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Chest compressions superimposed with sustained inflations during cardiopulmonary resuscitation in asphyxiated pediatric piglets

Pediatric Research volume 95, pages 988–995 (2024)Cite this article

Abstract

Background

Pediatric resuscitation guidelines recommend continuous chest compression with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation. We recently described that providing a constant high distending pressure, or sustained inflation (SI) while performing continuous chest compressions (CC = CC + SI) reduces time to return of spontaneous circulation (ROSC) in neonatal and pediatric piglets with asphyxia-induced cardiac arrest.

Methods

To determine if CC + SI compared to CCaV will improve frequency of achieving ROSC and reduce time to ROSC in asphyxiated pediatric piglets. Twenty-eight pediatric piglets (21–24 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to CC + SI or CCaV for resuscitation (n = 14/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.

Results

The mean(SD) duration of resuscitation was significantly reduced with CC + SI compared to CCaV with 208(190) vs. 388(258)s, p = 0.045, respectively. The number of piglets achieving ROSC with CC + SI and CCaV were 12/14 vs. 6/14, p = 0.046. Minute ventilation, end-tidal carbon dioxide, ventilation rate, and positive end expiratory pressures were also significantly improved with CC + SI.

Conclusions

CC + SI improves duration of resuscitation and increases number of piglets achieving ROSC secondary to improved minute ventilation.

Impact

  • Chest compressions superimposed with sustained inflation resulted in shorter duration of resuscitation

  • Chest compressions superimposed with sustained inflation resulted in higher number of piglets achieving return of spontaneous circulation

  • Further animal studies are needed to examine chest compressions superimposed with sustained inflation

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Fig. 1
Fig. 2: Kaplan-Meier survial graph.
Fig. 3

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Data availability

The datasets generated during the current study are available from the corresponding author on reasonable request.

References

  1. Topjian, A. A. et al. Part 4: Pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 142, https://doi.org/10.1161/CIR.0000000000000901 (2020).

  2. Soar, J. et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations: Summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 140, https://doi.org/10.1161/CIR.0000000000000734 (2019)

  3. Kitamura, T. et al. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet 375, 8 (2010).

  4. Sutton, R. M. et al. Ventilation rates and pediatric in-hospital cardiac arrest survival outcomes*. Crit. Care Med. 47, 1627–1636 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Schmölzer G. M. et al. Sustained inflation during chest compression: a new technique of pediatric cardiopulmonary resuscitation that improves recovery and survival in a pediatric porcine model. J. Am. Heart Assoc. 10, https://doi.org/10.1161/JAHA.120.019136 (2021).

  6. Schmölzer, G. M. et al. Cardiopulmonary resuscitation with chest compressions during sustained inflations: a new technique of neonatal resuscitation that improves recovery and survival in a neonatal porcine model. Circulation 128, 2495–2503 (2013).

    Article  PubMed  Google Scholar 

  7. Schmölzer, G. M. Chest compressions during sustained inflation during cardiopulmonary resuscitation in newborn infants translating evidence from animal studies to the bedside. JACC Basic Transl. Sci. 4, 116–121 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Li, E. S. et al. Chest compressions during sustained inflations improve recovery when compared to a 3:1 compression:ventilation ratio during cardiopulmonary resuscitation in a neonatal Porcine Model of Asphyxia. Neonatology 112, 337–346 (2017).

    Article  PubMed  Google Scholar 

  9. Li, E. S. et al. Return of spontaneous circulation is not affected by different chest compression rates superimposed with sustained inflations during cardiopulmonary resuscitation in newborn piglets. PLoS ONE 11, e0157249 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  10. Mustofa, J. et al. Effects of different durations of sustained inflation during cardiopulmonary resuscitation on return of spontaneous circulation and hemodynamic recovery in severely asphyxiated piglets. Resuscitation 129, 82–89 (2018).

    Article  CAS  PubMed  Google Scholar 

  11. Schmölzer, G. M., O. Reilly, M., Fray, C., van Os, S. & Cheung, P. Y. Chest compression during sustained inflation versus 3:1 chest compression:ventilation ratio during neonatal cardiopulmonary resuscitation: a randomised feasibility trial. Arch. Dis. Child Fetal Neonatal Ed. 103, F455–F460 (2018).

    Article  PubMed  Google Scholar 

  12. Xanthos, T. et al. Baseline hemodynamics in anesthetized landrace–large white swine: reference values for research in cardiac arrest and cardiopulmonary resuscitation models. J. Am. Assoc. Lab. Anim. Sci. 46, 5 (2007).

    Google Scholar 

  13. Kilkenny C., Browne W., Cuthill I., Emerson M., & Aktman D. Improving bioscience research reporting: The ARRIVE Guidelines for Reporting Animal Research. PLOS Biol. 8, e1000412 (2010)

  14. van Os, S. et al. Exhaled carbon dioxide can be used to guide respiratory support in the delivery room. Acta Paediatr. 103, 796–806 (2014).

    Article  PubMed  Google Scholar 

  15. Baik, N. et al. Reference ranges for cerebral tissue oxygen saturation index in term neonates during immediate neonatal transition after birth. Neonatology 108, 283–286 (2015).

    Article  PubMed  Google Scholar 

  16. Wollborn, J. et al. Standardized model of porcine resuscitation using a custom-made resuscitation board results in optimal hemodynamic management. Am. J. Emerg. Med. 36, 1738–1744 (2018).

    Article  PubMed  Google Scholar 

  17. Okubo, M., Chan, H. K., Callaway, C. W., Mann, N. C. & Wang, H. E. Characteristics of paediatric out-of-hospital cardiac arrest in the United States. Resuscitation 153, 227–233 (2020).

    Article  PubMed  Google Scholar 

  18. Jayaram, N., McNally, B., Tang, F. & Chan, P. S. Survival after out‐of‐hospital cardiac arrest in children. J. Am. Heart Assoc. 4, e002122 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Sutton, R. M. et al. Effect of physiologic point-of-care cardiopulmonary resuscitation training on survival with favorable neurologic outcome in cardiac arrest in pediatric icus: a randomized clinical trial. JAMA 327, 934 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  20. Manrique, G. et al. Comparison between synchronized and non-synchronized ventilation and between guided and non-guided chest compressions during resuscitation in a pediatric animal model after asphyxial cardiac arrest. PLoS ONE 14, e0219660 (2019).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Sutton, R. M. et al. Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest. Resuscitation 85, 983–986 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Lautz, A. J. et al. Hemodynamic-directed cardiopulmonary resuscitation improves neurologic outcomes and mitochondrial function in the heart and brain. Crit. Care Med. 47, e241–e249 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  23. O’Brien, C. E. et al. Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine. Resusc. Plus 8, 100174 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  24. Morgan, R. W. et al. A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival. Resuscitation 111, 41–47 (2017).

    Article  PubMed  Google Scholar 

  25. Kern, K. B., Ewy, G. A., Voorhees, W. D., Babbs, C. F. & Tacker, W. A. Myocardial perfusion pressure: A predictor of 24-hour survival during prolonged cardiac arrest in dogs. Resuscitation 16, 241–250 (1988).

    Article  CAS  PubMed  Google Scholar 

  26. Halperin, H. R. et al. Determinants of blood flow to vital organs during cardiopulmonary resuscitation in dogs. Circulation 73, 539–550 (1986).

    Article  CAS  PubMed  Google Scholar 

  27. Berg, R. A. et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 104, 2465–2470 (2001).

    Article  CAS  PubMed  Google Scholar 

  28. Ewy, G. A. et al. Improved neurological outcome with continuous chest compressions compared with 30:2 compressions-to-ventilations cardiopulmonary resuscitation in a realistic swine model of out-of-hospital cardiac arrest. Circulation 116, 2525–2530 (2007).

    Article  PubMed  Google Scholar 

  29. Pearson, J. W. Influence of peripheral vascular tone on cardiac resuscitation. Anesth. Analg. 44, 746 (1965).

    Article  CAS  PubMed  Google Scholar 

  30. Berg, R. A. et al. Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival. Circulation 137, 1784–1795 (2018).

    Article  PubMed  Google Scholar 

  31. Rudikoff, M. T., Freund P., & Weisfeldt M. L. Mechanisms of blood flow during cardiopulmonary resuscitation. Circulation 61, 8 (1980).

  32. Chandra, N., Rudikoff, M. & Weisfeldt, M. L. Simultaneous chest compression and ventilation at high airway pressure during cardiopulmonary resuscitation. Lancet 26, 175–178 (1980).

    Article  Google Scholar 

  33. Berkowitz, I. D. et al. Blood flow during cardiopulmonary resuscitation with simultaneous compression and ventilation in infant pigs. Pediatr. Res. 26, 558–559 (1989).

    Article  CAS  PubMed  Google Scholar 

  34. Aufderheide, T. P. et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 109, 1960–1965 (2004).

    Article  PubMed  Google Scholar 

  35. de Caen, A. R. et al. Part 12: pediatric advanced life support: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 132, S525–S542 (2015).

    Google Scholar 

  36. McInnes, A. D. et al. The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents. Resuscitation 82, 1025–1029 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  37. Li, E. S., Cheung, P. Y., O’Reilly, M. & Schmölzer, G. M. Change in tidal volume during cardiopulmonary resuscitation in newborn piglets. Arch. Dis. Child Fetal Neonatal Ed. 100, F530–F533 (2015).

    Article  PubMed  Google Scholar 

  38. Shim, G. H. et al. Effects of sustained inflation pressure during neonatal cardiopulmonary resuscitation of asphyxiated piglets. PLoS ONE 15, e0228693 (2020).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Berg, R. A. et al. End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation. Resuscitation 133, 173–179 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Hamrick, J. T. et al. End-tidal CO2–guided chest compression delivery improves survival in a neonatal asphyxial cardiac arrest model*. Pediatr. Crit. Care Med. 18, e575–e584 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  41. Nicoll, J. et al. Effect of cardiac output changes on exhaled carbon dioxide in newborn piglets. Resuscitation 84, 1439–1442 (2013).

    Article  CAS  PubMed  Google Scholar 

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Funding

We would like to thank the public for donating money to our funding agencies: This research has been facilitated by the Women and Children’s Health Research Institute through the generous support of the Stollery Children’s Hospital Foundation.

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Authors and Affiliations

  1. Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada

    Chelsea M. D. Morin, Po-Yin Cheung, Tze-Fun Lee, Megan O’Reilly & Georg M. Schmölzer

  2. Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada

    Chelsea M. D. Morin, Po-Yin Cheung, Tze-Fun Lee, Megan O’Reilly & Georg M. Schmölzer

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  1. Chelsea M. D. Morin
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  2. Po-Yin Cheung
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Contributions

Conception and design: G.M.S., P.Y.C., M.O.R., T.F.L. Collection and assembly of data: G.M.S., P.Y.C., M.O.R., T.F.L., C.M.D.M. Analysis and interpretation of the data: G.M.S., P.Y.C., M.O.R., T.F.L., C.M.D.M. Drafting of the article: G.M.S., P.Y.C., M.O.R., T.F.L., C.M.D.M. Critical revision of the article for important intellectual content: G.M.S., P.Y.C., M.O.R., T.F.L., C.M.D.M. Final approval of the article: G.M.S., P.Y.C., M.O.R., T.F.L., C.M.D.M.

Corresponding author

Correspondence to Georg M. Schmölzer.

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Morin, C.M.D., Cheung, PY., Lee, TF. et al. Chest compressions superimposed with sustained inflations during cardiopulmonary resuscitation in asphyxiated pediatric piglets. Pediatr Res 95, 988–995 (2024). https://doi.org/10.1038/s41390-023-02563-9

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