Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival
Authors: Morgan Ryan W. , Reeder Ron W. , Bender Dieter , Cooper Kellimarie K. , Friess Stuart H. , Graham Kathryn , Meert Kathleen L. , Mourani Peter M. , Murray Robert , Nadkarni Vinay M. , Nataraj Chandrasekhar , Palmer Chella A. , Srivastava Neeraj , Tilford Bradley , Wolfe Heather A. , Yates Andrew R. , Berg Robert A. , Sutton Robert M. ,   for the ICU-RESUS and Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Investigator Groups, Ahmed Tageldin , Bell Michael J. , Bishop Robert , Bochkoris Matthew , Burns Candice , Carpenter Todd C. , Carcillo Joseph A. , Dean J. Michael , Diddle J. Wesley , Federman Myke , Fernandez Richard , Fink Ericka L , Franzon Deborah , Frazier Aisha H. , Hall Mark , Hehir David A. , Horvat Christopher M. , Huard Leanna L. , Maa Tensing , Manga Arushi , McQuillen Patrick S. , Naim Maryam Y. , Notterman Daniel , Pollack Murray M. , Sapru Anil , Schneiter Carleen , Sharron Matthew P. , Tabbutt Sarah , Viteri Shirley , Wessel David , Zuppa Athena F. 
Published: November 2023

BACKGROUND:

Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (

ETCO
2

) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that “specific values to guide therapy have not been established in children.”

METHODS:

This prospective observational cohort study was a National Heart, Lung, and Blood Institute–funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest

ETCO
2

data were included. The primary exposure was event-level average

ETCO
2

during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between

ETCO
2

and outcomes as well as the association between

ETCO
2

and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate).

RESULTS:

Among 234 included patients, 133 (57%) had an event-level average

ETCO
2

≥20 mm Hg. After controlling for a priori covariates, average

ETCO
2

≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04–1.69];
P
=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00–1.49];
P
=0.046) compared with lower values.

ETCO
2

≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average

2

≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between

ETCO
2

groups.

CONCLUSIONS:

In this multicenter study of children with in-hospital cardiopulmonary arrest,

ETCO
2

≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.