Higher Ventilation Rate is Associated with Increased Return of Spontaneous Circulation in In-Hospital Cardiac Arrest Patients with Advanced Airways
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Background
Current cardiopulmonary resuscitation (CPR) guidelines recommend a ventilation rate of 10 breaths/min in adult cardiac arrest patients with an advanced airway in place; however, this guideline is based almost exclusively on animal model studies. The objective of this study was to examine the association between mean ventilation rates during in-hospital cardiac arrest with return of spontaneous circulation (ROSC).
Methods
This was a secondary analysis of a cohort undergoing CPR for in-hospital cardiac arrest with an advanced airway in place had that ventilation rate and end-tidal CO 2 (ETCO 2 ) continuously recorded. Subjects were enrolled at 25 tertiary care centers in the United States and United Kingdom. A subset of subjects also had intra-cardiac arrest arterial blood gases collected as part of routine clinical care.
Results
Ventilation rate and ETCO 2 measurements were collected for 222 subjects and arterial blood gas data for 127 subjects. We observed 84.7% of subjects were ventilated > 10 breaths/min. When dichotomized to subjects receiving close to current guidelines (6-12 breaths/min) and those with higher ventilation rates >12 breaths/min, subjects with higher ventilation rates had greater rate of ROSC (45% vs. 24% p = 0.009). Ventilation rate had a significant impact on ROSC even after adjusting for age, sex, shockable initial rhythm, pre-cardiac arrest severity of critical illness, and mechanical chest compression device usage, with an adjusted odds ratio of 1.15 per two breaths/min increase (95% CI 1.04-1.28; p = 0.006). Regression analysis suggested increasing ventilation rates may start to have a negative association with ROSC when beyond 26 breaths/min. Patients ventilated > 12 breaths/min demonstrated increased mean ETCO 2 levels (median 25 mm Hg vs. 17 mm Hg for those with mean ventilation rates within 6-12 breaths/min; p < 0.001). PaO 2 and PaCO 2 levels did not differ between ventilation groups, suggesting that the observed effects may relate to hemodynamic rather than ventilatory effects.
Conclusions
Ventilation in excess of guideline-recommended rates is common. Higher ventilation rates above 6-12 breaths and below 26 breaths/min were associated with increased odds of ROSC. This may be due to improved hemodynamics. Guidelines on ventilation during CPR may require further examination.
