High-
Performance
Ventilation
High
Performance
Ventilation
In the landscape of pre-hospital cardiopulmonary resuscitation (CPR), the emphasis has traditionally been placed on cardiac massage techniques, inadvertently sidelining the critical aspect of patient oxygenation during cardiac arrest. This oversight underscores the pressing need for a paradigm shift towards a comprehensive approach that integrates effective ventilation strategies alongside cardiac support.
Central to this shift is the definition of high-performance ventilation criteria, which not only aligns with CPR guidelines but also mitigates risks such as hyperventilation and gas leakage. However, translating these criteria into actionable practice poses a significant challenge without adequate monitoring and feedback mechanisms. It is within this context that the integration of Ventilation Feedback Devices (VFDs) emerges as an urgent imperative.
High-performance ventilation could
triple
survival rate
for cardiac arrest patients (8).
By providing real-time feedback and bridging the gap between guidelines and real-life practice, VFDs promise to enhance the quality and efficacy of ventilation interventions, ultimately improving patient outcomes. As we delve deeper into the argument for widespread adoption of VFDs, it becomes evident that they represent a crucial advancement in the pursuit of optimal resuscitative care.
In the landscape of pre-hospital cardiopulmonary resuscitation (CPR), the emphasis has traditionally been placed on cardiac massage techniques, inadvertently sidelining the critical aspect of patient oxygenation during cardiac arrest. This oversight underscores the pressing need for a paradigm shift towards a comprehensive approach that integrates effective ventilation strategies alongside cardiac support.
Central to this shift is the definition of high-performance ventilation criteria, which not only aligns with CPR guidelines but also mitigates risks such as hyperventilation and gas leakage. However, translating these criteria into actionable practice poses a significant challenge without adequate monitoring and feedback mechanisms. It is within this context that the integration of Ventilation Feedback Devices (VFDs) emerges as an urgent imperative.
By providing real-time feedback and bridging the gap between guidelines and real-life practice, VFDs promise to enhance the quality and efficacy of ventilation interventions, ultimately improving patient outcomes. As we delve deeper into the argument for widespread adoption of VFDs, it becomes evident that they represent a crucial advancement in the pursuit of optimal resuscitative care.
It's time to put the 'P' back in 'CPR'
Cardiac arrest management has evolved tremendously over the past 25 years, with innovations like Automated External Defibrillators (AEDs) and automated chest compression devices significantly improving survival rates [1].
As we contemplate these accomplishments, a discernible realization emerges concerning a pivotal element in CPR that may have been inadvertently overlooked: ventilation. While the acronym ‘CPR’ technically denotes ‘Cardio-Pulmonary Resuscitation,’ the focus is frequently centered on the circulatory aspect, with the primary goal of facilitating blood flow to ensure vital organs receive a sufficient supply of oxygen. By highlighting this truth, it becomes unequivocally clear that neglecting the role of effective ventilation undermines the fundamental purpose of blood circulation. While initial minutes of CPR may offer sufficient oxygen levels, especially in witnessed cardiac arrests, ventilation gains prominence as resuscitation progresses and oxygen depletes [2,3].
cardiac arrest
each year in France
each yearworldwide
The persistent challenge of sudden cardiac death continues to claim millions of lives each year, with global survival rates remaining stagnant below 10%. It is now imperative to acknowledge the pivotal role of ventilation in the resuscitation process [4]. The Lancet Commission on Sudden Cardiac Death has recently emphasized the urgency of mobilizing global efforts and fostering innovation to effectively reduce this global health burden.
Cardiac arrest management has evolved tremendously over the past 25 years, with innovations like Automated External Defibrillators (AEDs) and automated chest compression devices significantly improving survival rates [1].
As we contemplate these accomplishments, a discernible realization emerges concerning a pivotal element in CPR that may have been inadvertently overlooked: ventilation. While the acronym ‘CPR’ technically denotes ‘Cardio-Pulmonary Resuscitation,’ the focus is frequently centered on the circulatory aspect, with the primary goal of facilitating blood flow to ensure vital organs receive a sufficient supply of oxygen. By highlighting this truth, it becomes unequivocally clear that neglecting the role of effective ventilation undermines the fundamental purpose of blood circulation. While initial minutes of CPR may offer sufficient oxygen levels, especially in witnessed cardiac arrests, ventilation gains prominence as resuscitation progresses and oxygen depletes [2,3].
The persistent challenge of sudden cardiac death continues to claim millions of lives each year, with global survival rates remaining stagnant below 10%. It is now imperative to acknowledge the pivotal role of ventilation in the resuscitation process [4]. The Lancet Commission on Sudden Cardiac Death has recently emphasized the urgency of mobilizing global efforts and fostering innovation to effectively reduce this global health burden.
cardiac arrest
each year in France
each yearworldwide
The high-performance ventilation criteria
While the shift must be placed on the ventilation, it becomes imperative to delve into the intricacies of high-performance ventilation criteria in cardiopulmonary resuscitation (CPR). We can identify three pivotal elements that define effective ventilation strategies.
Optimal ventilation demands not only the delivery of adequate tidal volume to facilitate gas exchange but also the mitigation of gastric insufflation risks. Achieving this balance ensures efficient oxygenation while minimizing the potential for complications arising from gastric inflation.
Effective ventilation hinges on minimizing gas leakage to maintain optimal lung ventilation. Excessive leakage can compromise the delivery of oxygen to the lungs, undermining resuscitative efforts. Implementing robust sealing mechanisms and vigilant monitoring protocols is essential to minimize gas loss and maximize ventilation efficacy.
High-performance ventilation relies on the avoidance of hyperventilation-induced complications. Hyperventilation poses significant risks, including lung injuries and diminished venous return, which can impede overall resuscitation success.
In light of these factors, it seems evident that adherence to high-performance ventilation criteria is paramount in CPR scenarios. By prioritizing these principles, medical professionals can enhance ventilation efficacy, improve patient outcomes, and ultimately bolster survival rates following cardiac arrest.
While the shift must be placed on the ventilation, it becomes imperative to delve into the intricacies of high-performance ventilation criteria in cardiopulmonary resuscitation (CPR). We can identify three pivotal elements that define effective ventilation strategies.
Optimal ventilation demands not only the delivery of adequate tidal volume to facilitate gas exchange but also the mitigation of gastric insufflation risks. Achieving this balance ensures efficient oxygenation while minimizing the potential for complications arising from gastric inflation.
Effective ventilation hinges on minimizing gas leakage to maintain optimal lung ventilation. Excessive leakage can compromise the delivery of oxygen to the lungs, undermining resuscitative efforts. Implementing robust sealing mechanisms and vigilant monitoring protocols is essential to minimize gas loss and maximize ventilation efficacy.
High-performance ventilation relies on the avoidance of hyperventilation-induced complications. Hyperventilation poses significant risks, including lung injuries and diminished venous return, which can impede overall resuscitation success.
In light of these factors, it seems evident that adherence to high-performance ventilation criteria is paramount in CPR scenarios. By prioritizing these principles, medical professionals can enhance ventilation efficacy, improve patient outcomes, and ultimately bolster survival rates following cardiac arrest.
Provide an adequate volume
while minimizing the risk of gastric insufflation
Avoid excessive gas leakage
which can result in inadequate ventilation of the patient’s lungs.
Avoid hyperventilation
which creates lung injuries and reduces venous return
Survival is not enough !
While most of the research studies in the field of CPR are looking at ROSC and survival rates as the primary outcomes, the quality-of-life post-survival is equally crucial. The objective is not merely to save lives but to ensure that survivors can reclaim a semblance of normalcy.
Inadequate ventilation management during cardiac arrest can lead to severe complications such as Acute Respiratory Distress Syndrome (ARDS) (5). This condition often results in lung injuries and profound hypoxemia, significantly impacting patient outcomes. Proper ventilation strategies are crucial in mitigating the risk of ARDS and improving survival rates and conditions following cardiac events.
Brain injury after resuscitation, another common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. A study focusing on the long-term neurological consequences following out-of-hospital cardiac arrest (OHCA), highlighted the stark reality that neurological impairments persist even in those successfully resuscitated. Their findings reveal a striking statistic, indicating that only 4.3% of survivors achieve favorable neurological outcomes (CPC 1-2) at the 5-year mark (6).
Neurological complications, ranging from cognitive deficits to motor impairments, can profoundly turn survival into a prolonged struggle. Rehabilitative therapies can improve a person’s functional status in some cases, but these impairments often impact their ability to work, live independently, and engage in even the simplest daily activities, such as bathing, getting dressed, and interacting socially. As a result, psychological difficulties are also included in assessments of functional deficits following cardiac arrest and resuscitation, as many people may struggle with negative emotional repercussions during their recovery and long afterward (7).
Post cardiac arrest sequelae
Neurological outcomes
Respiratory insufficiency
Impacts on everyday life
While the deleterious consequences of inadequate ventilation on patient survival outcomes are well known, a recent study (8) demonstrates a significant improvement in neurological outcomes through adequate ventilation during the initial phases of cardiopulmonary resuscitation: effective ventilation through adequate tidal volume could increase the rates of favorable neurological outcomes fivefold (10.6% versus 2.4%; P < 0.0001).
Effective ventilation could multiply by five favorable neurological outcomes.
Challenge of adhering to guidelines without measurement
In the realm of cardiopulmonary resuscitation, particularly manual ventilation during cardiac arrest, a significant discrepancy exists between established guidelines and actual practice. For over two decades, the guidelines set forth by the European Resuscitation Council and the American Heart Association have remained largely unaltered, advocating for a tidal volume of 6-8 ml/kg and a ventilation rate of 10/min (9). This consistency was intended to facilitate uniform practice and improvement over time, but the reality presents a stark contrast. Studies reveal a systemic non-compliance with ventilation guidelines, challenging even among highly trained professionals. The need for a device making guidelines achievable standards is real.
In France, only 15% of 140 emergency medicine professionnals adhered to the guidelines (10).
In Denmark, 22% of 32 ambulance crews met the recommended standards (11).
In South Korea, 18.46% of delivered volumes were within the recommended range (12).
In the US, only 40% received a clinical significant tidal volume (13).
What is not measured cannot be improved
The guidelines establish explicit goals for delivering a certain tidal volume at a certain ventilation frequency. However, without a monitoring mechanism, these indicators are unattainable. Without a ventilation measurement tool, it is not possible to improve practice.
Without such tools, compliance is left to chance and subjective judgment, rendering any set limits ineffective. Thus, in medical practice, as in traffic management, the ability to measure is the bedrock upon which improvement and compliance rest. It is a simple yet profound truth: unmeasured objectives serve no purpose, for what cannot be quantified, cannot be corrected or perfected.
The issue of unmeasured ventilation quality has even been raised in a recent study, citing novel devices and methods enabling ventilation measurement during CPR (14).
From guidelines to the field : the need of real-time ventilation feedback devices (VFD)
The integration of Ventilation Feedback Devices (VFDs) into routine practice is an urgent imperative, bridging the gap between guidelines and the real life.
Numerous studies have evidenced a substantial enhancement in ventilation performance when utilizing devices such as the EOlife. This is exemplified by the study conducted by Khoury et al., which spanned advanced ventilation simulations both with basic and advanced airways. Their findings consistently indicated an improvement in targeted ventilation performance by over 70%, increasing from a mere 15% within the target range to 90% during BVM (10). Another recent study by Charlton et al., conducted using the- which only measure the volume delivered at the patient connector of the manual ventilator and do not account for inspiratory leaks – also demonstrated an improvement in the delivered volumes, increasing from 9% to 91% within the target range, although it was performed on intubated mannequins only (13).
These devices, when operational and approved by regulatory authorities, are not just safe; they provide a precise account of the tidal volumes administered to patients. Preliminary evidence strongly suggests they enhance adherence to guidelines.
Further, it is imperative that we empower EMS teams and healthcare organizations with the means to acquire these life-saving tools through administrative, political, and financial support. The recent study by A. Idris et al. (8) illustrates the societal impact of such advancements.
The integration of Ventilation Feedback Devices (VFDs) into routine practice is an urgent imperative, bridging the gap between guidelines and the real life.
Numerous studies have evidenced a substantial enhancement in ventilation performance when utilizing devices such as the EOlife. This is exemplified by the study conducted by Khoury et al., which spanned advanced ventilation simulations both with basic and advanced airways. Their findings consistently indicated an improvement in targeted ventilation performance by over 70%, increasing from a mere 15% within the target range to 90% during BVM (10). Another recent study by Charlton et al., conducted using the- which only measure the volume delivered at the patient connector of the manual ventilator and do not account for inspiratory leaks – also demonstrated an improvement in the delivered volumes, increasing from 9% to 91% within the target range, although it was performed on intubated mannequins only (13).
High-performance ventilation
could
triple
survival rate for
cardiac arrest patients (8).
These devices, when operational and approved by regulatory authorities, are not just safe; they provide a precise account of the tidal volumes administered to patients. Preliminary evidence strongly suggests they enhance adherence to guidelines.
Further, it is imperative that we empower EMS teams and healthcare organizations with the means to acquire these life-saving tools through administrative, political, and financial support. The recent study by A. Idris et al. (8) illustrates the societal impact of such advancements.
High-performance ventilation
could
triple
survival rate for
cardiac arrest patients (8).
High-performance ventilation
could
multiply by five
favorable neurological outcomes (8).
References
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- Sayre MR, Berg RA, Cave DM, et al. Hands-only (compressiononly) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117(16):2162-2167.
- Ornato JP, Peberdy MA. Cardiopulmonary Resuscitation. Totowa, NJ: Humana Press; 2005.
- Marijon, E., Narayanan, K., Smith, K., Barra, S., Basso, C., Blom, M. T., … (2023). The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action. The Lancet Commissions, 402(10405), 883-936. https://doi.org/10.1016/S0140-6736(23)00875-9.
- Nicholas J. Johnson, James A. Town, (2022) Don’t go breaking my. . .lungs? The acute respiratory distress syndrome is common, deadly, and probably underrecognized after cardiac arrest https://doi.org/10.1016/j.resuscitation.2022.06.002
- Baldi, E., Compagnoni, S., Buratti, S., Primi, R., Bendotti, S., Currao, A., … Savastano, S.; all the Lombardia CARe Researchers. (2021). Long-Term Outcome After Out-of-Hospital Cardiac Arrest: An Utstein-Based Analysis. Frontiers in Cardiovascular Medicine, 8:764043. DOI: 10.3389/fcvm.2021.764043.
- Lilja, G., Nilsson, G., Nielsen, N., Wise, M. P., Östman, I., & Cronberg, T. (2015). Anxiety and depression among out-of-hospital cardiac arrest survivors. Resuscitation, 97, 68-75. DOI: https://doi.org/10.1016/j.resuscitation.2015.09.389.
- Idris, A. H., Aramendi Ecenarro, E., Leroux, B., Jaureguibeitia, X., Yang, B. Y., Shaver, S., … Wang, H. E. (2023). Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation, 148. DOI: 10.1161/CIRCULATIONAHA.123.065561.
- Khoury, A., De Luca, A., Sall, F. S., Pazart, L., & Capellier, G. (2015). Performance of manual ventilation: how to define its efficiency in bench studies? A review of the literature. Anaesthesia, 70, 985-992. doi:10.1111/anae.13097
- Khoury, A., De Luca, A., Sall, F. S., Pazart, L., & Capellier, G. (2019). Ventilation feedback device for manual ventilation in simulated respiratory arrest: A crossover manikin study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 27(93). https://doi.org/10.1186/s13049-019-0674-7
- Lyngby, R. M., Clark, L., Kjoelbye, J. S., Oelrich, R. M., Silver, A., Christensen, H. C., Barfod, C., Lippert, F., Nikoletou, D., Quinn, T., & Folke, F. (2021). Higher resuscitation guideline adherence in paramedics with use of real-time ventilation feedback during simulated out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation Plus, 5(100082).
- Heo, S., Yoon, S. Y., Kim, J., Kim, H. S., Kim, K., Yoon, H., Hwang, S. Y., Cha, W. C., & Kim, T. (2020). Effectiveness of a real-time ventilation feedback device for guiding adequate minute ventilation: A manikin simulation study. Medicina, 56(278). doi:10.3390/medicina56060278.
- Karl Charlton, Graham McClelland, Karen Millican, Daniel Haworth, Paul Aitken-Fell, Michael Norton, The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations, Resuscitation Plus, Volume 6, 2021, 100130, ISSN 2666-5204, https://doi.org/10.1016/j.resplu.2021.100130.
- Johannes Wittig, Kristian Krogh, Simon Orlob, Bo Løfgren, Kasper G. Lauridsen (2024)
The black box of unmeasured intra-arrest ventilation DOI:https://doi.org/10.1016/j.resuscitation.2023.110015
Pictures credit : Archeon / Freepik / Adobe Stock
