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Hyperventilation in cardiac arrest—a systematic review and narrative synthesis

02 November 2023
Volume 15 · Issue 11



Resuscitation guidelines recommend delivering ventilations at a rate of 10 per minute. However, hyperventilation is commonly reported during out-of-hospital cardiac arrest resuscitation efforts, and the impact of this on patient outcomes is unclear. This review explores the reported rates, causes and patient outcomes of hyperventilation in the management of out-of-hospital cardiac arrest.


A systematic literature review with a narrative synthesis of three databases was carried out.


Thirteen papers met the eligibility criteria. These showed that ventilations were consistently delivered at a higher rate and tidal volume than are internationally recommended. Hyperventilation can occur because of clinician stress, a lack of situational awareness and a focus on other clinical interventions as well as poor leadership.


Hyperventilation is common during cardiac arrest management. Currently available human data do not produce sufficient evidence to favour any ventilation strategy; however, a harmful upper limit will exist. This review found no human randomised control studies examining how ventilation rate, tidal volume or pressure affect patient outcomes and this warrants further research.

There are around 30 000 cases of out-of-hospital cardiac arrest (OHCA) resuscitation in the UK each year (Hawkes et al, 2017). Resuscitation of patients in OHCA involves a combination of chest compressions, ventilation, defibrillation and drug administration. As part of advanced life support, the Resuscitation Council UK (RCUK) states that ventilations should be conducted at a rate of 10 per minute, and the RCUK's post-resuscitation care guidelines recommend varying the ventilation rates and volume to target a normal arterial partial pressure of carbon dioxide (PaCO2) of 4.5–6.0 kPa (Perkins et al, 2021a).

Typically, cardiac arrest results in combined respiratory and metabolic acidosis as pulmonary gas exchange ceases and cellular metabolism becomes anaerobic, resulting in cellular hypoxia and hypercapnia (Robba et al, 2020). This combination can reduce the effectiveness of drugs given to restart the heart, reduce the oxygen-carrying capacity of haemoglobin owing to its displacement by carbon dioxide, reduce myocardial contractility and cause myocardial irritability, therefore reducing the likelihood of sustaining a return of spontaneous circulation (ROSC) (Association of Ambulance Chief Executives, 2022).

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