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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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2
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Shepard LN, Nadkarni VM, Ng KC, Scholefield BR, Ong GY. ILCOR pediatric life support recommendations translation to constituent council guidelines: An emphasis on similarities and differences. Resuscitation 2024; 201:110247. [PMID: 38777078 DOI: 10.1016/j.resuscitation.2024.110247] [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: 04/03/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
The International Liaison Committee on Resuscitation (ILCOR) performs rigorous scientific evidence evaluation and publishes Consensus on Science with Treatment Recommendations. These evidence-based recommendations are incorporated by ILCOR constituent resuscitation councils to inform regional guidelines, and further translated into training approaches and materials and implemented by laypersons and healthcare providers in- and out-of-hospital. There is variation in council guidelines as a result of the weak strength of evidence and interpretation. In this manuscript, we highlight ten important similarities and differences in regional council pediatric resuscitation guidelines, and further emphasize three differences that identify key knowledge gaps and opportunity for "natural experiments."
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Affiliation(s)
- Lindsay N Shepard
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Kee-Chong Ng
- Department of Pediatric Emergency Medicine, Kandang Kerbau Women's and Children's Hospital, Singapore.
| | | | - Gene Y Ong
- Department of Pediatric Emergency Medicine, Kandang Kerbau Women's and Children's Hospital, Singapore.
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Shin J, Lee HJ, Jin KN, Shin JH, You KM, Lee SGW, Jung JH, Song KJ, Pak J, Park TY, Park CJ, Bae GT. Automatic Mechanical Ventilation vs Manual Bag Ventilation During CPR: A Pilot Randomized Controlled Trial. Chest 2024; 166:311-320. [PMID: 38373673 DOI: 10.1016/j.chest.2024.02.020] [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: 10/11/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND There is insufficient evidence supporting the theory that mechanical ventilation can replace the manual ventilation method during CPR. RESEARCH QUESTION Is using automatic mechanical ventilation (MV) feasible and comparable to the manual ventilation method during CPR? STUDY DESIGN AND METHODS This pilot randomized controlled trial compared MV and manual bag ventilation (BV) during CPR after out-of-hospital cardiac arrest (OHCA). Patients with medical OHCA arriving at the ED were randomly assigned to two groups: an MV group using a mechanical ventilator and a BV group using a bag valve mask. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were changes of arterial blood gas analysis results during CPR. Tidal volume, minute volume, and peak airway pressure were also analyzed. RESULTS A total of 60 patients were enrolled, and 30 patients were randomly assigned to each group. There were no statistically significant differences in basic characteristics of OHCA patients between the two groups. The rate of any return of spontaneous circulation was 56.7% in the MV group and 43.3% in the BV group, indicating no significant (P = .439) difference between the two groups. There were also no statistically significant differences in changes of PH, Pco2, Po2, bicarbonate, or lactate levels during CPR between the two groups (P values = .798, 0.249, .515, .876, and .878, respectively). Significantly lower tidal volume (P < .001) and minute volume (P = .009) were observed in the MV group. INTERPRETATION In this pilot trial, the use of MV instead of BV during CPR was feasible and could serve as a viable alternative. A multicenter randomized controlled trial is needed to create sufficient evidence for ventilation guidelines during CPR. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT05550454; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea; Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea.
| | - Kwang Nam Jin
- Department of Radiology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jung Ho Shin
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Kyoung Min You
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jin Hee Jung
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea; Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Jieun Pak
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Tae Yun Park
- Department of Internal Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Chang Je Park
- Department of Emergency Medicine, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Gi Tak Bae
- Department of Nursing, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
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Wang HE, Yu MI, Crowe RP, Nassal MMJ, Gage C, Hyer JM, Powell J, Ulintz A, Sharkey-Toppen T, Wei L, Moeller K, Panchal AR. Longitudinal Changes in Emergency Medical Services Advanced Airway Management. JAMA Netw Open 2024; 7:e2427763. [PMID: 39172452 PMCID: PMC11342135 DOI: 10.1001/jamanetworkopen.2024.27763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/18/2024] [Indexed: 08/23/2024] Open
Abstract
Importance Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care. Objective To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort. Design, Setting, and Participants This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024. Exposures Advanced airway management attempts, including ETI, SGA, and surgical airways. Main Outcomes and Measures The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics). Results Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent. Conclusions and Relevance In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.
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Affiliation(s)
- Henry E. Wang
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Mengda Ivy Yu
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | | | | | - Christopher Gage
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - J. Madison Hyer
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Jonathan Powell
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Alexander Ulintz
- Department of Emergency Medicine, The Ohio State University, Columbus
| | | | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Kim Moeller
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University, Columbus
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5
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Segond N, Debaty G. Mechanical Ventilation During CPR: The Emergence of Clinical Evidence. Chest 2024; 166:243-244. [PMID: 39122293 DOI: 10.1016/j.chest.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 08/12/2024] Open
Affiliation(s)
- Nicolas Segond
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes and University of Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France.
| | - Guillaume Debaty
- Emergency Department and Mobile Intensive Care Unit, University Hospital of Grenoble Alpes and University of Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, Grenoble, France
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Hopper K, Epstein SE, Burkitt-Creedon JM, Fletcher DJ, Boller M, Fausak ED, Mears K, Crews M. 2024 RECOVER Guidelines: Basic Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:16-43. [PMID: 38924625 DOI: 10.1111/vec.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review evidence and devise treatment recommendations for basic life support (BLS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to BLS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by 2 Evidence Evaluators, and findings were reconciled by BLS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk to benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Twenty questions regarding animal position, chest compression point and technique, ventilation strategies, as well as the duration of CPR cycles and chest compression pauses were examined, and 32 treatment recommendations were formulated. Out of these, 25 addressed chest compressions and 7 informed ventilation during CPR. The recommendations were founded predominantly on very low quality of evidence and expert opinion. These new treatment recommendations continue to emphasize the critical importance of high-quality, uninterrupted chest compressions, with a modification suggested for the chest compression technique in wide-chested dogs. When intubation is not possible, bag-mask ventilation using a tight-fitting facemask with oxygen supplementation is recommended rather than mouth-to-nose ventilation. CONCLUSIONS These updated RECOVER BLS treatment recommendations emphasize continuous chest compressions, conformation-specific chest compression techniques, and ventilation for all animals. Very low quality of evidence due to absence of clinical data in dogs and cats consistently compromised the certainty of recommendations, emphasizing the need for more veterinary research in this area.
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Affiliation(s)
- Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Jamie M Burkitt-Creedon
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
| | - Kim Mears
- Robertson Library, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Molly Crews
- Department of Small animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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7
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Sonmez E, Taslidere B, Ozkan A. A new method of pulse control in cardiopulmonary resuscitation; Continuous femoral pulse check. Am J Emerg Med 2024; 80:168-173. [PMID: 38613985 DOI: 10.1016/j.ajem.2024.03.026] [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: 01/03/2024] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES The reliability of manual pulse checks has been questioned but is still recommended in cardiopulmonary resuscitation (CPR) guidelines. The aim is to compare the 10-s carotid pulse check (CPC) between heart massage cycles with the continuous femoral pulse check (CoFe PuC) in CPR, and to propose a better location to shorten the interruption times for pulse check. METHODS A prospective study was conducted on 117 Non-traumatic CPR patients between January 2020 and January 2022. A total of 702 dependent pulse measurements were executed, where carotid and femoral pulses were simultaneously assessed. Cardiac ultrasound, end-tidal CO2, saturation, respiration, and blood pressure were employed for pulse validation. RESULTS The decision time for determining the presence of a pulse in the last cycle of CPR was 3.03 ± 1.26 s for CoFe PuC, significantly shorter than the 10.31 ± 5.24 s for CPC. CoFe PuC predicted the absence of pulse with 74% sensitivity and 88% specificity, while CPC predicted the absence of pulse with 91% sensitivity and 61% specificity. CONCLUSION CoFe PuC provides much earlier and more effective information about the pulse than CPC. This shortens the interruption times in CPR. CoFe PuC should be recommended as a new and useful method in CPR guidelines.
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Affiliation(s)
- E Sonmez
- Kütahya Health Sciences University, Medical School, Department of Emergency Medicine, Kütahya, Turkey
| | - B Taslidere
- Bezmialem Vakif University Medical Faculty, Department of Emergency Medicine, İstanbul, Turkey
| | - A Ozkan
- Bağcılar Training And Research Hospital, Department of Emergency Medicine, İstanbul, Turkey.
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8
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Noordergraaf GJ, Venema A. Ventilation and oxygenation during CPR: Is the time past to just bag it? Resuscitation 2024; 199:110228. [PMID: 38719069 DOI: 10.1016/j.resuscitation.2024.110228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Gerrit J Noordergraaf
- Dept of Anesthesiology, Resuscitation and Pain Management, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands.
| | - Alyssa Venema
- Dept of Anesthesiology, Resuscitation and Pain Management, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands.
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9
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García-Martínez M, Espinosa-Pereiro CE, Rodríguez-Núñez A. Bag and mask ventilation, an outstanding challenge that we should not leave behind. Resuscitation 2024; 199:110230. [PMID: 38705561 DOI: 10.1016/j.resuscitation.2024.110230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024]
Affiliation(s)
- M García-Martínez
- Simulation, Life Support & Intensive Case Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Spain; CLINURSID Research Group, School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - C E Espinosa-Pereiro
- Simulation, Life Support & Intensive Case Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Spain; CLINURSID Research Group, School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain; Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain.
| | - A Rodríguez-Núñez
- Simulation, Life Support & Intensive Case Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Spain; CLINURSID Research Group, School of Nursing, University of Santiago de Compostela, Santiago de Compostela, Spain; Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), RD21/0012/0025, Instituto de Salud Carlos III, Madrid, Spain
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10
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Marchese G, Bungaro E, Magliocca A, Fumagalli F, Merigo G, Semeraro F, Mereto E, Babini G, Roman-Pognuz E, Stirparo G, Cucino A, Ristagno G. Acute Lung Injury after Cardiopulmonary Resuscitation: A Narrative Review. J Clin Med 2024; 13:2498. [PMID: 38731027 PMCID: PMC11084269 DOI: 10.3390/jcm13092498] [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: 03/06/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Although cardiopulmonary resuscitation (CPR) includes lifesaving maneuvers, it might be associated with a wide spectrum of iatrogenic injuries. Among these, acute lung injury (ALI) is frequent and yields significant challenges to post-cardiac arrest recovery. Understanding the relationship between CPR and ALI is determinant for refining resuscitation techniques and improving patient outcomes. This review aims to analyze the existing literature on ALI following CPR, emphasizing prevalence, clinical implications, and contributing factors. The review seeks to elucidate the pathogenesis of ALI in the context of CPR, assess the efficacy of CPR techniques and ventilation strategies, and explore their impact on post-cardiac arrest outcomes. CPR-related injuries, ranging from skeletal fractures to severe internal organ damage, underscore the complexity of managing post-cardiac arrest patients. Chest compression, particularly when prolonged and vigorous, i.e., mechanical compression, appears to be a crucial factor contributing to ALI, with the concept of cardiopulmonary resuscitation-associated lung edema (CRALE) gaining prominence. Ventilation strategies during CPR and post-cardiac arrest syndrome also play pivotal roles in ALI development. The recognition of CPR-related lung injuries, especially CRALE and ALI, highlights the need for research on optimizing CPR techniques and tailoring ventilation strategies during and after resuscitation.
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Affiliation(s)
- Giuseppe Marchese
- UOC Anestesia e Rianimazione, Ospedale Nuovo di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
| | - Elisabetta Bungaro
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
| | - Francesca Fumagalli
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20122 Milan, Italy
| | - Giulia Merigo
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
- Department of Biomedical Sciences for Health, University of Milan, 20122 Milan, Italy
| | - Federico Semeraro
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, 40133 Bologna, Italy
| | - Elisa Mereto
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Giovanni Babini
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
| | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, University of Trieste, 34127 Trieste, Italy
| | | | - Alberto Cucino
- Department of Anaesthesia and Intensive Care Medicine, APSS, Provincia Autonoma di Trento, 38121 Trento, Italy;
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy (A.M.); (E.M.)
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.M.)
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11
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Colwell C. A Heads-Up on Salvaging Nonshockable Cardiac Arrest Cases. Crit Care Med 2024; 52:331-333. [PMID: 38240511 DOI: 10.1097/ccm.0000000000006062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Christopher Colwell
- Zuckerberg San Francisco General Hospital Department of Emergency Medicine and the University of California, San Francisco, CA
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12
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Morgan RW, Reeder RW, Bender D, Cooper KK, Friess SH, Graham K, Meert KL, Mourani PM, Murray R, Nadkarni VM, Nataraj C, Palmer CA, Srivastava N, Tilford B, Wolfe HA, Yates AR, Berg RA, Sutton RM. Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival. Circulation 2024; 149:367-378. [PMID: 37929615 PMCID: PMC10841728 DOI: 10.1161/circulationaha.123.066659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children." METHODS This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate). RESULTS Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups. CONCLUSIONS In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Dieter Bender
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (S.H.F.)
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (P.M.M.)
| | - Robert Murray
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Chandrasekhar Nataraj
- Villanova Center for Analytics of Dynamic Systems, Villanova University, PA (D.B., C.N.)
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City (R.W.R., C.A.P.)
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles (N.S.)
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit (K.L.M., B.T.)
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (R.M., A.R.Y.)
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania (R.W.M., K.K.C., K.G., V.M.N., H.A.W., R.A.B., R.M.S.)
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13
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Prekker ME, Robinson AE. Implementing a smaller-volume adult ventilation bag: Is the juice worth the squeeze? Resuscitation 2023; 193:110034. [PMID: 37926291 DOI: 10.1016/j.resuscitation.2023.110034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA; Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
| | - Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA; Hennepin Emergency Medical Services, Hennepin Healthcare, Minneapolis, Minnesota, USA.
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14
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Mälberg J, Marchesi S, Spangler D, Hadziosmanovic N, Smekal D, Rubertsson S. Continuous chest compressions are associated with higher peak inspiratory pressures when compared to 30:2 in an experimental cardiac arrest model. Intensive Care Med Exp 2023; 11:75. [PMID: 37938394 PMCID: PMC10632261 DOI: 10.1186/s40635-023-00559-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Ventilation during cardiopulmonary resuscitation (CPR) has long been a part of the standard treatment during cardiac arrests. Ventilation is usually given either during continuous chest compressions (CCC) or during a short pause after every 30 chest compressions (30:2). There is limited knowledge of how ventilation is delivered if it effects the hemodynamics and if it plays a role in the occurrence of lung injuries. The aim of this study was to compare ventilation parameters, hemodynamics, blood gases and lung injuries during experimental CPR given with CCC and 30:2 in a porcine model. METHODS Sixteen pigs weighing approximately 33 kg were randomized to either receive CPR with CCC or 30:2. Ventricular fibrillation was induced by passing an electrical current through the heart. CPR was started after 3 min and given for 20 min. Chest compressions were provided mechanically with a chest compression device and ventilations were delivered manually with a self-inflating bag and 12 l/min of oxygen. During the experiment, ventilation parameters and hemodynamics were sampled continuously, and arterial blood gases were taken every five minutes. After euthanasia and cessation of CPR, the lungs and heart were removed in block and visually examined followed by sampling of lung tissue which were examined using microscopy. RESULTS In the CCC group and the 30:2 group, peak inspiratory pressure (PIP) was 58.6 and 35.1 cmH2O (p < 0.001), minute volume (MV) 2189.6 and 1267.1 ml (p < 0.001), peak expired carbon dioxide (PECO2) 28.6 and 39.4 mmHg (p = 0.020), partial pressure of carbon dioxide (PaCO2) 50.2 and 61.1 mmHg (p = 0.013) and pH 7.3 and 7.2 (p = 0.029), respectively. Central venous pressure (CVP) decreased more over time in the 30:2 group (p = 0.023). All lungs were injured, but there were no differences between the groups. CONCLUSIONS Ventilation during CCC resulted in a higher PIP, MV and pH and lower PECO2 and PaCO2, showing that ventilation mode during CPR can affect ventilation parameters and blood gases.
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Affiliation(s)
- Johan Mälberg
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden.
| | - Silvia Marchesi
- Division of Intensive- and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Douglas Spangler
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | | | - David Smekal
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Sten Rubertsson
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
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15
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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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16
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O'Connell KJ, Dutta A, Myers S, Neubrand T, Sandler A, Keane R, Kerrey B, Donoghue A. Association between the presence of an advanced airway and ventilation rate during pediatric CPR: A report from the Videography in Pediatric Resuscitation (VIPER) collaborative. Resuscitation 2023; 191:109923. [PMID: 37597650 DOI: 10.1016/j.resuscitation.2023.109923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE To determine the association between presence of an advanced airway during pediatric cardiopulmonary resuscitation (CPR) and ventilation rates. METHODS Prospective observational study, January 2017 to June 2020. Patients ≤18 years receiving CC for ≥2 minutes were enrolled. Ventilation rate and type of airway (advanced airway (AA), either endotracheal tube (ETT) or supraglottic airway (SGA); or natural airway (NA)) were collected from video review and analyzed in 'CPR segments' (periods of CPR by individual providers). Ventilation rate (breaths per minute, bpm) was calculated for each segment; hyperventilation was defined as >12 bpm according to 2015 American Heart Association guidelines. Univariate analysis between airway type was done by χ2 testing. Multivariate regression was used to determine the association between the presence of AA with hyperventilation while controlling for within-patient covariance. RESULTS 779 CPR segments from 94 CPR event were analyzed. The mean ventilation rate per CPR segment across all events was 22 bpm (±16 bpm)). Mean ventilation rates were higher with AA, either ETT (24 ± 17 bpm) or SGA (34 ± 19 bpm), than with NA (17 ± 14, p < 0.001). Hyperventilation occurred more often with AA in place (ETT: 68%; SGA: 96%; NA: 43%; p < 0.001). The presence of AA was independently associated with hyperventilation (AOR 9.3, 95% CI 4.3-20.1). CONCLUSIONS During pediatric CPR, hyperventilation occurs more often with an AA in place than during CPR with NA. Future research should focus on respiratory physiology during pediatric CPR to determine optimal ventilation rate(s) during pediatric cardiac arrest.
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Affiliation(s)
- Karen J O'Connell
- Division of Emergency Medicine, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, United States.
| | - Anuj Dutta
- Georgetown University, Washington, DC, United States
| | - Sage Myers
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Tara Neubrand
- Division of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Alexis Sandler
- Division of Emergency Medicine, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Ryan Keane
- Duke University School of Medicine, Durham, NC, United States
| | - Benjamin Kerrey
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Aaron Donoghue
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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17
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [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] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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18
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Santos-Folgar M, Rodriguez-Nunez A, Barcala-Furelos R, Otero-Agra M, Martínez-Isasi S, Fernández-Méndez F. Trained Lifeguards Performing Pediatric Cardiopulmonary Resuscitation While Running: A Pilot Simulation Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1348. [PMID: 37628347 PMCID: PMC10453907 DOI: 10.3390/children10081348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
The aim of this study was to compare the quality of standard infant CPR with CPR in motion (i.e., walking and running) via performing maneuvers and evacuating the infant from a beach. Thirteen trained lifeguards participated in a randomized crossover study. Each rescuer individually performed three tests of 2 min each. Five rescue breaths and cycles of 30 chest compressions followed by two breaths were performed. Mouth-to-mouth-and-nose ventilation was carried out, and chest compressions were performed using the two-fingers technique. The manikin was carried on the rescuer's forearm with the head in the distal position. The analysis variables included compression, ventilation, and CPR quality variables, as well as physiological and effort parameters. Significantly lower compression quality values were obtained in running CPR versus standard CPR (53% ± 14% versus 63% ± 15%; p = 0.045). No significant differences were observed in ventilation or CPR quality. In conclusion, lifeguards in good physical condition can perform simulated infant CPR of a similar quality to that of CPR carried out on a victim who is lying down in a fixed position.
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Affiliation(s)
- Myriam Santos-Folgar
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain; (M.S.-F.); (R.B.-F.); (F.F.-M.)
- School of Nursing, Universidade de Vigo, 36004 Pontevedra, Spain
- Department of Obstetrics, Complexo Hospitalario of Pontevedra, 36001 Pontevedra, Spain
| | - Antonio Rodriguez-Nunez
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15706 A Coruña, Spain;
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela (CHUS), 15706 A Coruña, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15782 A Coruña, Spain
- Paediatric Critical, Intermediate and Palliative Care Section, Hospital Clínico Universitario de Santiago de Compostela, 15706 A Coruña, Spain
- Collaborative Research Network Orientated to Health Results (RICORS): Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin, RD21/0012/0025, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Roberto Barcala-Furelos
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain; (M.S.-F.); (R.B.-F.); (F.F.-M.)
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15706 A Coruña, Spain;
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela (CHUS), 15706 A Coruña, Spain
- Collaborative Research Network Orientated to Health Results (RICORS): Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin, RD21/0012/0025, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Martín Otero-Agra
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain; (M.S.-F.); (R.B.-F.); (F.F.-M.)
- School of Nursing, Universidade de Vigo, 36004 Pontevedra, Spain
| | - Santiago Martínez-Isasi
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15706 A Coruña, Spain;
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela (CHUS), 15706 A Coruña, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15782 A Coruña, Spain
- Collaborative Research Network Orientated to Health Results (RICORS): Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin, RD21/0012/0025, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Felipe Fernández-Méndez
- REMOSS Research Group, Faculty of Education and Sport Sciences, Universidade de Vigo, 36005 Pontevedra, Spain; (M.S.-F.); (R.B.-F.); (F.F.-M.)
- School of Nursing, Universidade de Vigo, 36004 Pontevedra, Spain
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15706 A Coruña, Spain;
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19
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Qureshi T, Hutton P, Pandit JJ. Sharpening PUMA's teeth: improving guidance for capnography to confirm tracheal intubation in cardiopulmonary resuscitation. Anaesthesia 2023; 78:937-942. [PMID: 36947864 DOI: 10.1111/anae.16002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/24/2023]
Affiliation(s)
- T Qureshi
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - P Hutton
- University of Birmingham, UK
- Guy's and St Thomas' NHS Foundation Trust (Heart, Lung and Critical Care Clinical Group), London, UK
| | - J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Oxford, UK
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20
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Jones B, Aiello S, Govender K, Shaw B, Tseng B, Dawad Z, McAulay M, Wilkinson N. The impact of a ventilation timing light on CPR Quality: A randomized crossover study. Resusc Plus 2023; 14:100404. [PMID: 37303854 PMCID: PMC10248546 DOI: 10.1016/j.resplu.2023.100404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
A ventilation timing light (VTL) is a small commercially available single-use device that is programmed to light up at six-second intervals prompting rescuers to provide a single controlled breath during manual ventilation. The device also indicates the duration of the breath by remaining illuminated for the duration of the inspiratory time. The aim of this study was to evaluate the impact of the VTL on a selection of CPR quality metrics. Methods A total of 71 paramedic students who were already proficient in performing high-performance CPR (HPCPR) were required to perform HPCPR with and without a VTL. The quality of the HPCPR delivered, reflected by the selected quality metrics; chest compression fraction (CCF), chest compression rate (CCR), and ventilation rate (VR), was then evaluated. Results While HPCPR with and without a VTL were both able to achieve guideline-based performance targets of CCF, CCR, and VR, the group who had used the VTL to deliver HPCPR were able to consistently provide 10 ventilations for every minute of asynchronous compressions (10 breath/min vs 8.7 breath/min p < 0.001). Conclusion The use of a VTL allows for a VR target of 10 ventilations per minute to be consistently achieved without compromising guideline-based compression fraction targets (>80%), and chest compression rates when used during the delivery of HPCPR in a simulated OHCA event.
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21
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Jaureguibeitia X, Aramendi E, Wang HE, Idris AH. Impedance-Based Ventilation Detection and Signal Quality Control During Out-of-Hospital Cardiopulmonary Resuscitation. IEEE J Biomed Health Inform 2023; 27:3026-3036. [PMID: 37028324 PMCID: PMC10336723 DOI: 10.1109/jbhi.2023.3253780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Feedback on ventilation could help improve cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest (OHCA). However, current technology that monitors ventilation during OHCA is very limited. Thoracic impedance (TI) is sensitive to air volume changes in the lungs, allowing ventilations to be identified, but is affected by artifacts due to chest compressions and electrode motion. This study introduces a novel algorithm to identify ventilations in TI during continuous chest compressions in OHCA. Data from 367 OHCA patients were included, and 2551 one-minute TI segments were extracted. Concurrent capnography data were used to annotate 20724 ground truth ventilations for training and evaluation. A three-step procedure was applied to each TI segment: First, bidirectional static and adaptive filters were applied to remove compression artifacts. Then, fluctuations potentially due to ventilations were located and characterized. Finally, a recurrent neural network was used to discriminate ventilations from other spurious fluctuations. A quality control stage was also developed to anticipate segments where ventilation detection could be compromised. The algorithm was trained and tested using 5-fold cross-validation, and outperformed previous solutions in the literature on the study dataset. The median (interquartile range, IQR) per-segment and per-patient F 1-scores were 89.1 (70.8-99.6) and 84.1 (69.0-93.9), respectively. The quality control stage identified most low performance segments. For the 50% of segments with highest quality scores, the median per-segment and per-patient F 1-scores were 100.0 (90.9-100.0) and 94.3 (86.5-97.8). The proposed algorithm could allow reliable, quality-conditioned feedback on ventilation in the challenging scenario of continuous manual CPR in OHCA.
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22
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Rodriguez-Ruiz E, Marcos-Alonso S, Campelo-Izquierdo M, Estany-Gestal A, Rodríguez-Núñez A. Are ICU nurses able to achieve their ventilation goals when bagging a patient? A pilot study. Med Intensiva 2023; 47:298-300. [PMID: 36202745 DOI: 10.1016/j.medine.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/16/2022] [Indexed: 04/29/2023]
Affiliation(s)
- E Rodriguez-Ruiz
- Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain; Simulation, Life Support & Intensive Care Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain; CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain.
| | - S Marcos-Alonso
- CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain; Pediatrician. Galician Public Health System (SERGAS), A Coruña, Spain
| | - M Campelo-Izquierdo
- Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
| | - A Estany-Gestal
- Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela, Spain
| | - A Rodríguez-Núñez
- Simulation, Life Support & Intensive Care Research Unit of Santiago de Compostela (SICRUS), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain; CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain; Paediatric Intensive Care Unit, Department of Pediatrics, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
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Prause G, Zoidl P, Eichinger M, Eichlseder M, Orlob S, Ruhdorfer F, Honnef G, Metnitz PGH, Zajic P. Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation 2023; 187:109765. [PMID: 36931453 DOI: 10.1016/j.resuscitation.2023.109765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/17/2023]
Abstract
AIM OF THE STUDY This study sought to assess the effects of increasing the ventilatory rate from 10 min-1 to 20 min-1 using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes. METHODS This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6 ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO2) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed. RESULTS The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20 min-1 group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p < 0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p = 0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p = 0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p = 0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97), p = 0.913], and median pCO2 [78 (51-105) vs. 86 (73-107) mmHg, p > 0.999] did not differ between groups. CONCLUSION 20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO2 washout, acidaemia, oxygenation, or rate of ROSC. CLINICALTRIALS gov Identifier: NCT04657393.
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Affiliation(s)
- Gerhard Prause
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Zoidl
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichinger
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichlseder
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Simon Orlob
- Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Felix Ruhdorfer
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabriel Honnef
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Philipp G H Metnitz
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria. https://twitter.com/PhZoidl
| | - Paul Zajic
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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Methods for calculating ventilation rates during resuscitation from out-of-hospital cardiac arrest. Resuscitation 2023; 184:109679. [PMID: 36572374 DOI: 10.1016/j.resuscitation.2022.109679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Ventilation control is important during resuscitation from out-of-hospital cardiac arrest (OHCA). We compared different methods for calculating ventilation rates (VR) during OHCA. METHODS We analyzed data from the Pragmatic Airway Resuscitation Trial, identifying ventilations through capnogram recordings. We determined VR by: 1) counting the number of breaths within a time epoch ("counted" VR), and 2) calculating the mean of the inverse of measured time between breaths within a time epoch ("measured" VR). We repeated the VR estimates using different time epochs (10, 20, 30, 60 sec). We defined hypo- and hyperventilation as VR <6 and >12 breaths/min, respectively. We assessed differences in estimated hypo- and hyperventilation with each VR measurement technique. RESULTS Of 3,004 patients, data were available for 1,010. With the counted method, total hypoventilation increased with longer time epochs ([10-s epoch: 75 sec hypoventilation] to [60-s epoch: 97 sec hypoventilation]). However, with the measured method, total hypoventilation decreased with longer time epochs ([10-s epoch: 223 sec hypoventilation] to [60-s epoch: 150 sec hypoventilation]). With the counted method, the total duration of hyperventilation decreased with longer time epochs ([10-s epochs: 35 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). With the measured method, total hyperventilation decreased with longer time epochs ([10-s epoch: 78 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). Differences between the measured and counted estimates were smallest with a 60-s time epoch. CONCLUSIONS Quantifications of hypo- and hyperventilation vary with the applied measurement methods. Measurement methods are important when characterizing ventilation rates in OHCA.
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Measuring ventilation during out-of-hospital cardiac arrest: PART of the equation. Resuscitation 2023; 184:109696. [PMID: 36681381 DOI: 10.1016/j.resuscitation.2023.109696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
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Lou J, Tian S, Kang X, Lian H, Liu H, Zhang W, Peran D, Zhang J. Airway management in out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Am J Emerg Med 2023; 65:130-138. [PMID: 36630861 DOI: 10.1016/j.ajem.2022.12.029] [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: 07/14/2022] [Revised: 12/07/2022] [Accepted: 12/18/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to compare the efficacy of the most commonly used out-of-hospital airway management methods in increasing the survival to discharge in patients with OHCA. METHODS We screened all relevant literature from database inception to 21st January 2019 in PubMed, Web of Science, Embase, and the Cochrane Library. We included all randomized controlled trials (RCTs) of airway management for OHCA in adults (≥16 years of age) with no limitations on publication status, publication date, or language. The primary outcome was survival to discharge. The secondary outcomes were the overall airway technique success rate, return of spontaneous circulation, and survival to hospital admission. RESULTS Overall, from 1986 to 2018, 9 RCTs involving 13,949 patients were included in the network meta-analysis, and the efficacy of six airway management methods for patients with OHCA were compared. However, none of the results were statistically significant. CONCLUSIONS As the gold standard of airway management for patients with out-of-hospital cardiac arrest in most countries, endotracheal intubation (ETI) has been widely used for many years. However, our systematic review and network meta-analysis showed that ETI is no better than other methods in increasing the survival to discharge. This is not directly proportional to the various preparations required before ETI. Additional randomized controlled trials are needed to identify more effective methods and improve patients' outcome.
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Affiliation(s)
- Jing Lou
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Sijia Tian
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Xuqin Kang
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China
| | - Huixin Lian
- Beijing Emergency Medical Center, Beijing, China
| | - Hongmei Liu
- Beijing Emergency Medical Center, Beijing, China
| | | | - David Peran
- Prague Emergency Medical Services, Prague, Czech Republic
| | - Jinjun Zhang
- Beijing Emergency Medical Center, Beijing, China; Beijing Emergency Medicine Research Institute, Beijing, China.
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Martínez-Isasi S, Jorge-Soto C, Castro-Fernández C, Baltar-Lorenzo C, Sobrido-Prieto M, Manteiga-Urbón J, Barcala-Furelos R. Pediatric Ventilation Skills by Non-Healthcare Students: Effectiveness, Self-Perception, and Preference. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3026. [PMID: 36833716 PMCID: PMC9964783 DOI: 10.3390/ijerph20043026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 06/18/2023]
Abstract
Since a great number of infant cardiopulmonary arrests occur outside of the hospital, it is crucial to train laypersons in cardiopulmonary resuscitation techniques, especially those professionals that will work with infants and children. The main objective of this study was to evaluate the efectiveness of ventilations performed by professional training students. The secondary objective was to analyze the preference between different ventilation and chest-compression methods. The sample consisted of 32 professional training students, 15 preschool students, and 17 physical education students. The activity was conducted separately for each group, and we provided a 10 min theoretical training about infant basic life support followed by a 45 min practical training using a Laerdal Little Anne QCPR CPR manikin. A practical test in pairs was organized to record the ventilation as performed by the participants, establishing the difference between the efficacious and the non-efficacious ones. Furthermore, we handed out a survey before and after training to evaluate their knowledge. More than 90% of the students completely agreed with the importance of learning cardiopulmonary resuscitation techniques for their professional future. More than half of the sample considered that they perform the rescue breathings with the mouth-to-mouth method better. We observed that through mouth-to-mouth-nose ventilations, the number of effective ventilations was significantly higher than the effective ventilations provided by a self-inflating bag and mask (EffectiveMtoMN 6.42 ± 4.27 vs. EffectiveMask 4.75 ± 3.63 (p = 0.007)), which was the preferred method. In terms of the compression method, hands encircling the chest was preferred by more than 85% of students. Mouth-to-mouth nose ventilation is more efficient than bag-face-mask ventilation in CPR as performed by professional training and physical activity students. This fact must be considered to provide higher-quality training sessions to professional training students.
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Affiliation(s)
- Santiago Martínez-Isasi
- CLINURSID Research Group, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
- SICRUS Research Group, Institute of Health Research of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Cristina Jorge-Soto
- CLINURSID Research Group, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
- SICRUS Research Group, Institute of Health Research of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Cecilia Castro-Fernández
- Nursing Faculty of Santiago de Compostela, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
| | - Clara Baltar-Lorenzo
- Nursing Faculty of Santiago de Compostela, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
| | | | - Jose Manteiga-Urbón
- Pediatric Emergencies Unit, Biomedic Research Institute of A Coruña—INIBIC, University Hospital of A Coruña (CHUAC), SERGAS, 15006 A Coruña, Spain
| | - Roberto Barcala-Furelos
- CLINURSID Research Group, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
- REMOSS Research Group, Faculty of Education and Sport Sciences, University of Vigo, 36005 Pontevedra, Spain
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Milne B. Con: We Should Not Routinely Intubate All Patients in Cardiac Arrest. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00040-X. [PMID: 36805378 DOI: 10.1053/j.jvca.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics & Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Department of Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom.
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Kopra J, Litonius E, Pekkarinen PT, Laitinen M, Heinonen JA, Fontanelli L, Mäkiaho TP, Skrifvars MB. Ventilation during continuous compressions or at 30:2 compression-to-ventilation ratio results in similar arterial oxygen and carbon dioxide levels in an experimental model of prolonged cardiac arrest. Intensive Care Med Exp 2023; 11:3. [PMID: 36607514 PMCID: PMC9823175 DOI: 10.1186/s40635-022-00485-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/17/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND In refractory out-of-hospital cardiac arrest, transportation to hospital with continuous chest compressions (CCC) from a chest compression device and ventilation with 100% oxygen through an advanced airway is common practice. Despite this, many patients are hypoxic and hypercapnic on arrival, possibly related to suboptimal ventilation due to the counterpressure caused by the CCC. We hypothesized that a compression/ventilation ratio of 30:2 would provide better ventilation and gas exchange compared to asynchronous CCC during prolonged experimental cardiopulmonary resuscitation (CPR). METHODS We randomized 30 anaesthetized domestic swine (weight approximately 50 kg) with electrically induced ventricular fibrillation to the CCC or 30:2 group and bag-valve ventilation with a fraction of inspired oxygen (FiO2) of 100%. We started CPR after a 5-min no-flow period and continued until 40 min from the induction of ventricular fibrillation. Chest compressions were performed with a Stryker Medical LUCAS® 2 mechanical chest compression device. We collected arterial blood gas samples every 5 min during the CPR, measured ventilation distribution during the CPR using electrical impedance tomography (EIT) and analysed post-mortem computed tomography (CT) scans for differences in lung aeration status. RESULTS The median (interquartile range [IQR]) partial pressure of oxygen (PaO2) at 30 min was 110 (52-117) mmHg for the 30:2 group and 70 (40-171) mmHg for the CCC group. The median (IQR) partial pressure of carbon dioxide (PaCO2) at 30 min was 70 (45-85) mmHg for the 30:2 group and 68 (42-84) mmHg for the CCC group. No statistically significant differences between the groups in PaO2 (p = 0.40), PaCO2 (p = 0.79), lactate (p = 0.37), mean arterial pressure (MAP) (p = 0.47) or EtCO2 (p = 0.19) analysed with a linear mixed model were found. We found a deteriorating trend in PaO2, EtCO2 and MAP and rising PaCO2 and lactate levels through the intervention. There were no differences between the groups in the distribution of ventilation in the EIT data or the post-mortem CT findings. CONCLUSIONS The 30:2 and CCC protocols resulted in similar gas exchange and lung pathology in an experimental prolonged mechanical CPR model.
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Affiliation(s)
- Jukka Kopra
- grid.15485.3d0000 0000 9950 5666Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Litonius
- grid.7737.40000 0004 0410 2071Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka T. Pekkarinen
- grid.7737.40000 0004 0410 2071Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Merja Laitinen
- VetCT Teleconsulting–Teleradiology Small Animal Team, Cambridge, UK
| | - Juho A. Heinonen
- grid.7737.40000 0004 0410 2071Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Luca Fontanelli
- grid.8982.b0000 0004 1762 5736Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Tomi P. Mäkiaho
- grid.15485.3d0000 0000 9950 5666Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Markus B. Skrifvars
- grid.15485.3d0000 0000 9950 5666Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Merrell JG, Scott AC, Stambro R, Boukai A, Cooper DD. Improved simulated ventilation with a novel tidal volume and peak inspiratory pressure controlling bag valve mask: A pilot study. Resusc Plus 2023; 13:100350. [PMID: 36654722 PMCID: PMC9841173 DOI: 10.1016/j.resplu.2022.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/05/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction The dangers of hyperventilation during resuscitation are well known. Traditional bag valve mask (BVM) devices rely on end users to control tidal volume (Vt), rate, and peak inspiratory pressures (PIP) of ventilation. The Butterfly BVM (BBVM) is a novel device intending to give greater control over these parameters. The objective of this pilot study was to compare the BBVM against a traditional device in simulated resuscitations. Methods Senior emergency medicine residents and fellows participated in a three-phase simulation study. First, participants used the Ambu Spur II BVM in adult and pediatric resuscitations. Vt, PIP, and rate were recorded. Second, participants repeated the resuscitations after a brief introduction to the BBVM. Third, participants were given a longer introduction to the BBVM and were tested on their ability to adjust its various settings. Results Nineteen participants were included in the adult arm of the study, and 16 in the pediatric arm. The BBVM restricted Vt delivered to a range of 4-8 ml/kg vs 9 ml/kg and 13 ml/kg (Ambu adult and Ambu pediatric respectively). The BBVM never exceeded target minute ventilations while the Ambu BVMs exceeded target minute ventilation in 2 of 4 tests. The BBVM failed to reliably reach higher PIP targets in one test, while the pediatric Ambu device had 76 failures of excessive PIP compared to 2 failures by the BBVM. Conclusion The BBVM exceeded the Ambu Spur II in delivering appropriate Vts and in keeping PIPs below target maximums to simulated adult and pediatric patients in this pilot study.
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Affiliation(s)
- Jonathan G. Merrell
- Department of Pediatrics, Indiana University School of Medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN, USA
- Compact Medical Inc, 7711 Ashtree Dr., Indianapolis, IN, USA
| | - Adam C. Scott
- Compact Medical Inc, 7711 Ashtree Dr., Indianapolis, IN, USA
| | - Ryan Stambro
- The Simulation Center at Fairbanks Hall, Indiana University Health, 340 W Tenth Street, Suite 4100, Indianapolis, IN, USA
| | - Amit Boukai
- Department of Emergency Medicine, Aventura Hospital and Medical Center, 20900 Biscayne Blvd, Aventura, FL, USA
| | - Dylan D. Cooper
- The Simulation Center at Fairbanks Hall, Indiana University Health, 340 W Tenth Street, Suite 4100, Indianapolis, IN, USA
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Corresponding author at: 340 W Tenth Street, Suite 4100, Indianapolis, IN 46202, USA.
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Maxey BS, White LA, Solitro GF, Conrad SA, Alexander JS. Experimental validation of a portable tidal volume indicator for bag valve mask ventilation. BMC Biomed Eng 2022; 4:9. [PMID: 36384855 PMCID: PMC9668705 DOI: 10.1186/s42490-022-00066-y] [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: 05/31/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Short-term emergency ventilation is most typically accomplished through bag valve mask (BVM) techniques. BVMs like the AMBU® bag are cost-effective and highly portable but are also highly prone to user error, especially in high-stress emergent situations. Inaccurate and inappropriate ventilation has the potential to inflict great injury to patients through hyper- and hypoventilation. Here, we present the BVM Emergency Narration-Guided Instrument (BENGI) - a tidal volume feedback monitoring device that provides instantaneous visual and audio feedback on delivered tidal volumes, respiratory rates, and inspiratory/expiratory times. Providing feedback on the depth and regularity of respirations enables providers to deliver more consistent and accurate tidal volumes and rates. We describe the design, assembly, and validation of the BENGI as a practical tool to reduce manual ventilation-induced lung injury. METHODS The prototype BENGI was assembled with custom 3D-printed housing and commercially available electronic components. A mass flow sensor in the central channel of the device measures air flow, which is used to calculate tidal volume. Tidal volumes are displayed via an LED ring affixed to the top of the BENGI. Additional feedback is provided through a speaker in the device. Central processing is accomplished through an Arduino microcontroller. Validation of the BENGI was accomplished using benchtop simulation with a clinical ventilator, BVM, and manikin test lung. Known respiratory quantities were delivered by the ventilator which were then compared to measurements from the BENGI to validate the accuracy of flow measurements, tidal volume calculations, and audio cue triggers. RESULTS BENGI tidal volume measurements were found to lie within 4% of true delivered tidal volume values (95% CI of 0.53 to 3.7%) when breaths were delivered with 1-s inspiratory times, with similar performance for breaths delivered with 0.5-s inspiratory times (95% CI of 1.1 to 6.7%) and 2-s inspiratory times (95% CI of -1.1 to 2.3%). Audio cues "Bag faster" (1.84 to 2.03 s), "Bag slower" (0.35 to 0.41 s), and "Leak detected" (43 to 50%) were triggered close to target trigger values (2.00 s, 0.50 s, and 50%, respectively) across varying tidal volumes. CONCLUSIONS The BENGI achieved its proposed goals of accurately measuring and reporting tidal volumes delivered through BVM systems, providing immediate feedback on the quality of respiratory performance through audio and visual cues. The BENGI has the potential to reduce manual ventilation-induced lung injury and improve patient outcomes by providing accurate feedback on ventilatory parameters.
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Affiliation(s)
- Benjamin S Maxey
- Department of Molecular & Cellular Physiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103-3932, USA
| | - Luke A White
- Department of Molecular & Cellular Physiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103-3932, USA
| | - Giovanni F Solitro
- Department of Orthopaedic Surgery, LSU Health Shreveport, Shreveport, LA, USA
| | - Steven A Conrad
- Department of Medicine, LSU Health Shreveport, Shreveport, LA, USA
- Department of Emergency Medicine, LSU Health Shreveport, Shreveport, LA, USA
- Department of Pediatrics, LSU Health Shreveport, Shreveport, LA, USA
| | - J Steven Alexander
- Department of Molecular & Cellular Physiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103-3932, USA.
- Department of Medicine, LSU Health Shreveport, Shreveport, LA, USA.
- Department of Neurology, LSU Health Shreveport, Shreveport, LA, USA.
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Strategies of Advanced Airway Management in Out-of-Hospital Cardiac Arrest during Intra-Arrest Hypothermia: Insights from the PRINCESS Trial. J Clin Med 2022; 11:jcm11216370. [DOI: 10.3390/jcm11216370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Trans-nasal evaporative cooling is an effective method to induce intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest (OHCA). The use of supraglottic airway devices (SGA) instead of endotracheal intubation may enable shorter time intervals to induce cooling. We aimed to study the outcomes in OHCA patients receiving endotracheal intubation (ETI) or a SGA during intra-arrest trans-nasal evaporative cooling. Methods: This is a pre-specified sub-study of the PRINCESS trial (NCT01400373) that included witnessed OHCA patients randomized during resuscitation to trans-nasal intra-arrest cooling vs. standard care followed by temperature control at 33 °C for 24 h. For this study, patients randomized to intra-arrest cooling were stratified according to the use of ETI vs. SGA prior to the induction of cooling. SGA was placed by paramedics in the first-tier ambulance or by physicians or anesthetic nurses in the second tier while ETI was performed only after the arrival of the second tier. Propensity score matching was used to adjust for differences at the baseline between the two groups. The primary outcome was survival with good neurological outcome, defined as cerebral performance category (CPC) 1–2 at 90 days. Secondary outcomes included time to place airway, overall survival at 90 days, survival with complete neurologic recovery (CPC 1) at 90 days and sustained return of spontaneous circulation (ROSC). Results: Of the 343 patients randomized to the intervention arm (median age 64 years, 24% were women), 328 received intra-arrest cooling and had data on the airway method (n = 259 with ETI vs. n = 69 with SGA). Median time from the arrival of the first-tier ambulance to successful airway management was 8 min for ETI performed by second tier and 4 min for SGA performed by the first or second tier (p = 0.001). No significant differences in the probability of good neurological outcome (OR 1.43, 95% CI 0.64–3.01), overall survival (OR 1.26, 95% CI 0.57–2.55), full neurological recovery (OR 1.17, 95% CI 0.52–2.73) or sustained ROSC (OR 0.88, 95% CI 0.50–1.52) were observed between ETI and SGA. Conclusions: Among the OHCA patients treated with trans-nasal evaporative intra-arrest cooling, the use of SGA was associated with a significantly shorter time to airway management and with similar outcomes compared to ETI.
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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Chapman JD, Geneslaw AS, Babineau J, Sen AI. Improving Ventilation Rates During Pediatric Cardiopulmonary Resuscitation. Pediatrics 2022; 150:188943. [PMID: 36000325 DOI: 10.1542/peds.2021-053030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Excessive ventilation at rates of 30 breaths per minute (bpm) or more during cardiopulmonary resuscitation (CPR) decreases venous return and coronary perfusion pressure, leading to lower survival rates in animal models. A review of our institution's pediatric CPR data revealed that patients frequently received excessive ventilation. METHODS We designed a multifaceted quality improvement program to decrease the incidence of clinically significant hyperventilation (≥30 bpm) during pediatric CPR. The program consisted of provider education, CPR ventilation tools (ventilation reminder cards, ventilation metronome), and individual CPR team member feedback. CPR events were reviewed pre- and postintervention. The first 10 minutes of each CPR event were divided into 20 second epochs, and the ventilation rate in each epoch was measured via end-tidal carbon dioxide waveform. Individual epochs were classified as within the target ventilation range (<30 bpm) or clinically significant hyperventilation (≥30 bpm). The proportion of epochs with clinically significant hyperventilation, as well as median ventilation rates, were analyzed in the pre- and postintervention periods. RESULTS In the preintervention period (37 events, 699 epochs), 51% of CPR epochs had ventilation rates ≥30 bpm. In the postintervention period (24 events, 426 epochs), the proportion of CPR epochs with clinically significant hyperventilation decreased to 29% (P < .001). Median respiratory rates decreased from 30 bpm (interquartile range 21-36) preintervention to 21 bpm (interquartile range 12-30) postintervention (P < .001). CONCLUSIONS A quality improvement initiative grounded in improved provider education, CPR team member feedback, and tools focused on CPR ventilation rates was effective at reducing rates of clinically significant hyperventilation during pediatric CPR.
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Affiliation(s)
- Jennifer D Chapman
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Andrew S Geneslaw
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - John Babineau
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Anita I Sen
- Department of Pediatrics, Columbia University Medical Center, New York, New York
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Uhm D, Kim A. Potential Maneuvers for Providing Optimal Tidal Volume Using the One-Handed EC Technique. Healthcare (Basel) 2022; 10:healthcare10081365. [PMID: 35893187 PMCID: PMC9329900 DOI: 10.3390/healthcare10081365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/18/2022] Open
Abstract
Bag-valve-mask is a device that manually provides positive oxygen pressure. The grip technique of the character E and C shape is recommended to carry out this effectively. However, when applying this method, the hand in which the direction of the EC technique should be performed and the degree of adhesion pressure while performing the technique are unknown. This study aims to identify the factors influencing tidal volume and to determine the ideal sealing method between mask and face in the one-handed EC technique to optimize the Vt. A simulation study was conducted using a mechanical lung model in a scenario that resembled respiratory arrest. Multiple regression analyses identified high peak pressure, high left spot adhesion strength of the mask, and low right spot and bottom spot adhesion strength of the mask as significant factors. To provide an optimal Vt, it may be necessary to apply more strength to the left area of the mask when forming the “C” shape with the thumb and index finger of left hand using the one-handed EC technique.
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Affiliation(s)
- Dongchoon Uhm
- Department of Emergency Medical Technology, Daejeon University, 62 Daehak-ro, Dong-gu, Daejeon 300-716, Korea;
| | - Ajung Kim
- Department of Emergency Medical Technology, Kyungil University, 50 Gamasil-gil, Hayang-eup 38428, Korea
- Correspondence: ; Tel.: +82-10-4932-5186
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Hagley SP, Kruppert A, Leal RO, Pizarro del Valle JC, Iannucci C, Hennink I, Boiron L, Hoehne SN. Self-Reported Clinical Practice of Small Animal Cardiopulmonary Resuscitation and Compliance With RECOVER Guidelines Among Veterinarians in Eight Western European Regions. Front Vet Sci 2022; 9:919206. [PMID: 35937302 PMCID: PMC9352391 DOI: 10.3389/fvets.2022.919206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe objective of this study was to assess whether small animal veterinarians across Western Europe are compliant with the 2012 cardiopulmonary resuscitation (CPR) guidelines by the Reassessment Campaign on Veterinary Resuscitation (RECOVER).MethodsA previously published online questionnaire from Switzerland was adapted and translated into 7 languages, corresponding to national languages in Austria, France, Germany, Ireland, Italy, Liechtenstein, Netherlands, Portugal, Spain, and the United Kingdom. The survey was distributed via respective national veterinary organizations and social media outlets. A subset of questions was analyzed to evaluate respondent demographics, RECOVER guideline awareness, and to allocate composite compliance scores for CPR preparedness, basic life support (BLS) and advanced life support (ALS). Percentages of group total (95% confidence interval) were calculated. Multivariable logistic regression was used to evaluate the effects of region of practice, gender, age, specialty training, and guideline awareness on compliance. Odds ratios (95% confidence interval) were generated and significance set at P < 0.05.ResultsNine-hundred and thirty respondents were included in analysis. Awareness of and compliance with RECOVER guidelines varied widely across regions. Compliance with all assessed RECOVER guideline recommendations was highest in Germany/Austria [14% (7- 27%)] and lowest in France and Portugal [0% (0–3%)]. CPR preparedness compliance was higher in participants aware of RECOVER guidelines [OR 10.1 (5.2-19.5)], those practicing in Germany/Austria [OR 4.1 (1.9–8.8)] or UK/Ireland [OR 2.2 (1.3–3.7)], and lower in those practicing in Portugal [OR 0.2 (0.1–0.9)]. Specialty training [OR 1.8 (1.1–2.9)], guideline awareness [OR 5.2 (3.2–8.6)], and practice in Germany/Austria [OR 3.1 (1.5–6.5)], UK/Ireland [OR 2.6 (1.7–4.1)], or the Netherlands [OR 5.3 (2.0–14.2)] were associated with increased BLS compliance. ALS compliance was higher in participants with guideline awareness [OR 7.0 (2.9–17.0)], specialty training [OR 6.8 (3.8–12.1)], those practicing in Germany/Austria [OR 3.5 (1.3–9.6)], UK/Ireland [OR 4.0 (1.9–8.3)], or Spain [OR 3.2 (1.2–8.3)] and in younger survey participants [OR 0.9 (0.9–1.0)].ConclusionsAwareness and compliance with RECOVER guidelines varied widely among countries surveyed, however overall compliance scores in all countries were considered low. Further research may highlight factors surrounding poor guideline awareness and compliance so targeted efforts can be made to improve veterinary CPR in Europe.
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Affiliation(s)
- Simon P. Hagley
- Emergency and Critical Care Department, Vets Now Referrals, Manchester, United Kingdom
| | - Anne Kruppert
- Division of Anaesthesia and Analgesia, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Rodolfo Oliveira Leal
- CIISA Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Lisbon, Portugal; Associate Laboratory for Animal and Veterinary Sciences (AL4AnimalS)
| | - José Carlos Pizarro del Valle
- , Small Animal Hospital, School of Veterinary Medicine, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Claudia Iannucci
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Imke Hennink
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Science, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ludivine Boiron
- Department of Emergency and Critical Care, Clinique Vétérinaire Languedocia, Montpellier, France
| | - Sabrina N. Hoehne
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA, United States
- *Correspondence: Sabrina N. Hoehne
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Contribution of chest compressions to end-tidal carbon dioxide levels generated during out-of-hospital cardiopulmonary resuscitation. Resuscitation 2022; 179:225-232. [PMID: 35835250 DOI: 10.1016/j.resuscitation.2022.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/23/2022] [Accepted: 07/05/2022] [Indexed: 12/20/2022]
Abstract
AIM Characterise how changes in chest compression depth and rate affect variations in end-tidal CO2 (ETCO2) during manual cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA). METHODS Retrospective analysis of adult OHCA monitor-defibrillator recordings having concurrent capnogram, compression depth, transthoracic impedance and ECG, and with atleast 1,000 compressions. Within each patient, during no spontaneous circulation, nearby segments with changes in chest compression depth and rate were identified. Average ETCO2 within each segment was standardised to compensate for ventilation rate variability. Contributions of relative variations in depth and rate to relative variations in standardised ETCO2 were characterised using linear and non-linear models. Normalisation between paired segments removed intra and inter-patient variation and made coefficients of the model independent of the scale of measurement and therefore directly comparable. RESULTS A total of 394 pairs of segments from 221 patients were analysed (33% female, median (IQR) age 66 (55-74) years). Chest compression depth and rate were 50.4 (43.2-57.0)mm and 111.1 (106.5-116.1)compressions per minute. ETCO2 before and after standardization was 32.1 (23.0-41.4)mmHg and 28.5 (19.4-38.7)mmHg. Linear model coefficient of determination was 0.89. Variation in compression depth mainly explained ETCO2 variation (coefficient 0.95, 95% confidence interval (CI): 0.93-0.98) while changes in compression rate did not (coefficient 0.04, 95% CI: 0.01-0.07). Non-linear trend analysis confirmed the results. CONCLUSION This study quantified the relative importance of chest compression characteristics in terms of their impact on CO2 production during CPR. With ventilation rate standardised, variation in chest compression depth explained variations in ETCO2 better than variation in chest compression rate.
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Jung E, Ro YS, Ryu HH, Shin SD. Association of prehospital airway management technique with survival outcomes of out-of-hospital cardiac arrest patients. PLoS One 2022; 17:e0269599. [PMID: 35666760 PMCID: PMC9170082 DOI: 10.1371/journal.pone.0269599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Despite numerous studies on airway management in out-of-hospital cardiac arrest (OHCA) patients, the choice of prehospital airway management technique remains controversial. Our study aimed to investigate the association between prehospital advanced airway management and survival outcomes according to a transport time interval (TTI) using nationwide OHCA registry database in Korea. Methods The inclusion criteria were patients with OHCA aged over 18 years old with a presumed cardiac etiology between January 2015 and December 2018. The primary outcome was survival to hospital discharge. The main exposure was the prehospital airway management technique performed by the emergency medical technicians (EMTs), classified as bag-valve mask (BVM), supraglottic airway (SGA), or endotracheal intubation (ETI).We performed multivariable logistic regression analysis and interaction analysis between the type of airway management and TTI for adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results Of a total of 70,530 eligible OHCA patients, 26,547 (37.6%), 38,391 (54.4%), and 5,592 (7.9%) were managed with BVM, SGA, ETI, respectively. Patients in the SGA and ETI groups had a higher odds of survival to discharge than BVM groups (aOR, 1.11 (1.05–1.16) and 1.13 (1.05–1.23)). And the rates of survival to discharge with SGA and ETI were significantly higher in groups with TTI more than 8 minutes (1.17 (1.08–1.27) and 1.38 (1.20–1.59)). Conclusion The survival to discharge was significantly higher among patients who received ETI and SGA than in those who received BVM. The transport time interval influenced the effect of prehospital airway management on the clinical outcomes after OHCA.
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Affiliation(s)
- Eujene Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ho Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University College of Medicine, Gwangju, Republic of Korea
- * E-mail:
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Wang H, Jaureguibeitia X, Aramendi E, Nichol G, Aufderheide T, Daya MR, Hansen M, Nassal M, Panchal A, Nikollah DA, Alonso E, Carlson J, Schmicker RH, Stephens S, Irusta U, Idris A. Airway Strategy and Ventilation Rates in the Pragmatic Airway Resuscitation Trial. Resuscitation 2022; 176:80-87. [PMID: 35597311 DOI: 10.1016/j.resuscitation.2022.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND We sought to describe ventilation rates during out-of-hospital cardiac arrest (OHCA) resuscitation and their associations with airway management strategy and outcomes. METHODS We analyzed continuous end-tidal carbon dioxide capnography data from adult OHCA enrolled in the Pragmatic Airway Resuscitation Trial (PART). Using automated signal processing techniques, we determined continuous ventilation rate for consecutive 10-second epochs after airway insertion. We defined hypoventilation as a ventilation rate <6 breaths/min. We defined hyperventilation as a ventilation rate >12 breaths/min. We compared differences in total and percentage post-airway hyper- and hypoventilation between airway interventions (laryngeal tube (LT) vs. endotracheal intubation (ETI). We also determined associations between hypo-/hyperventilation and OHCA outcomes (ROSC, 72-hour survival, hospital survival, hospital survival with favorable neurologic status). RESULTS Adequate post-airway capnography were available for 1,010 (LT n=714, ETI n=296) of 3,004 patients. Median ventilation rates were: LT 8.0 (IQR 6.5-9.6) breaths/min, ETI 7.9 (6.5-9.7) breaths/min. Total duration and percentage of post-airway time with hypoventilation were similar between LT and ETI: median 1.8 vs. 1.7 minutes, p=0.94; median 10.5% vs. 11.5%, p=0.60. Total duration and percentage of post-airway time with hyperventilation were similar between LT and ETI: median 0.4 vs. 0.4 minutes, p=0.91; median 2.1% vs. 1.9%, p=0.99. Hypo- and hyperventilation exhibited limited associations with OHCA outcomes. CONCLUSION In the PART Trial, EMS personnel delivered post-airway ventilations at rates satisfying international guidelines, with only limited hypo- or hyperventilation. Hypo- and hyperventilation durations did not differ between airway management strategy and exhibited uncertain associations with OCHA outcomes.
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Kshetry RL, Gupta A, Chattopadhyaya S, Srivastava M, Sharma S, Singh J, Gupta AD, Rajkumar S. Design and Analysis of a Low-Cost Electronically Controlled Mobile Ventilator, Incorporating Mechanized AMBU Bag, for Patients during COVID-19 Pandemic. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6436818. [PMID: 35368917 PMCID: PMC8968386 DOI: 10.1155/2022/6436818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/05/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
The outbreak of novel COVID-19 has severely and unprecedentedly affected millions of people across the globe. The painful respiratory distress caused during this disease calls for external assistance to the victims in the form of ventilation. The most common types of artificial ventilating units available at the healthcare facilities and hospitals are exorbitantly expensive to manufacture, and their number is fairly inadequate even in the so-called developed countries to cater to the burning needs of an ever-increasing number of ailing human subjects. According to available reports, without the provision of ventilation, the novel COVID-19 patients are succumbing to their ailments in a huge number of cases. This colossal problem of the availability of ventilator units can be addressed to a great extent by readily producible and cost-effective ventilating units that can be used on those suffering patients during an acute emergency and in the absence of conventional expensive ventilators at hospitals and medical care units. This paper has made an attempt to design and simulate a simple, yet effective, mechanized ventilator unit, which can be conveniently assembled without a profuse skillset and operated to resuscitate an ailing human patient. The stepper motor-controlled kinematic linkage is designed to deliver the patient with a necessitated discharge of air at optimum oxygen saturation through the AMBU bag connected in a ventilation circuit. With the associated code on MATLAB, the motor control parameters such as angular displacement and speed are deduced according to the input patient conditions (age group, tidal volume, breathing rate, etc.) and thereafter fed to the controller that drives the stepper motor. With a proposed feedback loop, the real-time static and dynamic compliance, airway resistance values can be approximately determined from the pressure variation cycle and fed to the controller unit to adjust the tidal volume as and when necessary. The simplistic yet robust design not only renders easy manufacturability by conventional and rapid prototyping techniques like 3D printing at different scales but also makes the product easily portable with minimal handling difficulty. Keeping the motto of Health for All as envisioned by the WHO, this low-cost indigenously engineered ventilator will definitely help the poor and afflicted towards their right to health and will help the medical professionals buy some time to manage the patient with acute respiratory distress syndrome (ARDS) towards recovery. Moreover, this instrument mostly includes readily available functional units having standard specifications and can be considered as standard bought-out items.
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Affiliation(s)
- Rohan Lal Kshetry
- School of Nuclear Studies and Application, Jadavpur University, Kolkata 700032, India
| | - Arnab Gupta
- Department of Mechanical Engineering, Indian Institute of Technology, Madras, Tamil Nadu, India
| | - Somnath Chattopadhyaya
- Department of Mechanical Engineering, Indian Institute of Technology (Indian School of Mines), Dhanbad 826004, India
| | - Madhulika Srivastava
- Department of Mechanical Engineering, Amrita School of Engineering, Amrita Vishwa Vidhyapeetham, Chennai, Tamil Nadu, India
| | - Shubham Sharma
- Mechanical Engineering Department, University Center for Research and Development, Chandigarh University, Mohali, Punjab, India
- Department of Mechanical Engineering, IK Gujral Punjab Technical University, Kapurthala 144603, India
| | - Jujhar Singh
- Department of Mechanical Engineering, IK Gujral Punjab Technical University, Kapurthala 144603, India
| | - Anirban Das Gupta
- Department of Anatomy, AIIMS Kalyani, NH–34 Connector,Basantapur, Saguna, West Bengal 741245, India
| | - S. Rajkumar
- Department of Mechanical Engineering, Faculty of Manufacturing, Institute of Technology, Hawassa University, Awasa, Ethiopia
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Zhang L, Jin K, Sun F, Xu J, Yu X, Zhu H, Fu Y, Liu D, Yu S. Assessment of a new volumetric capnography-derived parameter to reflect compression quality and to predict return of spontaneous circulation during cardiopulmonary resuscitation in a porcine model. J Clin Monit Comput 2022; 36:199-207. [PMID: 33511562 DOI: 10.1007/s10877-020-00637-1] [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: 04/01/2020] [Accepted: 12/17/2020] [Indexed: 11/25/2022]
Abstract
We aimed to evaluate a volumetric capnography (Vcap)-derived parameter, the volume of CO2 eliminated per minute and per kg body weight (VCO2/kg), as an indicator of the quality of chest compression (CC) and to predict the return to spontaneous circulation (ROSC) under stable ventilation status. Twelve male domestic pigs were utilized for the randomized crossover study. After 4 min of untreated ventricular fibrillation (VF), mechanical cardiopulmonary resuscitation and ventilation were administered. Following 5-min washout periods, each animal underwent two sessions of experiments: three types of CC quality for 5 min stages in the first session, followed by advanced life support, consecutively in two sessions. Different CC quality had a significant effect on the partial pressure of end-tidal carbon dioxide (PetCO2), VCO2/kg, aortic pressure (mean), aortic systolic pressure, aortic diastolic pressure, right atrial pressure (mean), and carotid blood flow (P < 0.05). With the improvement in CC quality, the values of PetCO2 and VCO2/kg also increased, and the difference between the groups was statistically significant (P < 0.05). The Spearman rank test revealed a significant correlation between the Vcap-derived parameters and hemodynamics. PetCO2 and VCO2/kg have similar capabilities for discriminating survivors from non-survivors, and the area under the curve for both was 0.97. VCO2/kg had similar performance as PetCO2 in reflecting the quality of CC and prediction of achieving ROSC under stable ventilation status in a porcine model of VF-related cardiac arrest. However, VCO2/kg requires a longer time to achieve a stable state after adjusting for quality of CC than PetCO2.
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Affiliation(s)
- Lili Zhang
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Kui Jin
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Feng Sun
- Emergency Department, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Jun Xu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Danyu Liu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Shanshan Yu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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W Lyng J, Guyette FX, Levy M, Bosson N. Prehospital Manual Ventilation: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:23-31. [PMID: 35001826 DOI: 10.1080/10903127.2021.1981506] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. Several strategies and adjunct technologies can increase the effectiveness of manual ventilation. NAEMSP recommends:All EMS clinicians must be proficient in bag-valve-mask ventilation.BVM ventilation should be performed using a two-person technique whenever feasible.EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.
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Carlson JN, Colella MR, Daya MR, J De Maio V, Nawrocki P, Nikolla DA, Bosson N. Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:54-63. [PMID: 35001831 DOI: 10.1080/10903127.2021.1971349] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends:Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA.Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest.EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation.Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.
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Lee JJ, Pyo SY, Lee JH, Park GJ, Kim SC, Kim H, Lee SW, Kim YM, Chai HS. Effects of Changes in Inspiratory Time on Inspiratory Flowrate and Airway Pressure during Cardiopulmonary Resuscitation: A Manikin-Based Study. KOSIN MEDICAL JOURNAL 2021. [DOI: 10.7180/kmj.2021.36.2.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives: Given that cardiopulmonary resuscitation (CPR) is an aerosol-generating procedure, it is necessary to use a mechanical ventilator and reduce the number of providers involved in resuscitation for in-hospital cardiac arrest in coronavirus disease (COVID-19) patients or suspected COVID-19 patients. However, no study assessed the effect of changes in inspiratory time on flowrate and airway pressure during CPR. We herein aimed to determine changes in these parameters during CPR and identify appropriate ventilator management for adults during CPR.Methods: We measured changes in tidal volume (Vt), peak inspiratory flow rate (PIFR), peak airway pressure (Ppeak), mean airway pressure (Pmean) according to changes in inspiratory time (0.75 s, 1.0 s and 1.5 s) with or without CPR. Vt of 500 mL was supplied (flowrate: 10 times/min) using a mechanical ventilator. Chest compressions were maintained at constant compression depth (53 ± 2 mm) and speed (102 ± 2/min) using a mechanical chest compression device.Results: Median levels of respiratory physiological parameters during CPR were significantly different according to the inspiratory time (0.75 s vs. 1.5 s): PIFR (80.8 [73.3 – 87.325] vs. 70.5 [67 – 72.4] L/min, P < 0.001), Ppeak (54 [48 – 59] vs. 47 [45 – 49] cmH<sub>2</sub>O, P < 0.001), and Pmean (3.9 [3.6 – 4.1] vs. 5.7 [5.6 – 5.8] cmH<sub>2</sub>O, P < 0.001).Conclusions: Changes in PIFR, Ppeak, and Pmean were associated with inspiratory time. PIFR and Ppeak values tended to decrease with increase in inspiratory time, while Pmean showed a contrasting trend. Increased inspiratory time in low-compliance cardiac arrest patients will help in reducing lung injury during adult CPR.
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Bakhsh A, Alghoribi R, Arbaeyan R, Mahmoud R, Alghamdi S, Saddeeg S. Endotracheal Intubation Versus No Endotracheal Intubation During Cardiopulmonary Arrest in the Emergency Department. Cureus 2021; 13:e19760. [PMID: 34938635 PMCID: PMC8685837 DOI: 10.7759/cureus.19760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 11/05/2022] Open
Abstract
Background There is a lack of studies addressing the short and long-term outcomes of using different airway interventions in patients with cardiopulmonary arrest in the emergency department (ED). This retrospective chart review aimed to investigate the effect of endotracheal intubation (ETI) versus no ETI during cardiopulmonary arrest in the ED on return of spontaneous circulation (ROSC) and survival to discharge. Methodology A total of 168 charts were reviewed from August 2017 to April 2019. Resuscitation characteristics were obtained from Utstein-style-based cardiopulmonary arrest flow sheets. Results Unadjusted analysis showed no difference in ROSC (45.5% in ETI vs. 54.5% in no-ETI) (p = 0.08) and survival to hospital discharge at 28 days (26.7% in ETI vs. 73.3% in non-ETI) (p = 0.07) when comparing ETI versus non-ETI airway management methods during cardiopulmonary resuscitation (CPR). After adjusting for confounding factors, our regression analysis revealed that the use of ETI is associated with lower odds of ROSC (odds ratio [OR] = 3.40, 95% confidence interval [CI] = [0.14-0.84]) and survival to hospital discharge at 28 days (OR = 0.20, 95% CI = [0.04-0.84]). Conclusions ETI during CPR in the ED is associated with worse ROSC and survival to hospital discharge at 28 days.
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Affiliation(s)
- Abdullah Bakhsh
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Reema Alghoribi
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Rehab Arbaeyan
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Raghad Mahmoud
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Sana Alghamdi
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Shahd Saddeeg
- Department of Emergency Medicine, King Abdulaziz University Hospital, Jeddah, SAU
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46
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Bosson N, Hansen M, Gausche-Hill M, Lewis RJ, Wendelberger B, Shah MI, VanBuren JM, Wang HE. Design of a novel clinical trial of prehospital pediatric airway management. Clin Trials 2021; 19:62-70. [PMID: 34875893 DOI: 10.1177/17407745211059855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency, Santa Fe Springs, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Roger J Lewis
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.,Berry Consultants, LLC, Austin, TX, USA
| | | | - Manish I Shah
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
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47
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Nassal MMJ, Jaureguibeitia X, Aramendi E, Irusta U, Panchal AR, Wang HE, Idris A. Novel application of thoracic impedance to characterize ventilations during cardiopulmonary resuscitation in the pragmatic airway resuscitation trial. Resuscitation 2021; 168:58-64. [PMID: 34506874 PMCID: PMC8928139 DOI: 10.1016/j.resuscitation.2021.08.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Significant challenges exist in measuring ventilation quality during out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Since ventilation is associated with outcomes in cardiac arrest, tools that objectively describe ventilation dynamics are needed. We sought to characterize thoracic impedance (TI) oscillations associated with ventilation waveforms in the Pragmatic Airway Resuscitation Trial (PART). METHODS We analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Fort Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signals. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases. We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test. RESULTS We included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71 Ω, Ae 0.70 Ω vs LT: Ai 0.46 Ω, Ae 0.45 Ω; p < 0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22 Ω, Ae 1.14 Ω VS LT: Ai 0.74 Ω, Ae 0.68 Ω; p < 0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups. CONCLUSION Compared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.
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Affiliation(s)
- Michelle M J Nassal
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Xabier Jaureguibeitia
- Department of Communication Engineering, BioRes Group, University of the Basque Country, Bilbao, Spain
| | - Elisabete Aramendi
- Department of Communication Engineering, BioRes Group, University of the Basque Country, Bilbao, Spain
| | - Unai Irusta
- Department of Communication Engineering, BioRes Group, University of the Basque Country, Bilbao, Spain
| | - Ashish R Panchal
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Ahamed Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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48
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Martinez-Ávila MC, Almanza Hurtado A, Trespalacios Sierra A, Rodriguez Yanez T, Dueñas-Castell C. Lazarus Phenomenon: Return of Spontaneous Circulation After Cessation of Prolonged Cardiopulmonary Resuscitation in a Patient With COVID-19. Cureus 2021; 13:e17089. [PMID: 34527476 PMCID: PMC8431987 DOI: 10.7759/cureus.17089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 11/14/2022] Open
Abstract
The pandemic caused by the SARS-CoV-2 or COVID-19 infection has had an unimaginable impact on health systems worldwide. Cardiorespiratory arrest remains a potentially reversible medical emergency that requires the performance of a set of maneuvers designed to replace and restore spontaneous breathing and circulation. Suspending cardiopulmonary resuscitation (CPR) usually corresponds to an ethical-clinical dilemma that the health professional in charge must assume. The “Lazarus phenomenon” is an unusual syndrome with a difficult pathophysiological explanation, defined as the spontaneous return of circulation in the absence of any life support technique or after the cessation of failed CPR maneuvers. We present the case of a 79-year-old patient hospitalized in the intensive care unit for septic shock of pulmonary origin associated with COVID-19 infection who presented cardiorespiratory arrest that required unsuccessful resuscitation maneuvers for 40 minutes, declared deceased. After 20 minutes of death, he presented a return to spontaneous circulation. The pathophysiological changes of the Lazarus phenomenon remind us of the limitations we have in determining when to end cardiopulmonary resuscitation and that its interruption must be approached with more caution, especially in the context of the COVID-19 pandemic.
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49
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Okubo M, Komukai S, Izawa J, Aufderheide TP, Benoit JL, Carlson JN, Daya MR, Hansen M, Idris AH, Le N, Lupton JR, Nichol G, Wang HE, Callaway CW. Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2021; 79:118-131. [PMID: 34538500 DOI: 10.1016/j.annemergmed.2021.07.114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/10/2021] [Accepted: 07/12/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest. METHODS We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute. RESULTS Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14). CONCLUSION In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junichi Izawa
- Department of Internal Medicine, Okinawa Prefectural Yaeyama Hospital, Okinawa, Japan
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Ahamed H Idris
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nancy Le
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Joshua R Lupton
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, USA
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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50
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Berve PO, Irusta U, Kramer-Johansen J, Skålhegg T, Aramendi E, Wik L. Tidal volume measurements via transthoracic impedance waveform characteristics: The effect of age, body mass index and gender. A single centre interventional study. Resuscitation 2021; 167:218-224. [PMID: 34480974 DOI: 10.1016/j.resuscitation.2021.08.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Measuring tidal volumes (TV) during bag-valve ventilation is challenging in the clinical setting. The ventilation waveform amplitude of the transthoracic impedance (TTI-amplitude) correlates well with TV for an individual, but poorer between patients. We hypothesized that TV to TTI-amplitude relations could be improved when adjusted for morphometric variables like body mass index (BMI), gender or age, and that TTI-amplitude cut-offs for ventilations with adequate TV (>400ml) could be established. MATERIALS AND METHODS Twenty-one consenting adults (9 female, and 9 overall overweight) during positive pressure ventilation in anaesthesia before scheduled surgery were included. Seventeen ventilator modes were used (⩾ five breaths per mode) to adjust different TVs (150-800 ml), ventilation frequencies (10-30 min-1) and insufflation times (0.5-3.5 s). TTI from the defibrillation pads was filtered to obtain ventilation TTI-amplitudes. Linear regression models were fitted between target and explanatory variables, and compared (coefficient of determination, R2). RESULTS The TV to TTI-amplitude slope was 1.39 Ω/l (R2=0.52), with significant differences (p<0.05) between male/female (1.04 Ω/l vs 1.84 Ω/l) and normal/overweight subjects (1.65 Ω/l vs 1.04 Ω/l). The median (interquartile range) TTI-amplitude cut-off for adequate TV was 0.51 Ω(0.14-1.20) with significant differences between males and females (0.58 Ω/0.39 Ω), and normal and overweight subjects (0.52 Ω/0.46 Ω). The TV to TTI-amplitude model improved (R2=0.66) when BMI, age and gender were included. CONCLUSIONS TTI-amplitude to TV relations were established and cut-offs for ventilations with adequate TV determined. Patient morphometric variables related to gender, age and BMI explain part of the variability in the measurements.
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Affiliation(s)
- P O Berve
- Norwegian National Advisory Unit for Prehospital Emergency Medicine (NAKOS), Oslo University Hospital - Ullevål and University of Oslo, Po Box 4956 Nydalen, N-0424 Oslo, Norway; Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway.
| | - U Irusta
- Communications Engineering Department, University of the Basque Country UPV/EHU, Alameda Urquijo S/N, 48013 Bilbao, Spain; Biocruces Bizkaia Health Research Institute, Cruces Plaza, 48903 Barakaldo, Bizkaia, Spain
| | - J Kramer-Johansen
- Norwegian National Advisory Unit for Prehospital Emergency Medicine (NAKOS), Oslo University Hospital - Ullevål and University of Oslo, Po Box 4956 Nydalen, N-0424 Oslo, Norway; Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - T Skålhegg
- Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
| | - E Aramendi
- Communications Engineering Department, University of the Basque Country UPV/EHU, Alameda Urquijo S/N, 48013 Bilbao, Spain; Biocruces Bizkaia Health Research Institute, Cruces Plaza, 48903 Barakaldo, Bizkaia, Spain
| | - L Wik
- Norwegian National Advisory Unit for Prehospital Emergency Medicine (NAKOS), Oslo University Hospital - Ullevål and University of Oslo, Po Box 4956 Nydalen, N-0424 Oslo, Norway; Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
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