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BLS-19-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-19
PICO Question:
In cats and dogs in CPA (P), does the use of any other specific peak inspiratory pressure (PIP) (I), compared to 40 cm H2O PIP (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Complications, Survival to discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurologic outcome
- Survival to Discharge
- ROSC
- Complications
Domain chairs: Steve Epstein, Kate Hopper; final edit by Jamie Burkitt
Evidence evaluators: none
Conflicts of interest: None reported
Search strategy: See attached document
Evidence Review:
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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, |
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No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Favorable neurologic outcome, Survival to discharge, ROSC, Complications |
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PICO Question Summary
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Introduction |
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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 |
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Consensus on science |
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For the most critical outcomes of Favorable neurological outcome, Survival to discharge, ROSC, and Complications, we identified no studies that address the PICO question.
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Treatment recommendation |
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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)
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Justification of treatment recommendation |
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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 |
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Knowledge gaps |
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No evidence is available regarding effective and safe peak inspiratory pressures for manual ventilation during chest compressions in dogs and cats.
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References:
1. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468.
2. Part 6: Advanced Cardiovascular Life Support. Circulation. 2000;102(suppl_1):I-95.
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