Ventilation during resuscitation

Ventilation during resuscitation can be the difference between life and death. For a long time, its importance in comparison to chest compression was underestimated. Today, however, there is a broad consensus that ventilation is an essential component of resuscitation and must not be neglected.¹

Despite this being recognized, adequate implementation of ventilation during resuscitation remains a challenge. A study in the USA in 2020 showed that only 3 out of 106 emergency medical teams were able to guarantee guideline-compliant ventilation during simulated resuscitation.²

3/106 emergency medical teams could guarantee guideline-compliant ventilation during resuscitation

In this context, WEINMANN ventilators offer reliable support for cardiopulmonary resuscitation. Their simple handling means they provide speedy assistance in the race against time, when every second could be the difference between life and death.

The objectives of cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is a life-saving procedure used in cases of respiratory and circulatory arrest. CPR consists of two main components: chest compressions to maintain the blood flow and artificial ventilation to supply the body with oxygen.

Maintaining a minimum circulation via CPR ensures that the body is supplied with enough oxygen and blood flows to vital organs such as the heart and brain. Chest compressions are crucial for enabling the circulation of oxygen-rich blood, while ventilation during resuscitation supplies the body with new oxygen and removes carbon dioxide. This artificial ventilation of the lungs is indispensable for preventing irreversible damage.

Objectives of ventilation during resuscitation

Resuscitation plays a crucial role in saving lives. Ventilation during resuscitation serves various medical purposes:

Oxygenation: The primary objective of ventilation is oxygenation - supplying the body with sufficient oxygen to guarantee adequate blood flow to vital organs such as the heart and brain.
Ventilation: In addition to supplying oxygen, ventilation is also used for exchanging oxygen and carbon dioxide (decarboxylation). This is crucial for avoiding an accumulation of carbon dioxide (hypercapnia), which could lead to respiratory acidosis.
Supporting circulation: Ideally, ventilation supports circulation through synchronous ventilation and chest compression.

Why is ventilation so important during resuscitation?

Early research concentrated primarily on Chest Compression Only CPR. However, it has been demonstrated that ventilation is indispensable for effective resuscitation. One study found that ventilation in more than 50% of compression pauses was associated with improved return of spontaneous circulation (ROSC), an increased survival rate and reduced neurological damage.³

The heart and brain react very sensitively to an oxygen deficiency, and therefore speedy ventilation with the highest possible oxygen concentration is crucial for avoiding life-threatening damage.⁴

A cardiac arrest causes the oxygen supply to stop abruptly. Due to their high metabolic rates, the heart and brain exhaust their limited oxygen and energy reserves within minutes. Speedy ventilation during resuscitation is therefore essential for avoiding irreversible damage, and the inspiratory oxygen concentration should be as high as possible.

The study “Bag-Valve-Mask Ventilation and Survival from Out-of-Hospital Cardiac Arrest: A Multicenter Study” by Ahamed Idris et al.⁵ looks at the effect of ventilation during resuscitation on

the outcome of the patient. According to this study, people who were reliably ventilated during the compression pauses display higher survival rates and less neurological damage. Therefore, chest compressions without ventilation are not recommended for professional personnel.⁶ In fact, quite the opposite: they should start ventilation as early as possible.⁷

Ventilation during resuscitation – these are the options

The guidelines on cardiopulmonary resuscitation tend to come from general recommendations on artificial ventilation. As such, there are also no specific recommendations when it comes to selecting the ventilation mode.

The choice of ventilation method during resuscitation mostly depends on whether or not the patient’s airway is secured. In the case of an unsecured airway, the following options are available:

Bag-valve-mask ventilation: A manual method in which oxygen is administered directly via a mask by squeezing a ventilation bag.
MEDUtrigger: A trigger that can be manually operated to cause mechanical breaths via a mask.

Following successful airway management, further options become available:

Bag-valve-tube ventilation: During intubation, the tube can be connected to a bag to enable manual ventilation.
Volume Controlled Ventilation (VCV): A mechanical ventilation method whereby the tidal volume is specified.
Pressure Controlled Ventilation (PCV): A mechanical ventilation method whereby the ventilation pressure is regulated.
Chest Compression Synchronized Ventilation (CCSV): A pressure-controlled ventilation mode that is synchronized with the chest compressions and initiates mechanical breaths.

Bag-valve-mask ventilation

Advantages: Quick application
Light weight
Disadvantages: No constant respiratory volume
No constant respiratory rate
Pressure peaks possible
Limited sealing
Gastric insufflation possible
2 rescuers required
Obstruction of the venous return flow due to asynchronous ventilation

MEDUtrigger

Advantages: Manual ventilation with a constant volume
Guideline-compliant, rapid implementation of 2 mechanical breaths in succession
Pressure limit and warning signals
Disadvantages: Mechanical ventilator required at the scene
No direct patient “feel”

Bag-valve-tube ventilation

Advantages: Quick application
Light weight
Disadvantages: No constant respiratory volume
No constant respiratory rate
1 rescuer required for ventilation
Possible pressure peaks and obstruction of the venous return flow due to asynchronous ventilation

Mechanical Volume Controlled Ventilation (VCV)

Advantages: Precise adjustment of respiratory volume and constant ventilation rate
No additional rescuers required for ventilation
Disadvantages: Possible pressure peaks and obstruction of the venous return flow due to asynchronous ventilation

Mechanical Pressure Controlled Ventilation (PCV)

Advantages: Constant ventilation pressure and rate
No additional rescuers required for ventilation
Disadvantages: Possible obstruction of the venous return flow due to asynchronous ventilation

Chest Compression Synchronized Ventilation (CCSV)

Advantages: Specially developed for resuscitation
Oxygenation and alveolar ventilation improved
Supports perfusion
No additional rescuers required for ventilation
Disadvantages: Airway management with endotracheal tube required

This is how WEINMANN supports ventilation during resuscitation

WEINMANN improves the efficiency of ventilation during resuscitation with an unsecured airway by using the MEDUtrigger. This function is available with MEDUMAT Easy^CPR, MEDUVENT Standard and MEDUMAT Standard² devices.

The MEDUtrigger gives the user flexibility when initiating individual mechanical breaths. A longer press on the trigger activates two guideline-compliant mechanical breaths with a maximum duration of five seconds. Unlike bag-valve-mask ventilation, the user is not dependent on a second person to maintain a mask seal. They can seal the mask with their hands while a ventilator performs the ventilation.

Once the airway has been secured, CCSV mode from WEINMANN offers effective respiratory support. This mode synchronously delivers a short mechanical breath for every chest compression. It is synchronized with the compressions, which means that a chest compression rate of 100/min, for instance, is accompanied by a corresponding ventilation rate. CCSV mode has a number of advantages:

Improved hemodynamics: In comparison with other ventilation modes, resuscitation with CCSV demonstrates improved oxygenation, a normal venous pH value and a significantly higher median arterial blood pressure, which indicates improved hemodynamics.
Improved alveolar ventilation: CCSV can prevent hypercapnia and thus counteract respiratory acidosis.
Improved cerebral oxygenation: CCSV contributes to an increase in cerebral oxygenation during resuscitation.
More precise ventilation: CCSV works with the preset ventilation values without exceeding the set ventilation pressure during resuscitation.

In this way, CCSV mode from WEINMANN supports reliable ventilation during resuscitation.

¹https://www.grc-org.de/files/Contentpages/document/Leitlinienkompakt_26.04.2022.pdf

²Neth MR, Benoit JL, Stolz U, McMullan J. Ventilation in Simulated Out-of-Hospital Cardiac Arrest Resuscitation Rarely Meets Guidelines. Prehosp Emerg Care. 2021 Sep-Oct;25(5):712-720. doi: 10.1080/10903127.2020.1822481. Epub 2020 Oct 6. PMID: 33021857.

³ Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023 Dec 5;148(23):1847-1856. doi: 10.1161/CIRCULATIONAHA.123.065561. Epub 2023 Nov 12. PMID: 37952192.

⁴ Skrifvars MB, Olasveengen TM, Ristagno G. Oxygen and carbon dioxide targets during and after resuscitation of cardiac arrest patients. Intensive Care Med. 2019 Feb;45(2):284-286. doi: 10.1007/s00134-018-5456-6. Epub 2018 Nov 12. PMID: 30421258.

⁵ Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson

⁶ Larsen R. Kardiopulmonale Reanimation. Anästhesie und Intensivmedizin für die Fachpflege. 2016 Jun 14:627–44. German. doi: 10.1007/978-3-662-50444-4_46. PMCID: PMC7531326.

⁷ Kardiopulmonale Reanimation bei Erwachsenen Von Shira A. Schlesinger , MD, MPH, Harbor-UCLA Medical Center