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Inadvertent Hyperventilation (IH) (which is the delivery of an excessive minute volume), during CPR or respiratory arrest, has been shown to be very common and to have severe detrimental effects on patient hemodynamics [1] as well as the associated risks of gastric insufflation and
pulmonary aspiration of stomach contents. In traumatic brain injury IH also contributes to increased brain ischemia [2].

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Current International Resuscitation Guidelines[3] clearly indicate that ventilations should be provided in a slow, controlled, manner with tidal volumes being limited to 6 – 7 ml/kg and ventilation rates to be in the 10 – 12 breaths per minute in adults. However, studies have shown ventilation rates to be 2 – 3 times this recommended rate[1] [4] with tidal volumes and airway pressures being excessive and inspiratory times being too short. While the physiological effects on these patients have been evaluated the additional cost of these negative actions on patient care in the hospital has not been clearly defined.

Pulmonary aspiration of stomach contents during CPR is, not surprisingly, very high. Felegi et al[5] in their 1996 study showed pulmonary aspiration rates as high as 33% in non-survivors of cardiac arrest. Lawes and Basket[6] reported in the Intensive Care medicine journal that “the incidence of pulmonary aspiration in a group of patients who did not respond to cardiopulmonary resuscitation (CPR) was assessed at autopsy and found to be 29%. This figure is undoubtedly an underestimate of the total problem. In survivors, any aspiration of stomach
contents will have seriously detrimental effects on morbidity and mortality.

Another issue related to inadvertent hyperventilation is barotrauma, due to excessive tidal volume delivery and breath stacking, which may require post-arrest treatment and intensive care stays. Emergency tracheal intubation is also not without significant risk.

When requiring ventilation in the ICU, patients also run the risk of ventilator associated pneumonia (VAP). Hunter, in his paper in the BMJ[7] stated: “Ventilator associated pneumonia is the most common healthcare associated infection in intensive care”. “The condition is associated with increased morbidity, mortality, length of stay, and costs”. VAP accounts for about half of all antibiotics given in the ICU. It occurs in 9-27% of mechanically ventilated patients. The condition is associated with increased ICU and hospital stay and has an estimated attributable mortality of 9%.

In the HCNA Series[8] it is stated that there are “ten conditions that use the greatest number of bed-days” in the ICU, one of which is inhalation pneumonitis (gastrointestinal contents)”. These ten conditions made up 32.8% of ICU bed days with an average length of stay 5.02
days. Nolan et al[9] stated in their article in anesthesia that, in the UK: “Mechanically ventilated survivors of cardiac arrest accounted for 24,132 (5.8%) of all admissions.”

Tan SS. et al[10] showed daily ICU costs in four European Countries to be in the range of €1168 – €2025 (£1000 – £1800) per day. In North America these average daily costs for a ventilated patient are estimated to be $5,500 per day[10]. Therefore, the per-patient cost of treating,
what is a potentially avoidable complication of cardiopulmonary resuscitation, is significant and estimated to be in the €5,800 – €10,000 (£5,000 – 9,000) range in Europe. In North America this cost is estimated to be $27,500[11].

These figures equate to an average annual cost burden (of out of hospital cardiac arrest and the issues related to Inadvertent Hyperventilation) on the various country healthcare systems of:

Review/Update

Estimated Cost of Inadvertent Hyperventilation on Intensive Care Departments O‐Two Medical Technologies Inc. 2016 Conclusions Inadvertent hyperventilation needs to be removed from the CPR equation to reduce both morbidity and mortality in cardiac arrest. The added cost of treating cardiac arrest survivors who have been respiratory compromised to the point of requiring ICU admission due to inadvertent
hyperventilation is significant. Improved methods of providing controlled ventilation (such as Automatic Transport Ventilators and flow controlling manual resuscitators need to be routinely employed during CPR. Technology-based solutions can assist in reducing this cost burden on healthcare systems (with minimal increased expenditure on devices and training) to provide controlled ventilation.

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