Abstract 203: Thoracic Impedance Reflects Differences Between Endotracheal and Laryngeal Advanced Airway During Mechanical Chest Compressions

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Xabier Jaureguibeitia ◽  
Elisabete Aramendi ◽  
Unai Irusta ◽  
Ahamed H Idris ◽  
Henry E Wang
Keyword(s):  
Dead Space ◽  
Compression Therapy ◽  
Laryngeal Tube ◽  
Thoracic Impedance ◽  
Chest Compressions ◽  
Wilcoxon Rank Sum Test ◽  
Advanced Airway ◽  
Management Techniques ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest

Background: Ventilations during out-of-hospital cardiac arrest (OHCA) produce thoracic impedance(TI) waveforms due to air volume changes in the lungs. Different airway management techniques, i.e. laryngeal tube (LT) and endotracheal intubation (ETI), may produce distinct TI waveforms as a result of different air flows and dead space volumes. Methods: Adult OHCA cases from the Pragmatic Airway Resuscitation Trial were analyzed. Cases recorded with Philips MRx monitor-defibrillators and treated with LUCAS mechanical CPR devices were considered, ensuring homogeneous TI acquisition and compression therapy. Impedance and capnogram signal intervals were extracted after successful airway insertion and during ongoing chest compressions. Ventilations were confirmed in the capnogram, and the associated TI waveforms were analyzed. Adaptive filtering was applied to remove compression artifacts, and the amplitudes (A i , A e ) and durations (D i , D e ) of the insufflation and exhalation phases were computed (see Figure). Each case was characterized by its observed median values. Differences between airway groups were assessed with a Wilcoxon rank sum test. Results: Data from 100 OHCA cases (57 LT and 43 ETI) were analyzed, totaling 10348 ventilations, with median (IQR) of 87 (51 - 146) ventilations per case. Median TI amplitudes for ETI and LT groups showed significant differences (p<0.05), with 1.1 (0.7 - 1.8) Ω and 0.7 (0.3 - 1.3) Ω for A i , and 1.0 (0.7 - 1.6) Ω and 0.6 (0.3 - 1.2) Ω for A e . No significant differences were observed for phase durations, 1.6 (1.3 - 2.0) s and 1.6 (1.2 - 1.8) s for D i , and 2.3 (1.8 - 3.3) s and 2.6 (2.0 - 3.3) s for D e . Conclusions: Significant differences on ventilation impedance waveform amplitudes were observed between patients treated with ETI and LT. This might be related to higher insufflated air volumes for ETI or larger dead space volumes for LT.

Abstract 264: Automatic Detection of Ventilations Using the Thoracic Impedance Signal During Lucas Chest Compressions

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Xabier Jaureguibeitia ◽  
Unai Irusta ◽  
Elisabete Aramendi ◽  
Pamela Owens ◽  
Henry E Wang ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Minute Ventilation ◽  
Lung Ventilation ◽  
Detection Algorithm ◽  
Ventilation Rate ◽  
Thoracic Impedance ◽  
Chest Compressions ◽  
Signal Processing Algorithm ◽  
Ventilation Rates ◽  
Mechanical Cpr

Introduction: Resuscitation from out-of-cardiac arrest (OHCA) requires control of both chest compressions and lung ventilation. There are few effective methods for detecting ventilations during cardiopulmonary resuscitation. Thoracic impedance (TI) is sensitive to changes in lung air volumes and may allow detection of ventilations but has not been tested with concurrent mechanical chest compressions. Hypothesis: It is possible to automatically detect and characterize ventilations from TI changes during mechanical chest compressions. Methods: A cohort of 420 OHCA cases (27 survivors to hospital discharge) were enrolled in the Dallas-Fort Worth Center for Resuscitation Research cardiac arrest registry. These patients were treated with the LUCAS-2 CPR device and had concurrent TI and capnogram recordings from MRx (Philips, Andover, MA) monitor-defibrillators. We developed a signal processing algorithm to suppress chest compression artifacts from the TI signal, allowing identification of ventilations. We used the capnogram as gold standard for delivered ventilations. We determined the accuracy of the algorithm for detecting capnogram-indicated ventilations, calculating sensitivity, the proportion of true ventilations detected in the TI, and positive predictive value (PPV), the proportion of true ventilations within the detections. We calculated per minute ventilation rate and mean TI amplitude, as surrogate for tidal volume. Statistical differences between survivors and non-survivors were assessed using the Mann-Whitney test. Results: We studied 4331 minutes of TI during CPR. There were a median of 10 (IQR 6-14) ventilations per min and 52 (30-81) ventilations per patient. Sensitivity of TI was 95.9% (95% CI, 74.5-100), and PPV was 95.8% (95% CI, 80.0-100). The median ventilation rates for survivors and non-survivors were 7.75 (5.37-9.91) min -1 and 5.64 (4.46-7.15) min -1 (p<10 -3 ), and the median TI amplitudes were 1.33 (1.03-1.75) Ω and 1.14 (0.77-1.66) Ω (p=0.095). Conclusions: An accurate automatic TI ventilation detection algorithm was demonstrated during mechanical CPR. The relation between ventilation rate during mechanical CPR and survival was significant, but it was not for impedance amplitude.

Abstract 13110: Novel Application of Thoracic Impedance to Characterize Ventilations During Cardiopulmonary Resuscitation in the Pragmatic Airway Resuscitation Trial

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Michelle Nassal ◽  
Xabier Jaureguibeitia ◽  
Elisabete Aramendi ◽  
Unai Irusta ◽  
Ashish R Panchal ◽  
...  
Keyword(s):  
Signal Processing ◽  
Cardiopulmonary Resuscitation ◽  
Adaptive Filtering ◽  
Laryngeal Tube ◽  
Thoracic Impedance ◽  
Chest Compressions ◽  
Controlled Ventilation ◽  
Novel Approach ◽  
Minute Duration ◽  
End Tidal

Introduction: Controlled ventilation is important in OHCA resuscitation, but there are few validated methods for accurate detection of ventilations. We sought to utilize changes in thoracic impedance (TI) to characterize resuscitation ventilations in the Pragmatic Airway Resuscitation Trial (PART). Methods: We analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Ft Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signal. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases of the ventilation impedance signal (Figure 1). We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test. Results: We included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71Ω, Ae 0.70Ω vs LT: Ai 0.46Ω Ae 0.45Ω, p<0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22Ω, Ae 1.14Ω VS LT: Ai 0.74Ω, Ae 0.68Ω, p<0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups. Conclusion: Compared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.

Abstract 152: Impact of Shock Timing During Mechanical CPR on Defibrillation Efficacy

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Robert G Walker ◽  
Alexander Esibov ◽  
Fred W Chapman
Keyword(s):  
Animal Studies ◽  
Pause Duration ◽  
Chest Compressions ◽  
Shock Delivery ◽  
Termination Rate ◽  
Compression Cycle ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest ◽  
Specific Phase ◽  
Exact Timing

Background: Mechanical CPR (mCPR) devices enable defibrillation shock delivery during ongoing chest compressions, without the pause required during manual CPR. It is unknown whether shock delivery during ongoing mCPR, vs. during a pause, affects VF termination efficacy. Animal studies suggest that during ongoing mCPR, timing a shock to a specific phase of the compression cycle may significantly affect shock efficacy. Methods: We retrospectively analyzed electronic defibrillator recordings from the Amsterdam Resuscitation Study (ARREST), a prospective out-of-hospital cardiac arrest registry. We identified cases with LUCAS mCPR and at least one shock delivered after mCPR initiation. Shocks were sorted by energy level, and the most prevalent (360 J) was selected for the present analysis. Continuous ECG and impedance signals were analyzed to determine VF termination (defined as absence of VF at 5 sec after shock) for each shock after mCPR initiation, and whether the shock was delivered during a pause or during mCPR. For shocks delivered during a pause we measured pre-shock pause duration; for shocks delivered without pausing we measured the exact timing of the shock during the compression cycle. Results: In 153 cases meeting analysis criteria, 509 360J shocks occurred after mCPR initiation; VF termination outcome could be determined for 460. VF termination for first eligible shock during mCPR in each case was 84/97 (87%) during a pause, and 79/93 (85%; p=0.74) during ongoing mCPR; for all eligible shocks, VF termination was 203/242 (83.9%) and 155/196 (79.1%; p=0.20) respectively. For shocks during mCPR, there were no statistically significant differences in VF termination rate for shocks during four equal length phases beginning with LUCAS piston upstroke: 39/44 (89%), 39/49 (80%), 35/51 (69%), 40/50 (80%) (p = 0.12). For shocks during a pause, VF termination rate did not differ for pre-shock pauses ≤5 sec (75/91, 82.4%) vs. >5 sec (128/151, 84.8%; p=0.63). Conclusions: Our results indicate that shocks can be delivered during ongoing mCPR without reducing defibrillation efficacy. The exact shock timing during the mCPR compression cycle did not significantly alter shock efficacy. VF termination rate was not affected by pre-shock pause duration during mCPR.

Abstract 184: Racial Disparities in Out-Of-Hospital Cardiac Arrest Interventions and Survival in the Pragmatic Airway Resuscitation Trial

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Joshua R Lupton ◽  
Robert Schmicker ◽  
Jestin Carlson ◽  
Clifton W Callaway ◽  
Heather Herren ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Airway Management ◽  
Racial Disparities ◽  
Secondary Analysis ◽  
Laryngeal Tube ◽  
Advanced Airway ◽  
Black Patients ◽  
Bystander Cpr ◽  
Hospital Cardiac Arrest ◽  
White Patients

Background: Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate how emergency medical services (EMS) provider assessment of race impacts OHCA interventions and survival. Our objective was to evaluate racial disparities in OHCA airway management and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART). Methods: We conducted a secondary analysis of adult OHCA patients enrolled in PART. Trial subjects were randomized to initial advanced airway management with laryngeal tube or endotracheal intubation. The primary independent variable was patient race (categorized by EMS as white, black, and other). We used general estimating equations (GEE) to examine the association of race (white or black) with airway attempt success, 72-hour survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander CPR, initial rhythm, arrest location, and randomization cluster. Results: Of 3002 patients, race was 1537 white, 860 black, and 605 other. Median times (min [interquartile range]) from dispatch to arrival (5.4 [2.8] vs. 5.0 [2.3]), arrival to CPR (2.2 [2.7] vs. 2.0 [2.7]), and arrival to airway attempt (12.2 [7.6] vs. 11.0 [7.4]) were longer for black compared to white patients, respectively. Black patients had lower unadjusted odds of shockable rhythms (OR 0.59; 95% CI 0.47, 0.74), bystander CPR (0.47; 0.39, 0.56), and survival to discharge (0.68; 0.50, 0.92) than white patients. After adjustment for confounders, black race was not associated with airway success (OR 1.13; 95% CI 0.9, 1.41), 72-hr survival (1.06; 0.81, 1.30), or survival to discharge (0.82; 0.57, 1.19). Conclusions: Although black patients had lower odds of shockable rhythms and bystander CPR, airway success and survival odds were similar to white patients. Further studies are needed to better understand disparities in survival from OHCA.

Thoracic Spine Fracture in a Survivor of Out-of-Hospital Cardiac Arrest with Mechanical CPR

2016 ◽  
Vol 31 (6) ◽  
pp. 684-686 ◽  
Author(s):  
Robert Trevor Marshall ◽  
Hemang Kotecha ◽  
Takuyo Chiba ◽  
Joseph Tennyson
Keyword(s):  
Cardiac Arrest ◽  
Vertebral Fracture ◽  
Thoracic Spine ◽  
Spine Fracture ◽  
Chest Compressions ◽  
Publication Type ◽  
Thoracic Spine Fracture ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest ◽  
Male Survivor

AbstractThis is a report of a thoracic vertebral fracture in a 79-year-old male survivor of out-of-hospital cardiac arrest with chest compressions provided by a LUCAS 2 (Physio-Control Inc.; Lund Sweden) device. This is the first such report in the literature of a vertebral fracture being noted in a survivor of cardiac arrest where an automated compression device was used.MarshallRT, KotechaH, ChibaT, TennysonJ. Thoracic spine fracture in a survivor of out-of-hospital cardiac arrest with mechanical CPR. Prehosp Disaster Med. 2016;31(6):684–686.

Abstract 165: Association of Advanced Airway Placement and Time to Epinephrine Administration in Patients With Out-of-Hospital Cardiac Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Joshua Lupton ◽  
Robert Schmicker ◽  
Mohamud Daya ◽  
Tom Aufderheide ◽  
Shannon Stephens ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
The United States ◽  
Laryngeal Tube ◽  
Early Administration ◽  
Epinephrine Administration ◽  
Kaplan Meier ◽  
Advanced Airway ◽  
Bystander Cpr ◽  
Independent Variable ◽  
Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a significant source of morbidity and mortality in the United States. In addition to cardiopulmonary resuscitation (CPR) and defibrillation, epinephrine and advanced airway management are often used in treatment. Recent studies suggest early administration of epinephrine is associated with improved survival. The purpose of this study was to evaluate the effect of airway type on timing to epinephrine in OHCA. Hypothesis: Patients who had laryngeal tube (LT) insertion as first attempted airway have shorter times to epinephrine administration compared to those with endotracheal intubation (ETI) as first attempted airway. Methods: Subjects enrolled in the Pragmatic Airway Resuscitation Trial who received epinephrine and primary ETI or LT were included. The dependent variable was timing to epinephrine administration after EMS arrival in minutes, the independent variable was first airway attempted (LT or ETI). Kaplan-Meier estimates of time to drug administration were used to account for censoring. Results: We included 2650 subjects (1423 LT and 1227 ETI). There were no significant differences in age, sex, first rhythm, EMS response time, witnessed arrest status, bystander CPR or proportion receiving epinephrine between the LT and ETI groups. Among all OHCA patients, LT and ETI had median minutes (95% CI) until epinephrine administration of 9.3 (9.0, 9.8) and 9.7 (9.4, 10.0), respectively (p=n.s.). For the VT/VF subgroup, the median minutes (95% CI) to epinephrine administration were 8.0 (7.8, 9.0) and 9.2 (8.7, 9.9) for LT and ETI, respectively (Figure, p=n.s.). Conclusions: Overall, advanced airway type did not affect time to epinephrine. Among those with initial VT/VF, there is a weak, non-statistically significant trend of longer time to epinephrine when ETI is used compared to LT. This difference may be a contributing component to improved survival with an initial LT airway strategy for OHCA.

scholarly journals The Effect of Implementing Mechanical Cardiopulmonary Resuscitation Devices on Out-of-Hospital Cardiac Arrest Patients in an Urban City of Taiwan

2021 ◽  
Vol 18 (7) ◽  
pp. 3636
Author(s):  
Yi-Rong Chen ◽  
Chi-Jiang Liao ◽  
Han-Chun Huang ◽  
Cheng-Han Tsai ◽  
Yao-Sing Su ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Primary Outcome ◽  
Medical Service ◽  
Spontaneous Circulation ◽  
High Quality ◽  
Urban City ◽  
Service Response Time ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest

High-quality cardiopulmonary resuscitation (CPR) is a key element in out-of-hospital cardiac arrest (OHCA) resuscitation. Mechanical CPR devices have been developed to provide uninterrupted and high-quality CPR. Although human studies have shown controversial results in favor of mechanical CPR devices, their application in pre-hospital settings continues to increase. There remains scant data on the pre-hospital use of mechanical CPR devices in Asia. Therefore, we conducted a retrospective cohort study between September 2018 and August 2020 in an urban city of Taiwan to analyze the effects of mechanical CPR devices on the outcomes of OHCA; the primary outcome was attainment of return of spontaneous circulation (ROSC). Of 552 patients with OHCA, 279 received mechanical CPR and 273 received manual CPR, before being transferred to the hospital. After multivariate adjustment for the influencing factors, mechanical CPR was independently associated with achievement of any ROSC (OR = 1.871; 95%CI:1.195–2.930) and sustained (≥24 h) ROSC (OR = 2.353; 95%CI:1.427–3.879). Subgroup analyses demonstrated that mechanical CPR is beneficial in shorter emergency medical service response time (≤4 min), witnessed cardiac arrest, and non-shockable cardiac rhythm. These findings support the importance of early EMS activation and high-quality CPR in OHCA resuscitation.

Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts

2017 ◽  
Vol 21 (5) ◽  
pp. 628-635 ◽  
Author(s):  
Angela F. Jarman ◽  
Christy L. Hopkins ◽  
J. Nicholas Hansen ◽  
Jonathan R. Brown ◽  
Christopher Burk ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Chest Compression ◽  
Advanced Airway ◽  
Hospital Cardiac Arrest

Abstract 170: Challenges in Implementing an ECPR Program for Out of Hospital Cardiac Arrest

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Meshe Chonde ◽  
Jeremiah Escajeda ◽  
Jonathan Elmer ◽  
Frank X Guyette ◽  
Arthur Boujoukos ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Inclusion Criteria ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Implementation Challenges ◽  
Shockable Rhythm ◽  
Bystander Cpr ◽  
Stay And Play ◽  
Load And Go ◽  
Mechanical Cpr ◽  
Hospital Cardiac Arrest

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapy. Many institutions are interested in developing their own ECPR program. However, there are challenges in logistics and implementation. Hypothesis: Development of an ECPR team and identification of UPMC Presbyterian as a receiving center will increase recognition of potential ECPR candidates. Methods: We developed an infrastructure of Emergency Medical Services (EMS), Medic Command, and an in-hospital ECPR team. We identified inclusion criteria for patients with an out of hospital cardiac arrest (OHCA) likely to have a reversible arrest etiology and developed them into a simple checklist. These criteria were: witnessed arrest with bystander CPR, shockable rhythm, and ages 18 to 60. We trained local EMS crews to screen patients and review the checklist with a Command Physician prior to transport to our hospital. Results: From October 2015 to March 31 st 2018, there were 1165 dispatches for OHCA, of which 664 (57%) were treated and transported to the hospital and 120 to our institution. Of these, five patients underwent ECPR. Of the remaining cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. Prehospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) underwent mechanical CPR with LUCAS device. Time from arrest to arrive on scene was 5 [IQR 4-6] min and time call MD command was 13 [IQR 7-21] min. Time to transport was 20 [IQR 19-21] min. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min. Conclusions: ECPR is a relatively infrequent occurrence. Implementation challenges include prompt identification of patients with reversible OHCA causes, preferential transport to an ECPR capable facility and changing the focus of EMS in these select patients from a “stay and play” to a “load and go” mentality.

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