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Cordioli RL, Grieco DL, Charbonney E, Richard JC, Savary D. New physiological insights in ventilation during cardiopulmonary resuscitation. Curr Opin Crit Care 2020; 25:37-44. [PMID: 30531537 DOI: 10.1097/mcc.0000000000000573] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In the setting of cardiopulmonary resuscitation (CPR), classical physiological concept about ventilation become challenging. Ventilation may exert detrimental hemodynamic effects that must be balanced with its expected benefits. The risks of hyperventilation have been thoroughly addressed, even questioning the need for ventilation, emphasizing the need to prioritize chest compression quality. However, ventilation is mandatory for adequate gas exchange as soon as CPR is prolonged. Factors affecting the capability of chest compressions to produce alveolar ventilation are poorly understood. In this review, we discuss the conventional interpretation of interactions between ventilation and circulation, from the perspective of novel physiological observations. RECENT FINDINGS Many patients with cardiac arrest exhibit 'intrathoracic airway closure.' This phenomenon is associated with lung volume reduction, impedes chest compressions to generate ventilation and overall limits the delivered ventilation. This phenomenon can be reversed by the application of small levels of positive end-expiratory pressure. Also, a novel interpretation of the capnogram can rate the magnitude of this phenomenon, contributing to clarify the physiological meaning of exhaled CO2 and may help assess the real amount of delivered ventilation. SUMMARY Recent advances in the understanding of ventilatory physiology during CPR shows that capnogram analysis not only provides information on the quality of resuscitation but also on the amount of ventilation produced by chest compressions and on the total amount of ventilation.
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Affiliation(s)
- Ricardo L Cordioli
- Department of Critical Care, Intensive Care Unit, Israelita Hospital Albert Einstein.,Department of Critical Care, Intensive Care Unit, Alemao Hospital Oswaldo Cruz Sao Paulo, Sao Paulo, Brazil
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Emmanuel Charbonney
- Université de Montréal, Montreal, Canada.,Laboratoire d'anatomie, Université du Québec à Trois-Rivières (UQTR)
| | - Jean-Christophe Richard
- SAMU74, Emergency Department, General Hospital of Annecy, Annecy.,INSERM UMR 1066, Creteil, France
| | - Dominique Savary
- SAMU74, Emergency Department, General Hospital of Annecy, Annecy
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Chalkias A, Pavlopoulos F, Koutsovasilis A, d'Aloja E, Xanthos T. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation 2017; 110:101-106. [DOI: 10.1016/j.resuscitation.2016.10.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/22/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
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Cordioli RL, Lyazidi A, Rey N, Granier JM, Savary D, Brochard L, Richard JCM. Impact of ventilation strategies during chest compression. An experimental study with clinical observations. J Appl Physiol (1985) 2015; 120:196-203. [PMID: 26586906 DOI: 10.1152/japplphysiol.00632.2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/13/2015] [Indexed: 11/22/2022] Open
Abstract
The optimal ventilation strategy during cardiopulmonary resuscitation (CPR) is unknown. Chest compression (CC) generates circulation, while during decompression, thoracic recoil generates negative pressure and venous return. Continuous flow insufflation of oxygen (CFI) allows noninterrupted CC and generates positive airway pressure (Paw). The main objective of this study was to assess the effects of positive Paw compared with the current recommended ventilation strategy on intrathoracic pressure (P(IT)) variations, ventilation, and lung volume. In a mechanical model, allowing compression of the thorax below an equilibrium volume mimicking functional residual capacity (FRC), CC alone or with manual bag ventilation were compared with two levels of Paw with CFI. Lung volume change below FRC at the end of decompression and P(IT), as well as estimated alveolar ventilation, were measured during the bench study. Recordings were obtained in five cardiac arrest patients to confirm the bench findings. Lung volume was continuously below FRC, and as a consequence P(IT) remained negative during decompression in all situations, including with positive Paw. Compared with manual bag or CC alone, CFI with positive Paw limited the fall in lung volume and resulted in larger positive and negative P(IT) variations. Positive Paw with CFI significantly augmented ventilation induced by CC. Recordings in patients confirmed a major loss of lung volume below FRC during CPR, even with positive Paw. Compared with manual bag ventilation, positive Paw associated with CFI limits the loss in lung volume, enhances CC-induced positive P(IT), maintains negative P(IT) during decompression, and generates more alveolar ventilation.
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Affiliation(s)
- Ricardo L Cordioli
- University Hospital of Geneva, Intensive Care Unit, Geneva, Switzerland; Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil; Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil;
| | - Aissam Lyazidi
- University Hospital of Geneva, Intensive Care Unit, Geneva, Switzerland; Laboratoire Rayonnement-Matière et Instrumentation, Département de Physique, Université Hassan 1er, Settat, Morocco; Institut Supérieur des Sciences de la Santé, Université Hassan 1er, Settat, Morocco
| | - Nathalie Rey
- Department of Anesthesia and Intensive Care Unit, Rouen, France
| | - Jean-Max Granier
- University Hospital of Geneva, Intensive Care Unit, Geneva, Switzerland
| | - Dominique Savary
- Emergency and Intensive Care Department, General Hospital of Annecy, Annecy, France
| | - Laurent Brochard
- Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; INSERM UMR 955, Creteil, France
| | - Jean-Christophe M Richard
- Emergency and Intensive Care Department, General Hospital of Annecy, Annecy, France; INSERM UMR 955, Creteil, France
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Intrathoracic Pressure Regulation Augments Stroke Volume and Ventricular Function in Human Hemorrhage. Shock 2015; 44 Suppl 1:55-62. [DOI: 10.1097/shk.0000000000000330] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oxygenation, ventilation, and airway management in out-of-hospital cardiac arrest: a review. BIOMED RESEARCH INTERNATIONAL 2014; 2014:376871. [PMID: 24724081 PMCID: PMC3958787 DOI: 10.1155/2014/376871] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 01/19/2014] [Indexed: 11/17/2022]
Abstract
Recently published evidence has challenged some protocols related to oxygenation, ventilation, and airway management for out-of-hospital cardiac arrest. Interrupting chest compressions to attempt airway intervention in the early stages of OHCA in adults may worsen patient outcomes. The change of BLS algorithms from ABC to CAB was recommended by the AHA in 2010. Passive insufflation of oxygen into a patent airway may provide oxygenation in the early stages of cardiac arrest. Various alternatives to tracheal intubation or bag-mask ventilation have been trialled for prehospital airway management. Simple methods of airway management are associated with similar outcomes as tracheal intubation in patients with OHCA. The insertion of a laryngeal mask airway is probably associated with worse neurologically intact survival rates in comparison with other methods of airway management. Hyperoxemia following OHCA may have a deleterious effect on the neurological recovery of patients. Extracorporeal oxygenation techniques have been utilized by specialized centers, though their use in OHCA remains controversial. Chest hyperinflation and positive airway pressure may have a negative impact on hemodynamics during resuscitation and should be avoided. Dyscarbia in the postresuscitation period is relatively common, mainly in association with therapeutic hypothermia, and may worsen neurological outcome.
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 832] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lim SH, Shuster M, Deakin CD, Kleinman ME, Koster RW, Morrison LJ, Nolan JP, Sayre MR. Part 7: CPR techniques and devices. Resuscitation 2010; 81 Suppl 1:e86-92. [DOI: 10.1016/j.resuscitation.2010.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Influence of an impedance threshold valve on ventilation with supraglottic airway devices during cardiopulmonary resuscitation in a manikin. Resuscitation 2010; 81:1010-3. [DOI: 10.1016/j.resuscitation.2010.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 03/12/2010] [Accepted: 03/18/2010] [Indexed: 11/23/2022]
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Demestiha TD, Pantazopoulos IN, Xanthos TT. Use of the impedance threshold device in cardiopulmonary resuscitation. World J Cardiol 2010; 2:19-26. [PMID: 21160680 PMCID: PMC2998865 DOI: 10.4330/wjc.v2.i2.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 02/23/2010] [Accepted: 02/24/2010] [Indexed: 02/06/2023] Open
Abstract
Although approximately one million sudden cardiac deaths occur yearly in the US and Europe, cardiac arrest (CA) remains a clinical condition still characterized by a poor prognosis. In an effort to improve the cardiopulmonary resuscitation (CPR) technique, the 2005 American Heart Association (AHA) Guidelines for CPR gave the impedance threshold device (ITD) a Class IIa recommendation. The AHA recommendation means that there is strong evidence to demonstrate that ITD enhances circulation, improves hemodynamics and increases the likelihood of resuscitation in patients in CA. During standard CPR, venous blood return to the heart relies on the natural elastic recoil of the chest which creates a transient decrease in intrathoracic pressure. The ITD further decreases intrathoracic pressure by preventing respiratory gases from entering the lungs during the decompression phase of CPR. Thus, although ITD is placed into the respiratory circuit it works as a circulatory enhancer device that provides its therapeutic benefit with each chest decompression. The ease of use of this device, its ability to be incorporated into a mask and other airway devices, the absence of device-related adverse effects and few requirements in additional training, suggest that ITD may be a favorable new device for improving CPR efficiency. Since the literature is short of studies with clinically meaningful outcomes such as neurological outcome and long term survival, further evidence is still needed.
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Affiliation(s)
- Theano D Demestiha
- Theano D Demestiha, Department of Anatomy, University of Athens, Medical School, 11527, Athens, Greece
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No assisted ventilation cardiopulmonary resuscitation and 24-hour neurological outcomes in a porcine model of cardiac arrest. Crit Care Med 2010; 38:254-60. [DOI: 10.1097/ccm.0b013e3181b42f6c] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mader TJ, Kellogg AR, Smith J, Hynds-Decoteau R, Gaudet C, Caron J, Murphy B, Paquette A, Sherman LD. A blinded, randomized controlled evaluation of an impedance threshold device during cardiopulmonary resuscitation in swine. Resuscitation 2008; 77:387-94. [DOI: 10.1016/j.resuscitation.2008.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 12/11/2007] [Accepted: 01/02/2008] [Indexed: 10/22/2022]
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Yannopoulos D, Aufderheide TP. Use of the Impedance Threshold Device (ITD). Resuscitation 2007; 75:192-3; author reply 193-4. [PMID: 17574321 DOI: 10.1016/j.resuscitation.2007.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 04/19/2007] [Accepted: 04/19/2007] [Indexed: 11/30/2022]
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In this issue. Resuscitation 2007. [DOI: 10.1016/j.resuscitation.2007.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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