b-card symposium

From the Idea to the Productb-card Concept & Functionalities

TuesdayMarch 7th

2017

Georges BOUSSIGNAC, MD & Nicolas PESCHANSKI, MD, PhD

Introductionto the b-cardConcept

©B.Garrigue,RN

ILCOR Cardiac Arrest Ventilation

UnresponsivepatientAbnormalrespiration

CallEmergencyServices

CPR30:2SetupDefibrilator

Minimizeinterruptions

ChocMinimizeinterreptions

CPRimmediatelyafter2minutes

Minimizeinterreptions

CPRimmediately

after2minutesMinimizeinterruptions

Post-Ressuscitationtreatment

SaO2 >94-98%NormalPaCO2ECG12lead

Treattheoriginofcardiacarrest

originTerapeutichypothermia

UnchocableRhythm

Asystole/PEA

ChocableRhythmFV-TV

ROSC

EvaluatetheRhythm

ILCOR2015

Optimizing Chest Compressions

Q

Why Optimizing

Chest Compressions?

Optimize chest compressions⇧ length compressions

⇧ depth of compressions

Increase cerebral and coronary perfusion

⇧ ROSC rate

DrGeorgesBoussignac

UnresponsivepatientAbnormalrespiration

CallEmergencyServices

CPR30:2SetupDefibrilator

Minimizeinterruptions

ChocMinimizeinterreptions

CPRimmediatelyafter2minutes

Minimizeinterreptions

CPRimmediately

after2minutesMinimizeinterruptions

Post-Ressuscitationtreatment

SaO2 >94-98%NormalPaCO2ECG12lead

Treattheoriginofcardiacarrestorigin

Terapeutichypothermia

UnchocableRhythm

Asystole/PEA

ChocableRhythmFV-TV

ROSC

Evaluatetherhythm

ILCOR2015

Oxygenation ?

EtCO2

ILCOR2015

O2

Correct oxygenation of the patient -> Efficacy of oxygenation

Control the quality of ventilation -> Capnography – EtC02

Recommendations

Can We Do Both

(Ventilation and Oxygenation)

Correctly and at the Same Time?

Q

ILCOR2015 CPR

30:2Continuous Ventilation 10-12/min

ILCOR2015

The goal is to ventilate and

oxygenate the patient by minimizing

chest compressions interruptions

without damaging hemodynamics

Ventilation Is Still A Stake

What Is the Current Practice of

Ventilation Techniques in the Field?

Q

Prolonged interruptions in chest compressions, for

reasons other than defibrillation, worsen clinical

outcomes for out-of-hospital cardiac arrest

patients with ventricular fibrillation

13

BrouwerT,WalkerR,ChapmanF,Koster,R.AssociationBetweenChestCompressionInterruptionsandClinicalOutcomesofVentricularFibrillationOut-of-HospitalCardiacArrest. Circulation. 2015;132:1030-1037.

DrGeorgesBoussignac

RealCPRIdealCPR

30 30 30 30

2 2 2

30 30 302

22

30Chestcompressions2insufflations

10s

20s

« Most of the time, interruption in chest compressions is too long (20 secs) and chest compressions are not delivered

Berg,etal.Circulation2001

Manual ventilation in the field todayDrGeorgesBoussignac

Interrupt chest compressions for ventilation

may damage heamodynamics during CPR (coronary perfusion pressure

falls)

Data AnalysisContinuous variables such as blood pressures, CPP, iCPP, and bloodgas analyses were evaluated by 2-tailed, unpaired Student’s t test anddescribed as mean!SEM. Continuous variables that were not nor-mally distributed (myocardial blood flows, cardiac outputs, andoxygen deliveries) were evaluated by Mann-Whitney U test anddescribed as median (25%, 75%). In the CC"RB group, wecompared the mean CPP during the first 2 compressions of each15-compression cycle with the last 2 compressions by pairedStudent’s t test. Comparisons of discrete variables, such as rate ofreturn of spontaneous circulation, 1-hour ICU survival, swine cere-bral performance categories, 24-hour survival, and 24-hour goodneurological outcome were evaluated by Fisher’s exact test.

ResultsFor the CC"RB group, the aortic relaxation (“diastolic”)pressures routinely decreased during the interval of 2 rescuebreaths when no compressions were provided, thereby alsodecreasing the CPPs (Figure 1). Therefore, the mean CPP ofthe first 2 compressions in each compression cycle was lowerthan that of the final 2 compressions (14!1 versus21!2 mm Hg, respectively, P#0.001). This difference was

demonstrable independently at each minute of the 12 minutesof CPR (Figure 2).Thirteen of the 14 animals survived 24 hours with good

neurological outcome. Six of the 7 CC animals and 5 of the7 CC"RB animals were in cerebral performance category 1at 24 hours (ie, normal); 1 in each group was in cerebralperformance category 2, mildly abnormal; and 1 CC"RBanimal was in cerebral performance category 3, severelydisabled. All 13 animals with good neurological outcomecould stand, walk, feed themselves, and actively resist re-straint. Animals in cerebral performance category 1 per-formed these tasks normally; animals in cerebral performancecategory 2 had slightly wobbly gaits, lethargy, or sluggishresponse to restraint. The only animal in category 3 could notwalk and responded quite sluggishly to restraint but woulddrink.At baseline, the CC and CC"RB groups did not differ in

weight, hemoglobin concentration, heart rate, blood pressure,or central venous pressure. Aortic and right atrial compres-sion pressures during each minute of CPR did not differbetween the 2 groups (Table 1). At each minute of CPR, the

Figure 1. Aortic (Ao, dark band) and right atrial(RA, light band) pressures during standard CPR,CC"RB, with a 15:2 compression:ventilation ratio.Aortic relaxation, or diastolic, pressure (lower bor-der of dark band) decreases during each set of 2breaths, resulting in lower CPP during first severalcompressions of next cycle. Right atrial relaxation,or diastolic, pressure is most inferior border. Dif-ference between Ao and RA relaxation pressuresis CPP.

Figure 2. Mean CPP of first 2 compressions (bot-tom line) and last 2 compressions (top line) ofeach 15-compression cycle during CPR withCC"RB at a compression:ventilation ratio of 15:2.Mean CPP difference: *P#0.05; †P#0.01;‡P#0.001.

Berg et al Adverse Effects of Rescue Breathing During CPR 2467

by on February 15, 2009 circ.ahajournals.orgDownloaded from

Side effects

Berg,etal.Circulation2001

DrGeorgesBoussignac

Consequences on Hemodynamics

Is There A Scientific Rational?

Q

Ventilation

during chest

compressions

triggers

asynchronisms

Decreaseofvenousreturn

Positivepressureatdecompression

DrGeorgesBoussignac

What Is Your Solution?

Q

The Conceptof b-card

DrGeorgesBoussignac

• The AV-CCCconceptimproveshemodynamicsandventilation

Ø Gas flow rate at 15L/minØ Turbulences (virtual valve)

created in b-card Ø Control the exit and entry of gas

from the respiratory tract and lungs

Ø Creation of static lung pressure of 5 to 8 cmH2O

BREATHING OUTCOMPRESSION

BREATHING INRELAXATION

Expiratory Resistance

During Chest Compression

Optimised energy transmission from chest compressions to the circulatory system

Increased Intrathoracic Pressure

Improved Heamodynamics

Inspiratory Resistance

During Chest Decompression

Negative Intrathoracic Pressure

Venous return

Increased pre-load and coronary perfusion

Increased cardiac output

b-card Maintains BP

Hands = Ventilator

Did You Test the b-card?

Q

ml

a

bc

d

e f

a. Ressort

b. Soufflet

c. Seringue

d. Prisedepression

danslesoufflet

e. Entréd’air

f. StyletetPapier

millimétrique

f

Pressure transmitted to the thoracic space

Change in lung volume: Vt and FRC

Impact of different ventilation strategies during chest compression. An experimental and clinical study. RL Cordioli, A Lyazidi,N Rey,, JM Grannier, D Savary, L Brochard , JC M Richard.

Bench Tests

Results

60,0

0

20

40

60

80

100

not aged Aged 3 years according to C2134

Pressure limitation under normal use (cmH2O)

Based on the samples tested, the higher end value of the statistical interval is 13.4 cmH2O compared to an acceptance criterion of maximum 60.0 cmH2O

Results

80,0

0

20

40

60

80

100

not aged Aged 3 years according to C2134

Pressure limitation under single fault condition 1:obstruction of the open system (cmH2O)

Based on the samples tested, the higher end value of the statistical interval is 41.4 cmH2O compared to an acceptance criterion of maximum 80.0 cmH2O.

Results

80,0

0

20

40

60

80

100

not aged Aged 3 years according to C2134

Pressure limitation under single fault condition n°2: inappropriate flow rate setting

(cmH2O)

Based on the samples tested, the higher end value of the statistical interval is 42.4 cmH2O compared to an acceptance criterion of maximum 80.0 cmH2O.

Results

- This report proves that b-card creates a positive intra-thoracic pressure at compression and a negative intra-thoracic pressure at decompression which helps improve the venous return and hemodynamics to the whole body. - Secondly, the tidal volume delivered is improved compare to Intermittent Positive Pressure Ventilation with Bag-Valve Mask (BVM). Indeed, the volume delivered at decompression is minimum 315 ml and maximum 369 ml.

SummaryResults

How To Use It?

Q

With a Mask

With a Supraglottic

Device

With an ET Tube

Use of b-card

Continuous Chest Compressions + b-card

April 2016: Evreux General HospitalCardiac Arrest 70-year-old Male CPR with b-card: SpO2 at 80 % then 90%.

b-card in Action

©A.Depil-Duval,MD

40

Conclusion

No Pause Should Be Your Cause

b-card symposium

Thank You for Your AttentionQ & A

TuesdayMarch 7th

2017

Georges BOUSSIGNAC, MD & Nicolas PESCHANSKI, MD, PhD