Pour la ventialation de l'AC en extra-hospitalier

1. Faut-il encore ventiler l’arrêt
cardiaque ?
Pour
M Ramakers
Praticien Hospitalier
Service de Réanimation Polyvalente
CH Mémorial, Saint Lô

2. Le souffle c’est la vie……
Merci de votre attention

3. Réanimation Cardio
Pulmonaire de base (RCPB) :
vers l’abandon de la
ventilation ?
Pourquoi ?

4. La ventilation : un progrès
• RESUSCITATION
Liss
FIGURE 1. Warm ashes, burning ex-crement,
or hot water applied to the
victim's abdomen were thought to be
beneficial in restoring heat and life to
the body. Figures 1 through 8 are re-produced
with permission of the Mu-seum
of Science and Industry, Chi-cago,
Illinois.
FIGURE 1. Warm ashes, burning ex-crement,
Over the years, warming were discarded, or hot water applied to the
placed inside a barrel which was rolled
to aid ventilation.
La base de la ressuscitation fût
pendant des siècles de réchauffer
le corps de la victime et de le
« stimuler » physiquement par
des méthodes plus ou moins
barbares
• En 1892 des auteurs Français
recommandaient de tirer
fortement et de façon rythmique
sur la langue
• Différentes techniques de
ventilation artificielles sont
décrites au début du XIXème
siècle mais ne connaîssent pas
un grand succès
FIGURE 2. Whipping the victim with
stinging nettles was considered help-ful
in "waking" him from a "'deep
sleep."
Other methods were developed in
the 1700s in response to a growing
number of deaths by drowning. Inver-sion
(Figure 4), practiced in Egypt
3,500 years ago, was popular in Europe
and the New World. The victim was
hung by his feet, with chest pressure
to aid expiration and pressure release
placed inside a barrel which was rolled
to aid ventilation.
Because of the increase in deaths by
drowning during this time, societies
were formed to organize efforts at re-suscitation.
England's Royal Humane
Society, founded in 1774, was preceded
by the Society for Recovery of
Drowned Persons, which began in
Amsterdam in 1767. Dutch recom-mendations
8 included the following:
1) warming the victim, which often re-quired
transporting him from the
scene of the drowning, but could be
accomplished by lighting a fire near
the victim, burying him in warm
sand, putting him in a warm bath, or
placing him in bed with one or two
volunteers; 2) removing swallowed or
aspirated water by positioning the vic-tim's
head lower than his feet and ap-plying
manual pressure to his ab-domen;
vomiting was induced by
Over the years, however, all except
warming were discarded, largely as a
result of the research of Benjamin
Brodie in England and Leroy d'Etiolles
in France.
Brodie denounced fumigation in
1811 after demonstrating that four
ounces of strong tobacco would kill a
dog, and one ounce would kill a cat.1
Ten years later, in a lecture on asphyx-ia,
he noted that two to three minutes
after breathing ceases the heart stops
beating, after which no method of ar-tificial
ventilation is of any value. He
believed that patients who recovered
did so whether or not artificial ven-tilation
was given, and he thought
that warming the victim was the most
important factor in resuscitation.
In 1829, Leroy d'Etiolles 1 demon-strated
that overdistention of the
lungs by a bellows could kill an ani-mal
easily, and this method was dis-continued.

5. Mais tout ne fût pas
une réussite……..
All these studies were flawed, how-ever,
because the subjects were intu-bated.
A number of articles in 1958
cited the inadequacy of all manual
techniques in the absence of endo-tracheal
intubation because the air-way
was not effectively patent in
e i t h e r the prone or s u p i n e posi-tion.
33"36 These studies demonstrated
the superiority of mouth-to-mouth re-suscitation.
The technician used his
hands to maintain an open airway, and
exhaled air was found to be safe and
effective for ventilating a person in
ventilatory arrest. 37 Keith had pre-saged
this development in 1909, when
he stated the following:
My mind is also open to the con-viction
that the ancient method of
mouth-to-mouth insufflation with
expiratory compression of the
chest may not prove more effective
than either; at least, if it should
happen fhat I may be found in an
apparently drowned condition, I
sincerely hope that my rescuer will
apply this prompt method to me as
15:1 January 1986
my first aid. It is air that my lungs
and blood then will stand urgently
in need of, not pressure, for if the
pulmonary circulation has ceased,
such pressure is, upon the evidence
at present at our disposal, more
likely to weaken than to strength-en
the heart. With the patient in
the prone position, the operator
will have great difficulty in know-ing
whether or not air is entering
and leaving the lungs freely; with
direct inflation one knows the ef-fect
immediately by placing the
hands on the epigastrium; the hand
is also needed there to produce ex-piration.
1
Fifty years after Keith's comments, in-vestigators
f i n a l l y had recognized
mouth-to-mouth resuscitation as the
most effective means of artificial ven-tilation
without an artificial airway.
CARDIOPULMONARY
RESUSCITATION
Closed-chest massage was the next
Annals of Emergency Medicine
Ø 1831 Darlympe propose de
passer un large bandage derrière
le patient puis de le croiser sur
la poitrine
Ø 1856 Marshall hall :
déplacement de la victime 16
fois par minute de l’estomac
(expiration) sur le côté
(inspiration)
Ø 1878 Benjamin Howard :
compression postérieure initiale
de la victime puis compression
des dernières côtes en décubitus
dorsal
All these studies were flawed, how-ever,
my first aid. It is air that my lungs
FIGURE 6, The Dalrymple method.
FIGURE 7. The Marshall Hall meth-od.
FIGURE 8. The Schafer prone pressure
method used pressure applied to the
victim's back, which forced the ab-domen
against the diaphragm and
caused expiration. Inspiration oc-curred
when the pressure was re-leased.
major advance in cardiopulmonary re-suscitation.
Its introduction in 196038
eliminated the need for open-chest
massage, which rarely was successful
o u t s i d e t h e o p e r a t i n g room.39, 40
Closed-chest massage, which could be
All these studies were flawed, how-ever,
because the subjects were intu-bated.
A number of articles in 1958
my first aid. It is air that my lungs
and blood then will stand urgently
in need of, not pressure, for if the
FIGURE 6, The Dalrymple method.
FIGURE 7. The Marshall Hall FIGURE 8. The Schafer prone method used pressure applied victim's back, which forced against the diaphragm caused expiration. Inspiration when the pressure major advance in cardiopulmonary Its introduction in eliminated the need for open-massage, which rarely was successful
o u t s i d e t h e o p e r a t i n g room.Closed-chest massage, which performed virtually anywhere, very popular and was endorsed

6. Et enfin….
Ø « Il monta, et se coucha sur l'enfant; il
mit sa bouche sur sa bouche, ses yeux
sur ses yeux, ses mains sur ses mains, et
il s'étendit sur lui. Et la chair de l'enfant
se réchauffa. »
Ø 1732 : réanimation d’un mineur
Ø 1802 : 500 cas de réanimation de
nouveaux nés
Ø Technique délaissée (voire méprisée)
par les Médecins…
Ø 1950 travaux de J Elam
Ø 1958 Research Council of the
National Academy of sciences :
recommande le bouche-à-bouche
comme la technique de choix

7. European Resuscitation Council Guidelines for Resuscitation 2010
Section 2. Adult basic life support and use of automated external
defibrillators
prevent
compressions is
purpose,
it may
compressions
combined
exchange
breaths,
be con-tinuous,
exceeding
and to
because
spinal
Checking the carotid pulse (or any other pulse) is an inaccu-rate
method of confirming the presence or absence of circulation,
both for lay rescuers and for professionals.50–52 There is, however,
no evidence that checking for movement, breathing or cough-ing
(“signs of a circulation”) is diagnostically superior. Healthcare
Fig. 2.11. Blow steadily into his mouth whilst watching for his chest to rise.

8. Et si ?

9. Reluctance of Internists and Medical Nurses to perform
mouth-to-mouth ventilation
BE Brenner, Arch Int Med, 1993
Ø Résidents, Médecins, Infirmières
Ø Questionnaire avec différents scénarios
Ø Volonté de réaliser du bouche-à-bouche dans ces différentes
situations
Ø Risque de contracter une infection
Ø Peur d’une procédure en justice
No.
contacted
Responding,
No.(%)
%
Unkwnown Trauma Child Gay Elderly
Resident
82 81(99) 54 36 99 21 64
Staff
physisian 510 352(69) 57 60 81 16 55
Registrered
Nurse 112 96(86) 20 32 75 10 33

10. Copyright
1995
by
the
American
Medical
Associa9on.
All
Rights
Reserved.
Applicable
FARS/DFARS
Restric9ons
Apply
to
Government
Use.
American
Medical
Associa9on,
515
N.
State
St,
Chicago,
IL
60610.
??diteur
American
Medical
Associa9on.
2
Bystander
Cardiopulmonary
Resuscita4on:
Concerns
About
Mouth-­‐to-­‐Mouth
Contact.
Locke,
Catherine;
Berg,
Robert;
Sanders,
Arthur;
Davis,
Melinda;
MA,
MEd;
Milander,
Melinda;
Kern,
Karl;
Ewy,
Gordon
Archives
of
Internal
Medicine.
155(9):938-­‐943,
May
8,
1995.
Figure
1
.
Percentage
of
respondents
"definitely"
or
"probably"
willing
to
perform
cardiopulmonary
resuscita9on
(CPR)
with
strangers
using
different
CPR
techniques.
CC+V
indicates
chest
compressions
plus
mouth-­‐to-­‐mouth
ven9la9on;
CC,
chest
compressions
alone

11. Copyright
1995
by
the
American
Medical
Associa9on.
All
Rights
Reserved.
Applicable
FARS/DFARS
Restric9ons
Apply
to
Government
Use.
American
Medical
Associa9on,
515
N.
State
St,
Chicago,
IL
60610.
??diteur
American
Medical
Associa9on.
3
Bystander
Cardiopulmonary
Resuscita4on:
Concerns
About
MouFthi-­‐gto-­‐uMroueth
C2on
tact.
Locke,
Catherine;
Berg,
Robert;
Sanders,
Arthur;
Davis,
Melinda;
MA,
MEd;
Milander,
Melinda;
Kern,
Karl;
Ewy,
Gordon
Archives
of
Internal
Medicine.
155(9):938-­‐943,
May
8,
1995.
Figure
2
.
Percentage
of
respondents
"definitely"
or
"probably"
willing
to
perform
cardiopulmonary
resuscita9on
(CPR)
with
friends
or
rela9ves
using
different
CPR
techniques.
CC+V
indicates
chest
compressions
plus
mouth-­‐to-­‐mouth
ven9la9on;
CC,
chest
compressions
alone

12. Attitudes toward the performance of bystander
cardiopulmonary resuscitation in Japan
T Taniguchi, Resuscitation, 2007 Attitudes toward the performance of bystander cardiopulmonary resuscitation 85
Table 3 Percentage of respondents willing to perform chest compression plus mouth-to-mouth ventilation/chest
compression alone
Scenarios
Stranger Trauma Child Elderly Relative
High school students 14.8/52.6* 18.1/50.9* 36.8*/63.6* 25.0/57.2* 41.1*/68.2*
Our previous study 13/73 18/66 50/80 23/70 53/85
High school teachers 28.5/75.2 30.4/70.8 51.7*/84.9 36.7/74.0 64.5/87.8
Our previous study 25/76 27/65 41/85 31/77 64/90
EMTs 27.5*/100 22.8*/99.3 86.6/100 44.3/100 92.6/100
Our previous study 67/97 68/96 85/94 42/86 96/99
Medical nurses 22.6*/88.9 19.5*/81.2 61.0*/92.2 35.7*/86.3 79.6*/96.5
Our previous study 34/87 36/81 85/94 42/86 88/96
Medical students 51.2*/96.6 41.9*/93.9 87.2/98.9 77.7/97.8 92.7/99.4
Our previous study 61/96 63/90 91/99 71/95 95/98
EMTs, emergency medical technicians
* P < 0.05 vs. our previous study.
CC plus MMV in all scenarios than in our previous
study.
Reasons for not performing CC plus MMV
(Figure 1)
the main reason among health care providers was
the fear of contracting disease.
The present study demonstrated that Japanese
high school students were reluctant to perform CC
plus MMV on a stranger or trauma victim with blood

13. Effectivement…

14. Lieu Période RCP - RCP + V + MCE MCE
RA Waalewijn
Resuscitation 2001
Pays-Bas
(Amsterdam) 1995/1997
429/922
46,5%
493/922
53,5%
437/493
88,6%
41/493
8,3%
T Iwami
Circulation 2007
Japon
(Osaka) 1998/2003
3550/4877
72,8%
1327/4877
27,2%
783/1327
59%
544/1327
41%
K Bohm
Circulation 2007
Suède 1990/2005 / 11275
8209/11275
73%
1145/11275
10%
SOS Kanto
The Lancet 2007
Japon
(Kanto) 2002/2003
2917/4068
71,7%
1151/4068
28,3%
712/1151
61,9%
439/1151
38,1%
TM Olasveengen
Acta Anasthesiol Scand 2008
Norvège
(Oslo) 2003/2006
269/695
39%
426/695
61%
287/426
66%
145/426
34%
MEH Ong
Resuscitation 2008
Singapour 2001/2004
1695/2136
79,4%
441/2136
20,6%
287/441
65,1%
154/241
34,9%
T Ogawa
BMJ 2011
Japon 2005/2007
56851/101781
55,7%
44930/101781
44,3%
19328/40035
48,3%
20707/40035
51,7%

15. Mais si on ne fait rien ce n’est
peut-être pas pire ?

16. Critère de jugement RCP + RCP - Test statistique
RA Waalewijn
Resuscitation 2001
Sortie vivant 14% 6% P < 0,001
T Iwami
Circulation 2007
Bonne évolution neurologique à J30 3,5% 2,1% /
SOS Kanto
The Lancet 2007
Bonne évolution neurologique à J30 5% 2% 2,4 (1,6 – 3,4)
TM Olasveengen
Acta Anasthesiol Scand 2008
Sortie vivant 11,8% 9% /
MEH Ong
Resuscitation 2008
Sortie vivant ou survie à J30 2,7% 0,5% /

17. Critère de jugement RCP - MCE seul Test statistique
RA Waalewijn
Resuscitation 2001
Sortie vivant 6% 15%
T Iwami
Circulation 2007
Bonne évolution neurologique à J30
2,1% 3,5% 1,70 (1,02 – 2,84)
SOS Kanto
The Lancet 2007
Bonne évolution neurologique à J30
2% 6% 3,0 (1,9 – 4,7)
TM Olasveengen
Acta Anasthesiol Scand 2008
Sortie vivant 9% 10% /
MEH Ong
Resuscitation 2008
Sortie vivant ou vivant à J30 0,5% 2,6% 5,0 (1,5 - 16,4)

18. Critère de jugement RCP - MCE + V Test statistique
RA Waalewijn
Resuscitation 2001
Sortie vivant 6% 14% /
T Iwami
Circulation 2007
Bonne évolution neurologique à J30 2,1% 3,6% 1,74 ( 1,12 – 2,71)
SOS Kanto
The Lancet 2007
Bonne évolution neurologique à J30 2% 4% /
TM Olasveengen
Acta Anasthesiol Scand
2008
Sortie vivant 9% 13% /
MEH Ong
Resuscitation 2008
Sortie vivant ou vivant à J30 0,5% 2,8% 5,4 (2,1 – 14,0)

19. Différence d’efficacité des deux
techniques ?

20. Critère de jugement MCE + V MCE seul Test statistique
RA Waalewijn
Resuscitation 2001
Sortie vivant 14% 15% p = 0,713
T Iwami
Circulation 2007
Bonne évolution neurologique à J30 3,5% 3,6% /
K Bohm
Circulation 2007
Vivant à J30 7,2% 6,7% 1,10 (0,86 – 1,40)
SOS Kanto
The Lancet 2007
Bonne évolution neurologique à J30 4% 6% 1,5 (0,9 – 2,5)
TM Olasveengen
Acta Anasthesiol Scand 2008
Sortie vivant 13% 10% p = 0,647
MEH Ong
Resuscitation 2008
Sortie vivant ou vivant à J30 2,8% 2,6% 0,9 (0, 3 – 3,1)
T Ogawa
BMJ 2011
Bonne évolution neurologique à J30 5,6% 4,6% 1,17 (1,02 – 1,35)

21. Une mauvaise interprétation….

22. The New England
Journal
of
Medicine
© Copyright, 2000, by the Massachusetts Medical Society
« The outcome after CPR with chest compression alone
is similar to that after chest compression with mouth-to-mouth
ventilation…. »
VOLUME 342
M
AY
25, 2000
NUMBER 21
CARDIOPULMONARY RESUSCITATION BY CHEST COMPRESSION ALONE
OR WITH MOUTH-TO-MOUTH VENTILATION
A
LFRED
H
ALLSTROM
, P
H
.D., L
EONARD
C
OBB
, M.D., E
LISE
J
OHNSON
, B.A.,
AND
M
ICHAEL
C
OPASS
, M.D.
A
BSTRACT
Background
Despite extensive training of citizens
of Seattle in cardiopulmonary resuscitation (CPR),
bystanders do not perform CPR in almost half of wit-nessed
cardiac arrests. Instructions in chest compres-sion
plus mouth-to-mouth ventilation given by dis-patchers
over the telephone can require 2.4 minutes.
In experimental studies, chest compression alone is
associated with survival rates similar to those with
chest compression plus mouth-to-mouth ventilation.
We conducted a randomized study to compare CPR
by chest compression alone with CPR by chest com-pression
plus mouth-to-mouth ventilation.
LTHOUGH bystander-initiated cardiopul-monary
resuscitation (CPR) has been asso-ciated
with an increase of 50 percent or
more in survival after out-of-hospital cardi-ac
arrest, and despite extensive training of citizens in
CPR techniques,
1,2
approximately half of the victims of
witnessed out-of-hospital cardiac arrests in the Seat-tle–
King County, Washington, area during the past
few decades did not receive bystander-initiated CPR.
To address this problem, investigators in King Coun-ty
initiated a program in which dispatchers were
taught to instruct callers in how to initiate CPR.
3,4
The
A

23. dispatcher.
Only 20 dispatcher-instructed bystanders (14 instructions for chest compression plus mouth-ventilation, 4 given instructions for chest Because Possible adverse effects on patient (%) 1.8 3.7
The coexisting conditions were cancer, cardiac disease, and diabetes.
·
of rounding, not all percentages total 100.
CARDIOPULMONARY RESUSCITATION BY CHEST COMPRESSION ALONE
T
A
LFRED
ABLE
OR WITH MOUTH-TO-MOUTH VENTILATION
H
ALLSTROM
, P
H
.D., L
EONARD
C
OBB
*CI denotes confidence interval.
May 25, 2000
4.
P
RIMARY
AND
S
, M.D., E
ECONDARY
LISE
A
O
J
OHNSON
, B.A.,
UTCOMES
A
AND
M
ICHAEL
C
OPASS
CCORDING
TO
, M.D.
T
REATMENT
G
ROUP
.
O
UTCOME
C
HEST
C
OMPRESSION
PLUS
M
OUTH
-
TO
-M
OUTH
V
ENTILATION
C
HEST
C
OMPRESSION
A
LONE
T
WO
-S
IDED
P V
ALUE
D
IFFERENCE
(95% CI)*
no./total no. (%) %
Discharged alive (primary
outcome)
29/278 (10.4) 35/240 (14.6) 0.18 4.2 (¡1.5 to 9.8)
Admitted to the hospital 95/279 (34.1) 97/241 (40.2) 0.15 6.1 (¡2.1 to 15.0)
A
BSTRACT
Background
Despite extensive training of citizens
of Seattle in cardiopulmonary resuscitation (CPR),
bystanders do not perform CPR in almost half of wit-nessed
cardiac arrests. Instructions in chest compres-sion
plus mouth-to-mouth ventilation given by dis-patchers
over the telephone can require 2.4 minutes.
In experimental studies, chest compression alone is
associated with survival rates similar to those with
chest compression plus mouth-to-mouth ventilation.
We conducted a randomized study to compare CPR
by chest compression alone with CPR by chest com-pression
plus mouth-to-mouth ventilation.
Methods
The setting of the trial was an urban, fire-department–
based, emergency-medical-care system
with central dispatching. In a randomized manner,
telephone dispatchers gave bystanders at the scene
of apparent cardiac arrest instructions in either chest
compression alone or chest compression plus mouth-to-
mouth ventilation. The primary end point was sur-vival
to hospital discharge.
Results
Data were analyzed for 241 patients ran-domly
assigned to receive chest compression alone
and 279 assigned to chest compression plus mouth-to-
mouth ventilation. Complete instructions were
delivered in 62 percent of episodes for the group re-ceiving
chest compression plus mouth-to-mouth
ventilation and 81 percent of episodes for the group
receiving chest compression alone (P=0.005). In-structions
for compression required 1.4 minutes less
to complete than instructions for compression plus
mouth-to-mouth ventilation. Survival to hospital dis-charge
was better among patients assigned to chest
compression alone than among those assigned to
chest compression plus mouth-to-mouth ventilation
(14.6 percent vs. 10.4 percent), but the difference
was not statistically significant (P=0.18).
Conclusions
The outcome after CPR with chest
LTHOUGH bystander-initiated cardiopul-monary
resuscitation (CPR) has been asso-ciated
with an increase of 50 percent or
more in survival after out-of-hospital cardi-ac
arrest, and despite extensive training of citizens in
CPR techniques,
1,2
approximately half of the victims of
witnessed out-of-hospital cardiac arrests in the Seat-tle–
King County, Washington, area during the past
few decades did not receive bystander-initiated CPR.
To address this problem, investigators in King Coun-ty
initiated a program in which dispatchers were
taught to instruct callers in how to initiate CPR.
3,4
The
instructions included airway management, mouth-to-
mouth ventilation, and chest compression. The in-vestigators
reported that dispatcher-instructed CPR
by bystanders was associated with a rate of survival
to hospital discharge that was similar to the historical
experience with bystander-initiated CPR, that the
time required to provide the instructions averaged 2.4
minutes, and that the most common reason for not
completing the instructions was the arrival of emer-gency-
medical-services personnel.
Since the average interval to a response in Seattle
was 3.1 minutes, as compared with 4.5 minutes in
the suburban communities where the King County
study was conducted, it was unclear whether imple-menting
such a program in Seattle might simply be a
drain on dispatch-center resources. In addition, stud-ies
in animals, particularly those by Meursing et al.,
5
demonstrated that central arterial oxygenation re-mains
relatively high for a substantial time after the
onset of ventricular fibrillation.
In 1989 we therefore began a preliminary trial of
dispatcher-instructed bystander CPR that compared
the value of instructions for chest compression only
with that of standard instructions for chest compres-sion

24. The New England Journal of Medicine
Help is on!
the way.
Is there someone else!
there who can help?
Yes No Yes
Tell that person!
exactly what I say.
Stop
!
I can tell you how to help until the!
medics arrive. Do you want to help?
Yes
No
No
Can you get the phone near him?
Listen carefully. I’ll tell you what to do.
Yes
Get him flat on his back on the floor.!
Strip his chest. Kneel by his side.!
Pinch the nose. With the other hand,!
lift the chin so the head bends back.!
Completely cover his mouth with yours.!
Force 2 deep breaths of air into the lungs.!
Just as if you were blowing up a big balloon.!
Remember: !
Flat on his back. Strip the chest.!
Pinch the nose. With the other hand,!
lift the chin so the head bends back.!
Force 2 breaths.!
Then come back to the phone!
Is he awake or breathing normally?
Yes
No
Listen carefully! I’ll tell you what to do next.
Put the heel of your hand on the center of the chest!
right between the nipples.!
Put your other hand on top of that hand.!
Push down firmly only on the heels of your hands,!
1 or 2 in. (2.5 or 5 cm). Do it 15 times.!
Just as if you were pumping the chest.!
Make sure the heel of your hand is on the center of!
the chest right between the nipples.!
Pump 15 times. Then pinch the nose and lift the chin!
so the head bends back. Two more breaths!
and pump the chest 15 times. Keep doing it!!
Pump the chest 15 times. Then 2 breaths.!
Keep pumping on the chest until help can take over!!
I’ll be hanging up now. Help is on the way.
Figure 1.
Protocol for Standard Instructions for CPR by Chest Compression Combined with Mouth-to-Mouth
Ventilation.
The instructions for CPR by chest compression alone do not include the shaded sections. In this example
it is assumed that the victim is male.

25. VOLUME 342
A
Ø Les instructions complètes de RCP sont délivrées chez 62% des
personnes dans le groupe avec ventilation et 81% dans le groupe
MCE seul (p<o,oo5)
Ø L’arrivée du service médical d’urgence est la première raison
expliquant cela : 20,8% groupe ventilation, 7,9% dans le groupe
MCE seul
Ø Donc, une partie non négligeable (mais non connue) des patients
du groupe ventilation n’ont pas (ou peu) bénéficier de MCE et/ou
de ventilation
Ø Le pronostic de diffère pas, que l’on fasse ou pas un MCE le plus
rapidement possible
M
AY
25, 2000
NUMBER 21
CARDIOPULMONARY RESUSCITATION BY CHEST COMPRESSION ALONE
OR WITH MOUTH-TO-MOUTH VENTILATION
A
LFRED
H
ALLSTROM
, P
H
.D., L
EONARD
C
OBB
, M.D., E
LISE
J
OHNSON
, B.A.,
AND
M
ICHAEL
C
OPASS
, M.D.
A
BSTRACT
Background
Despite extensive training of citizens
of Seattle in cardiopulmonary resuscitation (CPR),
bystanders do not perform CPR in almost half of wit-nessed
cardiac arrests. Instructions in chest compres-sion
plus mouth-to-mouth ventilation given by dis-patchers
over the telephone can require 2.4 minutes.
In experimental studies, chest compression alone is
associated with survival rates similar to those with
chest compression plus mouth-to-mouth ventilation.
We conducted a randomized study to compare CPR
by chest compression alone with CPR by chest com-pression
plus mouth-to-mouth ventilation.
Methods
The setting of the trial was an urban, fire-department–
based, emergency-medical-care system
with central dispatching. In a randomized manner,
telephone dispatchers gave bystanders at the scene
of apparent cardiac arrest instructions in either chest
compression alone or chest compression plus mouth-to-
mouth ventilation. The primary end point was sur-vival
to hospital discharge.
Results
Data were analyzed for 241 patients ran-domly
assigned to receive chest compression alone
and 279 assigned to chest compression plus mouth-to-
mouth ventilation. Complete instructions were
delivered in 62 percent of episodes for the group re-ceiving
chest compression plus mouth-to-mouth
ventilation and 81 percent of episodes for the group
receiving chest compression alone (P=0.005). In-structions
for compression required 1.4 minutes less
to complete than instructions for compression plus
mouth-to-mouth ventilation. Survival to hospital dis-charge
was better among patients assigned to chest
LTHOUGH bystander-initiated cardiopul-monary
resuscitation (CPR) has been asso-ciated
with an increase of 50 percent or
more in survival after out-of-hospital cardi-ac
arrest, and despite extensive training of citizens in
CPR techniques,
1,2
approximately half of the victims of
witnessed out-of-hospital cardiac arrests in the Seat-tle–
King County, Washington, area during the past
few decades did not receive bystander-initiated CPR.
To address this problem, investigators in King Coun-ty
initiated a program in which dispatchers were
taught to instruct callers in how to initiate CPR.
3,4
The
instructions included airway management, mouth-to-
mouth ventilation, and chest compression. The in-vestigators
reported that dispatcher-instructed CPR
by bystanders was associated with a rate of survival
to hospital discharge that was similar to the historical
experience with bystander-initiated CPR, that the
time required to provide the instructions averaged 2.4
minutes, and that the most common reason for not
completing the instructions was the arrival of emer-gency-
medical-services personnel.
Since the average interval to a response in Seattle
was 3.1 minutes, as compared with 4.5 minutes in
the suburban communities where the King County
study was conducted, it was unclear whether imple-menting
such a program in Seattle might simply be a
drain on dispatch-center resources. In addition, stud-ies
in animals, particularly those by Meursing et al.,
5
demonstrated that central arterial oxygenation re-mains
relatively high for a substantial time after the

26. Compression-only CPR or standard in out-of-hospital
cardiac arrest
L Svensson nejm, 2010
Compression-Only CPR or Standard CPR
Table 3. Survival Outcomes in the Study Population, According to Treatment Group.*
receiving standard CPR. There were no signifi-cant
differences between the two groups with
respect to the other secondary end points.
primarily in a small number of EMS dis-tricts.
We therefore performed a subgroup analy-sis
excluding districts where more than 18% of
patients were lost to follow-up. No difference
Outcome
Compression-
Only CPR
Standard
CPR
Two-Sided
P Value
Difference
(95% CI)
no. of patients/total no. (%) percentage points
Primary analysis
30-Day survival 54/620 (8.7) 46/656 (7.0) 0.26 1.7 (−1.2 to 4.6)
1-Day survival 147/613 (24.0) 136/652 (20.9) 0.18 3.1 (−1.5 to 7.7)
Survival to discharge from hospital 54/282 (19.1) 44/297 (14.8) 0.16 4.3 (−1.8 to 10.5)
Per-protocol analysis
30-Day survival 39/461 (8.5) 43/575 (7.5) 0.56 1.0 (−2.3 to 4.3)
1-Day survival 115/457 (25.2) 123/571 (21.5) 0.17 3.6 (−1.6 to 8.8)
Survival to discharge from hospital 39/220 (17.7) 42/261 (16.1) 0.63 1.6 (−5.1 to 8.4)
* Data from 1276 patients were included in the primary analysis, and data from 1036 were included in the per-protocol
analysis. Data for survival to discharge were missing for many patients who died before day 30. CI denotes confidence
interval, and CPR cardiopulmonary resuscitation.

27. 5 x 100 = 500
10 x 100 = 1000
Si on est seul…..

28. Quality of chest compressions during continuous CPR;
comparison between chest compression-only CPR and
conventional CPR
C Nishiyama Resuscitation, 2010
1154 C. Nishiyama et al. / Resuscitation 81 (2010) 1152–Fig. 2. CPR quality index, the proportion of chest compressions with appropri-ate
depth among the total chest compressions during 20-s CPR period, for chest
compression-only CPR and conventional CPR. Error bar indicates standard deviation.
tional CPR group over time. The decay of CPR was greater during
the chest compression-only CPR, and the intergroup difference in
the CPR quality index increased, reaching statistical significance at
61–80 s period (p = 0.003).
3.3. Interruption of chest compressions during 2-min CPR
lactate concentration, reports, physical ensure the adequacy the conventional might serve The 2005 emergency their chest but it does CPR due become aware begins.should be replaced of chest compressions. recommend 1min for chest Even if chest fatigability, min CPR than for this weakness. is expected bystander-we should increase bystander This study intermediate thoroughly decay. Second, scenario Ø Etude randomisée, volontaires
âgés de plus de 18 ans
Ø 2 groupes de 104 et 105
personnes, instructions
délivrées sur 2h (CPR-only) et
3h (conventional CPR)
Ø Evaluation de la qualité du
MCE (mannequin) pendant 2
min sur des périodes de 20 sec
Ø Diminution de la qualité du
MCE dans le temps, plus
marquée dans le groupe
« CPR-only »
Ø On note néanmoins un nombre
moins important de
compressions dans le groupe
« conventional CPR »

29. Le MCE assure une ventilation
satisfaisante ?

30. 80 90 PEA LMA No 10 39
Does compression-only cardiopulmonary resuscitation
generate adequate passive ventilation during cardiac arrest ?
CD Deakin Resuscitation, 2007
Ø Patients ayant un ACR en dehors de
Figure 1 Typical respiratory variables recorded during resuscitation, showing cyclical manual ventilation (A) and
interspersed passive ventilation (B) from chest compressions delivered by the LUCAS thumper. This example shows tidal
volumes of approximately 700 ml from manual ventilation delivered using a self-inflating bag, followed by volumes of
approximately 60 ml from passive ventilation. Corresponding end-tidal CO2 measurements are also shown.
l’hôpital, pris en charge aux
urgences, intubés et ventilés
Ø MCE par le systéme LUCAS en
annulant la décompression active,
rythme de 100/min
Ø Mesure des volumes expirés et de
l’EtCO2
Ø Analyse de la ventilation par MCE
seul durant la pose de la voie
veineuse centrale (environ une
minute)
Ø 17 patients inclus
Ø Vt médian : 41,5 ml(33,0 - 62,1ml)
Ø Volume minute CO2 médian :
19,5ml (15,9 – 33,8 ml; normales
150 – 180 ml)
Adequate passive ventilation during cardiac arrest Figure 2 Tidal volume (Vt):deadspace (Vd) ratio during
passive ventilation generated by LUCAS thumper (n = 16).
The boundaries of the box indicate the 25th and 75th
end-tidal CO2 during measurement EtCO2 is a measure of alveolar its production requiring both and pulmonary capillary blood compression-only CPR, we found of EtCO2 in most patients, suggesting gas exchange was occurring, passive tidal volumes being consistently the estimated anatomical deadspace. that gas transport mechanisms those described in high frequency be occurring due to the relatively frequency. These mechanisms bulk flow, longitudinal dispersion, asymmetric velocity profiles, diffusion.25 Mechanical agitation chest compression may also affect gases. Although this study high frequency mechanisms may exchange during compression-only

31. Interruption trop longue du
MCE avec la ventilation ?

32. the UCC-CPR branches of the study successfully. Of
these 24 paramedics, three (13%) were female. The
mean age was 36±1 years and ranged from 26 to
48 years. Thirteen (54%) were certified CPR instruc-tors
Single rescuer cardiopulmonary resuscitation : Can anyone
perform to the guidelines 2000 recommandations ?
TA Higdon Resuscitaion, 2006
and all 24 (100%) had taken at least one CPR
certification class within 2 years. Twenty of the 24
(83%) had performed CPR in an emergency situation
at least once.
During the performance of standard single res-cuer
Ø Etude sur mannequin
Ø 24 pompiers ayant reçu une formation à la RCPB dans les 2 dernières années
CPR, the average pause for rescue breathing
Ø Nouvelle technique de RCP : compressions thoraciques continues
Ø Pratique des 2 types de RCP avec enregistrement des paramètres par le mannequin et par
was 10±1 s with a range of 7—19 s. The mean num-ber
of ventilations delivered per minute during STD-CPR
was un 6±enregistrement 0.4 breaths/min vidéo
and the mean minute
Ø Première technique testée randomisée
compressions per minute when performing STD-CPR
(!2 = 22.76, p < 0.001)
A questionnaire completed anonymously by
all participating paramedics following testing
described the attitudes of this population regarding
CPR and mouth-to-mouth ventilation. When asked
if they would, if off duty, perform standard CPR
on a stranger who collapsed in a public place, 2
of 24 (8%) answered that they would definitely do
so. However, given the same scenario, 22/24 (92%)
responded that they would definitely be willing to
perform uninterrupted chest compressions. All but
one respondent indicated that they thought the
Table 2 Comparison of CPR techniques
STD-CPR (15:2) CC-CPR p-value
Time to 1st compression 27 ± 1.2 s 9±0.8 s <0.0001
Pause in compressions for rescue breaths 10 ± 1 s NA NA
Compression rate 99 ± 5 92±4 0.23
Compressions delivered/min 44 ± 2 88±5 <0.0001

33. recommendations. The Medical Ethics Review Board of the Academic
Medical Center in Amsterdam approved the study and gave a waiver
for the requirement of (written) informed consent. Details of the design
of the data collection in the ARREST study are described elsewhere.9
Duration of ventilations during cardiopulmonary
resuscitation by lay rescuers and first reponders : relationship
between delivering chest compressions and outcomes
SG Beesems Circulation, 2013
Study Design and Data Collection
The investigation was a prospective study of all persons who suffered
out-of-hospital cardiac arrest, an AED was attached, and received
CPR by trained lay rescuers in the period of September 2010 until
March 2011 in the Dutch province North Holland.
Medical students collected all AED ECG recordings shortly after
a cardiac arrest. These data were stored and analyzed with dedicated
software specific for each type of AED.
For the purpose of this study, we included only AEDs for which the
impedance recording (Physio Control LP500, LP1000, or LPCR+) or
the displacement transducer (Zoll AED Plus, ZOLL Inc., Chelmsford,
MA) allowed accurate determination of chest compressions.
Recordings were eligible for analysis if the AED had recorded at least
the first complete compression-ventilation cycle from the notification of
“start CPR” to “stop CPR” by the voice prompt of the AED before the
AED was disconnected by emergency medical service personnel. We
excluded ECGs with a compression/ventilation ratio other than 30:2
and ECGs that were not analyzable because of technical deficiencies.
We differentiated the dispatched first responders from the other lay
rescuers by the AED used. LP1000 and LP500 were used solely by
dispatched first responders; LPCR+ and the Zoll AED Plus were used
solely by nondispatched onsite rescuers.
Ø Prospective, observationnelle
Ø Patient ayant un ACR extrahospitalier, bénéficiant d’une RCP par un témoin un
pompier ou un policier, et équipé d’un défibrillateur automatique (DA)
Ø Analyse de l’enregistrement du DA afin de déterminer le nombre de compressions
thoraciques et la durée des périodes de ventilation
Ø Sont exclus les tracés non analysables, une période analysable < 2min, les RCP
avec uniquement un MCE, LES RCP avec un rapport compressions ventilation de
15/2
Ø 199 inclusions
Ø Durée interruption pour 2 insufflations : 7 sec (6 - 9)
Data Analysis
All recordings were annotated for initiation and termination of a
compression period. For our analysis, we selected the first and, when
available, the last complete cycle of CPR of an AED recording to
was not considered a true attempt to ventilate.
The chest compression fraction was the proportion of the total re-suscitation
time without spontaneous circulation during which chest
compressions were administered, averaged over the cycles analyzed
in our study. We analyzed the duration of each ventilation and chest
compression period, as well as the number of chest compressions and
ventilations delivered during each 2-minute CPR cycle. We calculated
the average duration of the ventilation period by adding the duration
of all ventilation cycles in the first cycle and (when available) the last
cycle and divided by the number of ventilation periods.
Follow-up
Survival to discharge was verified by contacting the hospital to which
the patient had been transported. We retrieved data on neurological
outcome at discharge from the hospital charts and estimated the ce-rebral
performance category: 1=good cerebral performance. 2=mod-erate
cerebral disability, 3=severe cerebral disability, 4=coma or
vegetative state, and 5=death.
Statistical Analyses
Statistical analyses were performed with standard software (SPSS ver-sion
18.0 for Mac, SPSS Inc, Chicago, IL). Time intervals and other
median values were expressed as medians (25th–75th percentiles).
Baseline comparisons were analyzed by calculating the χ2 statistic or
1-way ANOVA. The paired t test was used to determine statistical sig-nificance
between the number of compressions between periods 1 and
2. The number of ventilations delivered by dispatched first responders
and onsite rescuers was analyzed with the Mann-Whitney U test.
We examined the association between ventilation pause and sur-vival.
We measured the distribution of relevant baseline factors
possibly associated with survival. These factors were age, sex, wit-nessed
collapse, time interval from emergency call to attachment of
Figure 1. Schematic time frame of 1 cycle of an electronic recording from an automatic external defibrillator (AED) showing the ECG
(black line) and the impedance channel (green line) that reflects chest compressions. The 2 slower and shallower deflections during
the ventilation pauses reflect the impedance change caused by 2 insufflations. The AED voice prompt “start CPR” (cardiopulmonary
resuscitation) was marked as period 1 start (P1s). The first identifiable compression after the moment the compressions were started was
marked C1, even if it occurred before P1s. Likewise, the beginning of a period of ventilation was marked V1. We finished a period with

34. Duration of ventilations during cardiopulmonary resuscitation by lay
rescuers and first reponders : relationship between delivering chest
compressions and outcomes
SG Beesems Circulation, 2013
1588 Circulation April 16, 2013
including time from emergency call to attachment of the AED,
VF as initial rhythm, and type of lay rescuer, were unevenly
distributed between the ventilation groups. After adjustment for
baseline factors, ventilation pause duration was not associated
10,11 Earlier investigations demonstrated an associa-tion
pressures.between the proportion of resuscitation time that chest
compressions are administered and survival to hospital dis-charge
after out-of-hospital cardiac arrest.10 Therefore, the
Table 2. Ratio of Compressions and Ventilations Delivered
Ventilation Duration, s
3–5 6–7 8–9 10–12 ≥13 P Value*
Cases, n (%) 42 (21) 58 (29) 50 (25) 28 (14) 21 (11)
Chest compression rate/min, median† 107 (101–121) 105 (102–118) 113 (103–126) 111 (101–118) 106 (96–116) 0.18
Chest compression rate >100/min, % 81 80 88 82 72 0.73
Chest compression rate >120/min, % 26 19 34 14 14 0.39
Compressions/ventilations delivered, n/min‡ 95/3 84/3 84/3 84/3 70/2
≥60 chest compressions delivered/min, % 98 98 100 97 86 0.042
≥70 chest compressions delivered/min, % 95 93 96 89 43 <0.001
≥80 chest compressions delivered/min, % 93 66 72 54 19 <0.001
Chest compression fraction, median, %† 74 (68–79) 66 (61–70) 62 (57–66) 63 (54–74) 57 (49–63) <0.001
Survival, % (n/N) 12 (5/42) 22 (13/58) 26 (13/50) 29 (8/28) 43 (9/21) 0.007
*P value for trend.
†Chest compression fraction is presented as median (25th–75th percentile).
‡Numbers indicate the amount of compressions and single ventilations delivered in each minute.

35. Duration of ventilations during cardiopulmonary resuscitation by lay
rescuers and first reponders : relationship between delivering chest
compressions and outcomes
SG Beesems Circulation, 2013
Beesems et al Interruptions of Chest Compressions 1589
long interruptions of chest compressions, mainly caused by
pauses associated with defibrillation shocks.13,14 This paradox
can be attributed to the fact that other baseline factors that are
more important for predicting survival were unevenly distrib-uted
between the groups of ventilation duration. After adjust-ment
for the baseline factors, the ventilation pause duration was
a chest compression fraction of >60%, compatible with good
survival, is achieved in all ventilation groups except the longest.10
The importance of the minimal number of compressions
delivered per minute is emphasized in a recent study in which
the group of patients who received 75 to 100 compressions per
minute had significantly more return of spontaneous circulation
Table 4. Survival Analyses
Variable
OR (95% CI), Univariable
Analysis P Value
OR (95% CI), Multivariable
Analysis P Value
Ventilation duration of 3–5 s Reference Reference
Ventilation duration of 6–7 s 2.14 (0.70–6.55) 0.183 1.62 (0.43–6.10) 0.48
Ventilation duration of 8–9 s 2.60 (0.84–8.03) 0.097 1.02 (0.27–3.78) 0.98
Ventilation duration of 10–12 s 2.96 (0.85–10.3) 0.087 1.30 (0.29–5.97) 0.73
Ventilation duration ≥13 s 5.55 (1.55–19.8) 0.008 2.38 (0.46–12.1) 0.30
Time from emergency call to AED attachment 0.82 (0.74–0.90) <0.001 0.81 (0.71–0.92) <0.001
Dispatched first responder/onsite rescuers 0.29 (0.14–0.58) <0.001 0.67 (0.27–1.64) 0.38
VF as initial rhythm 26.2 (7.77–88.22) <0.001 32.6 (8.86–120.1) <0.001
CI indicates confidence interval; OR, odds ratio for survival; and VF, ventricular fibrillation.

36. RCP spécialisée : ventile-t-on
bien ?

37. Do we hyperventilate cardiac arrest patients ?
F John Resuscitation, 2007 Do we hyperventilate cardiac arrest patients? Figure 3 A typical recording (30 s) of ventilatory vari-ables
Ø during resuscitation, demonstrating persistently
1. Aufderheide TP, Sigurdsson high airway pressures and high respiratory rate.
induced hypotension resuscitation. Circulation 2. Aufderheide TP, Lurie KG. in two patients. In 11/12 (91.7%) patients, the air-way
and life-threatening pressure remained positive for more than 90%
resuscitation. Crit Care Med of the time. This contrasts with pre-hospital stud-ies
3. Cheifetz IM, Craig DM, volumes and pulmonary overdistention that document a positive airway pressure for
vascular mechanics 50%1 and 47.3%2 of the time, despite higher ventila-tion
swine model. Crit Care Med rates. The difference between the two studies
4. Karlsson T, Stjernstrom EL, may be related to the use of the LUCAS thumper to
regional blood flow during deliver chest compressions which is more efficient
study in the pig. Acta Anaesthesiol 5. Pepe PE, Raedler C, Lurie than manual compression12,13 and may contribute
management in to an overall increase in mean intrathoracic pres-sure.
detrimental? J Trauma 2003;The median airway pressure in this study
6. Theres H, Binkau J, Laule in right ventricular cardiac mechanical ventilation with Crit Care Med 1999;was 13.9 cmH2O which therefore requires a central
venous pressure in excess of this value to enable
venous return to the heart. Although central venous
All reported studies arrest have demonstrated hyperventilation. It is likely is a widespread problem, pre-hospital resuscitation. patients at an appropriate during all resuscitation Conflict of interest
No author has any conflict of this study.
References
Patients ayant un ACR
extrahospitalier et admis aux
urgences, intubés et ventilés
Ø MCE par le Système LUCAS
Ø Ventilation manuelle par
ballon par un médecin sénior
Ø Mesure de la FR, Vt, Paw,
Peep, Pmean, Pi, EtCO2
Ø La FR maximum et médiane
sont mesurée sur la période
de ventilation continue la
plus longue
Ø 12 patients inclus
Ø Hyperventilation en rapport
avec une augmentation de la
fréquence ventilatoire
Median Min Max
Patient weight (kg) 80.0 60 120
Time from initial arrest (min) 43.0 29 56
Minute volume (l/min) 13.0 4.6 21.3
Respiratory rate—–median (min−1) 21.0 7 37
Respiratory rate—–max (min−1) 25.5 9 41
Tidal volume (ml) 618.5 374 923
Peak end-expiratory pressure (cmH2O) 1.3 0 6.9
Mean airway pressure (cmH2O) 13.9 5.1 37.4
Peak inspiratory pressure (cmH2O) 60.6 46 106.1
Compliance-dynamic (ml/cmH2O) 20.4 5 68.2
% Time airway pressure >0 cmH2O (%) 95.3 87.9 100
Figure 1 Box and whisker plot showing distribution of
mean airway pressure during manual ventilation in 12
patients during cardiac arrest. The boundaries of the box
indicate the 25th and 75th percentile, and the line within
the box marks the median. Whiskers above and below the
box indicate the 90th and 10th percentiles, respectively.
Outlying points are shown as full circles.
out-of-hospital. No patient survived. Evidence of
aspiration was present in three patients.
Median tidal volume was in excess of 10 ml/kg in
3/12 patients.
Figure 1 shows the distribution of mean airway
pressure. Figure 2 shows distribution of respiratory
rate. Figure 3 shows a typical recording (30 s) of
ventilatory variables during resuscitation, demon-strating
persistently high airway pressures and high
respiratory rate.
Discussion
during CPR, hyperventilation occurred frequently.
Hyperventilation was caused by excess respiratory
rates rather than excessive tidal volumes. The
respiratory rate was at least double that recom-mended
in 9/12 (75%) patients whilst the tidal
volume was no higher than the recommended
10 ml/kg10 in 9/12 (75%) patients. The respiratory
rates are similar to findings previously reported
in hospital1,2,9 and pre-hospital studies.1,2 This is
the first study we are aware of to report human
in vivo tidal volumes during cardiopulmonary
resuscitation.
The airway pressures recorded were high, with
a maximum peak airway pressure over 100 cmH2O
Figure 2 Box and whisker plot showing respiratory rate
during manual ventilation in 12 patients during cardiac
arrest. The boundaries of the box indicate the 25th and
75th percentile, and the line within the box marks the
median. Whiskers above and below the box indicate the

38. Hyperventilation-induced hypotension during cardiopulmonary
resuscitation
TP Aufderheide Circulation, 2004
Aufderheide et al Hyperventilation-Induced Hypotension During CPR 1961
determine the
consequences of
informed consent
Part 50.24) after
was part of but
Drug Adminis-tration
exemption. The
Medical College of
in the City of
life support EMS
provided according to
team including
TABLE 1. Clinical Observational Study: Maximum Ventilation
Rate, Duration, and Percentage of Time in Which a Positive
Pressure Was Recorded in the Lungs (Mean!SEM)
Group
Ventilation Rate
(Breaths per Minute)
Ventilation Duration
(Seconds per Breath)
% Positive
Pressure
Group 1 37"4* 0.85"0.07† 50"4%
Group 2 22"3* 1.18"0.06† 44.5"8.2%
Group 3 30"3.2 1.0"0.7 47.3"4.3%
*P!0.05; †P!0.05; group 1, first 7 consecutive cases; group 2, subsequent
6 consecutive cases (after retraining); group 3, groups 1 and 2 combined.
(group 3), the ventilation rate for all 13 patients was 30 breaths per
minute (twice the AHA-recommended rate).
Individual recordings provide insight into the rate and duration of
ventilations provided by professional rescuers. Figure 1A represents
delivery of CPR relatively close to AHA guidelines. Only one such
Ø Etude clinique observationnelle
Ø Patients ayant fait un ACR extrahospitalier pris en
charge par l’équipe médicale d’urgence (EMU)
Ø Mesure de la FR et de la durée moyenne d’un cycle
respiratoire chez des patients intubés ventilés
Ø Première phase: 7 ACR consécutifs (groupe 1)
Ø Deuxième phase : formation de tout le personnel de
l’EMU sur la fréquence respiratoire de 12/min
Ø Troisième phase : 6 ACR consécutifs (groupe 2)
During the first 2 minutes of 5:1 was used on all Hemodynamic Protocol After the initial 2 minutes ventilation rates (12, random order, 3 different ventilation asynchronous manner, 3 seconds (20 per minute), with each breath delivered During CPR, aortic, continuously recorded. continuously and recorded collected before induction rate phase (after minute Survival Protocol Ventilation during synchronously with a initial 2 minutes of CPR, minutes of CPR with breaths per minute with 100% O2; or (3) 30 Five percent CO2 was evaluate the effect of hypocarbia. During these in an asynchronous manner second (30/min), with second.
During CPR, aortic, as ETCO2 and O2 saturation blood gas samples were end of each ventilation At the end of each biphasic defibrillator to 3 times, as needed.ventilated with a ventilator spontaneous circulation over 5 minutes. Survival rhythm generating a measurable observation after resuscitation. were performed after At the end of each with an intravenous potassium chloride.
1962 Circulation April 27, 2004
All values are expressed pressure was calculated right atrial diastolic were performed for pressures, and the average value for each animal. the time-averaged value Figure 1. A, This 16-second intrathoracic pressure recording
over a 10-second period. ANOVA and paired Fisher’s exact tests. depicts CPR performed relatively close to AHA guidelines.
Large-amplitude waves represent ventilations (11 breaths per
minute). Small-amplitude waves represent chest compressions

39. Hyperventilation-induced hypotension during
cardiopulmonary resuscitation
TP Aufderheide Circulation, 2004
Aufderheide et al Hyperventilation-Induced Hypotension During CPR 1963
TABLE 2. Animal Protocol I: Changes in Hemodynamics and
Arterial Blood Gases With Three Different Ventilation Rates
Delivered in Random Order (Mean!SEM)
Ventilation Rate, Breaths per Minute
12 20 30 P
Hemodynamics
SAP, mm Hg 68.8#4.7 62.7#4.2 60.1#3.6 0.33
CPP, mm Hg 23.4#1.0 19.5#1.8 16.9#1.8 0.03
MIP, mm Hg per minute 7.1#0.7 11.6#0.7 17.5#1.0 "0.0001
Arterial blood gases
pH 7.34#0.02 7.45#0.03 7.52#0.03 0.0006
PaCO2, mm Hg 22.7#2.7 15.6#2.2 11.6#1.5 0.005
PaO2, mm Hg 340.9#40.7 403.3#47.0 403.7#48.0 0.59
SAP, Systolic aortic pressure; CPP, coronary perfusion pressure; MIP, mean
intrathoracic pressure.
Statistical analysis was done by ANOVA. A value of P"0.05 was considered
statistically significant.
ROSC rate was 3 of 9 pigs; 2 of 3 pigs that survived received
12 ventilations per minute as the terminal ventilation rate
sequence.
Animal Survival Studies
The survival rate in pigs ventilated at 12 breaths per minute
(100% O2) was 6 of 7 (86%), compared with a survival rate
of 1 of 7 (17%) at a rate of 30 breaths per minute (100% O2),
and 1/7 (17%) at a ventilation rate of 30 breaths per minute
(5% CO2/95% O2) (P!0.006) (Figure 3). Mean intrathoracic
pressures were significantly higher with the higher ventilation
rates (P"0.0001), and coronary perfusion pressures were
lower (Table 3). Changes in arterial blood gases and ETCO2
Figure 3. Survival Study (n!7 pigs per group). Changes in
mean intrathoracic pressure (MIP), arterial CO2 (PaCO2), coronary
perfusion pressure (CPP), and survival rate, with hyperventilation
and correction of hypocapnia ($CO2). Probability value of "0.05
was considered statistically significant, based on ANOVA analy-sis
of the 3 groups.
Ø Etude animale
Ø Cochon intubés, ventilés, FV induite, début
de la RCP 6 min après début FV
Ø MCE 100/min, mécanique
Ø Ventilation par une valve à la demande,
durée du cycle 1 sec
Ø CPR 2 min avec rapport compression/
ventilation de 5/1
Ø Puis 3 groupes de 7 cochons :
Ø FR 12/min, FIO2 100% (groupe1)
Ø FR 30/min, FIO2 100% (groupe 2)
Ø FR 30/min FIO2 95%, FICO2 5% (groupe 3)
Ø CPR pendant 4 min
Ø Choc électrique (3 max)
Ø Mesure de la pression aortique, pression de
l’OD, pression intra-thoracique
Ø Survie à une heure

40. Peut-on optimiser la
ventilation ?

41. Closed-chest CPR performed with 6.5-cm circular
compression pad positioned over the sternum. The automated
device and the measurement of hemodynamic parameters have
been described previously.16 Compression and decompression excursion was measured continuously by the voltage output of a linear variable differential transformer.6 Compression-decom¬ pression forces were similarly monitored continuously using a piezo electric force transducer.6 These data, which included all hemodynamic measurements, assessment of the distal tracheal
pressure from a fluid-filled pressure transducer connected to the
distal end of the endotracheal tube, and measurements of cdoemcpormepsrseisosni/odnefcoormcpers,eswseiroen dcihgietsitzeedxocnu-rlsiinoen (aSnUdPcEoRmSprCeOsPsiEonI/I
v.295; GW Instruments; Somerville, Pa) and analyzed electroni¬ cally using a computerized recording system (Power Macintosh
7100/66 computer; Apple Computer; Cupertino, Calif).6 The protocol was designed to compare standard CPR alone
with standard CPR plus an inspiratory ITV. Each pig served as its
own control. The experimental protocol is seen in the schematic
in Figure 1.
Once catheters were placed into the left ventricle, right atrium,
and aorta, the right atrial diastolic pressures were maintained at
2.5 to 5 mm Hg with IV normal saline solution. Within 10 min of inducing ventricular fibrillation, the first radiolabeled micro-sphere
Optimizing Standard Cardiopulmonary IRemspuesdcaitnacteion With an Inspiratory Threshold Valve*
Keith G. Lurie, MD; Katherine A. Mulligan, BA; Scott McKnite, BS; Barry Detloff, BA; Paul Lindstrom, BS; and Karl H. Lindner, MD
eObxjcehcatnigvees:imTphriosvsetsudtyhewaefsfidceiseingcnyeodftsotaasnsdeasrsdwchaertdhieorpuinltmeornmairtyternetsuismcpietdatainocne(oCfPRi)n.spiratory gas Background: Standard CPR relies on the natural elastic recoil ofthe chest to transiently decrease
Ø Animale, prospective
Ø RCP standard / RCP standard + valve d’impédance inspiratoire (VII)
Ø 15 cochons, FV, RCP standard avec ou sans VII sur 4 périodes de 7 min
Ø MCE 80/min, FR 16 /min, Vt 450 ml, Ambu
Ø Mesure du débit sanguin ventriculaire (DSV), débit sanguin cérébral
intrathoracic pressures and thereby promote venous blood return to the heart. To further
enhance the negative intrathoracic pressures during the "relaxation" phase of CPR, we tested the hypothesis that intermittent impedance to inspiratory gases during standard CPR increases
coronary perfusion pressures and vital organ perfusion. Methods: CPR was performed with a pneumatically driven automated device in a porcine model
of ventricular fibrillation. Eight pigs were randomized to initially receive standard CPR alone, ewhxiclheansgeeven pigs initially received standard CPR plus intermittent impedance to inspiratory gas with a threshold valve set to .40 cm H20. The compressiomventilation ratio was 5:1
and the compression rate was 80/min. At 7-min intervals the impedance threshold valve (ITV) was either added or removed from the ventilation circuit such that during the 28 min of CPR, each
animal received two 7-min periods of CPR with the ITV and two 7-min periods without the valve.
Results: Vital organ blood flow was significantly higher during CPR performed with the ITV than d(umrLi/mnign/CgP)Rwapser0f.o3r2m±e0.d04wivtsho0u.t23t±h0e.0v3alwvie.thoTuottatlhelefItTVve(npt<r0i.c0u5l)a.r Cbelroeobdrafllobwlo(omdefalno±wS(EmML)/ min/g) was 20% higher with the ITV (+ITV, 0.23±0.02; -ITV, 0.19±0.02; p<0.05). Each time the
ITV was removed, there was a statistically significant decrease in the vital organ blood flow and
Ccoonrcolnuasriyonpse:rfIunstieornmiptrteesnsturie.mpedance to inspiratory flow of respiratory gases during standard
CPR significantly improves CPR efficiency during ventricular fibrillation. These studies under¬
score the importance of lowering intrathoracic pressures during the relaxation phase of CPR.
(DSC), pression de perfusion coronarienne (PPC)
(CHEST 1998; 113:1084-90)
tKheryeswhoolrddsv:alvaec;tivveentcroimcpurlearssfiiobrni-ldlaetcioonmpression CPR; cardiac arrest; cardiopulmonary resuscitation; heart; impedance
Abbreviations: ACD=active compression-decompression; CPP=coronary perfusion pressure; CPR=cardiopulmonary resuscitation; ITV=impedance threshold valve; NS=not significant
HP he potential value of increasing negative in-
-¦¦ trathoracic pressure during the decompression phase of cardiopulmonary resuscitation (CPR) with a
new technique termed active compression-decom¬ pression (ACD) CPR has been described recently.1-5 ACD CPR enhances the bellows-like action of the
chest. proved Use hemodynamic of this method is associated with im¬ status in animal models and
Chest, 1998
humans when compared recently, with conventional manual
efficacy CPR.15 More we demonstrated improved that the of ACD CPR could impedance be further by insertion of m(IoTdVe)ionftoventthreicruelsapriratory an inspiratory threshold valve
circuit.6 In a porcine available to (including the Harvard animal ventilator [Harvard
Apparatus; Dover, Mass] and the Siemens ventilator [Siemens; Munich Germany]), which we have previously used,136 had a significant amount of resistance to inspiration. That inspiratory resistance prevented us from testing our overall hypothesis. During CPR, respirations were delivered continuously at a rate of
16/min (one breath every five chest compressions) at a constant
tidal volume of approximately 450 mL. As previously described, ventilations were delivered during the decompression phase of
CPR.16
The ITV in this study consisted of two 20 cm H20 threshold
valves (Ambu Anesthesia PEEP Valve 20, No. 194011000; Ambu,
Inc; Glostrup, Denmark) connected in series between the endo¬
tracheal tube and the Ambu bag such that during the decom¬
pression phase, but in the absence of manual ventilation, the
valves opened only with greater than .40 cm H20 of inspiratory
pressure. In this fashion, more than .40 cm H20 of intrathoracic
pressure was required for inspiration of respiratory gases during four of every five compression cycles during performance of CPR
with the ITV. With standard CPR and without active bag ventilation, use of these threshold valves in series resulted in effectively no inspiratory movement of respiratory gases during the decompression phase of CPR. As shown in the protocol time
line, at 7-min intervals, the ITV was either added or removed
Time: 0 10 12 17 19 24 26
VF Start bead 1 ±ITV
CPR(±ITV)
bead2 dTV bead 3 ±ITV bead 4
Figure 1. Experimental protocol.
CHEST/113/4/APRIL, 1998 1085

42. Lurie et al Impedance Valve Improves Outcome After VF in Pigs 125
suffering. This study
guidelines7 on 40 female
received 7 mL (100
Dodge Animal Health) IM
18-gauge angiocath-eter
through a lateral ear
Abbott Laboratories) (2.3
intravenous bolus. While the
heavily sedated, they were
Medline Industries Inc).
mg of propofol and
!g · kg!1 · min!1 until
position. Femoral artery
conditions, and arterial
recorded as previously de-scribed.
recorded with a lead II
analyzed as previously
measured with a micro-manometer-
below the tip of the
CO2 SMO Plus Respi-ratory
Systems), arterial pres-sures,
recorded continuously during
experimental protocol. Animals
induction of ventricular
Figure 1. Schematic of respiratory gas flow through ITV.
were occluded during the manufacturing of the sham valves, such
that they functioned as a hollow conduit for respiratory gas ex-change.
As such, half of the ITVs were made as sham valves and the
other half were active. Figure 1 depicts the function of the ITV

43. Optimizing Standard Cardiopulmonary IRemspuesdcaitnacteion With an Inspiratory Threshold Valve*
Keith G. Lurie, MD; Katherine A. Mulligan, BA; Scott McKnite, BS; Barry Detloff, BA; Paul Lindstrom, BS; and Karl H. Lindner, MD
eObxjcehcatnigvees:imTphriosvsetsudtyhewaefsfidceiseingcnyeodftsotaasnsdeasrsdwchaertdhieorpuinltmeornmairtyternetsuismcpietdatainocne(oCfPRi)n.spiratory gas Background: Standard CPR relies on the natural elastic recoil ofthe chest to transiently decrease
Ø DSV moyen plus élevé dans le groupe avec VII : 0,32±0,11
intrathoracic pressures and thereby promote venous blood return to the heart. To further
enhance the negative intrathoracic pressures during the "relaxation" phase of CPR, we tested the hypothesis that intermittent impedance to inspiratory gases during standard CPR increases
coronary perfusion pressures and vital organ perfusion. Methods: CPR was performed with a pneumatically driven automated device in a porcine model
of ventricular fibrillation. Eight pigs were randomized to initially receive standard CPR alone, ewhxiclheansgeeven pigs initially received standard CPR plus intermittent impedance to inspiratory gas with a threshold valve set to .40 cm H20. The compressiomventilation ratio was 5:1
and the compression rate was 80/min. At 7-min intervals the impedance threshold valve (ITV) was either added or removed from the ventilation circuit such that during the 28 min of CPR, each
animal received two 7-min periods of CPR with the ITV and two 7-min periods without the valve.
Results: Vital organ blood flow was significantly higher during CPR performed with the ITV than d(umrLi/mnign/CgP)Rwapser0f.o3r2m±e0.d04wivtsho0u.t23t±h0e.0v3alwvie.thoTuottatlhelefItTVve(npt<r0i.c0u5l)a.r Cbelroeobdrafllobwlo(omdefalno±wS(EmML)/ min/g) was 20% higher with the ITV (+ITV, 0.23±0.02; -ITV, 0.19±0.02; p<0.05). Each time the
ITV was removed, there was a statistically significant decrease in the vital organ blood flow and
Ccoonrcolnuasriyonpse:rfIunstieornmiptrteesnsturie.mpedance to inspiratory flow of respiratory gases during standard
CPR significantly improves CPR efficiency during ventricular fibrillation. These studies under¬
score the importance of lowering intrathoracic pressures during the relaxation phase of CPR.
ml/min/g vs 0,23±0,05 ml/min/g ; p < 0,05
Ø DSC moyen plus élevé dans le groupe avec VII : 0,23±0,02
vs 0,19±0,02 ; p< 0,05
Ø PPC moyenne est plus élevée dans le groupe avec VVI :
14,8±1,3 mm Hg vs 12,5±1,5 mm Hg ; p = 0,07
Ø Augmentation de 20% de la PPC mais de 40% du DSV
(CHEST 1998; 113:1084-90)
Ø Effet de l’augmentation du retour veineux mais également
tKheryeswhoolrddsv:alvaec;tivveentcroimcpurlearssfiiobrni-ldlaetcioonmpression CPR; cardiac arrest; cardiopulmonary resuscitation; heart; impedance
Abbreviations: ACD=active compression-decompression; CPP=coronary perfusion pressure; CPR=cardiopulmonary resuscitation; ITV=impedance threshold valve; NS=not significant
d’autre mécanismes permetant une majoration de la
perfusion myocardique
HP he potential value of increasing negative in-
-¦¦ trathoracic pressure during the decompression phase of cardiopulmonary resuscitation (CPR) with a
new technique termed active compression-decom¬ pression (ACD) CPR has been described recently.1-5 ACD CPR enhances the bellows-like action of the
chest. Use of this method is associated with im¬ Chest, 1998
proved hemodynamic compared status in animal models and
humans when recently, with conventional manual
efficacy CPR.15 More we demonstrated improved that the of ACD CPR could impedance be further by insertion of threshold valve
m(IoTdVe)ionftoventthreicruelsapriratory an inspiratory circuit.6 porcine

44. 0.54
Optimizing Standard Cardiopulmonary IRemspuesdcaitnacteion With an Inspiratory Threshold Valve*
Keith G. Barry Detloff, Lurie, MD; Katherine A. Lindstrom, Mulligan, BA; Scott Lindner, McKnite, BS; BA; Paul BS; and Karl H. MD
eObxjcehcatnigvees:imTphriosvsetsudtyhewaefsfidceiseingcnyeodftsotaasnsdeasrsdwchaertdhieorpuinltmeornmairtyternetsuismcpietdatainocne(oCfPRi)n.spiratory gas Background: Standard CPR relies thereby on the natural elastic recoil ofthe chest to intrathoracic transiently decrease
pressures and promote venous blood return to the heart. To further
hypothesis enhance the negative intrathoracic impedance pressures during the "relaxation" inspiratory during phase of CPR, that we tested the perfusion intermittent to perfusion. gases standard CPR increases
and vital Methods: coronary pressures CPR was performed with organ Eight a pneumatically driven initially automated device in a porcine model
of ventricular fibrillation. initially pigs were randomized plus to impedance receive standard pigs CPR inspiratory alone, ewhxiclheansgeeven received standard CPR intermittent compressiomventilation to with gas compression a threshold valve set to .40 cm H20. The impedance ratio was 5:1
and the rate was 80/min. At 7-min intervals the threshold valve (ITV) either added or removed from periods the ventilation such that during was circuit the 28 min of CPR, each
animal received two 7-min of CPR with the ITV and two 7-min periods without the valve.
Results: d(umrLi/mnign/Vital Rwapser0f.organ o3r2m±blood e0.d04wivtsho0u.flow was significantly higher during CPR performed with the ITV than CgP)t23t±h0e.0v3alwvie.thoTuottatlhelefItTVve(npt<r0i.c0u5l)a.r Cbelroeobdrafllobwlo(omdefalno±wS(EmML)/ min/g) was 20% higher with the statistically ITV (+ITV, removed, significant 0.23±0.02; -ITV, 0.19±0.02; p<0.05). Each time the
Ccoonrcolnuasriyonpse:ITV was rfIunstieornmiptrteesnsturie.there was a decrease in the vital organ blood flow and
significantly mpedance efficiency to inspiratory during flow of improves respiratory during standard
CPR CPR ventricular fibrillation. gases These score the importance of lowering intrathoracic pressures during the relaxation (CHEST phase studies under¬
of CPR.
1998; 113:1084-90)
tKheryeswhoolrddsv:alvaec;tivveentcroimcpurlearssfiiobrni-ldlaetcioonmpression CPR; cardiac arrest; cardiopulmonary resuscitation; heart; impedance
Abbreviations: ITV=ACD=impedance active compression-threshold valve; decompression; significant
CPP=coronary perfusion pressure; CPR=cardiopulmonary resuscitation; NS=not HP he potential value of during increasing decompression negative in-
proved chest. Use hemodynamic of this method is associated with im¬ -¦¦ phase trathoracic cardiopulmonary pressure the status in animal models and
of resuscitation (CPR) with a
humans when compared recently, with conventional manual
new technique termed active (ACD) compression-decom¬ pression CPR has been described recently.1-5 efficacy CPR.15 More demonstrated that the of we ACD CPR could impedance be further improved by ACD CPR enhances the bellows-like action of the
insertion of threshold valve
m(IoTdVe)ionftoventthreicruelsapriratory an inspiratory circuit.6 5o
porcine 1 0.4H
is"5 ° 3
> o.H
0.0
10 20
Minutes After VF
2 b.
o
&
0.4
0.3H
1!
0.0
10 20 Minutes After VF
.i
30
2c.
<3A (A 0)
.2 G»
it
CcO o
20 H
15
10
10 20
Minutes After VF
30
Chest, 1998
Figure 2. Top (a): myocardial (open blood circles) flow (mean±SEM) assessed plus 2, 9, 16, (closed and 23 circles). min after initiation
of either standard CPR alone or standard CPR ventilatory the ITV After 7 min
of CPR, (the b): ITV brain was either added (mean±to or SEM) removed from the circuit. Asterisk indicates p<0.05. Center blood standard CPR alone (open flow after circles) assessed plus 2, 9, 16, and (closed 23 min initiation of either
standard CPR the ITV circles). After 7 min of CPR,

45. Use of an Inspiratory Impedance Valve Improves
Neurologically Intact Survival in a Porcine Model of
Ventricular Fibrillation
Keith G. Lurie, MD; Todd Zielinski, MS; Scott McKnite, BS;
Tom Aufderheide, MD; Wolfgang Voelckel, MD
Background—This study evaluated the potential for an inspiratory impedance threshold valve (ITV) to improve 24-hour
Ø Animale, survival and prospective
neurological function in a pig model of cardiac arrest.
Methods and Results—Using a randomized, prospective, and blinded design, we compared the effects of a sham versus
active ITV on 24-hour survival and neurological function. After 6 minutes of ventricular fibrillation (VF), followed by
Ø 40 cochons, 6 minutes of cardiopulmonary 20 dans resuscitation (CPR) with either a sham or an active valve, anesthetized pigs received 3
sequential 200-J shocks. If VF persisted, chaque they received epinephrine groupe
(0.045 mg/kg), 90 seconds of CPR, and 3 more 200-J
shocks. A total of 11 of 20 pigs (55%) in the sham versus 17 of 20 (85%) in the active valve group survived for 24 hours
(P!0.05). Neurological scores were significantly higher with the active valve; the cerebral performance score
Ø Sédatés, (1"normal, ventilés
5"brain death) was 2.2#0.2 with the sham ITV versus 1.4#0.2 with the active valve (P!0.05). A total
of 1 of 11 in the sham versus 12 of 17 in the active valve group had completely normal neurological function (P!0.05).
Peak end-tidal CO2 (PETCO2) values were significantly higher with the active valve (20.4#1.0) than the sham (16.8#1.5)
(P!0.05). PETCO2 $18 mm Hg correlated with increased survival (P!0.05).
Ø FV Conclusions—pendant Use of 6 a functional min ITV puis during standard RCP CPR significantly avec improved une 24-valve hour survival factice rates and neurological
ou une VII
Ø Après 6 min de RCP, les valves sont retirées et l’animal est
recovery. PETCO2 and systolic blood pressure were also significantly higher in the active valve group. These data support
further evaluation of ITV during standard CPR. (Circulation. 2002;105:124-129.)
Key Words: cardiac arrest ! fibrillation ! cardiopulmonary resuscitation ! valves ! survival ! arrhythmia ! brain
Survival rates remain poor for most patients who suffer
choqué ± Adrénaline en fonction d’une RACS
from a cardiac arrest. Studies on the mechanism of blood
flow during cardiopulmonary resuscitation (CPR) have re-cently
Ø Critère focused de on the jugement importance of the decompression : évolution phase
neurologique à H 24
of CPR.1–4 During the decompression phase of standard CPR,
a small vacuum is created within the chest relative to the rest
of the body every time the chest wall recoils back to its
resting position.5 This draws venous blood back into the right
heart. In addition, during the decompression phase of stan-dard
CPR, air is drawn into the lungs. We previously
described the use of an impedance threshold valve (ITV) to
prevent the inflow of respiratory gases during the active chest
wall recoil phase, or decompression phase, of standard
CPR.4,5 The ITV is a small (35-mL) disposable plastic valve
that is attached to the endotracheal tube or a face mask. It
works by allowing the rescuer to freely ventilate the patient
but impeding inspiratory airflow during the decompression
phase of CPR when the patient is not being actively venti-lated.
This creates a small vacuum within the chest to further
enhance venous return.
We recently demonstrated in a porcine model that use of
the ITV resulted in a nearly 2-fold increase in blood flow to
the brain and the heart after 6 minutes of ventricular fibril-lation
and 6 minutes of standard CPR.6 Although use of the
ITV during standard CPR has been reported previously in 2
studies involving $30 animals, to date there have been no
definitive data in support of a survival benefit from the use of
the ITV with standard CPR.4,6 Thus, the purpose of this
investigation was to test the hypothesis that the ITV would
improve neurological function and 24-hour survival in an
established animal model of cardiac arrest during perfor-mance
of standard CPR.
Methods
Preparatory Phase
The study was approved by the Committee of Animal Experimen-tation
at the University of Minnesota. Anesthesia was used in all
Circulation, 2002

46. Use of an Inspiratory Impedance Valve Improves
Neurologically Intact Survival in a Porcine Model of
Ventricular Fibrillation
TABLE 1. Twenty-Four Hour Survival and Neurological
Assessment Score
Sham Valve (n#20) Active Valve (n#20)
24-hour survival, n (%) 11 (55)* 17 (85)*
Neurological assessment
Consciousness 25.0!6.2 10.6!4.4*
Respiratory pattern 10.8!8.5* 0.0!0.0*
Painful stimulus 13.3!4.1 4.7!2.1
Muscle tone 16.7!5.6 5.9!2.7
Standing 5.0!2.6 1.2!1.2
Walking 13.3!3.3 5.3!2.1*
Restraint 30.8!5.3* 12.9!4.8*
Total deficit score 16.4!3.3† 5.8!1.8†
*P"0.05.
†P"0.02.
calculated on the basis of expected differences in 24-hour survival
between groups. All data are expressed as mean!SEM.
TABLE 2. Twenty-Assessment Score 24-hour survival, n (%) Neurological assessment
Consciousness Respiratory pattern Painful stimulus Muscle tone Standing Walking Restraint Total deficit score *P"0.05.
†P"0.002.
126 Circulation January 1/8, 2002
Keith G. Lurie, MD; Todd Zielinski, MS; Scott McKnite, BS;
Tom Aufderheide, MD; Wolfgang Voelckel, MD
Background—This study evaluated the potential for an inspiratory impedance threshold valve (ITV) to improve 24-hour
survival and neurological function in a pig model of cardiac arrest.
Methods and Results—Using a randomized, prospective, and blinded design, we compared the effects of a sham versus
active ITV on 24-hour survival and neurological function. After 6 minutes of ventricular fibrillation (VF), followed by
6 minutes of cardiopulmonary resuscitation (CPR) with either a sham or an active valve, anesthetized pigs received 3
sequential 200-J shocks. If VF persisted, they received epinephrine (0.045 mg/kg), 90 seconds of CPR, and 3 more 200-J
shocks. A total of 11 of 20 pigs (55%) in the sham versus 17 of 20 (85%) in the active valve group survived for 24 hours
(P!0.05). Neurological scores were significantly higher with the active valve; the cerebral performance score
(1"normal, 5"brain death) was 2.2#0.2 with the sham ITV versus 1.4#0.2 with the active valve (P!0.05). A total
of 1 of 11 in the sham versus 12 of 17 in the active valve group had completely normal neurological function (P!0.05).
Peak end-tidal CO2 (PETCO2) values were significantly higher with the active valve (20.4#1.0) than the sham (16.8#1.5)
(P!0.05). PETCO2 $18 mm Hg correlated with increased survival (P!0.05).
Conclusions—Use of a functional ITV during standard CPR significantly improved 24-hour survival rates and neurological
recovery. PETCO2 and systolic blood pressure were also significantly higher in the active valve group. These data support
further evaluation of ITV during standard CPR. (Circulation. 2002;105:124-129.)
Key Words: cardiac arrest ! fibrillation ! cardiopulmonary resuscitation ! valves ! survival ! arrhythmia ! brain
Survival rates remain poor for most patients who suffer
from a cardiac arrest. Studies on the mechanism of blood
flow during cardiopulmonary resuscitation (CPR) have re-cently
focused on the importance of the decompression phase
of CPR.1–4 During the decompression phase of standard CPR,
a small vacuum is created within the chest relative to the rest
of the body every time the chest wall recoils back to its
resting position.5 This draws venous blood back into the right
heart. In addition, during the decompression phase of stan-dard
CPR, air is drawn into the lungs. We previously
described the use of an impedance threshold valve (ITV) to
prevent the inflow of respiratory gases during the active chest
wall recoil phase, or decompression phase, of standard
CPR.4,5 The ITV is a small (35-mL) disposable plastic valve
that is attached to the endotracheal tube or a face mask. It
works by allowing the rescuer to freely ventilate the patient
but impeding inspiratory airflow during the decompression
phase of CPR when the patient is not being actively venti-lated.
This creates a small vacuum within the chest to further
enhance venous return.
We recently demonstrated in a porcine model that use of
the ITV resulted in a nearly 2-fold increase in blood flow to
the brain and the heart after 6 minutes of ventricular fibril-lation
and 6 minutes of standard CPR.6 Although use of the
ITV during standard CPR has been reported previously in 2
studies involving $30 animals, to date there have been no
definitive data in support of a survival benefit from the use of
the ITV with standard CPR.4,6 Thus, the purpose of this
investigation was to test the hypothesis that the ITV would
improve neurological function and 24-hour survival in an
established animal model of cardiac arrest during perfor-mance
of standard CPR.
Methods
Preparatory Phase
The study was approved by the Committee of Animal Experimen-tation
at the University of Minnesota. Anesthesia was used in all
Circulation, 2002

47. Use of an Inspiratory Impedance Valve Improves
Neurologically Intact Survival in a Porcine Model of
Ventricular Fibrillation
Lurie et al Impedance Valve Keith G. Improves Lurie, MD; Outcome Todd Zielinski, After MS; Scott VF McKnite, in Pigs BS;
127
Tom Aufderheide, MD; Wolfgang Voelckel, MD
Background—This study evaluated the potential for an inspiratory impedance threshold valve (ITV) to improve 24-hour
survival and neurological function in a pig model of cardiac arrest.
Methods and Results—Using a randomized, prospective, and blinded design, we compared the effects of a sham versus
active ITV on 24-hour survival and neurological function. After 6 minutes of ventricular fibrillation (VF), followed by
6 minutes of cardiopulmonary resuscitation (CPR) with either a sham or an active valve, anesthetized pigs received 3
sequential 200-J shocks. If VF persisted, they received epinephrine (0.045 mg/kg), 90 seconds of CPR, and 3 more 200-J
shocks. A total of 11 of 20 pigs (55%) in the sham versus 17 of 20 (85%) in the active valve group survived for 24 hours
(P!0.05). Neurological scores were significantly higher with the active valve; the cerebral performance score
(1"normal, 5"brain death) was 2.2#0.2 with the sham ITV versus 1.4#0.2 with the active valve (P!0.05). A total
of 1 of 11 in the sham versus 12 of 17 in the active valve group had completely normal neurological function (P!0.05).
Peak end-tidal CO2 (PETCO2) values were significantly higher with the active valve (20.4#1.0) than the sham (16.8#1.5)
(P!0.05). PETCO2 $18 mm Hg correlated with increased survival (P!0.05).
Conclusions—Use of a functional ITV during standard CPR significantly improved 24-hour survival rates and neurological
recovery. PETCO2 and systolic blood pressure were also significantly higher in the active valve group. These data support
further evaluation of ITV during standard CPR. (Circulation. 2002;105:124-129.)
Key Words: cardiac arrest ! fibrillation ! cardiopulmonary resuscitation ! valves ! survival ! arrhythmia ! brain
Survival rates remain poor for most patients who suffer
from a cardiac arrest. Studies on the mechanism of blood
flow during cardiopulmonary resuscitation (CPR) have re-cently
focused on the importance of the decompression phase
of CPR.1–4 During the decompression phase of standard CPR,
a small vacuum is created within the chest relative to the rest
of the body every time the chest wall recoils back to its
resting position.5 This draws venous blood back into the right
heart. In addition, during the decompression phase of stan-dard
This creates a small vacuum within the chest to further
enhance venous return.
We recently demonstrated in a porcine model that use of
the ITV resulted in a nearly 2-fold increase in blood flow to
the brain and the heart after 6 minutes of ventricular fibril-lation
and 6 minutes of standard CPR.6 Although use of the
ITV during standard CPR has been reported previously in 2
studies involving $30 animals, to date there have been no
definitive data in support of a survival benefit from the use of
the ITV with standard CPR.4,6 Thus, the purpose of this
investigation was to test the hypothesis that the ITV would
improve neurological function and 24-hour survival in an
established animal model of cardiac arrest during perfor-mance
Figure 4. End-tidal CO2 values were measured over 6-minute
study period. All values plotted from 10 to 24 mm Hg are
expressed as mean#SEM. Standard CPR was performed with
either a sham or active ITV. VF indicates ventricular fibrillation.
*P"0.05.
CPR, air is drawn into the lungs. We previously
described the use of an impedance threshold valve (ITV) to
prevent the inflow of respiratory gases during the active chest
wall recoil phase, or decompression phase, of standard
CPR.4,5 The ITV is a small (35-mL) disposable plastic valve
that is attached to the endotracheal tube or a face mask. It
works by allowing the rescuer to freely ventilate the patient
but impeding inspiratory airflow during the decompression
phase of CPR when the patient is not being actively venti-lated.
of standard CPR.
Methods
the diastolic blood pressure was !21 mm Hg (80%) com-pared
Preparatory Phase
The study was approved by the Committee of Animal Experimen-tation
with animals with a diastolic blood pressure of
at the University of Minnesota. Anesthesia was used in all
Circulation, 2002
"21 mm Hg (40%) (P"0.05).
PETCO2 levels were significantly higher among survivors

48. Use of an Inspiratory Impedance Valve Improves
Neurologically Intact Survival in a Porcine Model of
Ventricular Fibrillation
Keith G. Lurie, MD; Todd Zielinski, MS; Scott McKnite, BS;
Tom Aufderheide, MD; Wolfgang Voelckel, MD
Background—This study evaluated the potential for an inspiratory impedance threshold valve (ITV) to improve 24-hour
survival and neurological function in a pig model of cardiac arrest.
Ø Pas Methods d’effet and Results—indésirables Using a randomized, prospective, en and particulier blinded design, we compared pas the effects d’oedème
of a sham versus
active ITV on 24-hour survival and neurological function. After 6 minutes of ventricular fibrillation (VF), followed by
pulmonaire 6 minutes of cardiopulmonary clinique resuscitation ni (CPR) with either a sham or an active valve, anesthetized pigs received 3
sequential 200-J shocks. If VF persisted, they received anatomopathologique
epinephrine (0.045 mg/kg), 90 seconds of CPR, and 3 more 200-J
shocks. A total of 11 of 20 pigs (55%) in the sham versus 17 of 20 (85%) in the active valve group survived for 24 hours
(P!0.05). Neurological scores were significantly higher with the active valve; the cerebral performance score
""Ø Meilleur (1normal, 5brain death) was 2.2#0.2 with the sham ITV versus 1.4#0.2 with the active valve (P!0.05). A total
of 1 of 11 in pronostic the sham versus 12 of 17 neurologique
in the active valve group had completely normal neurological function (P!0.05).
Peak end-tidal CO2 (PETCO2) values were significantly higher with the active valve (20.4#1.0) than the sham (16.8#1.5)
(P!0.05). PETCO2 $18 mm Hg correlated with increased survival (P!0.05).
Conclusions—Use of a functional ITV during standard CPR significantly improved 24-hour survival rates and neurological
Ø Meilleur EtCO2
Ø A évaluer avec d’autres études
recovery. PETCO2 and systolic blood pressure were also significantly higher in the active valve group. These data support
further evaluation of ITV during standard CPR. (Circulation. 2002;105:124-129.)
Key Words: cardiac arrest ! fibrillation ! cardiopulmonary resuscitation ! valves ! survival ! arrhythmia ! brain
Survival rates remain poor for most patients who suffer
from a cardiac arrest. Studies on the mechanism of blood
flow during cardiopulmonary resuscitation (CPR) have re-cently
focused on the importance of the decompression phase
of CPR.1–4 During the decompression phase of standard CPR,
a small vacuum is created within the chest relative to the rest
of the body every time the chest wall recoils back to its
resting position.5 This draws venous blood back into the right
heart. In addition, during the decompression phase of stan-dard
CPR, air is drawn into the lungs. We previously
described the use of an impedance threshold valve (ITV) to
prevent the inflow of respiratory gases during the active chest
wall recoil phase, or decompression phase, of standard
CPR.4,5 The ITV is a small (35-mL) disposable plastic valve
that is attached to the endotracheal tube or a face mask. It
works by allowing the rescuer to freely ventilate the patient
but impeding inspiratory airflow during the decompression
phase of CPR when the patient is not being actively venti-lated.
This creates a small vacuum within the chest to further
enhance venous return.
We recently demonstrated in a porcine model that use of
the ITV resulted in a nearly 2-fold increase in blood flow to
the brain and the heart after 6 minutes of ventricular fibril-lation
and 6 minutes of standard CPR.6 Although use of the
ITV during standard CPR has been reported previously in 2
studies involving $30 animals, to date there have been no
definitive data in support of a survival benefit from the use of
the ITV with standard CPR.4,6 Thus, the purpose of this
investigation was to test the hypothesis that the ITV would
improve neurological function and 24-hour survival in an
established animal model of cardiac arrest during perfor-mance
of standard CPR.
Methods
Preparatory Phase
The study was approved by the Committee of Animal Experimen-tation
at the University of Minnesota. Anesthesia was used in all

49. Le souffle c’est la vie……
Merci de votre attention