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Abstract
Critical illness can threaten the adequacy of O2 delivery or CO2 excretion. Monitoring seeks to identify the adequacy of oxygenation and ventilation and to detect deterioration early. Advances in oximetry, capnography, and transcutaneous CO2 monitoring offer new opportunities for more accurate estimation of gas exchange, noninvasive monitoring of parameters previously not amenable (eg, total hemoglobin measurement), detection of disease, and prediction of fluid responsiveness.
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Südy R, Peták F, Kiss L, Balogh ÁL, Fodor GH, Korsós A, Schranc Á, Babik B. Obesity and diabetes: similar respiratory mechanical but different gas exchange defects. Am J Physiol Lung Cell Mol Physiol 2020; 320:L368-L376. [PMID: 33264577 DOI: 10.1152/ajplung.00439.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Diabetes mellitus increases smooth muscle tone and causes tissue remodeling, affecting elastin and collagen. Although the lung is dominated by these elements, diabetes is expected to modify the airway function and respiratory tissue mechanics. Therefore, we characterized the respiratory function in patients with diabetes with and without associated obesity. Mechanically ventilated patients with normal body shapes were divided into the control nondiabetic (n = 73) and diabetic (n = 31) groups. The other two groups included obese patients without diabetes (n = 43) or with diabetes (n = 30). The mechanical properties of the respiratory system were determined by forced oscillation technique. Airway resistance (Raw), tissue damping (G), and tissue elastance (H) were assessed by forced oscillation. Capnography was applied to determine phase 3 slopes and dead space indices. The intrapulmonary shunt fraction (Qs/Qt) and the lung oxygenation index (PaO2/FIO2) were estimated from arterial and central venous blood samples. Compared with the corresponding control groups, diabetes alone increased the Raw (7.6 ± 6 cmH2O.s/l vs. 3.1 ± 1.9 cmH2O.s/l), G (11.7 ± 5.5 cmH2O/l vs. 6.5 ± 2.8 cmH2O/l), and H (31.5 ± 11.8 cmH2O/l vs. 24.2 ± 7.2 cmH2O/l (P < 0.001 for all). Diabetes increased the capnographic phase 3 slope, whereas PaO2/FIO2 or Qs/Qt was not affected. Obesity alone caused similar detrimental changes in respiratory mechanics and alveolar heterogeneity, but these alterations also compromised gas exchange. We conclude that diabetes-induced intrinsic mechanical abnormalities are counterbalanced by hypoxic pulmonary vasoconstriction, which maintained intrapulmonary shunt fraction and oxygenation ability of the lungs.
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Overdevest E, van den Heuvel E, van Hoeven M. A retrospective analysis of CO 2 derived goal-directed perfusion variables under normothermic conditions: do we need to re-evaluate threshold values? Perfusion 2020; 36:853-860. [PMID: 33203311 DOI: 10.1177/0267659120972994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study investigated if current predictive values for increased lactate formation: VCO2i > 60 ml min-1 m-2, respiratory quotient (RQ) > 0.90, and DO2/VCO2 < 5.0, are valid under normothermic conditions. CO2 derived parameters were analyzed in 91 patients undergoing normothermic CABG and related to increase of blood lactate concentrations during bypass. In this study population, 85 patients (93%) had a median VCO2i above 60 ml min-1 m-2 and 53 patients (58%) had a DO2/VCO2 ⩽ 5.0. Eighteen patients (20%) had a median RQ ⩾ 0.90, but RQ remained with a maximum value of 0.94 below the biological threshold of 1.0. Increase of lactate concentrations remained without clinical significance and showed weak correlations with VCO2i (rs = 0.277, p = 0.008) and RQ (rs = 0.346, p = 0.001).The cohort was separated for the different CO2 variables by their median value to compare increase in lactate concentration. Patients with a high VCO2i (⩾70 ml min-1 m-2) and a high RQ (⩾0.82) showed significant higher increase in lactate concentration compared to patients with VCO2i < 70 ml min-1 m-2 (p = 0.004), and a RQ < 0.82 (p = 0.012). Groups separated by a median DO2/VCO2 of 4.8 did not show a difference in increase of lactate concentration in blood. In summary, specific CO2 derived threshold values for the prediction of lactate formation, which have been reported in other studies, cannot be confirmed with our findings. However, a CO2 production ⩾70 ml min-1 m-2 and a RQ ⩾ 0.82 in this study population were correlated with increased lactate formation. Because CO2 production during bypass depends on patient temperature, a different cutoff value, that may take into account the influence of demographic variables, should be determined during normothermic CPB.
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van Schuppen H, Boomars R, Kooij FO, den Tex P, Koster RW, Hollmann MW. Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review. Best Pract Res Clin Anaesthesiol 2020; 35:67-82. [PMID: 33742579 DOI: 10.1016/j.bpa.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/20/2022]
Abstract
Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.
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Hubble MW, Van Vleet L, Taylor S, Bachman M, Williams JG, Vipperman R, Renkiewicz GK. Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2020; 25:697-705. [PMID: 32986490 DOI: 10.1080/10903127.2020.1828518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed. OBJECTIVE To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA. METHODS This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks. RESULTS Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks. CONCLUSIONS An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.
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de Freitas Vianna JR, Pires Di Lorenzo VA, Lourenço da S Simões MM, Guerra JL, Jamami M. Effects of Zero PEEP and < 1.0 FIO2 on SpO2 and PETCO2 During Open Endotracheal Suctioning. Respir Care 2020; 65:1805-1814. [PMID: 32636279 DOI: 10.4187/respcare.07435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hyperoxygenation and hyperinflation, preferably with a mechanical ventilator, is the most commonly used technique to prevent the adverse effects of open endotracheal suctioning on arterial oxygenation and pulmonary volume. However, limited data are available on the effects of oxygen concentrations < 100% and PEEP with zero end-expiratory pressure (0 PEEP) to improve oxygenation and to maintain adequate ventilation during open endotracheal suctioning. The aim of this study was to analyze the behavior of [Formula: see text] and end-tidal CO2 pressure ([Formula: see text]) in open endotracheal suctioning using the 0 PEEP technique with baseline [Formula: see text] (0 PEEP baseline [Formula: see text]) and 0 PEEP + hyperoxygenation of 20% above the baseline value (0 PEEP [Formula: see text] + 0.20) in critically ill subjects receiving mechanical ventilation. METHODS This was a prospective, randomized, single-blind crossover study, for which 48 subjects with various clinical and surgical conditions were selected; of these, 38 subjects completed the study. The subjects were randomized for 2 interventions: 0 PEEP baseline [Formula: see text] and 0 PEEP [Formula: see text] + 0.20 during the open endotracheal suctioning procedure. Oxygenation was assessed via oxygen saturation as measured with pulse oximetry ([Formula: see text]), and changes in lung were monitored via [Formula: see text] using volumetric capnography. RESULTS In the intragroup analysis with 0 PEEP baseline [Formula: see text], there was no significant increase after open endotracheal suctioning in either [Formula: see text] (P = .63) or [Formula: see text] (P = .11). With 0 PEEP [Formula: see text] + 0.20, there was a significant increase in [Formula: see text] (P < .001), with no significant changes in [Formula: see text] (P = .55). In the intergroup comparisons, there was a significant increase compared to the basal values only with the 0 PEEP + 0.20 method at 1 min after hyperoxygenation (P < .001), post-immediately (P < .001), at 1 min after (P < .001), and at 2 min after open endotracheal suctioning (P < .001). CONCLUSIONS The appropriate indication of the hyperinflation strategy via mechanical ventilation using 0 PEEP with or without hyperoxygenation proved to be efficient to maintain [Formula: see text] and [Formula: see text] levels. These results suggest that the technique can minimize the loss of lung volume due to open endotracheal suctioning. (ClinicalTrials.gov registration NCT02440919).
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Abstract
Monitoring respiratory values such as breathing frequency, minute ventilation, breathing effort, and dyspnea are common in acute care. There is evidence that accurate monitoring and interpretation of these values leads to early identification and treatment of impending respiratory failure. Despite this evidence, some values, such as breathing frequency, are largely undervalued in the clinical setting. The undervaluation of breathing frequency is complex and will require a multifaceted approach, including education and improved technology, to reestablish its clinical potential. Many questions remain regarding how to most efficiently and effectively monitor other respiratory values, like noninvasive minute volume and breathing effort, as well. As technology continues to improve alongside the understanding of respiratory physiology, clinicians are able to apply basic clinical assessment skills and technology together to improve patient safety and outcomes.
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Prentice D, Deroche CB, Wipke-Tevis DD. Excluding Pulmonary Embolism with End-tidal Carbon Dioxide: Accuracy, Cost, and Harm Avoidance. West J Nurs Res 2020; 42:1022-1030. [PMID: 32406785 DOI: 10.1177/0193945920914492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO2) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults (n = 111). The financial impact and harm avoidance of adding EtCO2 to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO2 was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22-8.96; P = .01). For PE exclusion, an EtCO2 cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO2, one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO2 cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.
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Wollner E, Nourian MM, Booth W, Conover S, Law T, Lilaonitkul M, Gelb AW, Lipnick MS. Impact of capnography on patient safety in high- and low-income settings: a scoping review. Br J Anaesth 2020; 125:e88-e103. [PMID: 32416994 DOI: 10.1016/j.bja.2020.04.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs. METHODS We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included. RESULTS The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes. CONCLUSION Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.
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Duke-Novakovski T, Fujiyama M, Beazley SG. Comparison of mainstream (Capnostat 5) and two low-flow sidestream capnometers (VM-2500-S and Capnostream) in spontaneously breathing rabbits anesthetized with a Bain coaxial breathing system. Vet Anaesth Analg 2020; 47:537-546. [PMID: 32381351 DOI: 10.1016/j.vaa.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate agreement with PaCO2 of two low sampling rate sidestream capnometers and a mainstream capnometer in rabbits and the effect of using high fresh gas flow from a Bain coaxial breathing system. STUDY DESIGN Prospective, crossover study. ANIMALS A total of 10 New Zealand White rabbits weighing 3.4 ± 0.3 kg [mean ± standard deviation (SD)]. METHODS Two sidestream analyzers (Viamed VM-2500-S and Capnostream 35) with a sampling rate of 50 mL minute-1 and a mainstream capnometer (Capnostat 5) were tested. All capnometers used infrared spectroscopy and advanced microprocessor technology. Rabbits were anesthetized and intubated with noncuffed endotracheal tubes of 3 mm internal diameter and adequate seal. A sidestream sampling adapter or the mainstream capnometer was attached to the endotracheal tube and connected to a Bain coaxial breathing system. Oxygen (1.5 L minute-1) delivered sevoflurane to maintain anesthesia. An auricular artery catheter allowed blood sampling for PaCO2 analysis corrected to rectal temperature. Inspired and end-tidal carbon dioxide (Pe'CO2) measurements were recorded during blood sample withdrawal. From each rabbit, 10 paired PaCO2/Pe'CO2 measurements were obtained. Each rabbit was recovered from anesthesia and was anesthetized again with an alternate capnometer after 1 week. Data were analyzed using Bland-Altman and two-way anova for repeated measures. RESULTS Analysis included 100 paired samples. Negative bias reflects underestimation of PaCO2. Bland-Altman mean (±1.95 SD) was -16.7 (-35.2 to 1.8) mmHg for Capnostat 5, -27.9 (-48.6 to -7.2) mmHg for Viamed, and -18.1 (-34.3 to -1.9) mmHg for Capnostream. Viamed PaCO2-Pe'CO2 gradient was greater than other two capnometers. CONCLUSIONS All three capnometers underestimated PaCO2. Capnostat 5 and Capnostream performed similarly. CLINICAL RELEVANCE These capnometers underestimated PaCO2 in spontaneously breathing rabbits anesthetized using a Bain coaxial breathing system with high fresh gas flows.
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Peveling-Oberhag J, Michael F, Tal A, Welsch C, Vermehren J, Farnik H, Grammatikos G, Lange C, Walter D, Blumenstein I, Filmann N, Herrmann E, Albert J, Zeuzem S, Bojunga J, Friedrich-Rust M. Capnography monitoring of non-anesthesiologist provided sedation during percutaneous endoscopic gastrostomy placement: A prospective, controlled, randomized trial. J Gastroenterol Hepatol 2020; 35:401-407. [PMID: 31222832 DOI: 10.1111/jgh.14760] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/28/2019] [Accepted: 06/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance. METHODS In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group. RESULTS In the SM group, 57% episodes of hypoxemia (SpO2 < 90% for > 15 s) and 41% episodes of severe hypoxemia (SpO2 < 85% for > 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia. CONCLUSIONS Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.
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Paulich S, Cook TM, Hall H, Churchill H, Kelly FE. Two new algorithms for managing tracheostomy emergencies on the ICU. Br J Anaesth 2020; 125:e164-e165. [PMID: 32115184 DOI: 10.1016/j.bja.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 10/24/2022] Open
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O'Brien CE, Reyes M, Santos PT, Heitmiller SE, Kulikowicz E, Kudchadkar SR, Lee JK, Hunt EA, Koehler RC, Shaffner DH. Pilot Study to Compare the Use of End-Tidal Carbon Dioxide-Guided and Diastolic Blood Pressure-Guided Chest Compression Delivery in a Swine Model of Neonatal Asphyxial Cardiac Arrest. J Am Heart Assoc 2019; 7:e009728. [PMID: 30371318 PMCID: PMC6404892 DOI: 10.1161/jaha.118.009728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American Heart Association recommends use of physiologic feedback when available to optimize chest compression delivery. We compared hemodynamic parameters during cardiopulmonary resuscitation in which either end‐tidal carbon dioxide (ETCO2) or diastolic blood pressure (DBP) levels were used to guide chest compression delivery after asphyxial cardiac arrest. Methods and Results One‐ to 2‐week‐old swine underwent a 17‐minute asphyxial‐fibrillatory cardiac arrest followed by alternating 2‐minute periods of ETCO2‐guided and DBP‐guided chest compressions during 10 minutes of basic life support and 10 minutes of advanced life support. Ten animals underwent resuscitation. We found significant changes to ETCO2 and DBP levels within 30 s of switching chest compression delivery methods. The overall mean ETCO2 level was greater during ETCO2‐guided cardiopulmonary resuscitation (26.4±5.6 versus 22.5±5.2 mm Hg; P=0.003), whereas the overall mean DBP was greater during DBP‐guided cardiopulmonary resuscitation (13.9±2.3 versus 9.4±2.6 mm Hg; P=0.003). ETCO2‐guided chest compressions resulted in a faster compression rate (149±3 versus 120±5 compressions/min; P=0.0001) and a higher intracranial pressure (21.7±2.3 versus 16.0±1.1 mm Hg; P=0.002). DBP‐guided chest compressions were associated with a higher myocardial perfusion pressure (6.0±2.8 versus 2.4±3.2; P=0.02) and cerebral perfusion pressure (9.0±3.0 versus 5.5±4.3; P=0.047). Conclusions Using the ETCO2 or DBP level to optimize chest compression delivery results in physiologic changes that are method‐specific and occur within 30 s. Additional studies are needed to develop protocols for the use of these potentially conflicting physiologic targets to improve outcomes of prolonged cardiopulmonary resuscitation.
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Javaudin F, Her S, Le Bastard Q, De Carvalho H, Le Conte P, Baert V, Hubert H, Montassier E, Lascarrou JB, Leclère B. Maximum Value of End-Tidal Carbon Dioxide Concentrations during Resuscitation as an Indicator of Return of Spontaneous Circulation in out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2019; 24:478-484. [PMID: 31613696 DOI: 10.1080/10903127.2019.1680782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The end-tidal carbon dioxide (ETCO2) concentration during resuscitation (CPR) of an out-of-hospital cardiac arrest (OHCA) has an increasingly well-known prognostic value. Nevertheless, few studies have investigated its maximum value in different etiologies. Methods: It was a retrospective, observational, multicentre study from the French OHCA Registry. All adult OHCA with a known maximum value of ETCO2 during CPR were included. The primary end-point was to determine the area under the receiver operating characteristic curve (AUROC) of the maximum value of ETCO2 during resuscitation for the return of spontaneous circulation (ROSC). Results: Of the 53,048 eligible subjects from 2011 to 2018, ETCO2 was known in 32,249 subjects (61%). Among them, there were 9.2% of traumatic OHCA, 37.7% of suspected cardiac etiology and 16.4% of suspected respiratory etiology. The AUROC of maximum value of ETCO2 during CPR to achieve ROSC was 0.887 95CI [0.875-0.898] in traumatic OHCA, 0.772 95CI [0.765-0.780] in suspected cardiac etiology and 0.802 95CI [0.791-0.812] in suspected respiratory etiology. The threshold with no survivors at d-30 was <10 mmHg for traumatic etiologies and <6 mmHg for suspected cardiac and respiratory causes. The probability of ROSC increased with the value of ETCO2 in the 3 etiologies studied. Conclusions: The maximum value of ETCO2 during OHCA resuscitation was strongly associated with ROSC, especially in the case of a traumatic cause. This suggests that a single elevated ETCO2 value, regardless of time, could help to predict the outcome.
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Scully KR, Rickerby J, Dunn J. Implementation Science: Incorporating Obstructive Sleep Apnea Screening and Capnography Into Everyday Practice. J Perianesth Nurs 2019; 35:7-16. [PMID: 31495557 DOI: 10.1016/j.jopan.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/29/2019] [Accepted: 06/01/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This article describes the implementation and maintenance of obstructive sleep apnea (OSA) screening and capnography monitoring. DESIGN A quality improvement project. METHODS A multidisciplinary team provided staff education to three perianesthesia care units. Using the STOP-Bang screening tool, five or more positive responses indicated high risk for OSA. A postanesthesia care unit audit tool tracked STOP-Bang scores, capnography use, hypoventilation events, nursing interventions, and respiratory complications. FINDINGS Among 314 patients with OSA, 36% were identified as high risk. Nurses used capnography on 76% of OSA patients and were able to readily identify hypoventilation and intervene. Respiratory complications occurred in 10.8% (n = 34) requiring a higher level of care. Postimplementation, all six postanesthesia care units employ this best practice. CONCLUSIONS Perianesthesia nurses found OSA screening and capnography easy to incorporate into nursing practice. This process can reduce respiratory complications in the surgical patient with OSA. An Evidence-Based Practice Fellowship Program facilitated this practice change.
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Fujimoto S, Suzuki M, Sakamoto K, Ibusuki R, Tamura K, Shiozawa A, Ishii S, Iikura M, Izumi S, Sugiyama H. Comparison of End-Tidal, Arterial, Venous, and Transcutaneous P CO2. Respir Care 2019; 64:1208-1214. [PMID: 31337742 DOI: 10.4187/respcare.06094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We investigated the measurement of end-tidal partial pressure of carbon dioxide (PETCO2 ) with a capnometer in patients with respiratory failure, and we determined whether this technique could provide an alternative to measurement of PaCO2 using arterial blood gas analysis in the clinical setting. METHODS We measured PETCO2 in subjects with hypoxemic and hypercarbic respiratory failure using a capnometer. We simultaneously measured PaCO2 , venous partial pressure of carbon dioxide (Pv̄CO2 ), and transcutaneously measured partial pressure PCO2 (PtcCO2 ). We analyzed agreements among these parameters with Bland-Altman analysis. We obtained 30 samples from subjects with hypoxemic respiratory failure and 30 samples from subjects with hypercarbic respiratory failure. RESULTS Thirty subjects with hypoxemic respiratory failure and 18 subjects with hypercarbic respiratory failure participated in this study. Significant relationships were found between PETCO2 and PaCO2 , between PtcCO2 and PaCO2 , and between Pv̄CO2 and PaCO2 . Bland-Altman analysis of PETCO2 and PaCO2 in all subjects revealed a bias of 6.48 mm Hg (95% CI 4.93-8.03, P < .001) with a precision of 6.01 mm Hg. Bland-Altman analysis of PETCO2 and PaCO2 with hypoxemic respiratory failure revealed a bias of 5.14 mm Hg (95% CI 3.35-6.93, P < .001) with a precision of 4.80 mm Hg. Bland-Altman analysis of PETCO2 and PaCO2 in subjects with hypercarbic respiratory failure revealed a bias of 7.83 mm Hg (95% CI 5.27-10.38, P < .001) with a precision of 6.83 mm Hg. CONCLUSIONS PETCO2 can be measured simply using a capnometer, and PETCO2 measurements can estimate PaCO2 . However, the limits of agreement were wide. Therefore, care providers must pay attention to the characteristics and errors of these devices. These results suggest that measurement of PETCO2 might be useful for screening for hypercarbic respiratory failure in the clinical setting.
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The Effect of Asphyxia Arrest Duration on a Pediatric End-Tidal CO2-Guided Chest Compression Delivery Model. Pediatr Crit Care Med 2019; 20:e352-e361. [PMID: 31149967 PMCID: PMC6612600 DOI: 10.1097/pcc.0000000000001968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal CO2-guided chest compression delivery. DESIGN Preclinical randomized controlled study. SETTING University animal research laboratory. SUBJECTS Two-week-old swine. INTERVENTIONS After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal CO2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal CO2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS After 17 minutes of asphyxial arrest, mean end-tidal CO2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal CO2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal CO2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal CO2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal CO2-guided groups. CONCLUSIONS Our previously observed survival benefit of end-tidal CO2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal CO2-guided chest compression delivery is limited by severe asphyxia duration.
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Scrivens A, Zivanovic S, Roehr CC. Is waveform capnography reliable in neonates? Arch Dis Child 2019; 104:711-715. [PMID: 31217206 DOI: 10.1136/archdischild-2018-316577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 01/14/2023]
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Zito A, Berardinelli A, Butler R, Morrison SL, Albert NM. Association of End-Tidal Carbon Dioxide Monitoring With Nurses' Confidence in Patient Readiness for Postanesthesia Discharge. J Perianesth Nurs 2019; 34:971-977. [PMID: 31182292 DOI: 10.1016/j.jopan.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/04/2019] [Accepted: 01/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine if end-tidal carbon dioxide (etCO2) value increased nurses' perceptions of confidence in patients' readiness for postanesthesia care unit (PACU) discharge. DESIGN Prospective, cross-sectional, comparative, one-group (pre-post) design. METHODS Nurses completed 2 assessments of confidence in readiness for discharge, before and after etCO2 monitoring. Patient (discharge pain level, body mass index, sleep apnea history, and opioid use) and nurse factors were assessed. Analyses included descriptive and comparative statistics. FINDINGS Of 133 patients, mean (standard deviation) etCO2 was 36.1 (5.7) mm Hg. Nurses' confidence in readiness for discharge differed before and after etCO2 assessment. Confidence score decreased when etCO2 was low (P = .003) or high (P = .005), compared with normal values. In linear regression, etCO2 remained a factor in nurses' confidence in readiness for discharge (P < .001). CONCLUSIONS In a PACU, etCO2 monitoring changed nurses' perceptions of confidence in patients' readiness for discharge.
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Cracco O, Degrugilliers L, Rames C, Bécourt A, Bayat S. Change in capnogram waveform is associated with bronchodilator response and asthma control in children. Pediatr Pulmonol 2019; 54:698-705. [PMID: 30809972 DOI: 10.1002/ppul.24282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Airway hyper-reactivity, inflammation and remodeling contribute to inhomogeneity of ventilation-perfusion ratio VA·/Q· in asthma. Short-term variations in V.A/Q· can cause changes in expired capnographic indices. OBJECTIVES To measure acute changes in the phase 3 slope of the volumetric capnogram after β2-agonist inhalation (ΔSIII), for comparison with airway response based on FEV1 (ΔFEV1), and asthma control. SUBJECTS AND METHODS After ethical approval and informed consent, 72 children aged 6-18 y, followed up for asthma underwent spirometry and capnography before and after β-agonist inhalation through a spacer, using a side-stream rapid infrared analyzer. Asthma control was assessed using the GINA questionnaire. RESULTS Children with positive reversibility tests (defined as ΔFEV1>12%) had a significantly higher ΔSIII (m ± SE: 87.4 ± 41.4) versus those with negative tests (31.3 ± 14.0%, P = 0.001). Uncontrolled asthma was associated with a significantly larger ΔSIII (103.4 ± 64.0%, n = 7) compared to partly controlled (52.0 ± 26.1, n = 24; P = 0.009) and controlled asthma (30.8 ± 16.3, n = 41; P = 0.003). Neither Bohr dead space nor ΔFEV1 were different between asthma control groups. CONCLUSIONS ΔSIII was significantly larger in children with positive response to β2-agonist, and in uncontrolled asthmatics. To our knowledge these are the first data on exhaled CO2 phase III volumetric slope change and asthma control. The observed ΔSIII could be due to an increased ventilation of inhomogeneous peripheral lung units, and merits further evaluation as a potential phenotypic biomarker in asthma.
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Boriosi JP, Zhao Q, Preston A, Hollman GA. The utility of the pretracheal stethoscope in detecting ventilatory abnormalities during propofol sedation in children. Paediatr Anaesth 2019; 29:604-610. [PMID: 30801831 DOI: 10.1111/pan.13616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Monitoring of ventilation with capnography or a stethoscope is recommended because the detection of ventilatory abnormalities can be significantly delayed by the use of pulse oximetry alone in patients receiving supplemental oxygen. The aim of this study was to evaluate the diagnostic performance of the pretracheal stethoscope with pulse oximetry and capnography in detecting adverse respiratory events during propofol sedation in nonintubated children. We hypothesized that use of the pretracheal stethoscope would facilitate earlier detection of adverse respiratory events. METHODS This was a prospective observational study of children undergoing procedural sedation at a pediatric sedation program. A pretracheal stethoscope, pulse oximetry, and nasal capnography were attached at the discretion of the sedation nurse and provider to monitor ventilation. RESULTS We enrolled 104 patient encounters (mean recorded time, SD 8.3 ± 5.3 minutes) from February, 2015 to March, 2017. The pretracheal stethoscope was the first monitor to detect adverse events in 64% (25/39) of patients compared to 18% (7/39) for capnography and 15% (6/39) for pulse oximetry. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation. The positive predictive value for detecting a true ventilation abnormality and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 100% (90%-100%), 18% (10%-31%), and 27% (18%-38%), respectively. The negative predictive value and 95% CI of the pretracheal stethoscope, pulse oximetry, and capnography was 88% (82%-92%), 68% (59%-75%), and 70% (61%-78%), respectively. Limitations are short observation time, nonstandardized application of respiratory monitors, and too much focus on auscultation. CONCLUSION A pretracheal stethoscope in conjunction with capnography and pulse oximetry detects most sedation-related adverse events first. Auscultation performed best at detecting upper airway obstruction but capnography and pulse oximetry performed best at detecting hypoventilation.
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Jo YY, Kwak HJ. Sedation Strategies for Procedures Outside the Operating Room. Yonsei Med J 2019; 60:491-499. [PMID: 31124331 PMCID: PMC6536395 DOI: 10.3349/ymj.2019.60.6.491] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023] Open
Abstract
With the rapid development of diagnostic and therapeutic procedures performed outside the operating room (OR), the need for appropriate sedation care has emerged in importance to ensure the safety and comfort of patients and clinicians. The preparation and administration of sedatives and sedation care outside the OR require careful attention, proper monitoring systems, and clinically useful sedation guidelines. This literature review addresses proper monitoring and selection of sedatives for diagnostic and interventional procedures outside the OR. As the depth of sedation increases, respiratory depression and cardiovascular suppression become serious, necessitating careful surveillance using appropriate monitoring equipment.
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Abstract
Procedural sedation is used to alleviate pain and anxiety associated with diagnostic procedures in the acute care setting. Although commonly used, procedural sedation is not without risk. Key to reducing this risk is early identification of risk factors through presedation screening and monitoring during the procedure. Electrocardiogram, respiratory rate, blood pressure, and pulse oximetry commonly are monitored. These parameters do not reliably identify airway and ventilation compromise. Capnography measures exhaled carbon dioxide and provides early identification of airway obstruction and hypoventilation. Capnography is useful in patients receiving supplemental oxygen. In these patients, oxygen desaturation reported by pulse oximetry may lag during episodes of respiratory depression and apnea. Capnography indicates partial pressure of end-tidal carbon dioxide and provides information regarding airway integrity and patterns of ventilation compromise. Implementation of this technology may provide an additional layer of safety, reducing risk of respiratory compromise in patients receiving procedural sedation.
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Jungquist CR, Chandola V, Spulecki C, Nguyen KV, Crescenzi P, Tekeste D, Sayapaneni PR. Identifying Patients Experiencing Opioid-Induced Respiratory Depression During Recovery From Anesthesia: The Application of Electronic Monitoring Devices. Worldviews Evid Based Nurs 2019; 16:186-194. [PMID: 31050151 DOI: 10.1111/wvn.12362] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postsurgical patients experiencing opioid-related adverse drug events have 55% longer hospital stays, 47% higher costs associated with their care, 36% increased risk of 30-day readmission, and 3.4 times higher risk of inpatient mortality compared to those with no opioid-related adverse drug events. Most of the adverse events are preventable. GENERAL AIM This study explored three types of electronic monitoring devices (pulse oximetry, capnography, and minute ventilation [MV]) to determine which were more effective at identifying the patient experiencing respiratory compromise and, further, to determine whether algorithms could be developed from the electronic monitoring data to aid in earlier detection of respiratory depression. MATERIALS AND METHODS A study was performed in the postanesthesia care unit (PACU) in an inner city. Sixty patients were recruited in the preoperative admissions department on the day of their surgery. Forty-eight of the 60 patients wore three types of electronic monitoring devices while they were recovering from back, neck, hip, or knee surgery. Machine learning models were used for the analysis. RESULTS Twenty-four of the 48 patients exhibited sustained signs of opioid-induced respiratory depression (OIRD). Although the SpO2 values did not change, end-tidal CO2 levels increased, and MV decreased, representing hypoventilation. A machine learning model was able to predict an OIRD event 10 min before the actual event occurred with 80% accuracy. LINKING EVIDENCE TO ACTION Electronic monitoring devices are currently used as a tool to assess respiratory status using thresholds to distinguish when respiratory depression has occurred. This study introduces a potential paradigm shift from a reactive approach to a proactive approach that would identify a patient at high risk for OIRD. Capnography and MV were found to be effective tools in detecting respiratory compromise in the PACU.
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Cereceda-Sánchez FJ, Molina-Mula J. Systematic Review of Capnography with Mask Ventilation during Cardiopulmonary Resuscitation Maneuvers. J Clin Med 2019; 8:E358. [PMID: 30871214 PMCID: PMC6463178 DOI: 10.3390/jcm8030358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 02/05/2023] Open
Abstract
The latest guidelines identify capnography as an instrument used to assess bag-valve-mask ventilation during cardiopulmonary resuscitation (CPR). In this review, we analyzed the feasibility and reliability of capnography use with face mask ventilation during CPR maneuvers in adults and children. This systematic review was completed in December 2018; data for the study were obtained from the following databases: EBSCOhost, SCOPUS, PubMed, Índice Bibliográfico Español en Ciencias de la Salud (IBECS), TESEO, and Cochrane Library Plus. Two reviewers independently assessed the eligibility of the articles; we analyzed publications from different sources and identified studies that focused on the use of capnography with a face mask during CPR maneuvers in order to describe the capnometry value and its correlation with resuscitation outcomes and the assistance of professionals. A total of 888 papers were collected, and 17 papers were included that provided objective values for the use of capnography with a mask for ventilation. Four were randomized clinical trials (RCT) and the rest were observational studies. Four studies were completed in adults and 13 were completed in newborns. After the analysis of the papers, we recommended a capnographic level of C in adults and B in newborns. Despite the little evidence obtained, capnography has been demonstrated to facilitate the advanced clinical practice of mask ventilation in cardiopulmonary resuscitation, to be reliable in the early detection of heart rate increase in newborns, and to asses in-airway patency and lung aeration during newborn resuscitation.
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