Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Roman Skulec, Petr Vojtisek, Vladimir Cerny, Roman Skulec, Petr Vojtisek, Vladimir Cerny

Abstract

Background: The concept of personalized cardiopulmonary resuscitation (CPR) requires a parameter that reflects its hemodynamic efficiency. While intra-arrest ultrasound is increasingly implemented into the advanced life support, we realized a pre-hospital clinical study to evaluate whether the degree of compression of the right ventricle (RV) and left ventricle (LV) induced by chest compressions during CPR for out-of-hospital cardiac arrest (OHCA) and measured by transthoracic echocardiography correlates with the levels of end-tidal carbon dioxide (EtCO2) measured at the time of echocardiographic investigation.

Methods: Thirty consecutive patients resuscitated for OHCA were included in the study. Transthoracic echocardiography was performed from a subcostal view during ongoing chest compressions in all of them. This was repeated three times during CPR in each patient, and EtCO2 levels were registered. From each investigation, a video loop was recorded. Afterwards, maximal and minimal diameters of LV and RV were obtained from the recorded loops and the compression index of LV (LVCI) and RV (RVCI) was calculated as (maximal - minimal/maximal diameter) × 100. Maximal compression index (CImax) defined as the value of LVCI or RVCI, whichever was greater was also assessed. Correlations between EtCO2 and LVCI, RVCI, and CImax were expressed as Spearman's correlation coefficient (r).

Results: Evaluable echocardiographic records were found in 18 patients, and a total of 52 measurements of all parameters were obtained. Chest compressions induced significant compressions of all observed cardiac cavities (LVCI = 20.6 ± 13.8%, RVCI = 34.5 ± 21.6%, CImax = 37.4 ± 20.2%). We identified positive correlation of EtCO2 with LVCI (r = 0.672, p < 0.001) and RVCI (r = 0.778, p < 0.001). The strongest correlation was between EtCO2 and CImax (r = 0.859, p < 0.001). We identified that a CImax cut-off level of 17.35% predicted to reach an EtCO2 level > 20 mmHg with 100% sensitivity and specificity.

Conclusions: Evaluable echocardiographic records were reached in most of the patients. EtCO2 positively correlated with all parameters under consideration, while the strongest correlation was found between CImax and EtCO2. Therefore, CImax is a candidate parameter for the guidance of hemodynamic-directed CPR.

Trial registration: ClinicalTrial.gov, NCT03852225 . Registered 21 February 2019 - Retrospectively registered.

Keywords: End-tidal dioxide; Hemodynamic-directed cardiopulmonary resuscitation; Ultrasound.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Measurement of the maximal and minimal diameters of the right and left ventricles for calculation of compression indexes. a The arrow indicates the distance of the measurement site from the mitral annulus. Measured values of maximal right and left ventricular diameters. b Measurements of the minimal diameters of the right and left ventricles at the same distance from the mitral annulus as the measurements at a
Fig. 2
Fig. 2
Correlation of EtCO2 with LVCI and RVCI. EtCO2—end-tidal carbon dioxide level, LVCI—left ventricular compression index, RVCI—right ventricular compression index
Fig. 3
Fig. 3
Correlation between EtCO2 and CImax. EtCO2—end-tidal carbon dioxide level, CImax—maximal compression index
Fig. 4
Fig. 4
Correlation between RVCI and LVCI. LVCI—left ventricular compression index, RVCI—right ventricular compression index
Fig. 5
Fig. 5
The ROC curves for prediction of different EtCO2 levels by CImax. On the left, prediction of EtCO2 > 15 mmHg, in the middle prediction of EtCO2 > 20 mmHg and on the right prediction of EtCO2 > 25 mmHg. EtCO2—end-tidal carbon dioxide level

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