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van Eijk JA, Doeleman LC, Loer SA, Koster RW, van Schuppen H, Schober P. Ventilation during cardiopulmonary resuscitation: A narrative review. Resuscitation 2024; 203:110366. [PMID: 39181499 DOI: 10.1016/j.resuscitation.2024.110366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/12/2024] [Accepted: 08/15/2024] [Indexed: 08/27/2024]
Abstract
Ventilation during cardiopulmonary resuscitation is vital to achieve optimal oxygenation but continues to be a subject of ongoing debate. This narrative review aims to provide an overview of various components and challenges of ventilation during cardiopulmonary resuscitation, highlighting key areas of uncertainty in the current understanding of ventilation management. It addresses the pulmonary pathophysiology during cardiac arrest, the importance of adequate alveolar ventilation, recommendations concerning the maintenance of airway patency, tidal volumes and ventilation rates in both synchronous and asynchronous ventilation. Additionally, it discusses ventilation adjuncts such as the impedance threshold device, the role of positive end-expiratory pressure ventilation, and passive oxygenation. Finally, this review offers directions for future research.
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Affiliation(s)
- Jeroen A van Eijk
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands.
| | - Lotte C Doeleman
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Stephan A Loer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergdreef 9, Amsterdam, Netherlands
| | - Hans van Schuppen
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Patrick Schober
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
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Kill C, Manegold RK, Fistera D, Risse J. Airway management and ventilation techniques in resuscitation during advanced life support: an update. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:58. [PMID: 39182146 PMCID: PMC11344389 DOI: 10.1186/s44158-024-00195-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
For many years, ventilation has been an essential part of advanced life support (ALS) in cardiopulmonary resuscitation (CPR). Nevertheless, there is little evidence about the best method of ventilation during resuscitation for both out-of-hospital cardiac arrest (OHCA) and inhospital cardiac arrest (IHCA) patients. Effective ventilation is one of the two main keys to successful resuscitation. In this context, the question always arises as to which airway management, along with which ventilation mode, constitutes the best strategy. Conventional ventilation modes are not designed for cardiac arrest and show important limitations that must be considered when used in CPR. Manual ventilation without the use of an automated transport ventilator (ATV) could be shown to be uncontrolled in applied volumes and pressures and should be avoided. Mechanical ventilation with an ATV is therefore superior to manual ventilation, but both volume- and pressure-controlled ventilation modes are significantly influenced by chest compressions. With the newly designed chest compression synchronized ventilation (CCSV), a special ventilation mode for resuscitation is available. Further research should be conducted to obtain more evidence of the effect of ventilation during CPR on outcomes following OHCA and not only about how to secure the airway for ventilation during CPR.
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Affiliation(s)
- Clemens Kill
- Center of Emergency Medicine, University Hospital Essen, Essen, D-45147, Germany
- Center of Emergency Medicine, University Hospital Essen, Hufelandstrasse 55, Essen, 45122, Germany
| | - Randi Katrin Manegold
- Center of Emergency Medicine, University Hospital Essen, Essen, D-45147, Germany
- Center of Emergency Medicine, University Hospital Essen, Hufelandstrasse 55, Essen, 45122, Germany
| | - David Fistera
- Center of Emergency Medicine, University Hospital Essen, Essen, D-45147, Germany
- Center of Emergency Medicine, University Hospital Essen, Hufelandstrasse 55, Essen, 45122, Germany
| | - Joachim Risse
- Center of Emergency Medicine, University Hospital Essen, Essen, D-45147, Germany.
- Center of Emergency Medicine, University Hospital Essen, Hufelandstrasse 55, Essen, 45122, Germany.
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Gutierrez A, Kalra R, Chang KY, Steiner ME, Marquez AM, Alexy T, Elliott AM, Nowariak M, Yannopoulos D, Bartos JA. Bleeding and Thrombosis in Patients With Out-of-Hospital Ventricular Tachycardia/Ventricular Fibrillation Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. J Am Heart Assoc 2024; 13:e034516. [PMID: 38700025 PMCID: PMC11179947 DOI: 10.1161/jaha.123.034516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation improves outcomes after out-of-hospital cardiac arrest. However, bleeding and thrombosis are common complications. We aimed to describe the incidence and predictors of bleeding and thrombosis and their association with in-hospital mortality. METHODS AND RESULTS Consecutive patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest between December 2015 and March 2022 who met the criteria for extracorporeal cardiopulmonary resuscitation initiation at our center were included. Major bleeding was defined by the Extracorporeal Life Support Organization's criteria. Adjusted analyses were done to seek out risk factors for bleeding and thrombosis and evaluate their association with mortality. Major bleeding occurred in 135 of 200 patients (67.5%), with traumatic bleeding from cardiopulmonary resuscitation in 73 (36.5%). Baseline demographics and arrest characteristics were similar between groups. In multivariable analysis, decreasing levels of fibrinogen were independently associated with bleeding (adjusted hazard ratio [aHR], 0.98 per every 10 mg/dL rise [95% CI, 0.96-0.99]). Patients who died had a higher rate of bleeds per day (0.21 versus 0.03, P<0.001) though bleeding was not significantly associated with in-hospital death (aHR, 0.81 [95% CI. 0.55-1.19]). A thrombotic event occurred in 23.5% (47/200) of patients. Venous thromboembolism occurred in 11% (22/200) and arterial thrombi in 15.5% (31/200). Clinical characteristics were comparable between groups. In adjusted analyses, no risk factors for thrombosis were identified. Thrombosis was not associated with in-hospital death (aHR, 0.65 [95% CI, 0.42-1.03]). CONCLUSIONS Bleeding is a frequent complication of extracorporeal cardiopulmonary resuscitation that is associated with decreased fibrinogen levels on admission whereas thrombosis is less common. Neither bleeding nor thrombosis was significantly associated with in-hospital mortality.
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Affiliation(s)
- Alejandra Gutierrez
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Rajat Kalra
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Kevin Y Chang
- Department of Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Marie E Steiner
- Division of Hematology and Oncology, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
| | - Alexandra M Marquez
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
- Division of Pediatric Critical Care Medicine, Department of Pediatrics University of Minnesota School of Medicine Minneapolis MN
| | - Tamas Alexy
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Andrea M Elliott
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | | | - Demetris Yannopoulos
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
| | - Jason A Bartos
- Cardiovascular Division, Department of Medicine University of Minnesota School of Medicine Minneapolis MN
- Center for Resuscitation Medicine University of Minnesota School of Medicine Minneapolis MN
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Kalra R, Yannopoulos D, Bartos JA. Left ventricular unloading during VA-ECMO: A Gordian knot of physiology. Resuscitation 2024; 195:110122. [PMID: 38266769 DOI: 10.1016/j.resuscitation.2024.110122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Rajat Kalra
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Demetris Yannopoulos
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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Hsu CH, Trummer G, Belohlavek J, Yannopoulos D, Bartos JA. Wolf Creek XVII Part 7: Mechanical circulatory support. Resusc Plus 2023; 16:100493. [PMID: 37965244 PMCID: PMC10641702 DOI: 10.1016/j.resplu.2023.100493] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Introduction Failure to restore spontaneous circulation remains a major cause of death for cardiac arrest (CA) patients. Mechanical circulatory support, specifically extracorporeal cardiopulmonary resuscitation (ECPR), has emerged as a feasible and efficacious rescue strategy for selected refractory CA patients. Methods Mechanical Circulatory Support was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included optimal patient selection, pre-ECPR treatments, logistical and programmatic characteristics of ECPR programs, generalizability and effectiveness of ECPR, and prevention of reperfusion injury. Top 5 barriers to translation included cost/resource limitations, technical challenges, collaboration across multiple disciplines, limited patient population, and early identification of eligible patients. Top 5 research priorities focused on comparing the outcomes of prehospital/rapid transport strategies vs in-hospital ECPR initiation, implementation of high-performing ECPR system vs standard care, rapid patient identification tools vs standard clinical judgment, post-cardiac arrest bundled care vs no bundled care, and standardized ECPR clinical protocol vs routine care. Conclusion This overview can serve as an innovative guide to transform the care and outcome of patients with refractory CA.
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Affiliation(s)
- Cindy H. Hsu
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - George Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Germany
| | - Jan Belohlavek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Demetris Yannopoulos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Jason A. Bartos
- Department of Medicine-Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Bartos JA, Yannopoulos D. Starting an Extracorporeal Cardiopulmonary Resuscitation Program: Success is in the Details. Resuscitation 2023; 187:109792. [PMID: 37044354 DOI: 10.1016/j.resuscitation.2023.109792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN.
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN
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