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Cardio Pulmonary interactions during CPR
Pr Jean-Christophe M Richard
Pôle SAMU 74 Urgence et Réanimation Centre Hospitalier Annecy Genevois
CONFLICTS OF INTEREST
- Air Liquide Medical Systems (part time)
Financial support for research (Genève /Annecy/Angers)
-VYGON (personal fee for lectures)
-SHILLER
-MAQUET (NAVA)
-COVIDIEN (PAV+) (personal fee for lectures)
-DRAGER (SmartCare)
-GE (FRC)
Circulation Ventilation
Classical interpretation of ventilation during CPR
• ETI + curarised subjects Manual CC
generates 156mL of VT (0 to 390mL)
• ETT + cardiac arrest subjects Manual
CC generates no VT
The median Vt per compression : 41.5 ml (33.0-62.1 ml)
which was considerably less than measured dead space
ml
a
bc
d
e f
a. Ressort
b. Soufflet
c. Seringue
d. Prise de pression
dans le soufflet
e. Entré d’air
f. Stylet et Papier
millimétrique
f
Pressure transmitted into the
thoracic compartment
Change in lung volume: Vt and
FRC
FRC
ml
Reduction in lung volume below FRC
FRC
Reduction in lung volume below FRC induced by Chest
compressions
Flo
w
Paw
V
olu
me
Lung volume reduction below
FRC
FRC
Cordioli et al. J Appl
Physiol 2016
Flow limitation at PEEP 0
PEEP 3 cmH20 PEEP 0 cmH20
Thoracic airways closure limiting inspiratory flow during Chest
compressions
Cordioli et al. J Appl
Physiol 2016
Cordioli et al. Curent Op Crit Care (submitted)
oxygenation
CO
2 e
limin
atio
n
Impact of thoracic airway closure on ventilation and gas exchanges
Vt expired : 319±165 ml (ICC 30:2) 341±142 ml (CCC 30:2)
Risks associated with 30:2 bag mask CPR: Gastric Inflation
CO2 depends on ventilation and circulation
Both depend on chest compression
Accidental observation: Periodic variation of EtCO2 during CPR
Capnogram (EtCO2 waveform) during CPR varies periodically with chest
compressions and ventilation….
CO2
Paw
Capnograms obtained during chest compressions in OHCA
CO2
Capnograms obtained during chest compressions in OHCA
CO2
CO
2
Airways opening
measurements
P-P
aw
CO
2
ITP
CO
2
Intra thoracic
measurements
Thiel cadaver model with CO2 (CAVIAR lab)
Thiel cadaver model with CO2 (CAVIAR lab)
Cordioli et al. Curent Op Crit Care (submitted)
Full Airway patency: PEEP 10 cmH2O Partial and complete airway closure: PEEP < Pclosing
Insufflation from the
ventilator
Alveolar CO2 CO2 Wash out by
fresh gas
How to interpret capnogram during chest compressions?
Insufflation from the
ventilator
Bench Model of CPR with additional CO2
D Luca Grieco et al. AJRCCM (Epub ahead of print)
Full Airway patency: PEEP 5 cmH2O Partial airway closure: PEEP 0 cmH2O
Time
CO2
CO2max
CO2min
CO2
CO2maxAOI =
Airway Opening Index : AOI
= 75%
AOI = 85%
The AOI permits to characterize and quantify oscillations on capnogram that is
correlated with alveolar ventilation
AOI = 5%
CLINICAL OBSERVATIONAL STUDY : 100 OHCA patients:
D Luca Grieco et al. AJRCCM (Epub ahead of print)
Maximal EtCO2 value is the best surrogate of alveolar CO2
0
25
50
75
100
Patients
CO
2 (
mm
Hg
)
OHCA
N=90 Patients
CLINICAL OBSERVATIONAL STUDY : 100 OHCA patients:
D Luca Grieco et al. AJRCCM (Epub ahead of print)
Thiel cadaver model with CO2 (CAVIAR lab)
D Luca Grieco et al. AJRCCM (Epub ahead of print)
CLINICAL OBSERVATIONAL STUDY : 100 OHCA
patients:
Clinical implications:
D Luca Grieco, et al. AJRCCM (Epub ahead of print)
SU
RV
IVA
L
TIME
Brain perfusion guided therapy
4 7 10
Airway Closure? guided
therapy
ETCO2 guided therapy
Annecy CPR Round Table :
Two phase time sensitive model to OHCA
High Quality CPR
Early Defibrillation
Cardiac Pump
Goal Directed Optimization
Cardiac and Thoracic Pump
Consider ECMO
• Ventilation during CPR should be revisited to be adapted to this specific context
• Thoracic airways closure may impair oxygenation and CO2 elimination during CPR.
• Only maximal value of exhaled CO2 during CPR reflect alveolar CO2
• Capnogram oscillations reflect thoracic airways patency and ventilation quality during
CPR
• EtCO2 monitoring during CPR is highly recommended but not adapted to CPR
Recommended