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Ventilation during CPR

Theresa Mariero Olasveengen MD PhD

Department of Anesthesiology

Oslo University Hospital

No conflicts of interest.

Do we really need ventilationduring CPR?

Do we really need POSITIVE PRESSURE ventilation during CPR?

ILCOR/ANZCOR ALS Guidelines

6-10 ventilations/minute

1 second inspiration time

Volume = normal chest movement

No pauses when intubated

www.ilcor.org

resus.org.au

ILCOR/ANZCOR ALS Guidelines

10 ventilations pr minute with 1 secondinspiration time = 10 seconds/min

→ 17% of CPR time spent ventilating

100 compressions pre minute

→ 17 compressions during active ventilation

Death by hyperventilation

Aufderheide et al. Crit Care 2004

Ventilation during CPR

– During compressions (down-stroke)

↑ blood flow from thoracic cavity

↑ airway pressure

– During de-compressions (up-stroke)

↓ venous return

↓ coronary perfusion pressure

Synchronized ventilations?

– Ventilation during compressions (down-stroke)

↑ blood flow from thoracic cavity

↑ airway pressure

Synchronized ventilations?

Human case series – 11 patients

Chandra et al 1980

Synchronized ventilations?

OHCA RCT

Synchronized ventilations?

– Ventilation during de-compressions (down-stroke)

↓ venous return

↓ coronary perfusion pressure?

reasonable airway pressure

Guideline ventilation

Baseline → CA → 30:2 CPR

(2 min) (4 min) «Upstroke» ventilation

(8 min)

Pathology (y/n)“Upstroke”

(n=10)Guideline

(n=10)P-value

Blood/foam in thoracic cavity 0/10 4/6 0.025

Tracheal lacerations 5/5 6/4 0.1

Bronchial laceration 7/3 6/4 0.6

Traumatic bullae (severity score) 2±2 4±2 0.03

Atelectasis (severity score) 4±2 5±2 0.3

Low perfusion area (severity score) 26±11 22±12 0.9

Microhemorrhages (severity score) 11±8 15±9 0.3

Animals: Continuous passive oxygen insufflation?

• Improved effectiveness from compressions

– Higher arterial pressures

– Higher flow rates

• Comparable blood gases

• Comparable 24 h survival (swine)

Steen et al. Resuscitation 2004

Hayes et al. Resuscitation 2007

Soltez et al. Resuscitation 2019

Humans: Continuous passive oxygen insufflation?

• French RCT, 686 patients

– Survival to ICU discharge 2.4 vs. 2.3%

• US observational study, 1019 patients

– Neurologically intact survival 38.2 vs. 25.8%

– Adjusted odds ratio 2.5 (95% CI 1.3 to 4.6)

Bertrand et al. Crit Care Med 2006

Bobrow et al. Ann Emerg Med 2009

Do we really need POSITIVE PRESSURE ventilation during CPR?

→We might very well not…

Thank you!Questions?