Study Design

Reduced Quality Factors

0 = no serious, - = serious,

- - = very serious

Positive Quality Factors

0 = none, + = one, ++ = multiple

Dichotomous Outcome Summary

Non-Dichotomous Outcome Summary

Brief description

Overall Quality

High, moderate, low,
very low, none

No of studies

Study Type

RoB

Indirectness

Imprecision

Inconsistency

Large Effect

Dose-Response

Confounder

# Intervention with Outcome

# Control with Outcome

RR (95% CI)

Outcome: Favorable neurologic outcome, Survival to discharge, ROSC, Complications

0

Introduction

Ventilation during CPR can be performed manually or with a mechanical ventilator. Chest compressions increase intrathoracic and airway pressures, necessitating application of higher than normal (for that patient) peak inspiratory pressure (PIP) to facilitate ventilation. The optimal PIP during CPR has not been defined in human or veterinary medicine and is likely to vary between patients depending on factors such as thoracic conformation, respiratory pathology, and endotracheal tube size. The current human CPR guidelines recommend ventilation force be sufficient to generate a visible chest rise.1

Consensus on science

For the most critical outcomes of Favorable neurological outcome, Survival to discharge, ROSC, and Complications, we identified no studies that address the PICO question.

Treatment recommendation

We recommend that a peak inspiratory pressure be applied that creates visible but not excessive chest rise.(strong recommendation, expert opinion)

We recommend against use of a peak inspiratory pressure that exceeds 40 cmH2O when providing manual ventilation.(strong recommendation, expert opinion)

We recommend against use of a peak inspiratory pressure that exceeds 60 cmH2O when the patient is undergoing mechanical ventilation during CPR.(strong recommendation, expert opinion)

Justification of treatment recommendation

Changes in chest wall compliance due to chest compressions result in variable tidal volumes being delivered when a static PIP is applied in the setting of closed-chest CPR. As tidal volume is a major determinant of PaCO2, and given the variability of PIP required to generate adequate tidal volumes during CPR, we believe that the parameter of chest rise is more physiologically relevant to adequate ventilation in this setting than PIP.

Excessive airway pressures can be harmful. Thus, the committee decided to recommend a maximum of no more than 40 cmH2O PIP in the case of manual ventilation, consistent with the release valve limits commonly used on commercial rebreathing bags (https://www.ambu.com/emergency-care-and-training/resuscitators/product/ambu-spur-ii ; accessed 9 April 2023). Similarly, the committee selected a maximum of 60 cmH2O during mechanical ventilation based on American Heart Association CPR guidelines for people.2

Knowledge gaps

No evidence is available regarding effective and safe peak inspiratory pressures for manual ventilation during chest compressions in dogs and cats.