rcp alveoli ventilation with continuous chest compression - b-card concept & functionalities
TRANSCRIPT
b-card symposium
From the Idea to the Productb-card Concept & Functionalities
TuesdayMarch 7th
2017
Georges BOUSSIGNAC, MD & Nicolas PESCHANSKI, MD, PhD
Introductionto the b-cardConcept
©B.Garrigue,RN
ILCOR Cardiac Arrest Ventilation
UnresponsivepatientAbnormalrespiration
CallEmergencyServices
CPR30:2SetupDefibrilator
Minimizeinterruptions
ChocMinimizeinterreptions
CPRimmediatelyafter2minutes
Minimizeinterreptions
CPRimmediately
after2minutesMinimizeinterruptions
Post-Ressuscitationtreatment
SaO2 >94-98%NormalPaCO2ECG12lead
Treattheoriginofcardiacarrest
originTerapeutichypothermia
UnchocableRhythm
Asystole/PEA
ChocableRhythmFV-TV
ROSC
EvaluatetheRhythm
ILCOR2015
Optimizing Chest Compressions
Q
Why Optimizing
Chest Compressions?
Optimize chest compressions⇧ length compressions
⇧ depth of compressions
Increase cerebral and coronary perfusion
⇧ ROSC rate
DrGeorgesBoussignac
UnresponsivepatientAbnormalrespiration
CallEmergencyServices
CPR30:2SetupDefibrilator
Minimizeinterruptions
ChocMinimizeinterreptions
CPRimmediatelyafter2minutes
Minimizeinterreptions
CPRimmediately
after2minutesMinimizeinterruptions
Post-Ressuscitationtreatment
SaO2 >94-98%NormalPaCO2ECG12lead
Treattheoriginofcardiacarrestorigin
Terapeutichypothermia
UnchocableRhythm
Asystole/PEA
ChocableRhythmFV-TV
ROSC
Evaluatetherhythm
ILCOR2015
Oxygenation ?
EtCO2
ILCOR2015
O2
Correct oxygenation of the patient -> Efficacy of oxygenation
Control the quality of ventilation -> Capnography – EtC02
Recommendations
Can We Do Both
(Ventilation and Oxygenation)
Correctly and at the Same Time?
Q
ILCOR2015 CPR
30:2Continuous Ventilation 10-12/min
ILCOR2015
The goal is to ventilate and
oxygenate the patient by minimizing
chest compressions interruptions
without damaging hemodynamics
Ventilation Is Still A Stake
What Is the Current Practice of
Ventilation Techniques in the Field?
Q
Prolonged interruptions in chest compressions, for
reasons other than defibrillation, worsen clinical
outcomes for out-of-hospital cardiac arrest
patients with ventricular fibrillation
13
BrouwerT,WalkerR,ChapmanF,Koster,R.AssociationBetweenChestCompressionInterruptionsandClinicalOutcomesofVentricularFibrillationOut-of-HospitalCardiacArrest. Circulation. 2015;132:1030-1037.
DrGeorgesBoussignac
RealCPRIdealCPR
30 30 30 30
2 2 2
30 30 302
22
30Chestcompressions2insufflations
10s
20s
« Most of the time, interruption in chest compressions is too long (20 secs) and chest compressions are not delivered
Berg,etal.Circulation2001
Manual ventilation in the field todayDrGeorgesBoussignac
Interrupt chest compressions for ventilation
may damage heamodynamics during CPR (coronary perfusion pressure
falls)
Data AnalysisContinuous variables such as blood pressures, CPP, iCPP, and bloodgas analyses were evaluated by 2-tailed, unpaired Student’s t test anddescribed as mean!SEM. Continuous variables that were not nor-mally distributed (myocardial blood flows, cardiac outputs, andoxygen deliveries) were evaluated by Mann-Whitney U test anddescribed as median (25%, 75%). In the CC"RB group, wecompared the mean CPP during the first 2 compressions of each15-compression cycle with the last 2 compressions by pairedStudent’s t test. Comparisons of discrete variables, such as rate ofreturn of spontaneous circulation, 1-hour ICU survival, swine cere-bral performance categories, 24-hour survival, and 24-hour goodneurological outcome were evaluated by Fisher’s exact test.
ResultsFor the CC"RB group, the aortic relaxation (“diastolic”)pressures routinely decreased during the interval of 2 rescuebreaths when no compressions were provided, thereby alsodecreasing the CPPs (Figure 1). Therefore, the mean CPP ofthe first 2 compressions in each compression cycle was lowerthan that of the final 2 compressions (14!1 versus21!2 mm Hg, respectively, P#0.001). This difference was
demonstrable independently at each minute of the 12 minutesof CPR (Figure 2).Thirteen of the 14 animals survived 24 hours with good
neurological outcome. Six of the 7 CC animals and 5 of the7 CC"RB animals were in cerebral performance category 1at 24 hours (ie, normal); 1 in each group was in cerebralperformance category 2, mildly abnormal; and 1 CC"RBanimal was in cerebral performance category 3, severelydisabled. All 13 animals with good neurological outcomecould stand, walk, feed themselves, and actively resist re-straint. Animals in cerebral performance category 1 per-formed these tasks normally; animals in cerebral performancecategory 2 had slightly wobbly gaits, lethargy, or sluggishresponse to restraint. The only animal in category 3 could notwalk and responded quite sluggishly to restraint but woulddrink.At baseline, the CC and CC"RB groups did not differ in
weight, hemoglobin concentration, heart rate, blood pressure,or central venous pressure. Aortic and right atrial compres-sion pressures during each minute of CPR did not differbetween the 2 groups (Table 1). At each minute of CPR, the
Figure 1. Aortic (Ao, dark band) and right atrial(RA, light band) pressures during standard CPR,CC"RB, with a 15:2 compression:ventilation ratio.Aortic relaxation, or diastolic, pressure (lower bor-der of dark band) decreases during each set of 2breaths, resulting in lower CPP during first severalcompressions of next cycle. Right atrial relaxation,or diastolic, pressure is most inferior border. Dif-ference between Ao and RA relaxation pressuresis CPP.
Figure 2. Mean CPP of first 2 compressions (bot-tom line) and last 2 compressions (top line) ofeach 15-compression cycle during CPR withCC"RB at a compression:ventilation ratio of 15:2.Mean CPP difference: *P#0.05; †P#0.01;‡P#0.001.
Berg et al Adverse Effects of Rescue Breathing During CPR 2467
by on February 15, 2009 circ.ahajournals.orgDownloaded from
Side effects
Berg,etal.Circulation2001
DrGeorgesBoussignac
Consequences on Hemodynamics
Is There A Scientific Rational?
Q
Ventilation
during chest
compressions
triggers
asynchronisms
Decreaseofvenousreturn
Positivepressureatdecompression
DrGeorgesBoussignac
What Is Your Solution?
Q
The Conceptof b-card
DrGeorgesBoussignac
• The AV-CCCconceptimproveshemodynamicsandventilation
Ø Gas flow rate at 15L/minØ Turbulences (virtual valve)
created in b-card Ø Control the exit and entry of gas
from the respiratory tract and lungs
Ø Creation of static lung pressure of 5 to 8 cmH2O
BREATHING OUTCOMPRESSION
BREATHING INRELAXATION
Expiratory Resistance
During Chest Compression
Optimised energy transmission from chest compressions to the circulatory system
Increased Intrathoracic Pressure
Improved Heamodynamics
Inspiratory Resistance
During Chest Decompression
Negative Intrathoracic Pressure
Venous return
Increased pre-load and coronary perfusion
Increased cardiac output
b-card Maintains BP
Hands = Ventilator
Did You Test the b-card?
Q
ml
a
bc
d
e f
a. Ressort
b. Soufflet
c. Seringue
d. Prisedepression
danslesoufflet
e. Entréd’air
f. StyletetPapier
millimétrique
f
Pressure transmitted to the thoracic space
Change in lung volume: Vt and FRC
Impact of different ventilation strategies during chest compression. An experimental and clinical study. RL Cordioli, A Lyazidi,N Rey,, JM Grannier, D Savary, L Brochard , JC M Richard.
Bench Tests
Results
60,0
0
20
40
60
80
100
not aged Aged 3 years according to C2134
Pressure limitation under normal use (cmH2O)
Based on the samples tested, the higher end value of the statistical interval is 13.4 cmH2O compared to an acceptance criterion of maximum 60.0 cmH2O
Results
80,0
0
20
40
60
80
100
not aged Aged 3 years according to C2134
Pressure limitation under single fault condition 1:obstruction of the open system (cmH2O)
Based on the samples tested, the higher end value of the statistical interval is 41.4 cmH2O compared to an acceptance criterion of maximum 80.0 cmH2O.
Results
80,0
0
20
40
60
80
100
not aged Aged 3 years according to C2134
Pressure limitation under single fault condition n°2: inappropriate flow rate setting
(cmH2O)
Based on the samples tested, the higher end value of the statistical interval is 42.4 cmH2O compared to an acceptance criterion of maximum 80.0 cmH2O.
Results
- This report proves that b-card creates a positive intra-thoracic pressure at compression and a negative intra-thoracic pressure at decompression which helps improve the venous return and hemodynamics to the whole body. - Secondly, the tidal volume delivered is improved compare to Intermittent Positive Pressure Ventilation with Bag-Valve Mask (BVM). Indeed, the volume delivered at decompression is minimum 315 ml and maximum 369 ml.
SummaryResults
How To Use It?
Q
With a Mask
With a Supraglottic
Device
With an ET Tube
Use of b-card
Continuous Chest Compressions + b-card
April 2016: Evreux General HospitalCardiac Arrest 70-year-old Male CPR with b-card: SpO2 at 80 % then 90%.
b-card in Action
©A.Depil-Duval,MD
40
Conclusion
No Pause Should Be Your Cause
b-card symposium
Thank You for Your AttentionQ & A
TuesdayMarch 7th
2017
Georges BOUSSIGNAC, MD & Nicolas PESCHANSKI, MD, PhD