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August 15, 2010. Harnessing the Intrathoracic Pump Mechanisms to Enhance Circulation . Keith Lurie MD Professor of Emergency Medicine and Internal Medicine University of Minnesota Chief Medical Officer Advanced Circulatory Systems. Index Case 1987 Saved by a Household Plunger

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Presentation Transcript
slide1

August 15, 2010

Harnessing the Intrathoracic Pump

Mechanisms to Enhance Circulation

Keith Lurie MD

Professor of Emergency Medicine and Internal Medicine

University of Minnesota

Chief Medical Officer

Advanced Circulatory Systems

slide2

Index Case

1987

Saved by a

Household Plunger

San Francisco

General Hospital

intrathoracic pressure regulation therapy
Intrathoracic Pressure Regulation Therapy

ResQPOD:

for CPR

CirQlator:

for hypotension

in apneic pts

ResQGARD:

for hypotension

in spontaneously

breathing pts

All 3 devices cleared by FDA for clinical use

effect of inspiratory impedance during cpr on airway pressures
Effect of Inspiratory Impedance During CPR on Airway Pressures

1. Lowers intrathoracic pressure

2. Mimics gasping reflex

3. Lowers ICP

4. Refills the heart

5. Doubles circulation

Conventional or ACD CPR

with ITD

Conventional CPR

Enhanced Vacuum

effect of inspiratory impedance during spontaneous respiration
Effect of Inspiratory Impedance During Spontaneous Respiration

1. Lowers intrathoracic pressure

2. Lowers ICP

3. Refills the heart

4. Increases cerebral and systemic circulation

5. Harnesses the sympathetic nervous system

6. Mimics stress response to central hypovolemia

  • Intrathoracic Pressure

.

effect of intrathoracic pressure regulators
Effect of Intrathoracic Pressure Regulators

1. Lowers intrathoracic pressure

2. Lowers ICP

3. Refills the heart

4. Increases cerebral and

systemic circulation

or

active compression decompression cpr
Active Compression Decompression CPR

Metronome

Force Gauge

Suction Cup

Handle

slide8

Randomized Clinical Trial (Paris, France)

Survival After Cardiac Arrest

40

STD (n = 377)

35

ACD (n = 373)

30

25

20

15

Percent

*

*Statistically

significant

10

*

5

0

ICU

Hosp

Disch

1 Hr

24 Hr

1 Yr

ROSC

Admit

Plaisance P et al. Standard CPR and ACD resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 1999;341:569-75.

slide9
An impedance threshold device (ITD) selectively prevents unnecessary air from entering the chest during the recoil (decompression) phase of CPR
human data blood pressure
Human Data: Blood Pressure

Milwaukee, WI

*

*p<0.05

BP after 14 Minutes of ITD Use

n = 22

Pirrallo et al. Resuscitation 2005;66:13-20.

slide12

A Tale of Six EMS Systems: An Impedance Threshold Device and ‘New CPR’ Improves Survival Rates after Out-of-hospital Cardiac ArrestAufderheide et al Heart Journal 2010

acd cpr itd in humans the future

120

100

STD CPR

80

mmHg

60

ACD + ITD

40

20

0

Systolic

Diastolic

ACD CPR + ITD in HumansThe Future

Baseline

(Normal)

Plaisance et al. Circulation 2000;101:989-994

witnessed vf not resuscitated with 3 initial shocks n 70

ACD CPR + ITD in Humans

Witnessed VF not resuscitated with 3 initial shocks (n = 70)

Wolcke et al. Circulation 2003;108:2201-05.

*

*

*

*

Percentage

*

*p<0.05

inspiratory impedance effect

↑ Preload

↑ Coronary Artery Perfusion

↑ Blood Flow

to Vital Organs

↑ Cardiac Output

Greater Intrathoracic Vacuum

 Intracranial Pressure

 Resistance to Forward Blood Flow

 Cerebral Blood Flow

Inspiratory Impedance Effect

Inspiration through the ITD-7

clinical experience with hypotensive patients
Emergency Room

EMS

NASA Astronauts

Orthostatic Hypotension

Dialysis

Clinical Experience with Hypotensive Patients
benefit in patients n 10 with no iv
Benefit in Patients (n=10) with no IV

10 pts from Toledo and Minneapolis studies combined: P<0.01

Smith et al

J. Emerg Med 2010

effect of itpr on tracheal pressure and icp in apneic pigs
Effect of ITPR on Tracheal Pressure and ICP in Apneic Pigs

ITPR Application

Tracheal Pressure

1min

ITPR

ICP

cirqlator human studies
CirQlator™ Human Studies

Ventilation Source

ITPR

Bacterial Filter

ET Tube

Vacuum Source

clinical experience u of va dr ed nemergut asa 2010
Clinical Experience U of VA(Dr. Ed Nemergut ASA 2010)

Neuro ICU (n=10):

To date there has been a consistent decrease in ICP from ~ 20 mmHg to 15 mmHg and an increase in cerebral perfusion pressure

combined results icp
Combined Results: ICP

21 %

33 %

27 %

17 %

Device 1

Device 2

Baseline 2 4 6 8 10 Baseline 2 4 6 8 10

the future
The Future

Feedback control loops to regulate intrathoracic pressure (positive and negative pressures, tidal volume, ventilation rate) to optimize cerebral and systemic circulation

thank you
Thank you

Questions?