up CPR (EvUp)

• Targeted temperature management (TTM) after car-diac arrest (SysRev)

• Point-of-care ultrasound (POCUS) as a diagnostic tool during cardiac arrest (SysRev)

• Vasopressin and corticosteroids for cardiac arrest (SysRev)

• Post–cardiac arrest coronary angiography (CAG; SysRev Update)

• Vasopressors during cardiac arrest (EvUp)

• Cardiac arrest from pulmonary embolism (EvUp)

• Public-access devices (SysRev)

• Pediatric early warning systems (PEWSs; SysRev)

• Sequence of compression and ventilation (EvUp)

• Chest compression–only versus conventional CPR (EvUp)

• Drugs for the treatment of bradycardia (EvUp)

• Emergency transcutaneous pacing for bradycardia (EvUp)

• Extracorporeal CPR for pediatric cardiac arrest (EvUp)

• Intraosseous versus intravenous route of drug administration (EvUp)

• Sodium bicarbonate administration for children in cardiac arrest (EvUp)

• TTM (EvUp)

• Maintaining normal temperature immediately after birth in late preterm and term infants (SysRev)

• Suctioning clear amniotic fluid at birth (SysRev)

• Tactile stimulation for resuscitation immediately after birth (SysRev)

• Delivery room heart rate monitoring to improve outcomes for newborn infants (SysRev)

• Continuous positive airway pressure (CPAP) versus no CPAP for term respiratory distress in the delivery room (SysRev)

• Supraglottic airways (SGAs) for neonatal resuscitation (SysRev)

• Respiratory function monitoring during neonatal resuscitation at birth (SysRev)

• Prearrest prediction of survival after in-hospital cardiac arrest (IHCA; SysRev)

• BLS training for likely rescuers of high-risk populations (SysRev)

• Patient outcome and resuscitation team members attending advanced life support (ALS) courses (SysRev with EvUp)

• Blended learning for life support education (SysRev)

• Faculty development approaches for life support courses (ScopRev)

• Willingness to provide CPR (EvUp)

• Team and leadership training (EvUp)

• Medical emergency teams for adults (EvUp)

• Community initiatives to promote BLS (EvUp)

• Debriefing of CPR performance (EvUp)

• Spaced learning (EvUp)

• The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest (SysRev)

• Oral dilution for caustic substance ingestion (EvUp)

• Recognition of anaphylaxis (EvUp)

• Compression wraps for acute closed ankle joint injury (EvUp)

• Open chest wound dressings (EvUp)

• Bronchodilators for acute asthma exacerbation (EvUp)

• Optimal duration of cooling of burns with water (EvUp)

• Preventive interventions for presyncope (EvUp)

• Single-stage scoring systems for concussion (EvUp)

• Cooling techniques for exertional hyperthermia and heatstroke (EvUp)

• First aid use of supplemental oxygen for acute stroke (EvUp)

• Methods of glucose administration for hypoglycemia in the first aid setting (EvUp)

• Pediatric tourniquet types for life-threatening extremity bleeding (EvUp)

• Readers are encouraged to monitor the ILCOR website²  to provide feedback on planned SysRevs and to provide comments when additional draft reviews are posted.

This topic was prioritized by the BLS Task Force because the topic had not been reviewed since the 2015 CoSTR recommendations. This SysRev was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021293309). The full text of this CoSTR can be found on the ILCOR website.³ 

• Population: Adults and children with presumed cardiac arrest in any setting

• Intervention: Any passive ventilation technique (eg, positioning the body, opening the airway, passive oxygen administration, Boussignac tube, constant flow insufflation of oxygen) in addition to chest compressions

• Comparator: Standard CPR

• Outcome:

  • Critical: Survival to hospital discharge with good neurological outcome, survival to hospital discharge

  • Important: Return of spontaneous circulation (ROSC)

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and- after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated to October 16, 2021.

Two RCTs, 1 observational study, and a very small pilot RCT were identified.^4–7  The overall certainty of evidence was rated as very low. All the individual studies were at a critical risk of bias and indirectness. Because of a high degree of heterogeneity, the meta-analyses included only 2 RCTs in which passive ventilation through constant-flow insufflation of oxygen with the aid of a modified tracheal tube was compared with mechanical ventilation.^4,5  The observational study evaluated passive oxygen insufflation as part of a minimally interrupted CPR bundle (also including uninterrupted preshock and postshock chest compressions and early epinephrine administration).⁶  The pilot RCT compared 9 patients who received chest compression–induced ventilation that included CPAP with 11 patients who received volume-controlled ventilation during CPR.⁷  Key results are presented in Table 1.

We suggest against the routine use of passive ventilation techniques during conventional CPR (weak recommendation, very low–certainty evidence).

The complete evidence-to-decision table is included in Supplemental Appendix A.

Passive ventilation may represent an alternative to intermittent positive-pressure ventilation (PPV). It may shorten interruptions in chest compressions for advanced airway management and may overcome the potential harm from PPV (increased intrathoracic pressure leading to reduced venous return to the heart and reduced coronary perfusion pressure, then increased pulmonary vascular resistance).

The 2 larger RCTs^4,5  that were included compared intermittent PPV through a tracheal tube with continuous insufflation of oxygen through a modified tracheal tube, that is, a Boussignac tube. The Boussignac tube used in these studies generates a constant tracheal pressure of ≈10 cm H2O. When available, the active compressiondecompression device was used to perform CPR. These adjuncts may have played a role in the generation and magnitude of passive ventilation. The included observational study⁶  was highly confounded because multiple aspects of the CPR protocols compared were different, including the ventilation strategies, rhythm check timing, compression-toventilation ratios, and compression intervals between shocks. Overall, the certainty of evidence was rated as very low primarily because of the risk of bias attributable to indirectness.

We acknowledge that when emergency medical services systems have adopted a bundle of care that includes minimally interrupted cardiac resuscitation with passive ventilation, it is reasonable to continue with that strategy in the absence of compelling evidence to the contrary.

• The efficacy of passive ventilation in the lay rescuer setting

• The optimal method for ensuring a patent airway

• Whether there is a critical volume of air movement required to maintain ventilation/oxygenation

• The effectiveness of passive insufflation in children

This topic was prioritized by the BLS Task Force because the topic had not been reviewed since the 2015 CoSTR. This SysRev was registered in PROSPERO (CRD42019154784). The full text of this CoSTR can be found on the ILCOR website.⁸ 

• Population: Adults in cardiac arrest in any setting

• Intervention: Minimizing of pauses in chest compressions (higher CPR or chest compression fraction or shorter perishock pauses compared with control)

• Comparator: Standard CPR (lower CPR fraction or longer perishock pauses compared with intervention)

• Outcome:

  • Critical: Survival to hospital discharge with good neurological outcome and survival to hospital discharge

  • Important: ROSC

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated to December 17, 2021.

Three RCTs^9–11  and 21 observational studies^12–32  were identified. The evidence identified was divided into 5 categories, and results are summarized in Table 2:

1. RCTs designed to evaluate interventions affecting quality of CPR

2. Observational studies comparing outcomes before and after interventions designed to improve quality of care (including pauses in chest compressions) or between different systems that had differences in CPR fraction

3. Observational studies exploring associations between pauses in chest compressions and outcomes

4. Observational studies in which outcomes were compared between groups in different chest compression pause categories

5. Observational studies in which pauses in compressions were compared between survivors and nonsurvivors

The overall certainty of evidence was rated as very low for all outcomes, primarily because of a very serious risk of bias. All the individual studies were at a critical risk of bias attributable to confounding. Because of this and a high degree of heterogeneity, no meta-analyses could be performed, and the individual studies are difficult to interpret.

We suggest that CPR fraction and perishock pauses in clinical practice be monitored as part of a comprehensive quality improvement program for cardiac arrest designed to ensure high-quality CPR delivery and resuscitation care across resuscitation systems (weak recommendation, very low–certainty evidence).

We suggest that preshock and postshock pauses in chest compressions be as short as possible (weak recommendation, very low–certainty evidence).

We suggest that the CPR fraction during cardiac arrest (CPR time devoted to compressions) should be as high as possible and be at least 60% (weak recommendation, very low–certainty evidence).

The complete evidence-to-decision table is included in Supplemental Appendix A.

In making these recommendations, the BLS Task Force considered that low CPR fractions may not necessarily reflect lower quality of CPR, but we felt that it was important to provide a minimum value to aid guideline creators. The consensus within the resuscitation community is that high-quality CPR is important for patient outcomes and that high-quality CPR includes high CPR or chest compression fraction and short perishock pauses. Although the exact targets of these CPR metrics are uncertain, the strong belief in the benefit of minimizing pauses in compressions (along with the physiological rationale for the detrimental effect of no compressions) makes prospective clinical trials of long versus short compression pauses unlikely. The evidence identified in this review was either indirect (in that the interventional studies were developed for related purposes) or observational. Observational studies are challenged by the association between pauses in compressions and good outcome because resuscitation attempts of short duration in patients with shockable rhythms tend to have better outcomes than resuscitation attempts of long duration in patients with nonshockable rhythms. The number and proportion of pauses will depend on both cardiac rhythm and the duration of the resuscitation attempt; therefore, an optimal target will depend on the cardiac arrest characteristics. These factors make interpreting observational data and providing guidance for CPR metrics particularly challenging.

Experimental animal data indicate possible positive effects of postconditioning (improved cardiac and neurological function in animals treated with short, controlled pauses during initial CPR).^33,34  There are no human data to inform postconditioning during cardiac arrest. Weighing a theoretical possibility of positive effects from limited pauses in chest compressions against a certain detrimental effect of lack of chest compressions, we believe that it is reasonable to assume that there is a low risk of harm from a lack of chest compression pauses and that the possibility for desirable effects from fewer pauses outweighs this.

• Effect of a strategy of minimizing pauses in compressions compared with longer pauses in compressions

• Evaluation of limited pauses in compressions as part of a postconditioning strategy in humans

• Optimal pauses and CPR metrics for various subgroups (shockable versus nonshockable, short versus longer resuscitations, etc)

A ScopRev was completed for the 2020 CoSTR, and this topic was subsequently prioritized by the BLS Task Force. This SysRev was registered in PROSPERO (CRD42021240615). The full text of these CoSTRs can be found on the ILCOR website.³⁵ 

• Population: Adults and children receiving CPR after out-of- hospital cardiac arrest (OHCA)

• Intervention: Transport with ongoing CPR

• Comparator: Completing CPR on scene (until ROSC or termination of resuscitation)

• Outcome:

  • Critical: Survival to hospital discharge with good neurological outcome and survival to hospital discharge

  • Important: Quality of CPR metrics on scene versus during transport (reported outcomes may include rate of chest compressions, depth of chest compressions, chest compression fraction, interruptions to chest compressions, leaning on chest/incomplete release, rate of ventilation, volume of ventilation, duration of ventilation, pressure of ventilation), ROSC

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated to June 15, 2021.

The identified studies were divided into those evaluating the effect of transport with ongoing CPR on CPR quality and those evaluating the effect of transport with ongoing CPR on patient outcomes (survival). These results are reported in separate tables (Tables 3 and 4). The studies evaluating the effect of transport with ongoing CPR on CPR quality included a wide range of quality outcomes, including the impact of transport on the following:

1. Correct hand positioning

2. Chest compression rate

3. Chest compression depth

4. Pauses in compressions

5. Leaning on the chest/ incomplete release

6. Chest compression fraction/ hands-off time

7. Ventilation

8. Overall correct CPR

We suggest that providers deliver resuscitation at the scene rather than undertake ambulance transport with ongoing resuscitation unless there is an appropriate indication to justify transport (eg, extracorporeal membrane oxygenation; weak recommendation, very low– certainty evidence).

The quality of manual CPR may be reduced during transport. We recommend that whenever transport is indicated, emergency medical services providers should focus on the delivery of high-quality CPR throughout transport (strong recommendation, very low–certainty evidence).

Delivery of manual CPR during transport increases the risk of injury to providers. We recommend that emergency medical services systems have a responsibility to assess this risk and, when practicable, to implement measures to mitigate the risk (good practice statement).

The complete evidence-to-decision table is included in Supplemental Appendix A.

In making these recommendations, the BLS Task Force considered the complexity of the decision to transport or remain on scene, including patient factors (age, comorbidities), clinical considerations (scope of practice of clinicians‚ pathogenesis, rhythm, response to treatment), logistic considerations (location of arrest, challenges of extrication, resources required, journey to hospital), patient and responder safety considerations, and hospital capability (extracorporeal membrane oxy-genation or other advanced interventions). The BLS Task Force’s interpretation of available evidence for CPR quality outcomes is summarized in Table 5.

The BLS Task Force’s interpretation of available evidence for survival outcomes was that the single study that was identified reported lower survival among transported patients.⁴⁷  The certainty of evidence was very low, with considerable risk of remaining confounding despite the use of propensity score matching. Overall, the task force’s concerns about decreased CPR quality and provider safety when delivering CPR during transport outweighed the benefits of bringing patients to the hospital unless the hospital could offer specific treatments not available in the prehospital setting (eg, extracorporeal membrane oxygenation, CAG, echocardiography, or other potential investigations or treatments).

• There are only a few studies in humans.

• There are no studies in children.

• There are no studies addressing the impact on patient outcomes of CPR quality during transport.

• There are no studies on the impact of the presence or absence of an advanced airway on the effect of transport on ventilation during CPR.

This topic was prioritized by the BLS Task Force after the ScopRev that was completed for the 2020 CoSTR. This SysRev was registered in PROSPERO (CRD42021259983). The full text of this CoSTR can be found on the ILCOR website.⁴⁸ 

• Population: Adults and children in cardiac arrest after drowning

• Intervention: Resuscitation that incorporates a compression-first strategy (C-A-B)

• Comparator: Resuscitation that starts with ventilation (A-B-C)

• Outcome:

  • Critical: Survival to hospital discharge with good neurological outcome and survival to hospital discharge

  • Important: ROSC

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated to October 16, 2021.

Seven hundred thirty abstracts were reviewed, of which 9 were reviewed in full text. No studies were identified as relevant to the PICO question comparing initial resuscitation strategies (ventilation first or compression first) for cardiac arrests caused by drowning. To determine good practice statements, the reviewers identified literature and other consensus statements that related indirectly to the research question.

We recommend a compression-first strategy (C-A-B) for laypeople providing resuscitation for adults and children in cardiac arrest caused by drowning (good practice statement).

We recommend that health care professionals and those with a duty to respond to drowning (eg, lifeguards) consider providing rescue breaths/ventilation first (A-B- C) before chest compressions if they have been trained to do so (good practice statement).

The rationale for the ventilation-first strategy (differing from adult BLS treatment recommendations) is based on the hypoxic mechanism of cardiac arrest in drowning and the belief that earlier ventilation will reverse the hypoxia sooner, either preventing the patient from progressing from respiratory arrest to cardiac arrest or increasing the likelihood of ROSC after correcting the underlying pathogenesis.

A similar rationale is commonly invoked in pediatric cardiac arrest in which hypoxia is a more common cause than primary cardiac events.⁴⁹  ILCOR reviewed the evidence for initial resuscitation strategy in pediatric cardiac arrest in both 2015 and 2020.^50,51  No human studies were identified, and the Pediatric Life Support (PLS) Task Force did not recommend either strategy as superior. Instead, the task force noted that a compression-first strategy prioritized uniformity with adult guidelines and simplicity and a ventilation-first strategy prioritized more rapid reversal of hypoxia. Two manikin RCTs that were identified in the review demonstrated that ventilation was delayed by only 5.7 to 6 seconds with a compression-first strategy compared with a ventilation-first strategy.^52,53 

There is only indirect evidence to support a ventilation-first strategy in drowning. Another SysRev of resuscitation after drowning is currently being done to determine the impact of any ventilation at all as part of the resuscitation strategy. However, a recent ScopRev found that bystander CPR including ventilation was associated with better survival.⁵⁴  One retrospective observational study compared in-water resuscitation (ie, ventilation) with no ventilation for drowning victims in respiratory (and possibly cardiac) arrest. Survival

(87.5% versus 25%) and survival with favorable functional outcome (52.6% versus 7.4%) were higher in the in-water resuscitation cohort.⁵⁵  Another study describes significantly worse functional outcomes in children who drowned who experienced cardiac arrest compared with respiratory arrest only (81% versus 0%; P <0.001). Intervening with ventilation early in the arrest process before the heart has stopped (ie, addressing the hypoxic mechanism) may improve outcomes.⁵⁶ 

The recommendation for a compression-first strategy (C-A-B) for lay rescuers prioritizes simplicity and cohesiveness in training recommendations for laypeople, with the goal of faster resuscitation initiation. The recommendation is supported by manikin studies finding that there was limited delay in ventilation even with a compression-first strategy.

The recommendation for health care professionals and those with a duty to respond to consider providing rescue breaths/ventilation first (A-B-C) considers the indirect evidence suggesting that earlier ventilations may improve outcomes. It is unclear whether earlier ventilation may improve outcomes after cardiac arrest has occurred or if the benefit is exclusively in preventing respiratory arrest from deteriorating into cardiac arrest.

• No studies directly evaluated this question.

• Further research informed by the Utstein template for drowning may address this ongoing uncertainty.

The topics reviewed by EvUps are summarized in Table 6, with the PICO number, existing treatment recommendation, number of relevant studies identified, key findings, and whether a SysRev was deemed worthwhile. Complete EvUps can be found in Supplemental Appendix B.

Active temperature control has been a cornerstone of care for those who remain comatose after cardiac arrest. This SysRev was prompted by the publication of 2 large randomized trials comparing different strategies of temperature management since the previous ILCOR review in 2015.⁵⁷  A SysRev was therefore conducted on behalf of the ALS Task Force (PROSPERO; CRD42020217954).⁵⁸  The complete CoSTR can be found online.⁵⁹ 

For this PICO, study design, and time frame, 6 comparisons were included. Population, outcome, study design, and time frame included were the same for all comparisons.

• Population: Adults in Any Setting (In-Hospital or Out-of-Hospital) With Cardiac Arrest

• Intervention: TTM at 32° C to 34°C

• Comparator: No TTM (normothermia/fever prevention)

• Intervention: TTM induction before a specific time point (eg, prehospital or intracardiac arrest, ie, before ROSC)

• Comparator: TTM induction after that specific time point

• Intervention: TTM at a specific temperature (eg, 33° C)

• Comparator: TTM at a different specific temperature (eg, 36° C)

• Intervention: TTM for a specific duration (eg, 48 hours)

• Comparator: TTM at a different specific duration (eg, 24 hours)

• Intervention: TTM with a specific method (eg, external)

• Comparator: TTM with a different specific method (eg, internal)

• Intervention: TTM with a specific rewarming rate

• Comparator: TTM with a different specific rewarming rate or no specific rewarming rate

• Outcome: Critical—Survival and favorable neurologi-cal/functional outcome at discharge/≥30 days

• Study design: Controlled trials in humans, including RCTs and nonrandomized trials (eg, pseudorandomized trials). Observational studies, ecological studies, case series, case reports, reviews, abstracts, editorials, comments, letters to the editor, and unpublished studies were excluded. Studies assessing cost-effectiveness were included for a descriptive summary.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was conducted on October 30, 2020, and updated for clinical trials on June 17, 2021.

The search identified 2328 unique records, of which 139 full-text articles were assessed for eligibility. Articles reporting data from 32 trials published between 2001 and 2021 were included. The search identified 1 costeffectiveness analysis. We did not identify any trials assessing rewarming rate.

In the SysRev, studies were pooled such that the intervention labeled as TTM in the PICO question was targeting hypothermia (32° C–34° C), and the comparator labeled as no TTM was targeting normothermia or fever prevention. To avoid confusion and to accurately reflect the content of the included trials, we have replaced the term TTM with temperature control with hypothermia, and we replaced no TTM with temperature control with normothermia or fever prevention. To provide additional clarity for interpreting future clinical trials, SysRevs, and CoSTRs, the Task Force proposes new ILCOR definitions for the various forms of temperature control in post–cardiac arrest care under Justification and Evidence-to-Decision Framework Highlights.

We identified 6 RCTs comparing the use of temperature control with hypothermia and temperature control with normothermia or fever prevention.^60–65  No differences were found across any outcome, and key results are presented in Table 7.

We identified 10 RCTs^66–75  comparing the use of prehospital cooling with no prehospital cooling after OHCA, and no differences in critical outcomes were found (Table 8).

A single large RCT,⁷⁶  now known as the TTM trial, compared temperature control at 33° C with temperature control at 36° C and found no statistically significant difference in patient outcomes. Key results are presented in Table 9. Two much smaller RCTs compared management at 32° C versus 34° C, 32° C versus 33° C, and 33° C versus 34° C, finding no statistically significant difference for any of the comparisons.^77,78 

A single RCT⁷⁹  including 451 patients found no statistically significant difference in survival or favorable neurological outcome at 6 months between 48 and 24 hours of temperature control with hypothermia.

Three RCTs^80–82  including a total of 523 patients found no difference in survival or favorable neurological outcome at hospital discharge/28 days with endovascular cooling compared with surface cooling devices.

No studies were identified evaluating rewarming strategies.

We suggest actively preventing fever by targeting a temperature ≤37.5° C for patients who remain comatose after ROSC from cardiac arrest (weak recommendation, low-certainty evidence).

Whether subpopulations of cardiac arrest patients may benefit from targeting hypothermia at 32° C to 34° C remains uncertain.

Comatose patients with mild hypothermia after ROSC should not be actively warmed to achieve normothermia (good practice statement).

We recommend against the routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC (strong recommendation, moderate-certainty evidence).

We suggest surface or endovascular temperature control techniques when temperature control is used in comatose patients after ROSC (weak recommendation, low-certainty evidence).

When a cooling device is used, we suggest using a temperature control device that includes a feedback system based on continuous temperature monitoring to maintain the target temperature (good practice statement).

We suggest active prevention of fever for at least 72 hours in post–cardiac arrest patients who remain comatose (good practice statement).

The complete evidence-to-decision table is provided in Supplemental Appendix A.

In making these recommendations, the ALS Task Force agreed that we should continue to recommend active temperature control to prevent fever in post–cardiac arrest patients, although the evidence for this is limited.

The ALS Task Force also discussed the terminology of temperature control and felt that current terminology is somewhat problematic. The term TTM on its own is not helpful, and it is preferable to use the terms active temperature control, hypothermia, normothermia, or fever prevention. The ALS Task Force has also avoided use of the term TTM because this term is now very closely linked to the TTM and TTM2 RCTs. To provide additional clarity for interpreting future clinical trials, SysRevs, and CoSTRs, the Task Force proposes that the following terms be used:

• Temperature control with hypothermia: Active temperature control with the target temperature below the normal range

• Temperature control with normothermia: Active temperature control with the target temperature in the normal range

• Temperature control with fever prevention: Monitoring temperature and actively preventing and treating temperature above the normal range

• No temperature control: No protocolized active temperature control strategy

The majority of the ALS Task Force favored fever prevention as a strategy over hypothermia on the basis of evidence and because this intervention requires fewer resources and had fewer side effects than hypothermia treatment. The specifics of how normothermia was achieved were thought to be important, and the Task Force noted that in the TTM2 trial⁶¹  pharmacological measures (acetaminophen), uncovering the patient, and lowering ambient temperature were used to maintain a temperature of ≤37.5° C (99.5° F) in the normothermia/fever prevention group. If the temperature was >37.7° C (99.9° F), a cooling device was used and set at a target temperature of 37.5° C (99.5° F). Ninety-five percent of patients in the hypothermia group and 46% in the fever prevention group received temperature control with a device.

Several members of the task force wanted to leave open the option to use hypothermia (33° C). The discussions included the following:

• No trials have shown that normothermia is better than hypothermia.

• Among patients with nonshockable cardiac arrest, the Hyperion trial⁶⁴  showed better survival with favorable functional outcome in the hypothermia group (although 90-day survival was not significantly different and the Fragility Index was only 1).

• The largest temperature control studies have included mainly cardiac arrests with a primary cardiac cause, and this may not reflect the total population of post–cardiac arrest patients treated.

• Concerns were raised that the TTM2 trial cooling rates, which were similar to those in other studies, were too slow and that the time to target temperature was outside the therapeutic window.

• There was a unanimous desire to leave open the opportunity for further research on post–cardiac arrest hypothermia.

• There were concerns that poor implementation of temperature control may lead to patient harm. For example, the publication of the TTM trial in 2013 may have led to some clinicians abandoning temperature control after cardiac arrest, which in turn was associated with worse outcomes.^83–85 

• The comparison between 33° C and 36°C was included in a sensitivity analysis of 33° C versus normothermia/fever prevention. This did not change the point estimates.

• The task force made a good practice statement supporting the avoidance of active warming of patients who have passively become mildly hypothermic (eg, 32° C–36° C) immediately after ROSC because there was concern that rewarming may be a harmful intervention. In the TTM2 trial, patients in the normothermia/ fever prevention arm who had an initial temperature >33° C were not actively warmed.⁶¹  In the Hyperion trial, patients allocated to normothermia whose temperature was <36.5° C at randomization were warmed at 0.25° C/h to 0.5° C/h and then maintained at 36.5° C to 37.5° C.⁶⁴ 

The recommendation about prehospital cooling is unchanged from 2015 because we found no evidence that any method of prehospital cooling improved outcomes. The ALS Task Force recommends against the rapid infusion of large volumes of cold fluid immediately after ROSC in the prehospital setting because of higher rates of rearrest and pulmonary edema with that intervention in the largest of the included studies.⁷² 

There was no consensus on whether a feedback (ver-sus no feedback) cooling device should be used routinely, so this was added as a good practice statement because there is no evidence that this approach improves outcomes. There was consensus that temperature should be continually monitored by the cooling device to enable active control of temperature and to maintain a stable temperature. There was a comment that endovascular cooling may be superior for temperature control. Two recent SysRevs have conflicting conclusions.^86,87 

Our treatment recommendation on duration of temperature control is a good practice statement based on trials controlling temperature for at least 72 hours in those patients who remained sedated or comatose.

• Whether fever prevention changes outcome compared with no temperature control

• The effect of temperature control after extracorporeal CPR

• The effect of temperature control after IHCA

• Whether there is a therapeutic window within which hypothermic temperature control is effective in the clinical setting

• If a therapeutic window exists, whether there are clinically feasible cooling strategies that can rapidly achieve therapeutic target temperatures within the therapeutic window

• Whether the clinical effectiveness of hypothermia is dependent on providing the appropriate dose (target temperature and duration) on the basis of the severity of brain injury

• Whether there are subsets of post–cardiac arrest patients who would benefit from hypothermic temperature control as currently practiced

• Whether temperature control using a cooling device with feedback is more effective than temperature control without a feedback-controlled cooling device

A SysRev of the diagnostic accuracy of POCUS was prioritized by the ALS Task Force because ultrasound use during CPR continues to grow in popularity, often with the goal of identifying a reversible cause of arrest that can then be treated. This CoSTR focuses entirely on POCUS as a diagnostic tool and does not replace the 2021 CoSTR on POCUS as a prognostic tool during CPR.⁸⁸  The diagnostic SysRev was registered on PROS- PERO (CRD42020205207) and the full text of the CoSTR can be found online.^89‚90 

• Population: Adults with cardiac arrest in any setting

• Intervention: A particular finding on POCUS during CPR

• Comparator: An external confirmatory test or process including some component other than POCUS

• Outcome: Important—A specific cause or pathophysiological state that may have led to cardiac arrest

• Study design: Randomized and nonrandomized trials, cohort studies (prospective and retrospective), and case-control studies with data on both POCUS findings and an external reference standard to contribute to a contingency table (ie, true-positive, false-positive, false- negative, true-negative). Animal studies, ecological studies, case series, case reports, narrative reviews, abstracts, editorials, comments, letters to the editor, and unpublished studies were not excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated through October 6, 2021.

The overall certainty of evidence was rated as very low for diagnosis of all target conditions primarily because of risk of bias, inconsistency, and imprecision. As a result of critical risk of bias across all included studies and a high degree of clinical heterogeneity, no metaanalyses could be performed, and individual studies are difficult to interpret.

Only a single observational study⁹¹  provided sufficient information to calculate the sensitivity and specificity of POCUS for specific pathophysiological states, and these results are summarized in Table 10.

For the target conditions of cardiac tamponade, pericardial effusion, pulmonary embolism, myocardial infarction, aortic dissection, and hypovolemia, 11 observational studies^92–102  with a high risk of bias provided sufficient data to estimate individual positive predictive values only among small subsets of between 1 and 10 patients with OHCA, IHCA, or intraoperative cardiac arrest. Individual estimates of positive predictive value have very wide CIs and are difficult to interpret in the context of the very small subsets of subjects.

We suggest against routine use of POCUS during CPR to diagnose reversible causes of cardiac arrest (weak recommendation, very low–certainty evidence).

We suggest that if POCUS can be performed by experienced personnel without interrupting CPR, it may be considered as an additional diagnostic tool when clinical suspicion for a specific reversible cause is present (weak recommendation, very low–certainty evidence).

Any deployment of diagnostic POCUS during CPR should be carefully considered and weighed against the risks of interrupting chest compressions and misinterpreting the sonographic findings (good practice statement).

In making these recommendations, the ALS Task Force discussed that the inconsistent definitions and terminology used for sonographic evidence of specific causes of cardiac arrest were the primary source of clinical heterogeneity and that the establishment of uniform definitions and terminology to describe sonographic findings of reversible causes of cardiac arrest is very important.

The identified studies all have high risk of bias related to selection bias and ascertainment bias. Verification bias (when availability or use of the reference standard is influenced by test-positive or test-negative status) was present in all but 1 of the included studies. We strongly encourage subsequent investigations of POCUS during cardiac arrest to use methodology that mitigates these risks of bias, including standardized definition of time intervals for imaging acquisition, assessment of image quality, and experience of the sonographer, among others.

The task force discussed that the diagnostic utility of POCUS is affected by the clinical context. For example, a postoperative cardiac surgery patient with cardiac arrest may have a higher pretest probability for specific causes such as cardiac tamponade, pulmonary embolism, or acute hemorrhage. Conversely, the diagnostic utility of POCUS may be more limited in the context of undiffer-entiated cardiac arrest in the out-of-hospital setting.

Evidence showing that POCUS may increase the length of pauses in chest compressions was discussed as a very important consideration, especially given the lack of evidence for benefit from the use of POCUS.^103,104  Some studies suggest that transesophageal echocardiography can eliminate this problem.^105–107 

The task force noted that POCUS findings that may indicate myocardial infarction or pulmonary embolism outside of cardiac arrest may be much less specific during CPR. For example, wall motion abnormalities may result from the ischemia of a low-flow state or a preexisting infarct as opposed to a de novo myocardial infarction. Not treating a reversible cause of cardiac arrest risks failure of the resuscitation attempt or more severe post–cardiac arrest injury. Treating an incorrect diagnosis suggested by POCUS risks iatrogenic injury or delayed identification of the true underlying cause.

Because of the resources involved and the use of POCUS in current clinical practice, the task force expects that most diagnostic applications of POCUS will occur in a hospital-based setting as opposed to the prehospital setting.

The prognostic utility of POCUS to predict clinical outcomes is covered in a separate PICO Study Design, and Time Frame section.⁸⁹ 

• The diagnostic accuracy of POCUS during cardiac arrest using methodology that sufficiently minimizes risk of bias, especially selection bias, ascertainment bias, and verification bias

• Uniform definitions and terminology to describe sonographic findings of reversible causes of cardiac arrest or the associated reference standards

• The interrater reliability of POCUS diagnostic findings during cardiac arrest

• Resource requirements, cost- effectiveness, equity, acceptability, or feasibility of POCUS use during CPR

• Whether use of POCUS during CPR changes patient outcomes

This topic was prioritized by the ALS Task Force for consideration after the publication of a recent RCT¹⁰⁸  and a subsequent SysRev with individual patient data metaanalysis, which was identified as suitable for adolopment.¹⁰⁹  The full text of the CoSTR can be found online.¹¹⁰ 

• Population: Adults with cardiac arrest in any setting

• Intervention: Administration of the combination of vasopressin and corticosteroids during CPR

• Comparator: Not using vasopressin and corticoste-roids during CPR

• Outcome:

  • Critical: Health-related quality of life; survival with favorable functional outcome at discharge, 30, 60, 90, or 180 days, or 1 year; and survival at discharge, 30, 60, 90, or 180 days or 1 year

  • Important: ROSC

• Study design: RCTs were eligible for inclusion. Observational studies and unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract.

Three RCTs^108,111,112  were identified, all of which included patients with IHCA only.

One of the included trials,¹⁰⁸  which enrolled 501 patients, assessed health-related quality of life at 90 days measured by the EuroQol 5 Dimension 5 Level tool. Data were available from all 44 patients who survived to 90 days, and there was no difference in the EuroQol 5 Dimension 5 Level score.

Results from the meta-analysis of the 3 included RCTs for other clinical outcomes are presented in Table 11.

We did not find any evidence specific to OHCA. Therefore, all the results for this population were the same, with the evidence downgraded for indirectness for the OHCA population.

We suggest against the use of the combination of vasopressin and corticosteroids in addition to usual care for adult IHCA because of low confidence in effect estimates for critical outcomes (weak recommendation, lowto moderate-certainty evidence).

We suggest against the use of the combination of vasopressin and corticosteroids in addition to usual care for adult OHCA (weak recommendation, very low– to low-certainty evidence).

In making these recommendations, the ALS Task Force considered that the intervention (vasopressin and corticosteroids) given intra-arrest improved ROSC, but this did not clearly translate into an effect on other outcomes.

In all studies, the combination of vasopressin and corticosteroids was administered in addition to standard intra-arrest treatments, including epinephrine and defibrillation. The task force noted that the earlier 2 studies^111,112  reported improvements in outcomes beyond ROSC (eg, survival, favorable neurological outcome), but these effects were not observed in the later study.¹⁰⁸  The earlier 2 studies included post-ROSC corticosteroids in addition to the intra-arrest vasopressin and steroids, which was not the case in the more recent study. The earlier 2 studies were considered by the ILCOR ALS Task Force in 2015¹¹³ to be not sufficiently generalizable (eg, high rate of asystolic cardiac arrest, low baseline survival rate) for the task force to make a treatment recommendation supporting the use of the combination of vasopressin and corticosteroids.

The task force noted that the incorporation of these drugs into ALS treatment would present practical challenges because the addition of new drugs would add complexity to current treatment protocols. This was thought not to be warranted at this time, given the low confidence in effect estimates for any outcomes beyond ROSC, as well as the fact that only the earlier trials including post-ROSC steroids reported any difference in survival outcomes.

The task force noted that time to drug administration was longer in the trial when this was led by the cardiac arrest team¹⁰⁸  rather than dedicated research staff.^111,112  Time to drug administration would likely be markedly longer in the prehospital setting. We discussed the potential interaction between vasopressin and corticosteroids and the current uncertainty as to whether either drug alone or the combination was driving the observed effect on ROSC.

The potential value of an improvement in ROSC when there was no observed effect on longer-term outcomes was discussed. The task force has previously suggested some other interventions without a clear survival benefit (eg, amiodarone or lidocaine for refractory shockable rhythm). Those drugs, however, appear to have a survival benefit in some subgroups (ie, witnessed arrest), which was not clearly the case for vasopressin and steroids.

• Whether the combination of vasopressin and corticosteroids, in addition to current standard resuscitation, improves survival or favorable functional outcome

• Whether improvement in ROSC with the combination of vasopressin and corticosteroids is a result of the specific combination of drugs or if only 1 of the medications is producing the effect

• How timing of administration of the combination of vasopressin and corticosteroids during cardiac arrest modifies the effect

A SysRev was conducted and a new CoSTR was generated on this topic for 2021.⁸⁸  The search was updated this year to incorporate a new RCT on this topic and to identify any other relevant studies since publication of the previous SysRev. The original review was registered on PROSPERO (CRD42020160152).¹¹⁴ 

• Population: Unresponsive adults (>18 years of age) with ROSC after cardiac arrest

• Intervention: Emergent or early (2–6 hours) CAG with percutaneous coronary intervention (PCI) if indicated

• Comparator: Delayed CAG (within 24 hours)

• Outcome:

  • Critical: Survival to hospital discharge; functional survival to intensive care unit or hospital discharge; survival at 30, 90, and 180 days; func-tional survival at 30, 90, and 180 days

  • Important: Survival at 24 hours, coronary artery bypass graft, successful PCI, PCI frequency and adverse events of brain damage, recurrent cardiac arrest, arrhythmias, pneumonia, bleeding, acute worsening renal failure, injury or replacement therapy, shock, sepsis

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion for the 2021 CoSTR. Unpublished studies (eg, conference abstracts, trial protocols), case series, and case reports were excluded. For this 2022 update, only additional RCTs published since the prior search were included.

• Time frame: All years and all languages were included if there was an English abstract. The initial search was run on April 29, 2020. For the 2022 update, the search was rerun on January 7, 2022.

One new RCT and 1 secondary analysis of a previous RCT were identified.^115,116  This enabled additional metaanalyses of several critical outcomes for patients with no ST-segment elevation on a post-ROSC ECG, and these results are included here by subgroup of initial rhythm.

No statistically significant difference was noted in any of the critical outcomes comparing early CAG with late or no CAG. The updated results are presented in Table 12. Previously reported results from single studies are included in the full online CoSTR.¹¹⁸ 

The new RCT¹¹⁵  enrolled patients with all initial rhythms but provided a subgroup analysis of patients with initial shockable rhythm. A meta-analysis including the new data from the RCT and new data from a long-term outcome analysis of a previous trial¹¹⁶  is presented in Table 13. Results from single studies and all results with no new data from the 2021 CoSTR are available in the full online CoSTR.¹¹⁸ 

No new evidence was identified for this group. Previously reported evidence showed no statistically significant difference in outcomes based on early angiography or no early angiography. These results are presented in more detail in the online CoSTR.¹¹⁸ 

New meta-analyses were performed that included the 1 additional RCT identified since the last review.¹¹⁵  No significant differences were seen in any of the reported adverse outcomes, including ischemic stroke, intracranial bleeds, recurrent cardiac arrest, cardiac arrhythmias, pneumonia, acute pulmonary edema, bleeding, and acute kidney failure. Additional details, including meta-analysis results, are included in the online CoSTR.¹¹⁸ 

When CAG is considered for comatose postarrest patients without ST-segment elevation, we suggest that either an early or a delayed approach for angiography is reasonable (weak recommendation, low-certainty evidence).

We suggest early CAG in comatose post–cardiac arrest patients with ST-segment elevation (good practice statement).

The complete evidence-to-decision table is provided in Supplemental Appendix A.

This updated review used the search strategy from the 2021 CoSTR,⁸⁸  restricting the inclusion criteria to RCTs only. We found 1 new RCT¹¹⁵ and 1 analysis of long-term outcomes from a previously included RCT.¹¹⁶  The new RCT enabled additional meta-analyses for some critical outcomes, but the overall results, and therefore the treatment recommendations, remain unchanged.

In making the above recommendations, the ALS Task Force weighed the fact that we did not find sufficient evidence to demonstrate improved outcomes with early angiography for post–cardiac arrest patients without ST-segment elevation regardless of presenting cardiac arrest rhythm (shockable or nonshockable). Patients in cardiogenic shock after arrest were excluded from all studies, and there is unlikely to ever be clinical equipoise to support a randomized trial of delayed intervention in the shock cohort. There may be subgroups of patients without ST-segment elevation with high-risk features who would benefit from earlier CAG.

It is important to note that this review examined early CAG compared with a combined control group of late CAG or no CAG. It may be that survival and functional survival may not be the right outcomes to measure harm or benefit from an intervention that adjusts the timing of PCI in postarrest patients. We know that most patients admitted to hospital after cardiac arrest do not die of cardiac complications but instead die as a result of neurological injury. There are no significant differences in adverse event rates with either time interval.

For comatose patients with ST-segment elevation, there is no randomized clinical evidence for the timing of CAG. The task force acknowledges that early CAG, and percutaneous intervention if indicated, is the current standard of care for patients with ST-segment–elevation myocardial infarction who did not have a cardiac arrest. We found no compelling evidence to change this approach in patients with ST-segment elevation after cardiac arrest.

• Lack of a consistent definition for comparable time intervals to treatment for early compared with late angiography and PCI

• Whether early CAG improves survival/survival with favorable neurological outcome for postarrest patients with ST-segment elevation

• Whether angiography compared with no angiography improves outcomes in postarrest patients

• Whether angiography and PCI may improve outcomes in the no ST-segment elevation cohort who present in shock

• Whether CAG changes outcomes after IHCA

• Limited evidence for longer-term outcomes

• Relatively few studies examining health-related quality of life outcomes

• Whether newer or alternative end points such as functional or biochemical measures may show a benefit with timing of CAG in patients with cardiac arrest

The topics reviewed by EvUps are summarized in Table 14, with the PICO number, existing treatment recommendation, number of relevant studies identified, key findings, and whether a SysRev was deemed worthwhile. Complete EvUps can be found in Supplemental Appendix B.

This topic was chosen because of growing literature on the inclusion of children in public-access defibrillation programs, the increasing use of AEDs for children generally, and the wider availability of AEDs in the community. The review was conducted on behalf of both the PLS and BLS Task Forces (PROSPERO; CRD42017080475). The full text of this CoSTR is available on the ILCOR website.¹²⁰ 

• Population: Infants, children, and adolescents with nontraumatic OHCA

• Intervention: Application of, or shock delivery from, an AED by lay rescuers

• Comparator: Standard care by lay rescuer without AED application

• Outcome:

  • Critical: survival and functional outcome at hospital discharge

  • Important: ROSC; other outcomes as available

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The initial search was done on January 25, 2021, and updated on November 3, 2021.

The search identified 1163 unique articles, and 4 observational studies were included. Three articles^121–123  were from the CARES (Cardiac Arrest Registry to Enhance Survival) database in the United States. The data reported did not correspond to the PICO study design and time frame question in a usable manner, although AED use was part of the analyses. Raw data provided by CARES included the number of children who had a cardiac arrest, age groups of those children, the number who had an AED applied, and the outcomes at hospital discharge. From those numbers, the relative risk of survival if an AED was applied was calculated. Because several studies from the Japanese Fire and Disaster Management Agency had overlapping dates for data inclusion, the last article¹²⁴  (the most time inclusive) was chosen to avoid duplication of data.

Given the age-dependent risk of a shockable rhythm and age-dependent chance of survival, we analyzed the data in 3 age groups: <1, 1 to 12, and 13 to 18 years of age. The overall certainty of evidence was rated as very low for all outcomes, and the risk of bias was too high to enable meta-analysis. Table 15 summarizes the relative risks for the critical outcomes of Cerebral Performance Category (CPC) of 1 to 2 at 1 month, CPC of 1 to 2 at hospital discharge, and hospital discharge and bystander CPR with AED.

We suggest the use of an AED by lay rescuers for all children >1 year of age who have nontraumatic OHCA (weak recommendation, very low–certainty evidence).

We cannot make a recommendation for or against the use of an AED by lay rescuers for all children <1 year of age with nontraumatic OHCA.

The complete evidence-to-decision table is provided in Supplemental Appendix A.

In making these recommendations, the PLS Task Force considered that in all of the included studies, only a small percentage of children had an AED applied or shock delivered. The evidence showed that 120 of 7591 children from the CARES database had an AED applied and that 220 of 5899 children in the Japanese study had a shock delivered.^121–124  In making a weak recommendation, we considered the high relative risk and the relatively low number needed to treat for improved hospital discharge and favorable neurological outcomes at hospital discharge or 30 days, but we recognized that relatively few patients had an AED applied. There may be significant selection bias in those children who had the AED applied. The rescuers who applied the AED may be those who had a greater skill set and thus provided higher-quality CPR. In addition to treating shockable rhythms, AEDs provide instructions on CPR, which may help lay rescuers to perform CPR even if a shock is not required and dispatch instructions are not available.

The task force did not evaluate outcomes with chest compressions only versus chest compressions with rescue breaths because of the few children who had AEDs applied. There was substantial discussion about the potential for harm in applying an AED by delaying CPR and increasing the number and duration of pauses. In making a final recommendation, we acknowledged that the data were from nonselected rescuers and those events likely occurred, but the relative risks were still significantly in favor of AED application.

The task force had a robust discussion about this treatment recommendation. In making no recommendation about the use of AEDs in children <1 year of age, the task force considered the lack of a significant difference in outcomes. However, few patients (12) in this age group had an AED applied, and only 1 survived. This may have resulted in a type II error; thus, the task force did not make any recommendation. The task force recognized that there is a small population of infants who do have shockable rhythms, mainly those with inherited arrhythmia syndromes or congenital cyanotic cardiac disease. These infants could benefit from AED application. In the absence of dispatch CPR instructions, AEDs assist lay rescuers by providing CPR instructions, which could increase survival in infants without shockable rhythms.

• Absence of RCTs of AED use in children

• The interaction between high-quality CPR and the effect of AED application. This is particularly important in light of the importance of rescue breaths with chest compressions in pediatric cardiac arrest.

• Whether AED application alters outcomes on the basis of the type of CPR provided, that is, potential delay in the initiation of chest compressions, chest compression–only CPR, or conventional CPR with compressions and rescue breathing

• Whether AED application affects survival/functional survival beyond 30 days

• Whether there are possible advantages to using the pediatric modifications of AED application for younger children, especially those <8 years of age or who weigh <25 kg

• Whether the application of an AED is beneficial beyond shock delivery such as by directing the rescuer to perform appropriate actions.

This SysRev was prompted by our ScopRev of pediatric early warning scores conducted in 2020¹²⁵ and was undertaken to review our current treatment recommendations for PEWSs (PROSPERO; CRD42021269579). PEWSs encompass both the use of an early warning score and a protocolized response to that score. The full text of this CoSTR can be found on the ILCOR website.¹²⁶ 

• Population: Infants, children, and adolescents in any inpatient setting

• Intervention: PEWSs with or without rapid response teams or medical emergency teams

• Comparator: No PEWS or standard care (without a scoring system)

• Outcome:

  • Critical: significant clinical deterioration event, including but not limited to (1) unplanned/crash tracheal intubation, (2) unanticipated fluid resuscitation and inotropic/vasopressor use, (3) CPR or extracorporeal membrane oxygenation, and (4) death in patients (all-cause mortality) without a do-not-attempt-resuscitation order

  • Important: unplanned code events

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was updated to June 26, 2021.

We identified 12 studies, 1 RCT¹²⁷  and 11 cohort studies,^128–138  for inclusion in our SysRev (Table 16). The overall certainty of evidence was rated as very low (downgraded for very serious risk of bias and very serious imprecision) for all outcomes. Results are summarized in Table 16.

We suggest using PEWSs to monitor hospitalized children, with the aim of identifying those who may be deteriorating (weak recommendation, low-certainty evidence).

The full evidence-to-decision table is provided in Supplemental Appendix A.

In making these recommendations, the PLS Task Force considered the following: PEWSs should be part of an overall clinical response system, with the task force placing a higher value on improving health care providers’ ability to recognize and intervene for patients with deteriorating illness over the expense incurred by a health care system committing significant resources to implement these systems. The task force also noted that the complex process of optimizing patient care is likely to include both the implementation of PEWSs and ongoing education for health care providers. The PLS Task Force agreed that the decision to use PEWSs should be balanced between the use of existing resources and the capabilities of the health care setting to adapt to its use and the consequences of its use.

Evidence is limited, and there is equipoise about whether the use of PEWSs significantly decreases in-hospital pediatric mortality, significant clinical deterioration, and cardiopulmonary arrest events. In the context of resource-limited health systems, the need to use health care resources judiciously is especially important. Although no definitive benefits were found, the very weak evidence identified supports the use of PEWSs in systems with available resources that prioritize and value the potential to decrease the incidence of code events for inpatient children.

The task force recognized the significant limitations of the available evidence in its treatment recommendations but also the importance and the potential value of improving health care providers’ ability to recognize and intervene for patients with deteriorating illness. For settings already using PEWSs, local validation, site-specific adaptation of its use, and longitudinal evaluation of its effectiveness are important.

• Whether PEWS decrease pediatric cardiopulmonary arrest or improve mortality

• The relative contribution of PEWSs and other practice changes aimed at quality improvement (including educational processes, documentation review with feedback systems, and modification of other factors thought to improve the delivery of care) to changes in patient outcomes. Controlled trials and quality improvement methodology are suggested for further studies.

• The effect of rapid response teams, alone and in combination with PEWSs

• Whether the effect of PEWSs and rapid response teams varies by setting and patient type (eg, emergency department, pediatric oncology patients, patients in higherversus lower-resource settings)

• Prospective evaluations of different PEWSs for predicting, identifying, and providing early intervention for patients at risk for different forms of decompensation, including primary respiratory, circulatory, and neurological causes

• Effectiveness of various methods for PEWS implementation and staff training; data on feasibility, costeffectiveness, equity, and acceptability of integrating PEWSs into existing health care systems

The topics reviewed by EvUps are summarized in Table 17, with the PICO number, existing treatment recommendation, number of relevant studies identified, key findings, and whether a SysRev was deemed worthwhile. Complete EvUps can be found in Supplemental Appendix B.

Maintaining Normal Temperature Immediately After Birth in Late Preterm and Term Infants (SysRev)

A previous SysRev conducted for ILCOR concluded that there was a dose-responsive association between hypothermia on admission to a neonatal unit or postnatal ward and increased risk of mortality and other adverse outcomes.¹⁴⁰  A SysRev estimated that hypothermia was common in infants born in hospitals (prevalence range, 32%–85%) and homes (prevalence range, 11%–92%), even in tropical environments.¹⁴¹  A SysRev was initiated from a priority list from the ILCOR Neonatal Life Support (NLS) Task Force (PROSPERO; CRD42021270739). The full text of this review can be found on the ILCOR website.¹⁴² 

• Population: Late preterm and term newborn infants (≥34 weeks’ gestation)

• Intervention: Increased room temperature to≥23.0° C, thermal mattress, plastic bag or wrap, hat, heating and humidification of gases used for resuscitation, radiant warmer (with or without servo control), early monitoring of temperature, warm bags of fluid, warmed swaddling/clothing, skin-to-skin care with a parent, or any combination of these interventions

• Comparator: Drying, without any of the above interventions, and comparisons between interventions

• Outcome:

  • Critical: Survival

  • Important: Rate of normothermia on admission to neonatal unit or postnatal ward; rate of hypothermia and hyperthermia on admission to neonatal unit or postnatal ward; response to resuscitation (eg, need for assisted ventilation, highest Fio2). For this and all subsequent reviews, importance of outcomes was in accord with Strand et al¹⁴³  or by consensus of the task force for outcomes specific to each review. Additional outcomes are included in the full online CoSTR.¹⁴²  For the purposes of the review, the definitions in Table 18 were used.¹⁴⁴ 

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and- after studies, cohort studies) were eligible for inclusion. Unpublished studies were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was conducted to August 2, 2021.

The SysRev identified 35 studies (25 RCTs including 4625 participants^145–169  and 10 observational studies^170–179  including >3342 participants [number not reported in 1 study]). All RCTs had eligibility criteria that excluded some or all infants who were at high risk of needing resuscitation or who received resuscitation. The studies were conducted in high-, middle-, and low-resource countries, but few interventions were studied in all settings. None of the studies included out-of-hospital births. Temperature outcomes were reported in a wide variety of ways, constraining the meta-analysis. There were insufficient data to conduct any of the prespecified subgroup analyses.

The SysRev identified 1 cluster RCT including 825 late preterm and term newborn infants for this comparison.¹⁵²  All were born by caesarean section, so the study pertains specifically to operating room temperatures, and only temperatures of 20°C and 23°C were compared. Data relating to the key critical and important outcomes for this comparison are summarized in Table 19. Evidence for additional outcomes evaluated is included in the full online CoSTR.¹⁴² 

The SysRev found 10 RCTs including 1668 late preterm and term newborn infants for this comparison.^{148,150,154–157,160,163,164,166} 

Data relating to key critical and important outcomes are shown in Table 20. Evidence for additional outcomes evaluated is included in the full online CoSTR.¹⁴² 

The SysRev found 4 RCTs including 730 late preterm and term newborn infants for this comparison.^{147,155,159,165}  Data relating to key critical and important outcomes are shown in Table 21. Evidence for additional outcomes evaluated is included in the full online CoSTR.¹⁴²  Of note, this comparison included studies in which infants had been dried or not dried before the use of the plastic bag or wrap.

The SysRev found 2 RCTs including 698 late preterm and term newborn infants for this comparison.^146,168  Data relating to key critical and important outcomes are shown in Table 22. Evidence for additional outcomes evaluated is included in the full online CoSTR.¹⁴²  This comparison included studies in which infants had been dried or not dried before the use of the plastic bag or wrap.

For all other comparisons, no evidence-to-decision tables were developed, either because only single studies providing very low–certainty evidence were available or because no studies were found. Additional details on these comparisons are included in the online CoSTR.¹⁴² 

In late preterm and term newborn infants (≥34 weeks’ gestation), we suggest the use of room temperatures of 23° C compared with 20° C at birth in order to maintain normal temperature (weak recommendation, very low– certainty evidence).

In late preterm and term newborn infants (≥34 weeks’ gestation) at low risk of needing resuscitation, we suggest the use of skin-to-skin care with a parent immediately after birth rather than no skin-to-skin care to maintain normal temperature (weak recommendation, very low–certainty evidence).

In some situations in which skin-to-skin care is not possible, it is reasonable to consider the use of a plastic bag or wrap, among other measures, to maintain normal temperature (weak recommendation, very low– certainty evidence).

In late preterm and term newborn infants (≥34 weeks’ gestation), for routine use of a plastic bag or wrap in addition to skin-to-skin care immediately after birth compared with skin-to-skin care alone, the balance of desirable and undesirable effects was uncertain. Furthermore, the values, preferences, and cost implications of the routine use of a plastic bag or wrap in addition to skin-to-skin care are not known; therefore, no treatment recommendation can be formulated.

The complete evidence-to-decision tables are provided in Supplemental Appendix A.

In making these recommendations, the NLS Task Force considered that the review found evidence to support each of 3 interventions without evidence of adverse effects. Each of these interventions was thought likely to be low in cost and feasible in many settings.

In many facilities, immediate newborn infant care (including resuscitation if needed) takes place in the delivery or operating room, and it may not be practicable to alter room temperatures for very preterm births and not others. When a designated resuscitation room with separate temperature control is used, more individualized ambient temperature control may be feasible. Higher (>23° C) ambient temperatures have not been studied for late preterm and term infants. The adverse outcomes of maternal or neonatal hyperthermia could increase at higher ambient temperatures. Mortality may be increased among newborn infants with hyperthermia,¹⁸⁰  and hypoxic ischemic encephalopathy may be exacerbated by hyperthermia.¹⁸¹ 

For skin-to-skin care, there is insufficient evidence to make a recommendation for newborn infants at high risk of needing resuscitation because of the inclusion criteria of available studies. There is a much larger evidence base supporting the use of skin-to-skin care in preterm and term infants for a variety of maternal and neonatal outcomes.^182,183  Studies report some barriers to use, but overall, skin-to-skin care is judged to be acceptable by both parents and caregivers.^184–186  Skin-to-skin care is likely to be cost-effective, acceptable, and feasible in high-, middle-, and low-income countries.

For routine use of a plastic bag or wrap for late preterm and term newborn infants (≥34 weeks’ gestation), the balance of desirable and undesirable effects was considered uncertain because of the potential for unmeasured undesirable effects. These could include that a plastic bag or wrap might be seen as an alternative or impediment to skin-to-skin care. When they are used in combination with warming devices, there could be risk of hyperthermia. Costs to clinical services could be high if they were used for a high proportion of late preterm and term infants. The environmental impact was also considered. Cultural values and maternal preferences in relation to this specific intervention are not known. Although the NLS Task Force agreed that skin-to-skin care was preferred, a plastic bag or wrap may be reasonable when skin-to-skin care is not possible, especially for late preterm and low-birth-weight newborn infants, for births in which ambient temperatures are low and cannot be increased, when alternative equipment (eg, radiant warmer, incubator, thermal mattress) is not available, or with combinations of these circumstances.

The use of skin-to-skin care is likely to improve equity because of the low cost and feasibility for lowor middleincome countries. Room temperatures may or may not be easily adjustable in various settings. When a room temperature of 23°C cannot be achieved, the importance of skin-to-skin care may be greater.

The overall balance of risks and benefits for the use of a plastic bag or wrap combined with skin-to-skin care was considered uncertain because there was concern that plastic bags or wraps might impair the acceptability or safety of skin-to-skin care and thereby cause harm. As with the use of a plastic bag or wrap compared with standard care, costs may be a barrier, particularly in low-income countries, if the intervention was applied to a high proportion of births.

Additional gaps are included in the full online CoSTR.

• The balance of risks and benefits for each evidence-based intervention when combined with other interventions

• The best methods of maintaining normothermia in infants who received or were at high risk of receiving resuscitation

• The effectiveness of interventions for which no evidence was available or for which evidence was insufficient to make treatment recommendations, including the following:

  • Use of a thermal mattress, which may assume greater importance if a parent is unable to provide skin-to-skin care

  • Caps made of various materials

  • Use of heated, humidified gases for assisted ventilation

  • Early monitoring of temperature versus no early monitoring of temperature

  • The role of lowor moderately low–cost interventions such as prewarmed bags of intravenous fluid placed around the newborn infant or prewarmed swaddling and clothing

  • The effect of maternal hypothermia or hyperthermia on newborn infants’ temperatures

  • Standardizing the timing and method of recording temperature for all newborn infants, which would enhance the potential both for benchmarking and for meta-analysis of studies in future reviews.

To support air breathing at birth, oropharyngeal or nasopharyngeal suctioning has been a widespread practice for newborn infants. The 2010 CoSTR¹⁸⁷ and many subsequent guidelines have recommended selective use of upper airway suctioning, with use only if the airway appears obstructed or PPV is required, and there has been increasing concern that there may be adverse effects of routine upper airway suctioning. A ScopRev (NLS 596) found sufficient evidence to justify a SysRev.¹⁸⁸  A SysRev was initiated from a priority list from the ILCOR NLS Task Force (PROSPERO; CRD42021286258). The full text of this review can be found on the ILCOR website.¹⁸⁹ 

• Population: Newborn infants who are born through clear (not meconium-stained) amniotic fluid

• Intervention: Initial suctioning of the mouth and nose

• Comparator: No initial suctioning

• Outcome:

  • Critical: Advanced resuscitation and stabilization interventions (intubation, chest compressions, epinephrine) in the delivery room

  • Important: Receipt of assisted ventilation; receipt and duration of oxygen supplementation; adverse effects of intervention (eg, apnea, bradycardia, injury, infection, low Apgar scores, dysrhythmia); unanticipated admission to the neonatal intensive care unit (NICU)¹⁴³ 

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were eligible for inclusion. Unpublished studies, case series, and animal studies were excluded.

• Time frame: All years and all languages were included if an English abstract was available. The literature search was performed on September 21, 2021.

The SysRev identified 11 studies (9 RCTs including 1138 participants^190–198  and 2 observational studies^199,200 ) for inclusion. The studies enrolled predominantly healthy, low-risk term newborn infants. For 2 of the RCTs^193,194  enrolling 280 participants, the task force had concerns about the reliability of the oxygen saturation and heart rate data. Therefore, results of these studies have been excluded from the meta-analysis. In sensitivity analysis, exclusion of these studies did not change the overall outcome.

Data relating to the key critical and important outcomes for this comparison are summarized in Table 23. Evidence for additional outcomes that were evaluated is included in the full online CoSTR.¹⁸⁹ 

For all predefined subgroup analyses, insufficient data were available.

We suggest that suctioning of clear amniotic fluid from the nose and mouth should not be used as a routine step for newborn infants at birth (weak recommendation, very low–certainty evidence).

Airway positioning and suctioning should be considered if airway obstruction is suspected (good practice statement).

The complete evidence-to-decision table is provided in Supplemental Appendix A.

The NLS Task Force found no justification to routinely use an intervention such as oral and nasal suctioning in the absence of demonstrated benefit. The participants in the included studies were predominantly healthy, term newborn infants, and no benefit was found. There could also be potential for unmeasured harm if routine suctioning caused delay in resuscitation for those who require it. This SysRev recommendation does not apply to situations when there are concerns about airway obstruction.

• The role of suctioning of clear amniotic fluid at birth for newborn infants who are at high risk of needing respiratory support or more advanced resuscitation

• The role of suctioning of clear amniotic fluid at birth for preterm newborn infants

• Adherence to guidelines in relation to suctioning of the upper airway

Tactile stimulation has been included in the initial steps of stabilization of the newborn infant in the treatment recommendations from ILCOR in 1999, 2006, 2010, 2015, and 2020^{140,187,188,201,202}  largely on the basis of expert opinion. Because the effectiveness of tactile stimulation to facilitate breathing at birth has never been systematically evaluated by ILCOR, this PICO question was prioritized by the NLS Task Force for SysRev (PROSPERO; CRD42021227768).²⁰³  The full text of this CoSTR can be found on the ILCOR website.²⁰⁴ 

• Population: Term or preterm newborn infants immediately after birth with absent, intermittent, or shallow respirations

• Intervention: Any tactile stimulation performed within 60 seconds after birth and defined as 1 or more of the following: rubbing the chest/ sternum, rubbing the back, rubbing the soles of the feet, flicking the soles of the feet, or a combination of these methods. This intervention should be done in addition to routine handling with measures to maintain temperature.

• Comparator: Routine handling with measures to maintain temperature, defined as care taken soon after birth, including positioning, drying, and additional thermal care

• Outcome:

  • Critical: Survival as reported by authors; neurode-velopmental outcomes

  • Important: Establishment of spontaneous breathing without PPV (yes or no); time to the first spontaneous breath or crying from birth; time to a heart rate of ≥100 bpm from birth; intraventricular hemorrhage (only in preterm infants with <34 weeks’ gestation); oxygen or respiratory support at admission to a neonatal special care unit or NICU; admission to a neonatal special care unit or NICU for those not admitted by protocol on the basis of gestational age or birth weight¹⁴³ 

  • Potential subgroups were defined a priori: gestational age (<34, 34–36 6/7, and ≥37 weeks’ gestation), cord management (early cord clamping, delayed cord clamping, and cord milking), clinical settings (high and low resource), and method of stimulation (type, number, duration of stimuli).

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were eligible for inclusion. Unpublished studies (conference abstracts, trial protocols) and animal studies were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was first done on December 6, 2020, with the final update on September 17, 2021.

The SysRev identified 2 observational studies.^205,206  The study by Baik-Schneditz et al²⁰⁵  was not eligible for data analysis because of its critical risk of bias (mainly because of confounding by indication). Therefore, only the study by Dekker et al²⁰⁶  with 245 preterm newborn infants was analyzed (Table 24).

No data were reported on other prespecified outcomes or by subgroups.

We suggest that it is reasonable to apply tactile stimulation in addition to routine handling with measures to maintain temperature in newborn infants with absent, intermittent, or shallow respirations during resuscitation immediately after birth (weak recommendation, very low–certainty evidence).

Tactile stimulation should not delay the initiation of PPV for newborn infants who continue to have absent, intermittent, or shallow respirations after birth (good practice statement).

The complete evidence-to-decision table is provided in Supplemental Appendix A.

The NLS Task Force based the treatment recommendation on several inferences. The very limited available data suggest a possible benefit to tactile stimulation in decreasing the need for tracheal intubation in preterm infants, but the certainty of evidence is very low. The results of the single study identified should be analyzed with caution because of indirectness (all 245 infants were put on CPAP before tactile stimulation, in contrast to the common practice of tactile stimulation before CPAP or PPV), possible selection bias (among 673 infants who were video-recorded immediately after birth, 245 [36%] were included in the study), and confounding (the clinical indication of tactile stimulation was retrospectively assessed, and it could not be determined in 34% of the 585 tactile stimulation episodes). Additional observational studies showed that, in general, infants who received tactile stimulation responded with crying, grimacing, and body movements, although the methods of stimulation were variable and the outcomes analyzed were not exactly the same among the studies.^207–210  These studies could not be included in the SysRev because of the lack of control groups who did not receive tactile stimulation.

A single-center RCT compared single with repetitive tactile stimulation in newborn preterm infants immediately after birth. Patients in the repetitive stimulation group had higher oxygen saturation levels and lower oxygen requirements at the start of transport to the NICU. This study could not be included in the SysRev because of the lack of a control group who did not receive tactile stimulation. A singlecenter RCT compared back rubbing to foot flicking to provide tactile stimulation in preterm and term infants with birth weight >1500 g who did not cry at birth. There was no difference between the 2 techniques in achieving effe ctive crying to prevent the need for PPV.²¹¹  This study could not be included in the SysRev because of the lack of a control group who did not receive tactile stimulation.

In studies that analyze a bundle of procedures to stimulate respiratory transition at birth in low-resource settings, tactile stimulation, together with upper airway suction, triggered the initiation of spontaneous respirations.^212,213  These studies could not be included in the SysRev because of the inability to isolate the effects of tactile stimulation and the lack of a control group.

Despite the possible benefits outlined above, there are some concerns related to possible adverse effects of tactile stimulation in delaying the initiation of ventilation beyond 60 seconds after birth, which may then compromise the efficacy of the overall resuscitation.^209,211,214  In addition, there is a report of soft tissue trauma after tactile stimulation.²¹⁵ 

• The complete CoSTR provide a full list.²⁰⁴ 

• Effect of tactile stimulation on the main outcomes: Breathing without PPV; time to the first spontaneous breath or crying from birth; and time to a heart rate of ≥100 bpm from birth

• Effect of tactile stimulation on secondary outcomes: Death in the delivery room, hospital death; neurodevelopmental outcomes; intraventricular hemorrhage only in preterm infants; oxygen or respiratory support at admission to a neonatal special unit or NICU; and admission to a neonatal special unit or NICU for those not admitted by protocol

• Effects of tactile stimulation in different gestational ages and with different cord management strategies

• Which patients benefit from tactile stimulation (all patients, patients with apnea, those with irregular breathing, or other)

• Indications for tactile stimulation

• Efficacy of different methods of tactile stimulation (rubbing, flicking, or other) and locations on the body

• Optimal duration and number of each stimulus

Monitoring heart rate in the first minutes after birth was last reviewed by the NLS Task Force in 2015, at which time the focus was on which methods resulted in the most accurate measurement at the earliest time.¹⁴⁰  This SysRev focused on critical and important patient outcomes and was initiated from a priority list from the ILCOR NLS Task Force (PROSPERO; CRD42021283438). The full text of this review can be found on the ILCOR website.²¹⁶ 

• Population: Newborn infants in the delivery room

• Intervention: Use of ECG, Doppler device, digital stethoscope, photoplethysmography, video plethysmography, dry electrode technology, or any other newer modalities

• Comparator: (1) Pulse oximeter with or without auscultation; (2) auscultation alone; (3) between intervention comparison

• Outcome:

  • Critical: Chest compressions or epinephrine (adrenaline) administration; death before hospital discharge

  • Important: Duration of PPV; tracheal intubation; time from birth to a heart rate of ≥100 bpm as measured by ECG; resuscitation team performance; unanticipated admission to the NICU.¹⁴³ 

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, and cohort studies) were eligible for inclusion. Unpublished studies and case series were excluded.

• Time frame: All years and all languages were included if there was an English abstract. The literature search was performed on October 29, 2021.

The SysRev identified 2 RCTs^217,218  involving 91 newborn infants and 1 cohort study²¹⁹  involving 632 newborn infants.

Data relating to the key critical and important outcomes for this comparison are summarized in Table 25. Evidence for additional outcomes evaluated is included in the full online CoSTR.²¹⁶ 

No studies were found that provided outcomes relevant to this SysRev for other modalities versus pulse oximetry or auscultation (Comparison 2) or for betweenintervention comparisons (Comparison 3).

When resources permit, we suggest that the use of ECG for heart rate assessment of a newborn infant requiring resuscitation in the delivery room is reasonable (weak recommendation, low-certainty evidence).

When ECG is not available, auscultation with pulse oximetry is a reasonable alternative for heart rate assessment, but the limitations of these modalities should be kept in mind (weak recommendation, lowcertainty evidence).

There is insufficient evidence to make a treatment recommendation for the use of a digital stethoscope, audible or visible Doppler ultrasound, dry electrode technology, reflectance-mode green light photoplethysmography, or transcutaneous electromyography of the diaphragm for heart rate assessment of a newborn in the delivery room. Auscultation with or without pulse oximetry should be used to confirm the heart rate when ECG is unavailable or not functioning or when pulseless electric activity is suspected (good practice statement).

The evidence-to-decision table is provided in Supplemental Appendix A.

The treatment recommendations were informed by low-certainty evidence that, for most outcomes, did not demonstrate improvement or suggestion of harm for any critical or important outcome. The only exception was a lower proportion of infants intubated in the delivery room in an observational study when electrocardiographic monitoring was used,²¹⁹  a result that was not confirmed in the meta-analysis of 2 RCTs.^217,218  The potential advantages of rapid signal acquisition and continuous, accurate heart rate monitoring need to be weighed against the potential costs of equipment and training.

• Higher-certainty evidence for whether ECG or other modalities for heart rate assessment improve critical and important neonatal outcomes

• Impact of ECG or other modalities for heart rate measurement on resuscitation team performance

• Impact of ECG and other modalities for heart rate assessment on equity

• Cost-effectiveness of different modalities for heart rate assessment in the delivery room

• Whether the utility of various modalities varies by subgroups, including vigorous versus nonvigorous newborn infants, those who do or do not require tracheal intubation or more advanced resuscitation, by gestational age and weight, by method of umbilical cord management, and for pulseless electric activity

CPAP has been included in the neonatal resuscitation algorithm to help infants with persistently labored breathing or cyanosis after the initial steps of resuscitation. For spontaneously breathing preterm newborn infants with respiratory distress requiring respiratory support in the delivery room, ILCOR has suggested initial use of CPAP rather than tracheal intubation and intermittent PPV.¹⁸⁸  Although providing CPAP in the delivery room for late preterm and term infants has become increasingly frequent, this practice has not been systematically evaluated by ILCOR. Therefore, this PICO was prioritized by the NLS Task Force (PROSPERO; CRD42021225812).²¹⁹ 

The full text of this CoSTR can be found on the ILCOR website.²²⁰ 

• Population: In spontaneously breathing newborn infants with ≥34 weeks’ gestation with respiratory distress or low oxygen saturations during transition after birth

• Intervention: CPAP at different levels with or without supplemental oxygen

• Comparator: No CPAP with or without supplemental oxygen

• Outcome:

  • Critical: Chest compressions in the delivery room; death at hospital discharge; moderate to severe neurodevelopmental impairment (>18 months)

  • Important: Admissions to the NICU or higher level of care; receipt of any positive- pressure support in the NICU; receipt of tracheal intubation in the delivery room; use and duration of respiratory support in NICU; air-leak syndromes, including pneumothorax and pneumomediastinum; length of hospital stay¹⁴³ 

• Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies, and simulation studies) were eligible for inclusion. Unpublished studies (eg, conference abstracts, trial protocols) and animal studies were excluded.

• Time frame: All years and all languages were included if an English abstract was available. The literature search was first performed on November 30, 2020, and updated on October 11, 2021.