Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation
Restricted accessResearch articleFirst published online October, 2015
Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation
End-tidal carbon dioxide (ETCO2) measurements during cardiopulmonary resuscitation (CPR) reflect variable cardiac output over time, and low values have been associated with decreased survival. The goals of this review are to confirm and quantify this relationship and to determine the mean ETCO2 value among patients with return of spontaneous circulation (ROSC) as an initial step toward determining an appropriate target for intervention during resuscitation in the absence of prospective data.
Data Sources and Study Selection:
The PubMed database was searched for the key words “end-tidal carbon dioxide” or “capnometry” or “capnography” and “resuscitation” or “return of spontaneous circulation.” Randomized controlled trials, cohort studies, or case–control studies that reported ETCO2 values for participants with and without ROSC were included.
Data Extraction and Synthesis:
Twenty-seven studies met the inclusion criteria for qualitative synthesis. Twenty studies were included in determination of average ETCO2 values. The mean ETCO2 in participants with ROSC was 25.8 ± 9.8 mm Hg versus 13.1 ± 8.2 mm Hg (P = .001) in those without ROSC. Nineteen studies were included in a meta-analysis. The mean difference in ETCO2 was 12.7 mm Hg (95% confidence interval: 10.3-15.1) between participants with and without ROSC (P < .001). The mean difference in ETCO2 was not modified by the receipt of sodium bicarbonate, uncontrolled minute ventilation, or era of resuscitation guidelines. The overall quality of data by Grades of Recommendations, Assessment, Development and Evaluation criteria is very low, but no prospective data are currently available.
Conclusions:
Participants with ROSC after CPR have statistically higher levels of ETCO2. The average ETCO2 level of 25 mm Hg in participants with ROSC is notably higher than the threshold of 10 to 20 mm Hg to improve delivery of chest compressions. The ETCO2 goals during resuscitation may be higher than previously suggested and further investigation into appropriate targets during resuscitation is needed to diminish morbidity and mortality after cardiorespiratory arrest.
SteedmanDJRobertsonCE. Measurement of end-tidal carbon dioxide concentration during cardiopulmonary resuscitation. Arch Emerg Med. 1990;7(3):129–134.
2.
SehraRUnderwoodKChecchiaP. End tidal CO2 is a quantitative measure of cardiac arrest. Pacing Clin Electrophysiol. 2003;26(1 pt 2):515–517.
3.
BergRAHenryCOttoCW. Initial end-tidal CO2 is markedly elevated during cardiopulmonary resuscitation after asphyxial cardiac arrest. Pediatr Emerg Care. 1996;12(4):245–248.
4.
LahKKrizmaricMGrmecS. The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. Crit Care. 2011;15(1):R13.
5.
BhendeMSKarasicDGKarasicRB. End-tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest. Am J Emerg Med. 1996;14(4):349–350.
6.
MorrisonLJDeakinCDMorleyPT. Part 8: advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122(16 suppl 2):S345–S421.
7.
KleinmanMEde CaenALChameidesL. Pediatric basic and advanced life support chapter collaborators. part 10: pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122(16 suppl 2):S466–S515.
8.
DeakinCDNolanJPSoarJ. European resuscitation council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation. 2010;81(10):1305–1352.
9.
BiarentDBinghamREichC. European resuscitation council guidelines for resuscitation 2010 section 6. paediatric life support. Resuscitation. 2010;81(10):1364–1388.
10.
EcksteinMHatchLMalleckJMcClungCHendersonSO. End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Prehosp Disaster Med. 2011;26(3):148–150.
11.
AhrensTSchallomLBettorfK. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001;10(6):391–398.
12.
GrmecSKlemenP. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest?Eur J Emerg Med. 2001;8(4):263–269.
13.
SalenPO’ConnorRSierzenskiP. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes?Acad Emerg Med. 2001;8(6):610–615.
14.
LevineRLWayneMAMillerCC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337(5):301–306.
15.
CantineauJPLambertYMerckxP. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole: a predictor of outcome. Crit Care Med. 1996;24(5):791–796.
16.
AsplinBRWhiteRD. Prognostic value of end-tidal carbon dioxide pressures during out-of-hospital cardiac arrest. Ann Emerg Med. 1995;25(6):756–761.
17.
BhendeMSThompsonAE. Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics. 1995;95(3):395–399.
18.
WayneMALevineRLMillerCC. Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest. Ann Emerg Med. 1995;25(6):762–767.
19.
CallahamMBartonC. Prediction of outcome of cardiopulmonary resuscitation from end-tidal carbon dioxide concentration. Crit Care Med. 1990;18(4):358–362.
20.
SandersABKernKBOttoCWMilanderMMEwyGA. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. A prognostic indicator for survival. JAMA. 1989;262(10):1347–1351.
21.
FalkJLRackowECWeilMH. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med. 1988;318(10):607–611.
22.
MeaneyPABobrowBJManciniME. CPR Quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American heart association. Circulation. 2013;128(4):417–435.
23.
MoherDLiberatiATetzlaffJAltmanDG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097. doi:10.1371/journal.pmed1000097.
24.
GuyattGOxmanADAklEA. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–394.
25.
BalshemHHelfandMSchunemannHJ. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–406.
26.
GuyattGHOxmanADVistG. GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–415.
27.
GuyattGHOxmanADMontoriV. GRADE guidelines: 5. Rating the quality of evidence-publication bias. J Clin Epidemiol. 2011;64(12):1277–1282.
28.
GuyattGHOxmanADKunzR. GRADE guidelines: 6. Rating the quality of evidence—imprecision. J Clin Epidemiol. 2011;64(12):1283–1293.
29.
GuyattGHOxmanADKunzR. GRADE guidelines: 7. Rating the quality of evidence—inconsistency. J Clin Epidemiol. 2011;64(12):1294–1302.
30.
GuyattGHOxmanADKunzR. GRADE guidelines: 8. Rating the quality of evidence—indirectness. J Clin Epidemiol. 2011;64(12):1303–1310.
31.
HeradstveitBESundeKSundeGAWentzel-LarsenTHeltneJK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest—a clinical retrospective study in 575 patients. Resuscitation. 2012;83(7):813–818.
32.
PokornaMNecasEKratochvilJSkripskýRAndrlíkMFranekO. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010;38(5):614–621.
33.
KolarMKrizmaricMKlemenPGrmecS. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care. 2008;12(5):R115.
34.
GremcSKrizmaricMMallySKozeljASpindlerMLesnikB. Utstein style analysis of out-of-hospital cardiac arrest—bystander CPR and end expired carbon dioxide. Resuscitation. 2007;72(3):404–414.
35.
MallySJelatancevAGremcS. Effects of epinephrine and vasopressin on end-tidal carbon dioxide tension and mean arterial blood pressure in out-of-hospital cardiopulmonary resuscitation: an observational study. Crit Care. 2007;11(2):R39.
36.
GrmecSLahKTusek-BuncK. Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting. Crit Care. 2003;7(6):R139–R144.
37.
NakataniKYukiokaHFujimoriM. Utility of colorimetric end-tidal carbon dioxide detector for monitoring during prehospital cardiopulmonary resuscitation. Am J Emerg Med. 1999;17(2):203–206.
38.
MauerDSchneiderTElichDDickW. Carbon dioxide levels during pre-hospital active compression—decompression versus standard cardiopulmonary resuscitation. Resuscitation. 1998;39(1-2):67–74.
39.
WardKRMenegazziJJZelenakRRSullivanRJMcSwainNEJr. A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal PCO2 during human cardiac arrest. Ann Emerg Med. 1993;22(4):669–674.
40.
CallahamMBartonCMatthayM. Effect of epinephrine on the ability of end-tidal carbon dioxide readings to predict initial resuscitation from cardiac arrest. Crit Care Med. 1992;20(3):337–343.
41.
OrnatoJPShipleyJBRachtEM. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med. 1992;21(5):518–523.
42.
VaronAJMorrinaJCivettaJM. Clinical utility of a colorimetric end-tidal CO2 detector in cardiopulmonary resuscitation and emergency intubation. J Clin Monit. 1991;7(4):289–293.
43.
GarnettAROrnatoJPGonzalezERJohnsonEB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA. 1987;257(4):512–515.
44.
MonsieursKGDe ReggeMVansteelandtK. Excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest. Resuscitation. 2012;83(11):1319–1323.
45.
AbellaBSAlvaradoJPMyklebustH. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293(3):305–310.
46.
WikLKramer-JohansenJMyklebustH. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293(3):299–304.
47.
NilesDENishisakiASuttonRM. Comparison of relative and actual chest compression depths during cardiac arrest in children, adolescents, and young adults. Resuscitation. 2012;83(3):320–326.
48.
AufderheideTPLurieKG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004;32(9 suppl):S345–S351.
49.
O’NeillJFDeakinCD. Do we hyperventilate cardiac arrest patients?Resuscitation. 2007;73(1):82–85.
50.
JacobsINadkarniVBahrJ; the ILCOR Task Force on Cardiac and Cardiopulmonary Resuscitation Outcomes. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international Liaison committee on resuscitation (American heart association, European resuscitation council, Australian resuscitation council, New Zealand resuscitation council, heart and stroke foundation of Canada, InterAmerican heart foundation, resuscitation councils of Southern Africa). Circulation. 2004;110(21):3385–3397.
51.
ToumaODaviesM. The prognostic value of end tidal carbon dioxide during cardiac arrest: a systematic review. Resuscitation. 2013;84(11):1470–149.
