Gasping in response to basic resuscitation efforts: observation in a Swine model of cardiac arrest

Different forms of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the Western world with an estimated number of 275 000 treated with resuscitation attempts by the Emergency Medical Services (EMS) in Europe each year. Overall survival rates remain low, and most studies indicate that around 1 out 10 will survive to 30 days. Amongst the strongest factors associated with survival in OHCA is first recorded rhythm amendable to defibrillation, early defibrillation and prompt initiation of cardiopulmonary resuscitation (CPR). Overall, CPR started prior to EMS arrival has repeatedly been shown to be associated with survival rates 2-3 times higher compared with no such initiation. The primary goal of CPR is to generate sufficient blood flow to vital organs, mainly the brain and heart, until restoration of spontaneous circulation can be achieved. Barriers to the initiation of CPR by bystanders in OHCA include fear of being incapable, causing harm, and transmission of infectious diseases. Partly due to these barriers, and low rates of CPR, the concept of CPR with compression only was proposed as a simpler form of resuscitation with the aim to be more widely accepted by the public in the 1990s. But how reliable is the evidence supporting this simpler form of CPR, and are the outcomes after CO-CPR comparable to standard CPR?

Gasping during refractory out-of-hospital cardiac arrest is a prognostic marker for favourable neurological outcome following extracorporeal cardiopulmonary resuscitation: a retrospective study

Background

Gasping during cardiac arrest is associated with favourable neurological outcomes for out-of-hospital cardiac arrest. Moreover, while extracorporeal cardiopulmonary resuscitation (ECPR) performed for refractory cardiac arrest can improve outcomes, factors for favourable neurological outcomes remain unknown. This study aimed to examine whether gasping during cardiac arrest resuscitation during transport by emergency medical services (EMS) was independently associated with a favourable neurological outcome for patients who underwent ECPR. This retrospective study was based on medical records of all adult patients who underwent ECPR due to refractory cardiac arrest. The primary endpoint was neurologically intact survival at discharge. The study was undertaken at Sapporo Medical University Hospital, a tertiary care centre approved by the Ministry of Health, Labour and Welfare, located in the city of Sapporo, Japan, between January 2012 and December 2018.

Results

Overall, 166 patients who underwent ECPR were included. During transportation by EMS, 38 patients exhibited gasping, and 128 patients did not. Twenty patients who exhibited gasping during EMS transportation achieved a favourable neurological outcome (20/38; 52.6%); 14 patients who did not exhibit gasping achieved a favourable neurological outcome (14/128; 10.9%). Gasping during transportation by EMS was independently associated with favourable neurological outcome irrespective of the type of analysis performed (multiple logistic regression analysis, odds ratio [OR] 9.52; inverse probability of treatment weighting using propensity score, OR 9.14).

Conclusions

The presence of gasping during transportation by EMS was independently associated with a favourable neurological outcome in patients who underwent ECPR. The association of gasping with a favourable neurological outcome in patients with refractory cardiac arrest suggests that ECPR may be considered in such patients.

The prognostic value of agonal respiration in refractory cardiac arrest: a case series of non-shockable cardiac arrest successfully resuscitated through extracorporeal cardiopulmonary resuscitation

Background

Agonal respiration following out-of-hospital cardiac arrest is associated with favorable neurological outcomes. Resuscitation using extracorporeal membrane oxygenation could contribute to achieving favorable neurological outcomes in patients with refractory cardiac arrest.

Case presentation

We report two cases of refractory cardiac arrest with non-shockable rhythms and agonal respiration; both patients were successfully resuscitated through extracorporeal cardiopulmonary resuscitation (ECPR). Both patients were breathing spontaneously upon arrival. One patient was asystolic and the other experienced pulseless electrical activity followed by ventricular fibrillation. Agonal respiration was observed in both and ECPR was implemented, leading to a favorable neurological outcome at discharge.

Conclusion

The presence of agonal respiration has the potential to confer a favorable neurological outcome in patients with refractory cardiac arrest if maintained, even when the initial cardiac rhythm is not shockable. In these cases, resuscitation should not be abandoned, and ECPR should be considered.

Prognostic value of gasping for short and long outcomes during out-of-hospital cardiac arrest: an updated systematic review and meta-analysis

Objective

We systematically reviewed the literature to investigate whether gasping could predict short and long outcomes in patients with out of hospital cardiac arrest (OHCA).

Methods

PubMed, Embase, and Cochrane Library were searched for observational studies regarding the prognostic effect of gasping on short and long outcomes in adults with OHCA. The primary outcome was return of spontaneous circulation (ROSC). The secondary outcomes were favorable neurological outcome at discharge or at 30 days after cardiac arrest;long term (≥6 months) survival; initial shockable rhythm.The Mantel-Haenszel method with random-effects model was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs).

Results

Five studies (six cohorts) were included in the final analysis. In the pooled analysis, gasping was not only associated with a significant increase in ROSC (RR, 1.87; 95% CI, 1.64–2.13; I² = 70%), but also a high likelihood of favorable neurological outcomes (RR, 3.79; 95% CI, 1.86–7.73), long-term survival (RR, 3.46; 95% CI, 1.70–7.07), and initial shockable rhythm (RR, 2.25; 95% CI, 2.05–2.48).

Conclusions

Current evidence indicates that gasping can predict short and long outcomes in patients with OHCA.In addition, gasping is associated with a high likelihood of initial shockable rhythm,which may contribute to positive outcomes.

Advancing resuscitation science

PURPOSE OF REVIEW

To describe an alternative approach for improving survival of patients with out-of-hospital cardiac arrest (OHCA). The survival of patients with OHCA has been poor and relatively unchanged for decades in spite of recurrent national and international guidelines. Although there are exceptions, many thought and continue to think that any change in the guidelines for cardiopulmonary resuscitation should be based on randomized controlled trials in humans. However, many factors, including the need for informed consent, the marked variability of patients, and the variability of the type and quality of bystander and advanced resuscitation efforts, all make such studies problematic. Thus, potentially life-saving procedures are often withheld for decades, resulting in unnecessary loss of life.

RECENT FINDINGS

Many improvements in public health conditions have been made using models of continuous quality improvement. When applied to resuscitation science, once baseline data are obtained, changes based on reliable experimental findings are instituted and outcomes measured. This approach has now been shown to result in significant improvement in neurologically intact survival of patients with OHCA.

SUMMARY

Following this model, we found significant improvement in survival of patients with a witnessed OHCA primary cardiac arrest.

Current Approaches to Cardiopulmonary Resuscitation

Real progress has been made in improving long-term outcome after out-of-hospital cardiac arrest in the past 10 years. Many communities have doubled their survival-to-hospital-discharge rate during this period. Common features of such successful programs include the following: (1) 911 dispatcher-assisted cardiopulmonary resuscitation (CPR) instruction, (2) bystander chest compression-only CPR program, (3) public access defibrillation, including targeted automated external defibrillator programs, (4) renewed emphasis on minimally interrupted chest compressions by emergency medical services responders, and (5) aggressive postresuscitation care, including targeted temperature management and early coronary angiography and intervention. An important lesson from these successful community efforts is that multiple, simultaneous changes to the local cardiac arrest response system are necessary to improve survival. The next exciting step in this quest appears to be the treatment of refractory cardiac arrest with the combination of mechanical CPR, intra-arrest hypothermia, extracorporeal CPR with mechanical circulatory support devices, and early coronary intervention.

Role of manual and mechanical chest compressions during resuscitation efforts throughout cardiac arrest

The previously published randomized trials of mechanical versus manual resuscitation of patients with cardiac arrest are inconclusive, but a recent systematic review concluded: "There is no evidence that mechanical cardiopulmonary resuscitation devices improve survival; to the contrary they may worsen neurological outcome." However, in our view, none of the randomized trials to date are definitive as the manual groups with primary cardiac arrest have not been treated optimally; that is, with minimally interrupted manual chest compressions, as advocated with cardiocerebral resuscitation. Since the mechanical chest compression devices work on different principles, it is possible that, while they may not be as effective and may even be worse in some subsets of patients, they may be preferable in others. Nevertheless, there are situations where manual chest compressions are not practical and, in these, mechanical devices may well be preferable. The Thumper® (Michigan Instruments, MI, USA) and the LUCAS™ (Jolife AB, Lund, Sweden) devices produce sternal compressions at 100 per min. By contrast, the AutoPulse® (ZOLL Circulation, CA, USA) produces chest compressions at a rate of only 80 per min. Since chest compression rate, as reviewed in this article, is important, one would guess that the devices that can produce a faster rate would be more effective. On the other hand, it could be that sternal compressions with manual or mechanical devices may be more or less effective depending on the arrested patient's chest configuration. We speculate that in the subset of patients with barrel chests, where sternal compressions are less likely to be operative, the AutoPulse might be more effective, but less effective in thin-chested individuals, where direct cardiac compression is the major mechanism of forward blood flow in the manual, Thumper and LUCAS methods. The original LUCAS device had the potential of active decompression as well as compression. To market in the USA, holes had to be placed in the 'suction cup'. It would be informative to know whether the original LUCAS device is more effective than the device in which the active decompression has been deactivated.

The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.