Sustained Inflation During Chest Compression: A New Technique of Pediatric Cardiopulmonary Resuscitation That Improves Recovery and Survival in a Pediatric Porcine Model

Background Chest compression (CC) during sustained inflations (CC+SI) compared with CC with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation in asphyxiated pediatric piglets will reduce time to return of spontaneous circulation (ROSC). Methods and Results Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure <25 mm Hg with bradycardia. After cardiac arrest, piglets were randomized to CC+SI (n=12) or CCaV (n=12) or sham (n=8). Sham‐operated animals had no asphyxia. Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded. There were no differences in baseline parameters or the duration and degree of asphyxiation. Median (interquartile range) Time to ROSC was 248 (41–346) seconds compared with 720 (167–720) seconds in the CC+SI group and CCaV group, respectively ( P =0.0292). There was a 100% higher rate of ROSC in the CC+SI group versus CCaV group, with 10 (83%) versus 5 (42%) achieving ROSC ( P =0.089), respectively. Piglets in the CC+SI and CCaV groups received intravenous epinephrine boluses to achieve ROSC (8/12 versus 10/12 P =0.639). There was a significantly higher minute ventilation in the CC+SI group, which was secondary to a 5‐fold increase in the number of inflations per minute and a 1.5‐fold increase in tidal volume. Conclusions CC+SI reduced time to ROSC and improved survival compared with using CCaV. CC+SI allowed passive ventilation of the lung while providing chest compressions. This technique warrants further studies to examine the potential to improve outcomes in pediatric patients with cardiac arrest. Registration URL: https://www.preclinicaltrials.eu ; Unique identifier: PCTE0000152.

Sustained Inflation Reduces Pulmonary Blood Flow during Resuscitation with an Intact Cord

The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation–SI vs. positive pressure ventilation–V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with DCC improves gas exchange and hemodynamics in near-term lambs with asphyxial bradycardia. A total of 28 lambs were asphyxiated to a mean blood pressure of 22 mmHg. Lambs were randomized based on the timing of cord clamping (ECC—immediate, DCC—60 s) and mode of initial ventilation into five groups: ECC + V, ECC + SI, DCC, DCC + V and DCC + SI. The magnitude of placental transfusion was assessed using biotinylated RBC. Though an asphyxial bradycardia model, 2–3 lambs in each group were arrested. There was no difference in primary outcomes, the time to reach baseline carotid blood flow (CBF), HR ≥ 100 bpm or MBP ≥ 40 mmHg. SI reduced pulmonary (PBF) and umbilical venous (UV) blood flow without affecting CBF or umbilical arterial blood flow. A significant reduction in PBF with SI persisted for a few minutes after birth. In our model of perinatal asphyxia, an initial SI breath increased airway pressure, and reduced PBF and UV return with an intact cord. Further clinical studies evaluating the timing of cord clamping and ventilation strategy in asphyxiated infants are warranted.

Politics, Central Bank, Monetary Regime and Government Bankruptcy

The damages and suffering caused by inflation during the course of history are enormous. Still, the worst excesses of inflation occurred not before the 20th century. This development was a consequence of the further technical development of money from coins to paper money and book money together with changes in the monetary regime or constitution ruling supply and control of money. Sustained inflation has always been a mone-tary phenomenon in the sense that the increase of the money supply is a necessary condition for its occurrence. Moreover, if an increase of the money supply is permanently outstripping the growth of real gross domestic product it is also a sufficient condi-tion for inflation. But that is not the whole story. For it has still to be asked which are the factors and institutional settings that allow the excessive growth of the money supply. And here historical evidence provides a clear answer (Figure 1). During the rule of the gold and silver standards until the outbreak of the World War I or after the restoration of it until the Great Depression of the 1930s no upward trend of the price level, but only long-term swings can be observed. But after the demise of the convertibility of banknotes into gold at a fixed parity and thus the introduction on a discretionary paper money standard the price level rises dramatically even in the respective developed countries.

The 2011-2020 long-term sustained inflation at Long Valley Caldera: investigation of the interaction of magmatic and tectonic processes

&lt;p&gt;The Long Valley Caldera, California (USA), has been restless over the past few decades, experiencing seismic swarms and ground deformation episodes. The last inflation began in late 2011, when a radially symmetric tumescence was detected coinciding with a large resurgent dome within the caldera. Since then, a continuous inflation with quasi-steady rate of ~1.5 cm/yr has been observed.&lt;span&gt;&amp;#160; &lt;/span&gt;Earthquakes mostly occur within the caldera along the South Moat Seismic Zone, to the south of the maximum deformation area. Although the area is tectonically active, increased seismic activity has been documented during periods of renewed inflation since the onset of this tumescence in 1978. In this study, we aim to investigate the nature and dynamics of the long-term unrest at Long Valley Caldera, as well as to provide new insights into the interaction between magmatic and tectonic processes. For this purpose, we consider a variety of datasets including geodetic and seismic records over the period spanning from late 2011 to the end of 2020. A complete seismic catalog supports our study, with more than 200 M2.5-4.5 earthquakes recorded since 2011, most with epicenters located within the caldera. Measurements from a dense network of continuous GPS stations collected in the last 10 years are analyzed in combination with high resolution Interferometric Synthetic Aperture Radar (InSAR) data. For full temporal coverage, we integrate InSAR velocities obtained from the acquisition of different satellite missions. We use, in particular, data from SAR systems operating with X and C-bands such as TerraSAR-X, COSMO-SkyMed and Sentinel-1. The multi-sensor dataset (i.e., GPS and multi-mission InSAR data) compensate the limitations of each technique, with reliable mapping of the deformation pattern evolving over several years. Data analysis highlights uplift velocities with peaks of ~2 cm/yr within the caldera and beyond its southern rim. Moreover, compared to the first half of the period of analysis (2011-2014), the area affected by high deformation rates is broader in the last several years (2017-2020). Models based on the geodetic data are developed to constrain the deformation source and to better interpret the observed signals. This study is motivated as a contribution to the understanding of this long-lived caldera unrest, for a more reliable hazard assessment.&lt;/p&gt;

Is Chest Compression Superimposed with Sustained Inflation during Cardiopulmonary Resuscitation an Alternative to 3:1 Compression to Ventilation Ratio in Newborn Infants?

Approximately 0.1% for term and 10–15% of preterm infants receive chest compression (CC) in the delivery room, with high incidence of mortality and neurologic impairment. The poor prognosis associated with receiving CC in the delivery room has raised concerns as to whether specifically-tailored cardiopulmonary resuscitation methods are needed. The current neonatal resuscitation guidelines recommend a 3:1 compression:ventilation ratio; however, the most effective approach to deliver chest compression is unknown. We recently demonstrated that providing continuous chest compression superimposed with a high distending pressure or sustained inflation significantly reduced time to return of spontaneous circulation and mortality while improving respiratory and cardiovascular parameters in asphyxiated piglet and newborn infants. This review summarizes the current available evidence of continuous chest compression superimposed with a sustained inflation.

Asphyxiated Female and Male Newborn Piglets Have Similar Outcomes With Different Cardiopulmonary Resuscitation Interventions

Background: Male newborns have a greater risk of poor cardiovascular and respiratory outcomes compared to females. The mechanisms associated with the “male disadvantage” remains unclear. We have previously shown no difference between male and female newborn piglets during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery. However, it is unknown if there are differences in resuscitation outcomes between males and females during different cardiopulmonary resuscitation techniques.Intervention and Measurements: Secondary analysis of 184 term newborn mixed breed duroc piglets (1–3 days of age, weighing 2.0 (0.2) kg) from seven different studies, which were exposed to 30–50 min of normocapnic hypoxia followed by asphyxia until asystole. This was followed by cardiopulmonary resuscitation. For the analysis, piglets were divided into male and female groups, as well as resuscitation technique groups (sustained inflation, 3:1 compression-to-ventilation ratio, or asynchronous ventilations during chest compressions). Cardiac function, carotid blood flow, and cerebral oxygenation were continuously recorded throughout the experiment.Main results: Regardless of resuscitation technique, there was no significant difference between males and females in the number achieving return of spontaneous circulation (ROSC) [95/123 (77%) vs. 48/61 (79%)], the time to achieve ROSC [112 (80–185) s vs. 110 (77–186) s], and the 4-h survival rate [81/95 (85%) vs. 40/48 (83%)]. Levels of the injury markers interleukin (IL)−1ß, IL-6, IL-8, and tumor necrosis factor-α in frontoparietal cortex tissue homogenates were similar between males and females.Conclusions: Regardless of resuscitation technique, there was no significant effect of sex on resuscitation outcome, survival, and hemodynamic recovery in asphyxiated newborn piglets.

Physiological effects of different recruitment maneuvers in a pig model of ARDS

Background In acute respiratory distress syndrome (ARDS), lung recruitment maneuvers can recruit collapsed alveoli in gravity-dependent lung regions, improving the homogeneity of ventilation distribution. This study used electrical impedance tomography to investigate the physiological effects of different recruitment maneuvers for alveolar recruitment in a pig model of ARDS. Methods ARDS was induced in ten healthy male pigs with repeated bronchoalveolar lavage until the ratio of arterial partial pressure of oxygen (PaO2) of fraction of inspired oxygen (P/F) was < 100 mmHg and remained stable for 30 min (TARDS). ARDS pigs underwent three sequential recruitment maneuvers, including sustained inflation, increments of positive end-expiratory pressure (PEEP), and pressure-controlled ventilation (PCV) applied in random order, with 30 mins at a PEEP of 5 cmH2O between maneuvers. Respiratory mechanics, hemodynamics, arterial blood gas, and electrical impedance tomography were recorded at baseline, TARDS, and before and after each recruitment maneuver. Results In all ten pigs, ARDS was successfully induced with a mean 2.8 ± 1.03 L bronchoalveolar lavages. PaO2, P/F, and compliance were significantly improved after recruitment with sustained inflation, increments of PEEP or PCV (all p < 0.05), and there were no significant differences between maneuvers. Global inhomogeneity index significantly decreased after recruitment with sustained inflation, increments of PEEP, or PCV. There were no significant differences in global inhomogeneity before or after recruitment with the different maneuvers. The decrease in global inhomogeneity index (ΔGI) was significantly greater after recruitment with increments of PEEP compared to sustained inflation (p = 0.023), but there was no significant difference in ΔGI between increments of PEEP and PCV or between sustained inflation and PCV. Conclusion Sustained inflation, increments of PEEP, and PCV increased oxygenation, and regional and global compliance of the respiratory system, and decreased inhomogeneous gas distribution in ARDS pigs. Increments of PEEP significantly improved inhomogeneity of the lung compared to sustained inflation, while there was no difference between increments of PEEP and PCV or between sustained inflation and PCV.