End-tidal carbon dioxide (ETCO2) at intubation and its increase after 10 minutes resuscitation predicts survival with good neurological outcome in out-of-hospital cardiac arrest patients



      To evaluate whether end-tidal carbon dioxide (ETCO2) value at intubation and its early increase (10 min) after intubation predict both the survival to hospital admission and the survival at hospital discharge, including good neurological outcome (CPC 1–2), in patients with out-of-hospital cardiac arrest (OHCA).


      All consecutive OHCA patients of any etiology between 2015 and 2018 in Pavia Province (Italy) and Ticino Region (Switzerland) were considered. Patients died before ambulance arrival, with a “do-not-resuscitate” order, without ETCO2 value or with incomplete data were excluded.


      The study population consisted of 668 patients. An ETCO2 value at intubation > 20 mmHg and its increase 10 min after intubation were independent predictors (after correction for known predictors of OHCA outcome) of survival to hospital admission and survival at hospital discharge. Relative to hospital discharge with good neurological outcome, ETCO2 at intubation and its 10-min change were confirmed predictors both individually and in a bivariable analysis (OR 1.83, 95 %CI 1.02–3.3; p = 0.04 and OR 3.9, 95 %CI 1.97–7.74; p < 0.001, respectively). This was confirmed also when accounting for gender, age, etiology and location. After further adjustment for bystander and CPR status, presenting rhythm and EMS arrival time, the ETCO2 change remained an independent predictor.


      ETCO2 value > 20 mmHg at intubation and its increase during resuscitation improve the prediction of survival at hospital discharge with good neurological outcome of OHCA patients. ETCO2 increase during resuscitation is a more powerful predictor than ETCO2 at intubation. A larger prospective study to confirm this finding appears warranted.


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        • Hayakawa K.
        • Tasaki O.
        • Hamasaki T.
        • Sakai T.
        • Shiozaki T.
        • Nakagawa Y.
        • et al.
        Prognostic indicators and outcome prediction model for patients with return of spontaneous circulation from cardiopulmonary arrest: The Utstein Osaka Project.
        Resuscitation. 2011; 82: 874-880
        • Baldi E.
        • Contri E.
        • Burkart R.
        • Bywater D.
        • Duschl M.
        The three dimension model of the out-of-hospital cardiac arrest.
        Resuscitation. 2019; 138: 44-45
        • Valenzuela T.D.
        • Roe D.J.
        • Cretin S.
        • Spaite D.W.
        • Larsen M.P.
        Estimating effectiveness of cardiac arrest interventions: A logistic regression survival model.
        Circulation. 1997; 96: 3308-3313
        • Seewald S.
        • Wnent J.
        • Lefering R.
        • Fischer M.
        • Bohn A.
        • Jantzen T.
        • et al.
        CaRdiac Arrest Survival Score (CRASS) — A tool to predict good neurological outcome after out-of-hospital cardiac arrest.
        Resuscitation. 2020; 146: 66-73
        • Gräsner J.T.
        • Meybohm P.
        • Lefering R.
        • Wnent J.
        • Bahr J.
        • Messelken M.
        • et al.
        ROSC after cardiac arrestthe RACA score to predict outcome after out-of-hospital cardiac arrest.
        Eur Heart J. 2011; 32: 1649-1656
        • Caputo M.L.
        • Baldi E.
        • Savastano S.
        • Burkart R.
        • Benvenuti C.
        • Klersy C.
        • et al.
        Validation of the return of spontaneous circulation after cardiac arrest (RACA) score in two different national territories.
        Resuscitation. 2019; 134: 62-68
        • Baldi E.
        • Caputo M.L.
        • Savastano S.
        • Burkart R.
        • Klersy C.
        • Benvenuti C.
        • et al.
        An Utstein-based model score to predict survival to hospital admission: The UB-ROSC score.
        Int J Cardiol. 2020; 308: 84-89
        • Sandroni C.
        • De Santis P.
        • D’Arrigo S.
        Capnography during cardiac arrest.
        Resuscitation. 2018; 132: 73-77
        • Sheak K.R.
        • Wiebe D.J.
        • Leary M.
        • Babaeizadeh S.
        • Yuen T.C.
        • Zive D.
        • et al.
        Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.
        Resuscitation. 2015; 89: 149-154
        • Ward K.R.
        • Menegazzi J.J.
        • Zelenak R.R.
        • Sullivan R.J.
        • McSwain N.E.
        A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal Pco2 during human cardiac arrest.
        Ann Emerg Med. 1993; 22: 669-674
        • Grmec Š.
        • Križmarič M.
        • Mally Š.
        • Koželj A.
        • Špindler M.
        • Lešnik B.
        Utstein style analysis of out-of-hospital cardiac arrest-Bystander CPR and end expired carbon dioxide.
        Resuscitation. 2007; 72: 404-414
        • Chicote B.
        • Aramendi E.
        • Irusta U.
        • Owens P.
        • Daya M.
        • Idris A.
        Value of capnography to predict defibrillation success in out-of-hospital cardiac arrest.
        Resuscitation. 2019; 138: 74-81
        • Savastano S.
        • Baldi E.
        • Raimondi M.
        • Palo A.
        • Belliato M.
        • Cacciatore E.
        • et al.
        End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest.
        Resuscitation. 2017; 121: 71-75
        • Hubble M.W.
        • Van Vleet L.
        • Taylor S.
        • Bachman M.
        • Williams J.G.
        • Vipperman R.
        • et al.
        Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest.
        Prehospital Emerg Care. 2021; 25: 697-705
        • Frigerio L.
        • Baldi E.
        • Aramendi E.
        • Chicote B.
        • Irusta U.
        • Contri E.
        • et al.
        End-tidal carbon dioxide (ETCO2) and ventricular fibrillation amplitude spectral area (AMSA) for shock outcome prediction in out-of-hospital cardiac arrest. Are they two sides of the same coin?.
        Resuscitation. 2021; 160: 142-149
        • Engel T.W.
        • Thomas C.
        • Medado P.
        • Bastani A.
        • Reed B.
        • Millis S.
        • et al.
        End tidal CO2 and cerebral oximetry for the prediction of return of spontaneous circulation during cardiopulmonary resuscitation.
        Resuscitation. 2019; 139: 174-181
        • Touma O.
        • Davies M.
        The prognostic value of end tidal carbon dioxide during cardiac arrest: A systematic review.
        Resuscitation. 2013; 84: 1470-1479
        • Crickmer M.
        • Drennan I.R.
        • Turner L.
        • Cheskes S.
        The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity.
        Resuscitation. 2021; 167: 76-81
        • Gutiérrez J.J.
        • Leturiondo M.
        • De Gauna S.R.
        • Ruiz J.M.
        • Azcarate I.
        • González-Otero D.M.
        • et al.
        Assessment of the evolution of end-tidal carbon dioxide within chest compression pauses to detect restoration of spontaneous circulation.
        PLoS One. 2021; 16: e0251511
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • Berg R.A.
        • Billi J.E.
        • Bossaert L.
        • et al.
        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 Resusci.
        Circulation. 2004; 110: 3385-3397
        • Perkins G.D.
        • Jacobs I.G.
        • Nadkarni V.M.
        • Berg R.A.
        • Bhanji F.
        • Biarent D.
        • et al.
        Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest.
        Resuscitation. 2015; 96: 328-340
        • Savastano S.
        • Vanni V.
        • Burkart R.
        • Raimondi M.
        • Canevari F.
        • Molinari S.
        • et al.
        Comparative performance assessment of commercially available automatic external defibrillators: A simulation and real-life measurement study of hands-off time.
        Resuscitation. 2017; 110: 12-17
        • Baldi E.
        • Schnaubelt S.
        • Caputo M.L.
        • Klersy C.
        • Clodi C.
        • Bruno J.
        • et al.
        Association of Timing of Electrocardiogram Acquisition After Return of Spontaneous Circulation With Coronary Angiography Findings in Patients With Out-of-Hospital Cardiac Arrest.
        JAMA Netw open. 2021; 4: e2032875
        • Soar J.
        • Böttiger B.W.
        • Carli P.
        • Couper K.
        • Deakin C.D.
        • Djärv T.
        • et al.
        European Resuscitation Council Guidelines 2021: Adult advanced life support.
        Resuscitation. 2021; 161: 115-151
        • 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
        • Ahrens T.
        • Schallom L.
        • Bettorf K.
        • Ellner S.
        • Hurt G.
        • O’Mara V.
        • et al.
        End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest.
        Am J Crit Care. 2001; 10: 391-398
        • Herlitz J.
        • Engdahl J.
        • Svensson L.
        • Young M.
        • Ängquist K.A.
        • Holmberg S.
        Can we define patients with no chance of survival after out-of-hospital cardiac arrest?.
        Heart. 2004; 90: 1114-1118
        • Waalewijn R.A.
        • Tijssen J.G.P.
        • Koster R.W.
        Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: Results from the Amsterdam Resuscitation Study (ARRESUST).
        Resuscitation. 2001; 50: 273-279
        • Liu X.
        Classification accuracy and cut pointselection.
        Stat Med. 2012; 31: 2676-2686
        • Paiva E.F.
        • Paxton J.H.
        • O’Neil B.J.
        The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.
        Resuscitation. 2018; 123: 1-7
        • Ji C.
        • Brown T.P.
        • Booth S.J.
        • Hawkes C.
        • Nolan J.P.
        • Mapstone J.
        • et al.
        Risk prediction models for out-of-hospital cardiac arrest outcomes in England.
        Eur Hear J - Qual Care Clin Outcomes. 2021; 7: 198-207
        • Hreinsson J.P.
        • Thorvaldsson A.P.
        • Magnusson V.
        • Fridriksson B.T.
        • Libungan B.G.
        • Karason S.
        Identifying out-of-hospital cardiac arrest patients with no chance of survival: An independent validation of prediction rules.
        Resuscitation. 2020; 146: 19-25
        • Andersson P.
        • Johnsson J.
        • Björnsson O.
        • Cronberg T.
        • Hassager C.
        • Zetterberg H.
        • et al.
        Predicting neurological outcome after out-of-hospital cardiac arrest with cumulative information; development and internal validation of an artificial neural network algorithm.
        Crit Care. 2021; 25: 83
        • Axelsson C.
        • Karlsson T.
        • Axelsson Å.B.
        • Herlitz J.
        Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (PETCO2) during CPR in out-of-hospital cardiac arrest (OHCA).
        Resuscitation. 2009; 80: 1099-1103
        • Lah K.
        • Križmarić M.
        • Grmec Š.
        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
        • 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
        • Brinkrolf P.
        • Borowski M.
        • Metelmann C.
        • Lukas R.P.
        • Pidde-Küllenberg L.
        • Bohn A.
        Predicting ROSC in out-of-hospital cardiac arrest using expiratory carbon dioxide concentration: Is trend-detection instead of absolute threshold values the key?.
        Resuscitation. 2018; 122: 19-24

      Linked Article

      • CPR capnography: It’s not where you’ve been, but where you’re going
        ResuscitationVol. 181
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          Expired end-tidal carbon dioxide (ETCO2) capnography has been posited as a reliable non-invasive marker of the adequacy of cardiopulmonary resuscitation (CPR) since the mid-1980s.1 The prevailing theory is that adequate cardiac output generated by high-quality external chest compressions should produce ETCO2 levels approaching normal physiologic values, assuming no other impairments to gas exchange. In the setting of high-quality CPR, persistently low ETCO2 levels have been shown to be associated with poor survival, while higher ETCO2 levels (particularly if increasing during CPR) correlate with increased likelihood of return of spontaneous circulation (ROSC) and survival to hospital discharge.
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