Data supporting the use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.

The data presented in this article are related to the research article, "The Use of End-Tidal Carbon Dioxide (ETCO2) Measurement to Guide Management of Cardiac Arrest: A Systematic Review" [1]. This article is a systematic review and meta-analysis of existing data on the subject of whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adult patients experiencing cardiac arrest in any setting. These data are made publicly available to enable critical or extended analyses.

Specifications Table

Value of the data

These data describe evidence available in the English-language medical literature pertaining to end-tidal carbon dioxide measurement as it correlates with return of spontaneous circulation (ROSC) or survival to hospital discharge in adult patients experiencing cardiac arrest in any setting.

These data allow other researchers to extend the statistical analyses.

Data

These data report findings determined through the 2015 Consensus on Science and Treatment Recommendations process, managed by the International Liaison Committee on Resuscitation (www.ilcor.org/seers). These data include those studies that were considered to be most relevant in the determination of the utility of end-tidal carbon dioxide (ETCO2) measurement in the management of cardiac arrest in any setting. These data have been reported as the results of this effort to describe the use of ETCO2 in adult cardiac arrest, and are provided in a summary article describing their utility for adult patient experiencing cardiac arrest in any clinical setting [1]. A total of 17 full-text articles were included in the qualitative synthesis [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], and 5 articles were included in the quantitative analysis [3], [4], [5], [6], [7]. Fig. 1 shows a flow diagram of search results, including those full-text articles that were included in the qualitative synthesis and the quantitative analysis. Fig. 2 shows a Forest plot of the correlation between ETCO2 and ROSC. Fig. 3 shows a Forest plot of the correlation between specific ETCO2 levels and survival to hospital discharge. Table 1 shows the characteristics of the included studies. Table 2 shows a summary of findings, including ETCO2 level higher or lower than 10- or 20-mmHg for predicting outcome following cardiac arrest.

Fig. 1

Flow diagram of search results.

Fig. 2

Forest plot of the correlation between ETCO2 and ROSC: A. Initial ETCO2 ≥ 10 mmHg; B. Initial ETCO2 ≥ 20 mmHg; C. 20-min ETCO2 ≥ 10 mmHg; D. 20-min ETCO2 ≥ 20 mmHg.

Fig. 3

Forest plot of the correlation between specific ETCO2 levels and survival to hospital discharge: A. Initial ETCO2 ≥ 10 mmHg; B. Initial ETCO2 ≥ 20 mmHg; C. 20-min ETCO2 ≥ 10 mmHg; D. 20-min ETCO2 ≥ 20 mmHg.

Table 1

Characteristics of the included studies.

Study year	Design	N	Population		VF/VT (%)	Asystole/PEA (%)	ETCO2measurement	Time of ETCO2measurement (cut-off, mmHg)	Outcome(s)	Results	Potential bias	Included in meta-analysis	ROSC/Survival
Ahrens 2001	Prospective cohort	127	IHCA and Helicopter	76.0		24.0a	Capnography	Initial, 5, 10, 15, 20 min, and final (≥ 10 and ≥ 20)	ROSC	ETCO2 ≥ 20 mmHg at 5 and 10 min – 94.4% of survival	Convenience sampling 14% have already achieved ROSC	Yes	43% ROSC
													31.5% STFH
									STFH	ETCO2 ≤ 17.5 mmHg at 15 min – 91.9% of non-survival			13.7% SHD
									SHD
Callaham 1990	Prospective cohort	55	OHCA	10.9		54.5/34.6	Capnometry	Initial (≥ 10 and ≥ 20)	ROSC	ETCO2 ≥ 15 mmHg predicted ROSC (sensitivity 71% and specificity of 98%)	Rescuers not blinded	Yes	25.5% ROSC
											Small number of patients
Cantineau 1996	Prospective cohort	120	OHCA	6.3		90.6/3.1	Capnometry	Initial and maximum (≥ 10)	ROSC	ETCO2 ≥ 10 mmHg predicted ROSC (sensitivity 87% and specificity of 74%)	90.6% asystole	Yes	31.7% ROSC
Wayne 1995	Prospective cohort	90	OHCA	0.0		0.0/100.0	Capnography	20 min (≥ 10)	ROSC	ETCO2 ≥ 10 mmHg predicted ROSC (sensitivity 97.3% and specificity 100.0%)	Only PEA	Yes	17.8% ROSC
									SHA
													14.4% SHA
									SHD
													7.8% SHD
Levine 1997	Prospective cohort	150	OHCA	0.0		0.0/100.0	Capnography	20 min (≥ 10)	ROSC	ETCO2 ≤ 10 mmHg predicted non-survival (sensitivity 100% and specificity of 100%)	Only PEA Includes data from Wayne's study	Yes	23.3% ROSC
									SHD
													10.7% SHD
Sanders 1989	Prospective cohort	35	IHCA	47.3		27.1/25.6	Capnometry	Average (≥ 10)	ROSC	All patients with ROSC had average ETCO2 ≥ 10 mmHg	Small number of patients	No	25.7% ROSC
									SHD
													8.6% SHD
Salen 2001	Prospective cohort	53	IHCA	0.0		0.0/100.0	Capnography	Initial (≥ 16)	SHA	ETCO2 ≥ 16 mmHg associated with survival to admission	Convenience sampling	No	11.3% SHA
											Small number of patients
Eckstein 2011	Retrospective cohort	3121	OHCA	16.9		NA	Capnography	Initial (≥ 10 and ≥ 20)	ROSC	ETCO2 ≥ 10 mmHg associated with ROSC (OR 4.79; 95% CI 3.10 to 4.42)c	Retrospective large study, but an unreliable OR is provided	No	22.4% ROSC
Asplin 1995	Prospective cohort	27	OHCA	48.2		NA	Capnography	1 and 2 min (No specific cut-off)	ROSC	Higher ETCO2 levels in ROSC vs. non-ROSC (23.0 vs. 13.2 at 1 min, 26.8 vs. 15.4 at 2 min)	Convenience sampling	No	51.9% ROSC
									SHD
											Small number of patients
													11.1% SHD
Grmec 2001	Prospective cohort	139	OHCA	40.3		51.8/7.9	Capnometry	Initial, final and average (≥ 10)	ROSC	ETCO2 ≥ 10 mmHg predicted ROSC (sensitivity 100.0% and specificity of 74.1%, 81.4%, and 90.0%, respectively for initial, average, and final ETCO2)	–	No	38.1% ROSC
									SHD
													16.6% SHD
Grmec 2003	Prospective cohort	185	OHCA	76.2		23.8b	Capnometry	Initial, final and average (≥ 10)	ROSC	Average and final ETCO2 higher in ROSC patients. Initial ETCO2 higher in ROSC patients only if cardiac origin	Includes data from Grmec 2001	No	64.3% ROSC
									SID
													24.3% SID
Grmec 2007	Prospective cohort	389	OHCA	40.1		40.9/19.0	Capnometry	Initial, final and average (≥ 10)	ROSC	Initial ETCO2 ≥ 10 mmHg associated with ROSC	Includes data from Grmec 2003	No	60.9% ROSC
									SHA
													50.1% SHA
									SHD
													21.1% SHD
Heradstveit 2012	Retrospective cohort	575	OHCA	34.4		46.3/19.3	Capnography	Average, minimum and maximum (No specific cut-off)	ROSC	ETCO2 higher in ROSC patients	Retrospective	No	49.7% ROSC
									SHA
													40.4% SHA
Kolar 2008	Retrospective cohort	737	OHCA	41.2		38.4/20.4	Capnometry	20 min (≥ 14.3)	ROSC	ETCO2 ≥ 14.3 mmHg predicted ROSC (sensitivity 100% and specificity 100%),	Retrospective Includes data from Grmec 2001, 2003, and 2007	No	59.4% ROSC
									SHA
													54.6% SHA
									SHD
													23.1% SHD
Lah 2011	Prospective cohort	114	OHCA	55.3		44.7b	Capnometry	Initial and every 1 min (No specific cut-off)	ROSC	Higher initial ETCO2 for those with ROSC if primary cardiac arrest (34.6 vs. 24.7 mmHg)	Comparison between asphyxial and cardiac origin of the arrest	No	63.2% ROSC
									SID
													52.6% SID
									SHD				29.8% SHD
Mauer 1998	Prospective cohort	120	OHCA	49.1		17.9/33.0	Capnometry	Initial and every 2 min (≥ 15.0)	ROSC	All admitted patients had an ETCO2 ≥ 15 mmHg	ETCO2 was a secondary endpoint	No	57.5% ROSC
									SHA
													27.5% SHA
									SHD
													10.8% SHD
Rognås 2014	Prospective cohort	271	OHCA	NA		NA	Capnography	Initial (≥ 10)	ROSC	4/22 patients with ETCO2 ≤ 10 mmHg had ROSC.	23% lacking measurements	No	4 of 22 patients (18.2%) had ROSC with ETCO2 ≤ 1.3 kPa
										No specific cut-off should be used during resuscitation

ETCO2, end-tidal CO2; NA, not available; IHCA, in-hospital cardiac arrest; OHCA, out-of-hospital cardiac arrest; OR, odds ratio; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; VF, ventricular fibrillation; VT, ventricular tachycardia; ROSC, return of spontaneous circulation; STFH, survival to twenty-four hours following cardiac arrest; SHA, survival to hospital admission; SID, survival to intensive care unit discharge; SHD, survival to hospital discharge.

Includes asystole, PEA, and 14% in supraventricular tachycardia with a pulse, after intubation and first ETCO2 measurement.

Includes asystole and PEA.

Upper limit of confidence interval lower than OR.

Table 2

Summary of findings: ETCO2 higher vs. ETCO2 lower than 10 or 20 mmHg for predicting outcome following cardiac arrest.

Quality assessment

No. of patients

Effect

Quality

Importance

No. of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

ETCO2higher

ETCO2lower

Relative (95% CI)

Absolute (95% CI)

ROSC (Initial ETCO2 ≥ 10 vs. < 10 mmHg)

3a,b,c

observational studies

seriousd

not serious

not serious

not serious

very strong association

80/134 (59.7%)

16/140 (11.4%)

OR 10.7 (5.6–20.3)

483 more per 1000 (from 326 more to 620 more)

LOW

CRITICAL

dose response gradient

ROSC (Initial ETCO2 ≥ 20 vs. < 20 mmHg)

2a,b

observational studies

seriousd,e

not serious

not serious

not serious

very strong association

34/42 (81.0%)

32/136 (23.5%)

OR 12.2 (5.1–29.2)

574 more per 1000 (from 406 more to 675 more)

LOW

CRITICAL

ROSC (20 min ETCO2 ≥ 10 vs. < 10 mmHg)

3a,f,g

observational studies

very seriousd,h

seriousi

not serious

not serious

very strong association

64/79 (81.0%)

1/215 (0.5%)

OR 181.6 (40.1–822.6)

805 more per 1000 (from 351 more to 966 more)

LOW

CRITICAL

all plausible residual confounding would reduce the demonstrated effect

ROSC (20 min ETCO2 ≥ 20 vs. < 20 mmHg)

1a

observational study

seriousd

not serious

not serious

not serious

very strong association

12/13 (92.3%)

2/41 (4.9%)

OR 234,0 (19.5–2811.4)

874 more per 1000 (from 451 more to 944 more)

LOW

CRITICAL

Survival at discharge (Initial ETCO2 ≥ 10 vs. < 10 mmHg)

1a

observational study

seriousd

not serious

not serious

not serious

very strong association

14/68 (20.6%)

1/45 (2.2%)

OR 11.4 (1.4–90.2)

184 more per 1000 (from 9 more to 650 more)

LOW

CRITICAL

Survival at discharge (Initial ETCO2 ≥ 20 vs. < 20 mmHg)

1a

observational study

seriousd

not serious

not serious

not serious

very strong association

12/34 (35.3%)

3/79 (3.8%)

OR 13.8 (3.6–53.4)

315 more per 1000 (from 86 more to 640 more)

LOW

CRITICAL

Survival at discharge (20 min ETCO2 ≥ 10 vs. < 10 mmHg)

1a

observational study

seriousd

not serious

not serious

seriousj

none

4/25 (16.0%)

1/28 (3.6%)

OR 5.1 (0.5–49.5)

123 more per 1000 (from 18 fewer to 611 more)

VERY LOW

CRITICAL

Survival at discharge (20 min ETCO2 ≥ 20 vs. < 20 mmHg)

1a

observational study

seriousd

not serious

not serious

not serious

very strong association

4/12 (33.3%)

1/41 (2.4%)

OR 20,0 (2.0–203.3)

309 more per 1000 (from 23 more to 811 more)

LOW

CRITICAL

All observational studies start with low quality ratings, and we have decided not to downgrade on risk of bias because of the very strong association between higher ETCO2 levels and ROSC or survival at discharge.

Ahrens [3].

Callaham [4].

Cantineau [5].

Convenience sampling, with 14% having already achieved ROSC.

Small number of patients.

Levine [7].

Wayne [6].

Includes data from previous study.

high heterogeneity (I2 = 78%).

Large confidence interval that crosses 1.0.

Experimental design, materials and methods

This review includes information on resuscitation questions developed through the 2015 Consensus on Science and Treatment Recommendations (CoSTR) development process, managed by the International Liaison Committee on Resuscitation (ILCOR) [19]. The questions were developed by ILCOR Task Force members, utilizing strict conflict of interest guidelines [20]. In general, each question was assigned to two experts to complete a detailed structured review of the literature, and complete a detailed evidence evaluation. Evidence evaluations are discussed at ILCOR meetings to reach consensus prior to publication as the Consensus on Science and Treatment Recommendations [19], [20], [21], [22].

Subject area	Cardiac arrest, clinical evidence
More specific subject area	The utility of end-tidal carbon dioxide measurement as it correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting.
Type of data	Table, Figures
How data was acquired	Review of primary articles pertaining to end-tidal carbon dioxide measurement as it correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting.
Data format	Analyzed data
Experimental factors	Description of the published literature on end-tidal carbon dioxide measurement as it correlates with return of spontaneous circulation (ROSC) or survival in adults experiencing cardiac arrest in any setting.
Experimental features	Systematic review
Data source location	Original English-language articles identified from search of Embase, MEDLINE, and Cochrane Databases.
Data accessibility	Data are available with this article