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Azcarate I, Urigüen JA, Leturiondo M, Sandoval CL, Redondo K, Gutiérrez JJ, Russell JK, Wallmüller P, Sterz F, Daya MR, Ruiz de Gauna S. The Role of Chest Compressions on Ventilation during Advanced Cardiopulmonary Resuscitation. J Clin Med 2023; 12:6918. [PMID: 37959385 PMCID: PMC10647836 DOI: 10.3390/jcm12216918] [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: 09/26/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
Background: There is growing interest in the quality of manual ventilation during cardiopulmonary resuscitation (CPR), but accurate assessment of ventilation parameters remains a challenge. Waveform capnography is currently the reference for monitoring ventilation rate in intubated patients, but fails to provide information on tidal volumes and inspiration-expiration timing. Moreover, the capnogram is often distorted when chest compressions (CCs) are performed during ventilation compromising its reliability during CPR. Our main purpose was to characterize manual ventilation during CPR and to assess how CCs may impact on ventilation quality. Methods: Retrospective analysis were performed of CPR recordings fromtwo databases of adult patients in cardiac arrest including capnogram, compression depth, and airway flow, pressure and volume signals. Using automated signal processing techniques followed by manual revision, individual ventilations were identified and ventilation parameters were measured. Oscillations on the capnogram plateau during CCs were characterized, and its correlation with compression depth and airway volume was assessed. Finally, we identified events of reversed airflow caused by CCs and their effect on volume and capnogram waveform. Results: Ventilation rates were higher than the recommended 10 breaths/min in 66.7% of the cases. Variability in ventilation rates correlated with the variability in tidal volumes and other ventilatory parameters. Oscillations caused by CCs on capnograms were of high amplitude (median above 74%) and were associated with low pseudo-volumes (median 26 mL). Correlation between the amplitude of those oscillations with either the CCs depth or the generated passive volumes was low, with correlation coefficients of -0.24 and 0.40, respectively. During inspiration and expiration, reversed airflow events caused opposed movement of gases in 80% of ventilations. Conclusions: Our study confirmed lack of adherence between measured ventilation rates and the guideline recommendations, and a substantial dispersion in manual ventilation parameters during CPR. Oscillations on the capnogram plateau caused by CCs did not correlate with compression depth or associated small tidal volumes. CCs caused reversed flow during inspiration, expiration and in the interval between ventilations, sufficient to generate volume changes and causing oscillations on capnogram. Further research is warranted to assess the impact of these findings on ventilation quality during CPR.
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Affiliation(s)
- Izaskun Azcarate
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
- Department of Applied Mathematics, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain
| | - Jose Antonio Urigüen
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
- Department of Applied Mathematics, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain
| | - Mikel Leturiondo
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | | | - Koldo Redondo
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | - José Julio Gutiérrez
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | - James Knox Russell
- Center for Policy and Research in Emergency Medicine (CPR-EM), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA; (J.K.R.); (M.R.D.)
| | - Pia Wallmüller
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.W.); (F.S.)
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.W.); (F.S.)
| | - Mohamud Ramzan Daya
- Center for Policy and Research in Emergency Medicine (CPR-EM), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA; (J.K.R.); (M.R.D.)
| | - Sofía Ruiz de Gauna
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
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Benoit JL, Lakshmanan S, Farmer SJ, Sun Q, Gray JJ, Sams W, Tadesse DG, McMullan JT. Ventilation rates measured by capnography during out-of-hospital cardiac arrest resuscitations and their association with return of spontaneous circulation. Resuscitation 2023; 182:109662. [PMID: 36481240 DOI: 10.1016/j.resuscitation.2022.11.028] [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: 09/13/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical guidelines for adult out-of-hospital cardiac arrest (OHCA) recommend a ventilation rate of 8-10 per minute yet acknowledge that few data exist to guide recommendations. The goal of this study was to evaluate the utility of continuous capnography to measure ventilation rates and the association with return of spontaneous circulation (ROSC). METHODS This was a retrospective observational cohort study. We included all OHCA during a two-year period and excluded traumatic and pediatric patients. Ventilations were recorded using non-invasive continuous capnography. Blinded medically trained team members manually annotated all ventilations. Four techniques were used to analyze ventilation rate. The primary outcome was sustained prehospital ROSC. Secondary outcomes were vital status at the end of prehospital care and survival to hospital admission. Univariable and multivariable logistic regression models were constructed. RESULTS A total of 790 OHCA were analyzed. Only 386 (49%) had useable capnography data. After applying inclusion and exclusion criteria, the final study cohort was 314 patients. The median ventilation rate per minute was 7 (IQR 5.4-8.5). Only 70 (22%) received a guideline-compliant ventilation rate of 8-10 per minute. Sixty-two (20%) achieved the primary outcome. No statistically significant associations were observed between any of the ventilation parameters and patient outcomes in both univariable and multivariable logistic regression models. CONCLUSIONS We failed to detect an association between intra-arrest ventilation rates measured by continuous capnography and proximal patient outcomes after OHCA. Capnography has poor reliability as a measure of ventilation rate. Achieving guideline-compliant ventilation rates remains challenging.
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Affiliation(s)
- Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Shyam Lakshmanan
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Sam J Farmer
- University of Kentucky College of Medicine - Northern Kentucky Campus, Highland Heights, KY, USA.
| | - Qin Sun
- Data Management and Analysis Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - J Jordan Gray
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Woodrow Sams
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | | | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Bhandari S, Coult J, Counts CR, Bulger NE, Kwok H, Latimer AJ, Sayre MR, Rea TD, Johnson NJ. Investigating the Airway Opening Index during Cardiopulmonary Resuscitation. Resuscitation 2022; 178:96-101. [PMID: 35850376 DOI: 10.1016/j.resuscitation.2022.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/27/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Chest compressions during CPR induce oscillations in capnography (ETCO2) waveforms. Studies suggest ETCO2 oscillation characteristics are associated with intrathoracic airflow dependent on airway patency. Oscillations can be quantified by the Airway Opening Index (AOI). We sought to evaluate multiple methods of computing AOI and their association with return of spontaneous circulation (ROSC). METHODS We conducted a retrospective study of 307 out-of-hospital cardiac arrest (OHCA) cases in Seattle, WA during 2019. ETCO2 and chest impedance waveforms were annotated for the presence of intubation and CPR. We developed four methods for computing AOI based on peak ETCO2 and the oscillations in ETCO2 during CCs (ΔETCO2). We examined the feasibility of automating ΔETCO2 and AOI calculation and evaluated differences in AOI across the methods using nonparametric testing (p=0.05). RESULTS Median [interquartile range] AOI across all cases using Methods 1-4 was 28.0% [17.9-45.5%], 20.6% [13.0-36.6%], 18.3% [11.4-30.4%], and 22.4% [12.8-38.5%], respectively (p<0.001). Cases with ROSC had a higher median AOI than those without ROSC across all methods, though not statistically significant. Cases with ROSC had a significantly higher median [interquartile range] ΔETCO2 of 7.3 mmHg [4.5-13.6 mmHg] compared to those without ROSC (4.8 mmHg [2.6-9.1 mmHg], p<0.001). CONCLUSION We calculated AOI using four proposed methods resulting in significantly different AOI. Additionally, AOI and ΔETCO2 were larger in cases achieving ROSC. Further investigation is required to characterize AOI's ability to predict OHCA outcomes, and whether this information can improve resuscitation care.
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Affiliation(s)
- Shiv Bhandari
- Department of Medicine, University of Washington, Seattle, WA.
| | - Jason Coult
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Natalie E Bulger
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Heemun Kwok
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; University of Washington Airlift Northwest, Seattle, WA
| | - Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA; Seattle Fire Department, Seattle, WA
| | - Thomas D Rea
- Department of Medicine, University of Washington, Seattle, WA; Division of Emergency Medical Services, Public Health - Seattle & King County
| | - Nicholas J Johnson
- Division of Emergency Medical Services, Public Health - Seattle & King County; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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