End-Tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest

doi:10.1016/S0735-6757(96)90046-7

The American Journal of Emergency Medicine

Volume 14, Issue 4, July 1996, Pages 349-350

https://doi.org/10.1016/S0735-6757(96)90046-7 Get rights and content

Abstract

A study was undertaken to determine the pattern of end-tidal carbon dioxide (etco₂) changes during asphyxia-induced cardiac arrest in a pediatric canine model. Eleven intubated, anesthetized, paralyzed dogs (mean age, 4.1 mo; mean weight, 5.5 kg) were used. Asphyxia was induced by clamping the endotracheal tube (ETT) and discontinuing ventilation. Cardiac arrest ensued a few minutes later, after which closed-chest cardiopulmonary resuscitation (CPR) and ventilation were initiated. The etco₂ level was recorded at baseline and every minute during CPR. Mean baseline etco₂ was 31.9 mm Hg. The initial etco₂ immediately after unclamping the ETT (mean, 35 mm Hg) was higher than subsequent values (mean, 12.4 mm Hg; P < .001). There was a sudden increase in etco₂ to a mean of 27.0 mm Hg at or just before return of spontaneous circulation (ROSC) in all 11 cases (P < .01). During CPR, etco₂ levels were initially high, decreased to low levels, and increased again at ROSC. This pattern, not previously described, is different from that observed in animal and adult cardiac arrest caused by ventricular fibrillation, during which etco₂ decreases to almost zero after the onset of arrest, begins to increase after the onset of effective CPR, and increases to normal levels at ROSC. In this model of asphyxial arrest, continued cardiac output prior to arrest allows continued delivery of CO₂ to the lungs, resulting in higher alveolar CO₂; this, in turn, is reflected as increased etco₂ once ventilation is resumed during CPR. Further study is needed to determine whether the pattern of etco₂ changes can be used prospectively to define the etiology of cardiac arrest.

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To evaluate the cost-effectiveness of EtCO₂ monitoring during in-hospital cardiorespiratory arrest (CA) care outside the intensive care unit (ICU) and emergency room department.
We performed a cost-effectiveness analysis based on a simple decision model cost analysis and reported the study using the CHEERS checklist. Model inputs were derived from a retrospective Brazilian cohort study, complemented by information obtained through a literature review. Cost inputs were gathered from both literature sources and contacts with hospital suppliers.
The analysis was carried out from the perspective of a tertiary referral hospital in a middle-income country.
The study population comprised individuals experiencing in-hospital CA who received cardiopulmonary resuscitation (CPR) by rapid response team (RRT) in a hospital ward, not in the ICU or emergency room department.
Two strategies were assumed for comparison: one with an RRT delivering care without capnography during CPR and the other guiding CPR according to the EtCO₂ waveform.
Incremental cost-effectiveness rate (ICER) to return of spontaneous circulation (ROSC), hospital discharge, and hospital discharge with good neurological outcomes.
The ICER for EtCO₂ monitoring during CPR, resulting in an absolute increase of one more case with ROSC, hospital discharge, and hospital discharge with good neurological outcome, was calculated at Int$ 515.78 (361.57–1201.12), Int$ 165.74 (119.29–248.4), and Int$ 240.55, respectively.
In managing in-hospital CA in the hospital ward, incorporating EtCO2 monitoring is likely a cost-effective measure within the context of a middle-income country hospital with an RRT.
European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth
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The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
Quantitative end-tidal CO<inf>2</inf> can predict increase in heart rate during infant cardiopulmonary resuscitation
2019, Heliyon
To determine the end-tidal CO₂ (ETCO₂) value that predicts a HR > 60 beats per minute (bpm) with the best sensitivity and specificity during neonatal/infant cardiopulmonary resuscitation (CPR) defined as chest compressions ± epinephrine in neonates/infants admitted to a CVICU/PICU.
This was a retrospective cohort study from 1/1/08 to 12/31/12 of all infants ≤6 month of age who received CPR and had ETCO₂ documented during serial resuscitations in the pediatric (PICU) or pediatric cardiovascular intensive care units (CVICU) of Children's Medical Center of Dallas. A receiver operator characteristic (ROC) curve was generated to determine the ETCO₂ cut-off with the best sensitivity and specificity for predicting HR > 60 bpm. Each ETCO₂ value was correlated to the infant's HR at that specific time.
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This study provides critical clinical information regarding correlation between ETCO₂ values and an adequate rise in heart rate in neonates and young infants during CPR. Quantitative ETCO₂ monitoring allows CPR to progress uninterrupted without need to pause to check heart rate every 60 seconds until the critical ETCO₂ threshold is reached. Quantitative ETCO₂ monitoring as an adjunct to cardiac monitoring during infant CPR might enhance perfusion and improve outcomes.
Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest
2016, Resuscitation
Citation Excerpt :
Another use of ETCO2 in resuscitation of OHCA patients would be the indication of ROSC with abrupt and sustained rise of ETCO2 during resuscitation.8–13 Various studies had confirmed that ETCO2 level was higher after ROSC.8,11–13 ETCO2 level during OHCA reflects tissue metabolism, alveolar ventilation, tissue and lung perfusion.
To evaluate the diagnostic accuracy of an abrupt and sustained increase in end-tidal carbon dioxide (ETCO₂) to indicate return of spontaneous circulation (ROSC) during resuscitation of patient with out-of-hospital cardiac arrest.
Cross-sectional study.
Emergency department of two regional hospitals.
Patients with age ≥18 years old, suffered non-traumatic out-of-hospital cardiac arrest with active resuscitation and endotracheal intubation performed in emergency department, were included. ETCO₂ value was charted throughout resuscitation. Time of ROSC was remarked. ETCO₂ levels before and after ROSC were compared. Diagnostic accuracy of ETCO₂ rise ≥10 mmHg, ETCO₂ rise ≥20 mmHg, and ETCO₂ rise to the level ≥40 mmHg were evaluated for indicating ROSC.
ETCO₂ level immediately after ROSC was higher as compared to the value before return of circulation (median ETCO₂ was 32 mmHg and 41 mmHg respectively, p = 0.033). With ETCO₂ rise ≥10 mmHg, the sensitivity was low (33%, 95% CI 22–47%), while specificity was 97% (95% CI 91–99%). Positive and negative predictive values were 83% (95% CI 62–95%) and 74% (95% CI 66–81%) respectively. The diagnostic accuracy was higher in cardiac arrest with presumed non-cardiac etiology (sensitivity 45%, specificity 100%) as compared to those with cardiac etiology (sensitivity 18%, specificity 97%).
The feature of an abrupt rise of ETCO₂ was a specific but non-sensitive marker of ROSC in patient with out-of-hospital cardiac arrest.
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Although high quality cardiopulmonary resuscitation is one of the most significant factors related to favourable outcome, its quality depends on many components, such as airway management, compression depth and chest recoil, hands-off time, and early defibrillation. The most common way of controlling the resuscitation efforts is monitoring of end-tidal carbon dioxide. The International Liaison Committee on Resuscitation suggests this method both for in-hospital and out-of-hospital cardiac arrest. However, despite the abundant human and animal studies supporting the usefulness of end-tidal carbon dioxide, its optimal values during cardiopulmonary resuscitation remain controversial. In this review, the advantages and effectiveness of end-tidal carbon dioxide during cardiopulmonary resuscitation are discussed and specific target values are suggested based on the available literature.

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Original contributionEnd-Tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest

Abstract

Ann Emerg Med

Am J Emerg Med

Resuscitation

Ann Emerg Med

J Am Coll Cardiol

End-tidal carbon dioxide concentration during cardiopulmonary resuscitation

N Engl J Med

Original contribution
End-Tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest