Advertisement

The prognostic value of end tidal carbon dioxide during cardiac arrest: A systematic review

      Abstract

      Introduction

      Cardiac arrest is a common presentation to the emergency care system. The decision to terminate CPR is often challenging to heath care providers. An accurate, early predictor of the outcome of resuscitation is needed. The purpose of this systematic review is to evaluate the prognostic value of ETCO2 during cardiac arrest and to explore whether ETCO2 values could be utilised as a tool to predict the outcome of resuscitation.

      Method

      Literature search was performed using Medline and EMBASE databases to identify studies that evaluated the relationship between ETCO2 during cardiac arrest and outcome. Studies were thoroughly evaluated and appraised. Summary of evidence and conclusions were drawn from this systematic literature review.

      Results

      23 observational studies were included. The majority of studies showed that ETCO2 values during CPR were significantly higher in patients who later developed ROSC compared to patients who did not. Several studies suggested that initial ETCO2 value of more than 1.33 kPa is 100% sensitive for predicting survival making ETCO2 value below 1.33 kPa a strong predictor of mortality. These studies however had several limitations and the 100% sensitivity for predicting survival was not consistent among all studies.

      Conclusion

      ETCO2 values during CPR do correlate with the likelihood of ROSC and survival and therefore have prognostic value. Although certain ETCO2 cut-off values appears to be a strong predictor of mortality, the utility of ETCO2 cut-off values during CPR to accurately predict the outcome of resuscitation is not fully established. Therefore, ETCO2 values cannot be used as a mortality predictor in isolation.

      Abbreviations:

      ETCO2 (end tidal carbon dioxide), CPR (cardiopulmonary resuscitation), ROSC (return of spontaneous circulation), RCT (randomised controlled trial), IQR (interquartile range), ED (emergency department), kPa (kiloPascal), CI (confidence interval), EMS (emergency medical services), PEA (pulseless electrical activity), BP (blood pressure), PPV (positive predictive value), NPV (negative predictive value), OR (odds ratio), MAP (mean arterial pressure), VF (ventricular fibrillation), VT (ventricular tachycardia), SD (standard deviation)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Nolan J.P.
        • Laver S.R.
        • Welch C.A.
        • Harrison D.A.
        • Gupta V.
        • Rowan K.
        Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database.
        Anaesthesia. 2007; 62: 1207-1216
        • Nunn J.F.
        Ventilation and end-tidal carbon dioxide tension; a study during routine anaesthesia.
        Anaesthesia. 1958; 13: 124-137
        • Gudipati C.V.
        • Weil M.H.
        • Bisera J.
        • Deshmukh H.G.
        • Rackow E.C.
        Expired carbon dioxide: a noninvasive monitor of cardiopulmonary resuscitation.
        Circulation. 1988; 77: 234-239
        • Shibutani K.
        • Muraoka M.
        • Shirasaki S.
        • Kubal K.
        • Sanchala V.T.
        • Gupte P.
        Do changes in end-tidal PCO2 quantitatively reflect changes in cardiac output?.
        Anesth Analg. 1994; 79: 829-833
        • Kalenda Z.
        The capnogram as a guide to the efficacy of cardiac massage.
        Resuscitation. 1978; 6: 259-263
        • Pokorna M.
        • Necas E.
        • Kratochvil J.
        • Skripsky R.
        • Andrlik M.
        • Franek O.
        A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO2) at the moment of return of spontaneous circulation.
        J Emerg Med. 2009; 38: 614-621
        • Kolar M.
        • Krizmaric M.
        • Klemen P.
        • Grmec S.
        Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study.
        Crit Care. 2008; 12: R115
        • Grmec S.
        • Kupnik D.
        Does the Mainz Emergency Evaluation Scoring (MEES) in combination with capnometry (MEESc) help in the prognosis of outcome from cardiopulmonary resuscitation in a prehospital setting?.
        Resuscitation. 2003; 58: 89-96
        • Grmec S.
        • Klemen P.
        Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest?.
        Eur J Emerg Med. 2001; 8: 263-269
        • Levine R.L.
        • Wayne M.A.
        • Miller C.C.
        End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.
        N Engl J Med. 1997; 337: 301-306
        • Wayne M.A.
        • Levine R.L.
        • Miller C.C.
        Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest.
        Ann Emerg Med. 1995; 25: 762-767
        • Sanders A.B.
        • Kern K.B.
        • Otto C.W.
        • Milander M.M.
        • Ewy G.A.
        End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. A prognostic indicator for survival.
        JAMA. 1989; 262: 1347-1351
        • Callaham M.
        • Barton C.
        Prediction of outcome of cardiopulmonary resuscitation from end-tidal carbon dioxide concentration.
        Crit Care Med. 1990; 18: 358-362
        • Callaham M.
        • Barton C.
        • Matthay M.
        Effect of epinephrine on the ability of end-tidal carbon dioxide readings to predict initial resuscitation from cardiac arrest.
        Crit Care Med. 1992; 20: 337-343
        • Grmec S.
        • Krizmaric M.
        • Mally S.
        • Kozelj A.
        • Spindler M.
        • Lesnik B.
        Utstein style analysis of out-of-hospital cardiac arrest--bystander CPR and end expired carbon dioxide.
        Resuscitation. 2007; 72: 404-414
        • Lah K.
        • Križmarić M.
        • Grmec S.
        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: R13
        • Mally S.
        • Jelatancev A.
        • Grmec S.
        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: R39
        • Grmec S.
        • Lah K.
        • Tusek-Bunc K.
        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: R139-R144
        • Ahrens T.
        • Schallom L.
        • Bettorf K.
        • et al.
        End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest.
        Am J Crit Care. 2001; 10: 391-398
        • Salen P.
        • O’Connor R.
        • Sierzenski P.
        • et al.
        Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes?.
        Acad Emerg Med. 2001; 8: 610-615
        • Mauer D.
        • Schneider T.
        • Elich D.
        • Dick W.
        Carbon dioxide levels during pre-hospital active compression–decompression versus standard cardiopulmonary resuscitation.
        Resuscitation. 1998; 39: 67-74
        • Asplin B.R.
        • White R.D.
        Prognostic value of end-tidal carbon dioxide pressures during out-of-hospital cardiac arrest.
        Ann Emerg Med. 1995; 25: 756-761
        • Entholzner E.K.
        • Mielke L.L.
        • Breinbauer B.M.
        • et al.
        End-tidal carbon dioxide during preclinical CPR: correlation with primary outcome.
        Am J Emerg Med. 1996; 14: 109-111
        • Garnett A.R.
        • Ornato J.P.
        • Gonzalez E.R.
        • Johnson E.B.
        End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation.
        JAMA. 1987; 257: 512-515
        • Steedman D.J.
        • Robertson C.E.
        Measurement of end-tidal carbon dioxide concentration during cardiopulmonary resuscitation.
        Arch Emerg Med. 1990; 7: 129-134
        • Aichinger G.
        • Zechner P.M.
        • Prause G.
        • et al.
        Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients.
        Prehosp Emerg Care. 2012; 16: 251-255
        • Krep H.
        • Mamier M.
        • Breil M.
        • Heister U.
        • Fischer M.
        • Hoeft A.
        Out-of-hospital cardiopulmonary resuscitation with the AutoPulse system: a prospective observational study with a new load-distributing band chest compression device.
        Resuscitation. 2007; 73: 86-95
        • Heradstveit B.E.
        • Sunde K.
        • Sunde G.A.
        • Wentzel-Larsen T.
        • Heltne J.K.
        Factors complicating interpretation of capnography during advanced life support in cardiac arrest–a clinical retrospective study in 575 patients.
        Resuscitation. 2012; 83: 813-818
        • Eckstein M.
        • Hatch L.
        • Malleck J.
        • McClung C.
        • Henderson S.O.
        End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest.
        Prehosp Disaster Med. 2011; 26: 148-150
        • Deakin C.D.
        • Morrison L.J.
        • Morley P.T.
        • et al.
        International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 8: advanced life support.
        Resuscitation. 2010; 81S (e93–e174 e119)
        • Neumar R.W.
        • Otto C.W.
        • Link M.S.
        • et al.
        Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2010; 122: S729-S767