Evaluation of end-tidal carbon dioxide gradient as a predictor of volume responsiveness in spontaneously breathing healthy adults

María C Arango-Granados, Virginia Zarama Córdoba, Andrés M Castro Llanos, Luis A Bustamante Cristancho, María C Arango-Granados, Virginia Zarama Córdoba, Andrés M Castro Llanos, Luis A Bustamante Cristancho

Abstract

Background: Methods to guide fluid therapy in spontaneously breathing patients are scarce. No studies have reported the accuracy of end-tidal CO2 (ET-CO2) to predict volume responsiveness in these patients. We sought to evaluate the ET-CO2 gradient (ΔET-CO2) after a passive leg rise (PLR) maneuver to predict volume responsiveness in spontaneously breathing healthy adults.

Methods: We conducted a prospective study in healthy adult human volunteers. A PLR maneuver was performed and cardiac output (CO) was measured by transthoracic echocardiography. ET-CO2 was measured with non-invasive capnographs. Volume responsiveness was defined as an increase in cardiac output (CO) > 12% at 90 s after PLR.

Results: Of the 50 volunteers, 32% were classified as volume responders. In this group, the left ventricle outflow tract velocity time integral (VTILVOT) increased from 17.9 ± 3.0 to 20.4 ± 3.4 (p = 0.0004), CO increased from 4.4 ± 1.5 to 5.5 ± 1.6 (p = 0.0), and ET-CO2 rose from 32 ± 4.84 to 33 ± 5.07 (p = 0.135). Within the entire population, PLR-induced percentage ∆CO was not correlated with percentage ∆ET-CO2 (R2 = 0.13; p = 0.36). The area under the receiver operating curve for the ability of ET-CO2 to discriminate responders from non-responders was of 0.67 ± 0.09 (95% CI 0.498-0.853). A ΔET-CO2 ≥ 2 mmHg had a sensitivity of 50%, specificity of 97.06%, positive likelihood ratio of 17.00, negative likelihood ratio of 0.51, positive predictive value of 88.9%, and negative predictive value of 80.5% for the prediction of fluid responsiveness.

Conclusions: ΔET-CO2 after a PLR has limited utility to discriminate responders from non-responders among healthy spontaneously breathing adults.

Keywords: Blood volume determination; Capnography; Cardiac output; Doppler echocardiography; Hemodynamic monitoring.

Conflict of interest statement

Ethics approval and consent to participate

This research is in line with the international recommendations on human research, the Nuremberg code, the Helsinki agreement, and the CIOM guidelines. This study was approved by the Institutional Ethics Committee of the Fundación Valle del Lili Hospital (approval letter no. 611-2017). The study protocol is registered in this department under the number 1184.

Consent for publication

All informed consents are duly signed and stored in the Institutional Ethics Committee of the Fundación Valle del Lili Hospital (Cali–Colombia).

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow of participants through the study. *Defined as ∆ET-CO2 

Fig. 2

Among responders, behavior during PLR…

Fig. 2

Among responders, behavior during PLR maneuver of a ET-CO2, b VTI LVOT ,…

Fig. 2
Among responders, behavior during PLR maneuver of a ET-CO2, b VTILVOT, c HR, and d CO. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; HR, heat rate; CO cardiac output

Fig. 3

Among non-responders, behavior during PLR…

Fig. 3

Among non-responders, behavior during PLR maneuver of a ET-CO2, b VTI LVOT ,…

Fig. 3
Among non-responders, behavior during PLR maneuver of a ET-CO2, b VTILVOT, c HR, and d CO. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; HR, heat rate; CO, cardiac output

Fig. 4

Correlation between PLR-induced changes in…

Fig. 4

Correlation between PLR-induced changes in ET-CO 2 and a CO and b VTI…

Fig. 4
Correlation between PLR-induced changes in ET-CO2 and a CO and b VTILVOT. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; CO, cardiac output

Fig. 5

Receiver operating characteristics curves regarding…

Fig. 5

Receiver operating characteristics curves regarding the ability of ET-CO 2 to discriminate responders…

Fig. 5
Receiver operating characteristics curves regarding the ability of ET-CO2 to discriminate responders (CO increase ≥ 12%) and non-responders after a PLR maneuver. ET-CO2, end-tidal carbon dioxide; CO, cardiac output; PLR, passive leg rise
Fig. 2
Fig. 2
Among responders, behavior during PLR maneuver of a ET-CO2, b VTILVOT, c HR, and d CO. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; HR, heat rate; CO cardiac output
Fig. 3
Fig. 3
Among non-responders, behavior during PLR maneuver of a ET-CO2, b VTILVOT, c HR, and d CO. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; HR, heat rate; CO, cardiac output
Fig. 4
Fig. 4
Correlation between PLR-induced changes in ET-CO2 and a CO and b VTILVOT. ET-CO2, end-tidal carbon dioxide; VTILVOT, left ventricle outflow tract velocity time integral; CO, cardiac output
Fig. 5
Fig. 5
Receiver operating characteristics curves regarding the ability of ET-CO2 to discriminate responders (CO increase ≥ 12%) and non-responders after a PLR maneuver. ET-CO2, end-tidal carbon dioxide; CO, cardiac output; PLR, passive leg rise

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