cardio pulmonary interactions during cpr...• ventilation during cpr should be revisited to be...
TRANSCRIPT
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Cardio Pulmonary interactions during CPR
Pr Jean-Christophe M Richard
Pôle SAMU 74 Urgence et Réanimation Centre Hospitalier Annecy Genevois
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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)
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Circulation Ventilation
Classical interpretation of ventilation during CPR
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• ETI + curarised subjects Manual CC
generates 156mL of VT (0 to 390mL)
• ETT + cardiac arrest subjects Manual
CC generates no VT
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The median Vt per compression : 41.5 ml (33.0-62.1 ml)
which was considerably less than measured dead space
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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
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ml
Reduction in lung volume below FRC
FRC
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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
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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
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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
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Vt expired : 319±165 ml (ICC 30:2) 341±142 ml (CCC 30:2)
Risks associated with 30:2 bag mask CPR: Gastric Inflation
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CO2 depends on ventilation and circulation
Both depend on chest compression
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Accidental observation: Periodic variation of EtCO2 during CPR
Capnogram (EtCO2 waveform) during CPR varies periodically with chest
compressions and ventilation….
CO2
Paw
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Capnograms obtained during chest compressions in OHCA
CO2
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Capnograms obtained during chest compressions in OHCA
CO2
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CO
2
Airways opening
measurements
P-P
aw
CO
2
ITP
CO
2
Intra thoracic
measurements
Thiel cadaver model with CO2 (CAVIAR lab)
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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
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Insufflation from the
ventilator
Alveolar CO2 CO2 Wash out by
fresh gas
How to interpret capnogram during chest compressions?
Insufflation from the
ventilator
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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
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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%
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CLINICAL OBSERVATIONAL STUDY : 100 OHCA patients:
D Luca Grieco et al. AJRCCM (Epub ahead of print)
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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)
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Thiel cadaver model with CO2 (CAVIAR lab)
D Luca Grieco et al. AJRCCM (Epub ahead of print)
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CLINICAL OBSERVATIONAL STUDY : 100 OHCA
patients:
Clinical implications:
D Luca Grieco, et al. AJRCCM (Epub ahead of print)
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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
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• 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