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“… with a slight breath the lung will swell and the heart becomes strong … and as I do this and take care that the lung is inflated at intervals, the motion of the heart does not stop …”
Vesalius (1514 –1564)
Maintaining a patent airway is of paramount importance if the lungs are to be inflated successfully with high inspired oxygen concentration during cardiopulmonary resuscitation (CPR) attempts. The association between delivering adequate breaths via a patent airway and maintenance of cardiac function was clearly recognized by Vesalius in the sixteenth century. Patients requiring CPR often have an obstructed airway, usually caused by loss of consciousness, but occasionally it may be the primary cause of cardiopulmonary arrest. Prompt assessment, with control of the airway and ventilation of the lungs is essential. This will help to prevent secondary hypoxic damage to the brain and other vital organs as well as maintaining cardiac function. Without adequate oxygenation it may be impossible to restore a spontaneous cardiac output from a myocardium in cardiac arrest.
An extensive review of the science behind airway management during cardiac arrest was published recently: the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR). The European Resuscitation Council (ERC) Basic Life Support (BLS) and Advanced Life Support (ALS) Working Parties have recently published new guidelines on management of the airway during cardiac arrest and these were based partly on the recommendations published in CoSTR.
Jerry P. Nolan, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath BA1 3NG, UK,
Douglas Chamberlain, Department of Resuscitation Medicine, School of Medicine, Cardiff University, Wales, UK,
William H. Montgomery, Department of Anesthesiology, Straub Clinic and Hospital, University of Hawaii School of Medicine, Honolulu, Hawaii, USA,
Vinay M. Nadkarni, Departments of Anesthesia, Critical Care and Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Clinical guidelines aredefinedby the Institute ofMedicine in the United States as“systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” The main objective of guidelines is to improve the quality of care received by patients by closing the gap between what clinicians do and what scientific evidence supports. Guidelines provide a point of referencefor auditing performanceof clinicians or hospitals and may improve effectiveness and efficiency. The development of guidelines requires appropriate resources: expert clinicians, group process leaders, and financial support. All these statements refer to guideline development in general, but they are particularly relevant to the development of resuscitation guidelines that have existed for at least 40 years. The steps involved in the process for developing evidence-based guidelines have been outlined by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group (Table 71.1).
This chapter will review the history of consensus development in resuscitation, the role of the International Liaison Committee on Resuscitation (ILCOR), the process involved in undertaking a systematic review of resuscitation science, and the writing of clinical guidelines based on a consensus of the science.
The history of international CPR consensus and guideline development
The modern approach to cardiopulmonary resuscitation (CPR) was described in the late 1950s and early 1960s. Although this was undoubtedly the birth of CPR, it was immediately realized that the challenge was to spread the word and educate healthcare workers and laypeople throughout the world. This same challenge faces us today whenever CPR guidelines are modified and updated.
Gas-powered resuscitators (ventilators) designed to be used primarily for resuscitation should be basic and simple to use. They offer many advantages over manual methods of ventilation during in-hospital cardiopulmonary resuscitation. Portable ventilators intended for critical care transport require additional, more sophisticated features such as: adjustable pressure limiting valves, air-mixing, airway pressure gauge, independent tidal volume and rate controls, and a Positive End-Expiratory Pressure (PEEP) valve. The performance of six gas-powered resuscitators/portable ventilators (TransPAC, Oxylog, Ambu Matic, ERA 2000, Uni-Vent, and MARS) was evaluated.
The accuracy of volumes delivered to a test lung at three different compliance and resistance settings, was assessed for each ventilator prior to clinical evaluation during cardio-pulmonary resuscitation (CPR) and patient transport.
In each circumstance, measured tidal volumes and levels of minute ventilation decreased as resistance was increased and compliance reduced. Much of this loss of measured tidal volume occurred through inspiratory pressure relief valves that tended to start leaking at pressures below the preset level. Increasing levels of back-pressure resulted in further reductions in tidal volume when the ventilators were tested using the air-mix mode (available on three of the devices). In general, each resuscitator functioned well when used during CPR within the hospital.
Each resuscitator tested failed to deliver the preset volumes and this must be considered during their use. Inspiratory pressure relief valves for all but one of the ventilators tested would not permit the delivery of adequate levels of ventilation in patients with low pulmonary compliance and/or high airway resistance.
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