Feasibility of waveform capnography as a non-invasive monitoring tool during cardiopulmonary resuscitation

Abstract

Sudden cardiac arrest (SCA) is one of the leading causes of death in the industrialized world and it includes the sudden cessation of circulation and consciousness, confirmed by the absence of pulse and breathing. Cardiopulmonary resuscitation (CPR) is one of the key interventions for patient survival after SCA, a life-saving procedure that combines chest compressions and ventilations to maintain a minimal oxygenated blood flow.To deliver oxygen, an adequate blood flow must be generated, by effective CPR, during the majority of the cardiac arrest time. Although monitoring the quality of CPR performed by rescuers during cardiac arrest has been a huge step forward in resuscitation science, in 2013, a consensus statement from the American Heart Association prioritized a new type of CPR quality monitoring focused on the physiological response of the patient instead of how the rescuer is doing.To that end, current resuscitation guidelines emphasize the use of waveform capnography during CPR for patient monitoring. Among several advantages such as ensure correct tube placement, one of its most important roles is to monitor ventilation rate, helping to avoid potentially harmful over-ventilation. In addition, waveform capnography would enable monitoring CPR quality, early detection of ROSC and determining patient prognosis. However, several studies have reported the appearance of fast oscillations superimposed on the capnogram, hereinafter CC-artifact, which may hinder a feasible use of waveform capnography during CPR. In addition to the possible lack of reliability, several factors need to be taken into account when interpreting ETCO2 measurements. Chest compressions and ventilation have opposing effects on ETCO2 levels. Chest compressions increase CO2 concentration, delivering CO2 from the tissues to the lungs, whilst ventilations remove CO2 from the lungs, decreasing ETCO2. Thus, ventilation rate acts as a significant confounding factor.This thesis analyzes the feasibility of waveform capnography as non-invasive monitoring tool of the physiological response of the patient to resuscitation efforts. A set of four intermediate goals was defined.First, we analyzed the incidence and morphology of the CC-artifact and assessed its negative influence in the detection of ventilations and in ventilation rate and ETCO2 measurement. Second, several artifact suppression techniques were used to improve ventilation detection and to enhance capnography waveform. Third, we applied a novel strategy to model the impact of ventilations and ventilation rate on the exhaled CO2 measured in out-of-hospital cardiac arrest capnograms, which could allow to measure the change in ETCO2 attributable to chest compressions by removing the influence of concurrent ventilations. Finally, we studied if the assessment of the ETCO2 trends during chest compressions pauses could allow to detect return of spontaneous circulation, a metric that could be useful as an adjunct to other decision tools