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Resuscitation. 2015 Apr;89:149-54. doi: 10.1016/j.resuscitation.2015.01.026. Epub 2015 Jan 30.

Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.

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Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, United States.
Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States.
Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, United States.
Department of Medicine, University of Chicago, Chicago, IL, United States.
Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States.
Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, United States. Electronic address:



Cardiopulmonary resuscitation (CPR) guidelines recommend the administration of chest compressions (CC) at a standardized rate and depth without guidance from patient physiologic output. The relationship between CC performance and actual CPR-generated blood flow is poorly understood, limiting the ability to define "optimal" CPR delivery. End-tidal carbon dioxide (ETCO2) has been proposed as a surrogate measure of blood flow during CPR, and has been suggested as a tool to guide CPR despite a paucity of clinical data. We sought to quantify the relationship between ETCO2 and CPR characteristics during clinical resuscitation care.


Multicenter cohort study of 583 in- and out-of-hospital cardiac arrests with time-synchronized ETCO2 and CPR performance data captured between 4/2006 and 5/2013. ETCO2, ventilation rate, CC rate and depth were averaged over 15-s epochs. A total of 29,028 epochs were processed for analysis using mixed-effects regression techniques.


CC depth was a significant predictor of increased ETCO2. For every 10mm increase in depth, ETCO2 was elevated by 1.4mmHg (p<.001). For every 10 breaths/min increase in ventilation rate, ETCO2 was lowered by 3.0mmHg (p<.001). CC rate was not a predictor of ETCO2 over the dynamic range of actual CC delivery. Case-averaged ETCO2 values in patients with return of spontaneous circulation were higher compared to those who did not have a pulse restored (34.5±4.5 vs 23.1±12.9mmHg, p<.001).


ETCO2 values generated during CPR were statistically associated with CC depth and ventilation rate. Further studies are needed to assess ETCO2 as a potential tool to guide care.


Capnography; Cardiopulmonary resuscitation; End-tidal carbon dioxide; Sudden cardiac arrest

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