Resuscitation 83 (2012) 789–790
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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Capnography during cardiopulmonary resuscitation
Use of waveform capnography during cardiac arrest was recom-
mended in the 2010 International Consensus on Cardiopulmonary
Resuscitation (CPR) Science with Treatment Recommendations.1
A primary benefit includes confirmation that a tracheal tube (or
other airway device) has been placed correctly and is providing
ventilation of the lungs.2 Capnography is considerably more reli-
able than either clinical assessment by auscultation or observation
of chest wall movement. The recent 4th National Audit Project
of The Royal College of Anaesthetists and Difficult Airway Society
examined Major Complications of Airway Management in the UK.
It did not focus on airway management during cardiac arrest, but
it included 11 instances where failure to use or correctly inter-
pret capnography led to unrecognised oesophageal intubations
during cardiac arrest, most of which led to avoidable death or
brain injury.3,4 We can assume that the incidence of unrecognised
oesophageal intubation is higher when waveform capnography is
not used during cardiac arrest. There is strong evidence to support
the use of waveform capnography in this situation (CPR will gener-
ate an attenuated, but not absent, end-tidal CO2 trace),5 with data
demonstrating 100% sensitivity and 100% specificity in identifying
correct tracheal tube placement.6 In contrast to waveform capnog-
raphy, studies of alternative devices to determine correct tube
placement (such as colorimetric end-tidal CO2 detectors, syringe
aspiration oesophageal detector, self-inflating bulb oesophageal
detector and non-waveform end-tidal capnometers) have been
shown to have accuracy that is not substantially better than clinical
assessment.7–15
During cardiac arrest, waveform capnography may also be used
to guide the effectiveness of chest compressions and to provide an
early indication of return of spontaneous circulation (ROSC). How-
ever, there is currently insufficient evidence to recommend the use
of end-tidal CO2 monitoring as a method of prognostication during
cardiac arrest.1
In this issue of the journal, Heradstveit and colleagues from
the Emergency Medical Service of Haukeland University Hospital
in Bergen, Norway, present data that suggest capnography may
become a more useful tool for optimising and individualising ALS
in patients experiencing of out-of-hospital cardiac arrest (OHCA).16
A retrospective observational study was performed using data
collected routinely from 918 OHCA patients. Of these, 194 were
excluded and 149 did not have capnography data recorded. Data
were analysed from the remaining 575 patients. Based on all avail-
able clinical evidence, the cause of cardiac arrest was considered
to be cardiac in 58%, respiratory in 20%, pulmonary embolism (PE)
in 2% and unknown in 19%. Patients who developed cardiac arrest
from a respiratory (excluding PE) cause were observed to have
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http://dx.doi.org/10.1016/j.resuscitation.2012.04.002
significantly higher end-tidal CO2 values compared with those of
other causes. The authors suggest that this is because these patients
have a period of rising CO2 from reduced or absent ventilation
prior to cardiac arrest, rather than having a better cardiac out-
put during CPR. In contrast, the few patients developing cardiac
arrest from pulmonary embolus had significantly lower end-tidal
CO2 values, presumably because of reduced blood flow through the
pulmonary circulation, despite effective CPR. End-tidal CO2 values
also varied with the person performing chest compressions. The
authors propose using end-tidal CO2 values to optimise the qual-
ity of CPR and indicate when poor technique or rescuer fatigue
may be compromising effective compressions; they suggest that
a fall in end-tidal CO2 may be an indication for a different person
to take over. Interestingly, patients who gained ROSC had signif-
icantly higher end-tidal CO2 values compared to those who did
not have ROSC, regardless of the initial cardiac rhythm or cause
of the arrest. Importantly, the authors caution the use of specific
cut-off values of end-tidal CO2 to prognosticate during cardiac
arrest. They correctly state that there are several confounding fac-
tors that affect the end-tidal CO2 value. These are demonstrated
in the study findings and include the cause of cardiac arrest,
the initial rhythm, effectiveness of bystander and first responder
CPR, and time from cardiac arrest to initiation of end-tidal CO2
monitoring.
Heradstveit and colleagues also discuss the important limita-
tions of their study. The average, highest and lowest end-tidal CO2
recordings were estimated by the attendant anaesthetist. This may
have lead to recording errors and also introduces the possibility
of (unintended) bias. During cardiac arrest, patients’ lungs were
manually ventilated by the anaesthetist and while this may have
led to over or under-ventilation the impact of this on end-tidal CO2
in a ‘low-flow’ state is surprisingly small. However, hyperventila-
tion during cardiac arrest decreases coronary perfusion pressure
and, based on animal data, decreases survival.17 Determination of
the cause of cardiac arrest is difficult and incorrect categorisation
of the type of cardiac arrest may influence the data. The authors
acknowledge that the number of cardiac arrests of unknown cause
is high and had no post-mortem results to confirm or refute any
presumed pre-hospital diagnosis. In particular, only 12 patients had
a presumed diagnosis of PE (based on clinical history and an initial
rhythm of pulseless electrical activity or asystole), which was much
lower than previously reported. This confirms that diagnosis of PE
is difficult during cardiac arrest. The fact that significantly lower
end-tidal CO2 values were reported in patients with PE compared
with patients with other causes of cardiac arrest is an interesting
finding but should be interpreted with caution.
790 Editorial / Resuscitation 83 (2012) 789–790
Waveform capnography during cardiac arrest is now well estab-
lished in clinical practice. It has a recognized role in determining
correct airway placement and pulmonary ventilation. Defibrillators
are appearing that incorporate continuous capnography monitor-
ing. It is useful for assessing effectiveness of chest compressions,
and for early detection of ROSC. However, it must be emphasized
that end-tidal CO2 is currently much more of use in determining
confirmation of tracheal tube placement and ventilation, rather
than the additional uses described in this paper. The study by Her-
adstveit and colleagues asks more questions than it answers. The
next step is to undertake high quality prospective studies to deter-
mine whether robustly recorded end-tidal CO2 monitoring during
cardiac arrest can provide the clinician with robust information
about diagnosis of cause, appropriate interventions and prognosis.
Conflict of interest statement
The authors have no conflict of interests to declare.
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Edward Scarth ∗
Tim Cook
Royal United Hospital, Combe Park, Bath BA1 3NG,
United Kingdom
∗ Corresponding author. Tel.: +44 0 7930393497.
E-mail address: edscarth@me.com (E. Scarth)
3 April 2012
4 April 2012