Effect of bag valve ventilation versus mechanical ventilation after endotracheal intubation during cardiopulmonary resuscitation on outcomes following out-of-hospital cardiac arrest: a propensity score analysis

doi:10.5847/wjem.j.1920-8642.2025.062

Abstract

Abstract:

BACKGROUND: In this study, we aimed to evaluate the impact of mechanical ventilator (MV) utilizaton during cardiopulmonary resuscitation (CPR) on out-of-hospital cardiac arrest (OHCA) patient clinical outcomes in the emergency department.

METHODS: This single-centered, retrospective, case-control study analyzed electronic medical records. Patients aged >18 years with non-traumatic OHCA who were treated at an emergency medical center between January 2019 and December 2023 were included. These patients were accessed according to the ventilatory method used: MV ventilation (volume control, tidal volume 6-8 mL/kg, frequency 10 beat per minute, inspiratory time 1 s) and manual resuscitator bag valve (BV) ventilation. The primary outcome was the return of spontaneous circulation (ROSC). After 1:1 propensity score matching, the clinical outcomes were analyzed.

RESULTS: A total of 649 patients were enrolled in this study. Before matching, the clinical outcomes and pneumothorax incidence did not differ between the MV and BV groups. After 1:1 matching between the two groups using propensity scores, 522 patients (261 MV and 261 BV) were analyzed. Propensity score matching yielded an adequate balance (standardized mean difference <0.10) for all covariates. The estimated odds ratio (OR) for ROSC was 1.23 (95% confidence interval [CI]: 0.85-1.77; P=0.267), for survival at hospital admission was 1.02 (95%CI: 0.68-1.53; P=0.918), for survival at hospital discharge was 2.31 (95%CI: 1.10-5.20; P=0.033), and for good neurologic outcome was 2.56 (95%CI: 0.84-9.43; P= 0.116).

CONCLUSION: In patients with OHCA admitted to the emergency department, MV ventilation during CPR showed clinical outcomes similar to those of BV ventilation in most measures. However, survival at hospital discharge was significantly higher in the MV group, suggesting potential benefits of MV use in selected patients.

Key words: Cardiac arrest, Mechanical ventilation, Bag valve ventilation

Young Min Kim, Hyun Seok Chai, Gwan Jin Park, Sang Chul Kim, Hoon Kim, Seok Woo Lee, Hyeon Jeong Park, Han Bit Kim, Hyo Been Lee, Ji Han Lee. Effect of bag valve ventilation versus mechanical ventilation after endotracheal intubation during cardiopulmonary resuscitation on outcomes following out-of-hospital cardiac arrest: a propensity score analysis[J]. World Journal of Emergency Medicine, 2025, 16(4): 313-320.

Figures/Tables 5

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Variables	BV group (n=282)	MV group (n=367)	P-value
Age, years, mean±SD	67.9±17.4	67.5±16.8	0.620
Male, n (%)	173 (61.3)	237 (64.6)	0.445
Body mass index, kg/m², mean±SD	22.4±4.6	22.6±4.9	0.894
Comorbidities, n (%)
Malignancy	50 (17.8)	76 (20.9)	0.379
Diabetes mellitus	84 (29.9)	114 (31.3)	0.762
Hypertension	111 (39.5)	133 (36.5)	0.492
Dyslipidemia	22 (7.8)	26 (7.1)	0.859
Chronic kidney disease	38 (13.5)	39 (10.7)	0.333
Chronic liver disease	16 (6.2)	18 (5.8)	0.973
Asthma/COPD	21 (7.4)	25 (6.9)	0.887
Previous CVA	34 (12.1)	41 (11.3)	0.838
Previous MI	20 (7.1)	29 (8.0)	0.800
Witnessed cardiac arrest, n (%)	186 (66.4)	256 (69.9)	0.386
Bystander performed CPR, n (%)	187 (66.3)	266 (72.5)	0.122
Initial rhythm, n (%)			0.697
Asystole	175 (62.1)	229 (62.4)
PEA	73 (25.9)	87 (23.7)
VT or VF	34 (12.1)	51 (13.9)
Defibrillation, n (%)	75 (26.6)	95 (25.9)	0.888
No-flow time, min, mean±SD	6.6±9.2	7.1±10.0	0.497
Total chest compression time, min, mean±SD	41.9±19.1	51.1±23.8	<0.001
EMS chest compression time, min, mean±SD	23.3±14.4	23.3±12.6	0.632
ED chest compression time, min, mean±SD	18.7±13.4	27.7±20.8	<0.001
Laboratory findings, mean±SD
Hemoglobin, g/dL	11.1±3.7	11.0±3.4	0.872
Total bilirubin, mg/dL	0.8±1.6	0.7±1.0	0.953
Creatinine, mg/dL	2.1±2.5	2.1±2.3	0.489
Lactic acid, mmol/L	12.9±5.8	13.8±8.0	0.233
Presumed cause of arrest, n (%)			0.169
Cardiogenic	47 (16.7)	46 (12.5)
Noncardiogenic	235 (83.3)	321 (87.5)
Acute aortic syndrome	1 (0.4)	2 (0.5)
Pulmonary embolism	6 (2.1)	4 (1.1)
Sepsis	7 (2.5)	11 (3.0)
Respiratory failure	49 (17.4)	51 (13.9)
Hypovolemia	13 (4.6)	21 (5.7)
Cerebral hemorrhage	8 (2.8)	4 (1.1)
Others (unknown)	151 (53.5)	228 (62.1)

Outcomes	Before propensity score matching			After propensity score matching
Outcomes	BV group (n=282)	MV group (n=367)	P-value	BV group (n=261)	MV group (n=261)	P-value
ROSC, n (%)	98 (34.8)	116 (31.6)	0.447	82 (31.4)	94 (36.0)	0.308
Survival at hospital admission, n (%)	76 (27.0)	75 (20.4)	0.064	61 (23.4)	62 (23.8)	1.000
Survival at hospital discharge, n (%)	19 (6.7)	23 (6.3)	0.936	10 (3.8)	22 (8.4)	0.045
Good neurologic outcomes at discharge*, n (%)	9 (3.2)	10 (2.7)	0.909	4 (1.5)	10 (3.8)	0.176
Pneumothorax^#, n (%)	9/214 (4.2)	15/317 (4.7)	0.942	9/198 (4.6)	7/198 (3.5)	0.295

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