ABC | Volume 114, Nº6, June 2020

Statement Guimarães et al. Position Statement: Cardiopulmonary Resuscitation of Patients with Confirmed or Suspected COVID-19 – 2020 Arq Bras Cardiol. 2020; 114(6):1078-1087 ○ Positive end-expiratory pressure (PEEP): zero. ○ Alarms: set tidal volume alarms to the minimum and maximum allowed by the ventilator and pressure alarms to 60 cmH 2 O (maximum) and 1 or 0 cmH 2 O (minimum). The high and low minute volume alarms should be set to the maximum and minimum allowed by the device. The respiratory rate alarm should be set to the maximum allowed by the device, and the apnea time, to 60 seconds. • The exact same parameters apply in children; Continuously assess whether the ventilator can maintain these parameters without auto-triggering, which leads to hyperventilation and air trapping with excessive pressures (systematically above 60 cm H 2 O). In children, temporary disconnection from the ventilator may be necessary; in this case, BVM ventilation with a HEPA filter should be performed; • Some ventilators provide a “CPR mode” function, which automatically adjusts the alarm limits and ventilator parameters as described above. For mechanically ventilated patients, it is recommended that a HEPA filter be placed in the ventilation circuit after the orotracheal tube and a second filter at the expiratory circuit; 16,20,21 • To minimize aerosol generation, the tube should be clamped with a strong straight hemostat whenever there is a need to switch ventilator circuits (BVM to mechanical ventilator circuit, for instance); • For the safety of the team and the patient, adhesive pads (which do not require disconnection from the ventilator) should always be preferred for defibrillation. If manual (paddle) defibrillation is needed, the ventilator should be placed in standby mode and the orotracheal tube disconnected from the ventilator, keeping the HEPA filter attached to the tube, only after the shock has been delivered. 7. Chest Compressions • High-quality chest compressions should be performed, ensuring: ○ A compression rate of 100 to 120 compressions per minute. ○ In adults, a compression depth of at least 5 cm (compressions deeper than 6 cm should be avoided). ○ In infants, compression depth should be one-third of the anteroposterior diameter of the chest; in children, it should be one-third of the anteroposterior diameter of the chest or at least 5 cm. • Allow full recoil of chest after each compression; do not lean on the patient’s chest; •Minimize interruptions in chest compressions; pauses should be limited to 10 seconds at most (for two breaths). Consider performing CPR with the goal of the highest possible chest compression fraction, aiming at a minimum of 60% to 80%; • Rotate out with another team member every 2 minutes to avoid rescuer fatigue, which can lead to poor compressions; • If the patient is in the supine position, compressions should be performed in the center of the chest, on the lower half of the breastbone (sternum); • Considering the need for PPE use to limit the risk of aerosol generation, the strenuous nature of resuscitation maneuvers, the potential for rescuer fatigue and exhaustion, and the need to minimize the number of team members present during resuscitation, use of a mechanical chest compression device is advised for adults whenever one is available. 8. Cardiopulmonary Resuscitation in the Prone Position • If the patient is in prone position with no invasive airway in place, he or she should be quickly repositioned supine, CPR should be initiated, and an invasive airway device should be placed as soon as possible, preferably by orotracheal intubation; • If the patient is already intubated and ventilated, it is recommended that CPR maneuvers be initiated with the patient still in prone position. The surface landmark for hand placement is the exact posterior projection of the site for chest compressions, i.e., in the interscapular region, at the T7-T10 level (Figure 4). Attempts to de-prone (i.e., return the patient to the supine position) should be performed with maximum care to avoid ventilator disconnection and minimize the risk of aerosolization. If adhesive defibrillator pads are available, they should be placed in an anteroposterior arrangement; 10,22,23 Chart 1 – Mechanical ventilator settings for cardiopulmonary resuscitation. Volume assist-control ventilation mode; VT = 6 mL/kg PBW Respiratory rate = 10 bpm FiO2 = 100% Flow trigger = disabled or sensitivity threshold -15 to -20 PEEP = 0 VT alarms = maximum and minimum allowed by device Pressure alarms = 60 cmH 2 O maximum, 1 or 0 cmH 2 O minimum High and low minute volume alarms = maximum and minimum allowed by device Apnea time = 60 seconds FiO 2 : fraction of inspired oxygen; PBW: predicted body weight; PEEP: positive end-expiratory pressure; VT: tidal volume. Source: Personal collection. Figure 4 – Hand placement for compressions on a patient in the prone position. 23 1083