Igor Chęciński
1, Dorota Zyśko
1, Jacek Smereka
1, Jacek Gajek
2,
Janina Mirecka-Świerzko
3, Ryszard Ściborski
3, Marek Brodzki
1,
Paweł Wróblewski
1, Andrzej Czyrek
4, Anil K. Agrawal
5The Presence of Agonal Respiration During
Cardiac Arrest and Resuscitation Attempts by Witnesses
Obecność oddychania agonalnego a podejmowanie prób resuscytacji
przez przygodnych świadków zdarzenia
1 Teaching Department for the Emergency Medical Service, Wroclaw Medical University, Poland 2 Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
3 County Sanitary-Epidemiological Station, Olesnica, Poland 4 County Hospital, Olawa, Poland
5 2nd Department of General and Oncological Surgery, Wroclaw Medical University, Poland
Abstract
Background. Agonal respiration could be defined as a terminal pattern occurring due to anoxia or brain ischemia and is often seen in patients in the early phase of cardiac arrest.
Objective. To assess bystander CPR (cardio-pulmonary resuscitation) frequency in patients in cardiac arrest with and without agonal respirations and the influence of this phenomenon on clinical outcome.
Material and Methods. A retrospective study was conducted on EMS cardiac arrest medical records from one district in Poland with a resident population of 73,000 from January 1st, 2004 to December 31st, 2005.
Results. Sixty-six patients aged 65.4 ± 13 years were eligible for inclusion in the study. Bystander CPR was formed on 20 patients, 8 of them had agonal respiration assessed by the bystander. Bystander CPR was not per-formed on 46 patients and 15 of them had agonal respiration. Emergency medical service staff reported agonal respiration on arrival in 14 cases and 8 of them had had resuscitation attempts provided by bystanders. A stepwise logistic regression analysis revealed that survival to hospital admission is related to agonal respiration at the time emergency medical service staff arrival (OR-12.4 CI 2.4–63.4 p < 0.001).
Conclusions. The presence of agonal respiration during cardiac arrest is not related to rarer resuscitation attempts by witnesses. Agonal respiration and CPR attempts by laypersons may improve short-term clinical outcome (Adv Clin Exp Med 2011, 20, 6, 761–765).
Key words: agonal respiration, cardiac arrest, CPR.
Streszczenie
Wprowadzenie. Oddychanie agonalne występuje wtedy, kiedy dochodzi do niedotlenienia lub niedokrwienia mózgu i często jest stwierdzane u pacjentów z zatrzymaniem krążenia.
Cel pracy. Ocena, czy prowadzenie przez przygodnych świadków zdarzenia resuscytacji krążeniowo-oddechowej u pacjentów z zatrzymaniem krążenia wpływa na występowanie oddychania agonalnego oraz jakie to zjawisko ma znaczenie na krótkoterminowe przeżycie pacjentów.
Materiał i metody. Badanie miało charakter retrospektywny i polegało na analizie dokumentacji medycznej dotyczącej przypadków zatrzymania krążenia na obszarze działania Pogotowia Ratunkowego Podstacji w Oławie, który zamieszkuje 73 000 mieszkańców, od 1 stycznia 2004 r. do 31 grudnia 2005 r.
Wyniki. Do badania zakwalifikowano 66 pacjentów w wieku 65,4 ± 13,0 lat. Resuscytacja przez przygodnych świadków zdarzenia była podjęta u 20 pacjentów, z których u 8 występowało oddychanie agonalne stwierdzone przez tych świadków. Przygodni świadkowie zdarzenia nie podjęli resuscytacji u 46 pacjentów, z których 15 miało agonalne oddychanie. Członkowie zespołów ratownictwa medycznego stwierdzili występowanie oddychania
ago-Adv Clin Exp Med 2011, 20, 6, 761–765 ISSN 1230-025X
ORIGINAl PAPERS
nalnego u 14 osób, wśród nich u 8 pacjentów przygodni świadkowie zdarzenia prowadzili czynności resuscytacyjne. Krokowa regresja logistyczna pozwoliła na wykazanie, że przeżycie do czasu przyjęcia do szpitala było związane ze stwierdzeniem oddychania agonalnego przez członków zespołów ratownictwa medycznego: OR-12.4 CI 2.4–63.4 (p < 0.001).
Wnioski. Obecność oddychania agonalnego nie jest czynnikiem, który wpływa na podjęcie lub zaniechanie czynności resuscytacyjnych przez przygodnych świadków zdarzenia. Oddychanie agonalne i podjęcie przez przy-godnych świadków zdarzenia czynności resuscytacyjnych może poprawiać krótkoterminowe rokowanie (Adv Clin Exp Med 2011, 20, 6, 761–765).
Słowa kluczowe: oddychanie agonalne, zatrzymanie krążenia, CRP.
Agonal respiration could be defined as a termi-nal pattern occurring due to anoxia or brain isch-emia [1] and is often seen in patients (up to 55% or probably higher) in the early phase of cardiac ar-rest [2–5]. Agonal respiration is more frequent in ventricular fibrillation compared to other cardiac arrest rhythms [5]. It is often described as barely or occasionally breathing, occasional gasps, problem or irregular breathing, heavy or labored breath-ing, sighbreath-ing, noisy breathbreath-ing, gurglbreath-ing, moanbreath-ing, groaning or snorting [6]. Agonal breathing should not be mistaken for normal breathing and as a sign of life which could result in withholding or a delay in cardiopulmonary resuscitation attempts [2–4]. laypersons often inform dispatchers that victims are breathing although they are in cardiac arrest and present agonal gasps [2]. In mammals, respira-tory rhythm generation depends on the respirarespira-tory network, located in the preBötzinger complex in the brainstem which consists of two types of pace-maker neurons. Their bursting properties rely on the riluzole-sensitive persistent sodium current in the first type and in the second type they are sen-sitive to Cd2+ and flufenamic acid, a calcium-de-pendent nonspecific cationic current blocker [7]. Normoxia and hypoxia exert disparate effects on their activity and the pattern of respiration [8].
Agonal breathing is associated with important cardiorespiratory changes: improved pulmonary gas exchange, increased venous return to the heart, increased cardiac output, cardiac contractility, aor-tic pressure, and coronary perfusion pressure has an auto-resuscitative meaning in immature mam-mals and improves the outcome of cardiopulmo-nary resuscitation in mature mammals [1, 9]. The presence of agonal breathing suggests better brain stem oxygenation i.e. shorter duration of the cardi-ac arrest or its other primary mechanisms support-ing the circulation even minimally. On the other hand it may simulate vital signs and thus delay re-suscitation attempts. The ability of laypersons to recognize cardiac arrest when agonal respiration is present is believed to be low [5].
The aim of the study was to assess bystander cardio-pulmonary resuscitation (CPR) frequency in patients in cardiac arrest with and without
ago-nal respiration and the influence of its presence on clinical outcome assessed as hospital admission survival.
Material and Methods
A retrospective analysis of medical records from one Emergency Medical System call center responsible for one district (an area which in ad-ministration terms is a second level of the local government in Poland) with a resident population of 73,000. In the analyzed region, the EMS dis-patchers were instructed to encourage and support witnesses in performing CPR in cases of suspected cardiac arrest. The authors analyzed all medical records of the Emergency Medical Service from January 1st, 2004 to December 31st, 2005. Patients in cardiac arrest at presentation were identified and only victims in whom resuscitation efforts were started were included for further analysis. The patient’s age, sex, arrival time, bystander CPR, abnormal respiration as assessed by bystanders and the physician after EMS arrival, ECG rhythm, and survival to hospital admission were analyzed. Cardiac arrest was recognized by the EMS physi-cian according to European Resuscitation Council Guidelines for Resuscitation 2005 [10].
Statistical Analysis
The data was presented as a mean and respec-tive standard deviations for continuous variables and a number or percentages for categorical vari-ables. The differences between variables were as-sessed with a T-test, Mann-Whitney U-test or χ2 test as appropriate.
arrival and relevant CPR data and agonal respira-tion presence during the emergency call were also studied.
A P value less than 0.05 was considered sig-nificant.
Results
The authors identified 66 patients aged 64.5 ± 13 years who were eligible for inclusion in the study. The demographics and out-of-hospital characteristics are presented in Table 1. The me-dian of the time to the arrival was 6 minutes.
Bystander CPR was performed on 20 patients,
8 of them (40%) had agonal respiration assessed by the bystander. Bystander CPR was not performed in 46 patients and 15 of them had agonal respira-tion (33%). There was no associarespira-tion between the presence of agonal respiration and bystander CPR performance (p = ns).
A stepwise logistic analysis revealed that the only factor related to bystander CPR performance was the longer time from the emergency call to emergency medical service staff arrival on the scene. longer arrival times resulted in an increase in bystander CPR resuscitation (OR 3.01 CI 1.02– 9.4 p < 0.05).
Emergency medical service staff reported ago-nal respiration on arrival in 14 cases (8 cases with
Table 1. Patients and out-of-hospital cardiac arrest characteristics
Tabela 1. Charakterystyka pacjentów i pozaszpitalnego zatrzymania krążenia
Total (liczba pacjentów)
Bystander resuscitation attempts
(Podjęcie resuscytacji przez przygodnych świadków zdarzenia)
p Survived to hospital admission
(Przeżycie do czasu przy-bycia do szpitala)
p
n = 66 YES n = 20 NO n = 46 YES n = 29 NO n = 37
Age: mean ± SD
(Wiek: średnia ± SD) 64.5 ± 13.0 61.4 ± 11.9 65.9 ± 11.9 NS 65.5 ± 13.2 63.8 ± 12.9 Male gender – %
(Płeć męska – %) 70 80 65 NS 69 70 NS
Witnessed cardiac arrest – % (Zatrzymanie krążenia przy świad-kach – %)
82 90 78 NS 93 73 NS
Cardiac arrest at home – %
(Zatrzymanie krążenia w domu – %) 70 40 82 < 0.01 72 68 NS
Bystander resuscitation attempts – % (Podjęcie resuscytacji przez świad-ków zdarzenia – %)
30 100 0 41 22 NS
Agonal respiration assessed by wit-nesses – %
(Oddychanie agonalne w ocenie świadków zdarzenia – %)
35 40 33 NS 62 14 < 0.05
Agonal respiration assessed by EMS medical staff – %
(Oddychanie agonalne w ocenie zes-połu ratownictwa medycznego – %)
21 40 13 < 0.05 41 5 < 0.05
VF/PVT at presentation – % (VF/PVT w pierwszym badaniu EKG – %)
48 70 39 < 0.05 62 38 NS
Alive to hospital admission – % (Przeżycie do przyjęcia do szpitala – %)
44 63 40 < 0.05 100 0
Time to EMS arrival – min (Czas do przybycia zespołu ratow-nictwa medycznego – min)
7.1 ± 4.4 5.5 ± 4.9 7.8 ± 4.0 < 0.05 6.1 ± 3.4 7.9 ± 4.9 NS
CPR instituted and 6 not resuscitated by layper-sons). Agonal breathing during the emergency call and bystander CPR were related to agonal respira-tion presence at the time of medical staff arrival (p < 0.05).
A stepwise logistic regression analysis revealed that survival to hospital admission is related to ago-nal respiration at the time of emergency medical ser-vice staff arrival (OR-12.4 CI 2.4–63.4 p < 0.001).
Discussion
Agonal respiration is a frequent finding during cardiac arrest and its presence decreases with re-lapsing time. In this study, the frequency of agonal respiration reported by laypeople and recorded by dispatchers was 35%. This frequency is similar to that reported by others authors. Clark et al. and Bang et al. reported 40% and Vaillancourt et al. 37% incidence of agonal breathing during out-of- -hospital cardiac arrest [6, 11, 12]. A slightly lower incidence in present study may be the consequence of the study’s retrospective design, which could fa-vor underestimation of assessed events.
Agonal respiration may lead to the abandoning of resuscitation attempts by a bystander because of the conviction of life signs presence. This problem should be overcome by cardiac arrest recogni-tion by the dispatcher and bystander instrucrecogni-tion to perform CPR [4]. Perkins et al. demonstrated improved diagnostic accuracy and sensitivity of cardiac arrest recognition by giving instruction in recognizing agonal breathing [13].
In present study there was no difference be-tween the CPR frequency performed by bystand-ers in patients with and without agonal respiration. This finding indicates that other factors than ago-nal respiration played a role in undertaking resus-citation attempts. The possible factors would be:
the quality of dispatcher instructions and the phys-ical and psychologphys-ical ability of the layperson to perform CPR. The frequency of agonal breathing upon emergency medical staff arrival was higher in patients who received bystander CPR.
The role of cerebral blood flow maintenance in supporting agonal respiration confirms the ob-servation of the duration of agonal respiration in patients in whom, on their own request, ventilator support was removed. The cessation of mechanical ventilation in these patients with preserved cardiac function and untreatable progressive neurological conditions could lead to long-lasting (up to 40 mi-nutes) agonal respiration prior to terminal apnea [14].
Present study confirms the importance of resuscitation attempts provided by witnesses in order to prolong the period of agonal breathing, which in turn may lead to minimal respiratory and circulatory function. Correctly provided resus-citation prolongs the period of agonal breathing. The authors have found that patients with agonal respiration at presentation had better short-term survival rates than patients without agonal respira-tion, which is concordant with the results of other studies.
The presence of agonal respiration may in-dicate higher than critical oxygen delivery to the brainstem and confirms the good quality of CPR when it is maintained, but on the other hand it may be confusing for the rescuer when attempts to restore spontaneous circulation are ineffective but agonal respiration persists. In such circumstances, the decision to stop further resuscitation attempts is especially difficult.
The authors concluded that presence of agonal respiration during cardiac arrest is not related to rarer resuscitation attempts by witnesses. Agonal respiration and CPR attempts by laypersons may improve short-term clinical outcome.
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Address for correspondence:
Dorota Zyśko
Teaching Department for the Emergency Medical Service Wroclaw Medical University
Bartla 5 51-618 Wrocław Poland
Tel.: +48 600 125 283
Conflict of interest: None declared
