• Domenico L Grieco, J Brochard Laurent L 1 Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada. , Adrien Drouet, Irene Telias, Stéphane Delisle, Gilles Bronchti, Cecile Ricard, Marceau Rigollot, Bilal Badat, Paul Ouellet, Emmanuel Charbonney, Jordi Mancebo, Alain Mercat, Dominique Savary, and Richard Jean-Christophe M JM 4 SAMU74, Emergency Department, General Hospital of Annecy, Annecy, France. .
• 1 Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
• Am. J. Respir. Crit. Care Med. 2019 Mar 15; 199 (6): 728-737.

RationaleEnd-tidal CO2 (EtCO2) is used to monitor cardiopulmonary resuscitation (CPR), but it can be affected by intrathoracic airway closure. Chest compressions induce oscillations in expired CO2, and this could reflect variable degrees of airway patency.ObjectivesTo understand the impact of airway closure during CPR, and the relationship between the capnogram shape, airway closure, and delivered ventilation.MethodsThis study had three parts: 1) a clinical study analyzing capnograms after intubation in patients with out-of-hospital cardiac arrest receiving continuous chest compressions, 2) a bench model, and 3) experiments with human cadavers. For 2 and 3, a constant CO2 flow was added in the lung to simulate CO2 production. Capnograms similar to clinical recordings were obtained and different ventilator settings tested. EtCO2 was compared with alveolar CO2 (bench). An airway opening index was used to quantify chest compression-induced expired CO2 oscillations in all three clinical and experimental settings.Measurements And Main ResultsA total of 89 patients were analyzed (mean age, 69 ± 15 yr; 23% female; 12% of hospital admission survival): capnograms exhibited various degrees of oscillations, quantified by the opening index. CO2 value varied considerably across oscillations related to consecutive chest compressions. In bench and cadavers, similar capnograms were reproduced with different degrees of airway closure. Differences in airway patency were associated with huge changes in delivered ventilation. The opening index and delivered ventilation increased with positive end-expiratory pressure, without affecting intrathoracic pressure. Maximal EtCO2 recorded between ventilator breaths reflected alveolar CO2 (bench).ConclusionsDuring chest compressions, intrathoracic airway patency greatly affects the delivered ventilation. The expired CO2 signal can reflect CPR effectiveness but is also dependent on airway patency. The maximal EtCO2 recorded between consecutive ventilator breaths best reflects alveolar CO2.

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