Fast or Slow Rescue Ventilations: A Predictive Model of Gastric Inflation

BACKGROUND: Rescue ventilations are given during respiratory and cardiac arrest. Tidal volume must assure oxygen delivery; however, excessive pressure applied to an unprotected airway can cause gastric inflation, regurgitation, and pulmonary aspiration. The optimal technique provides mouth pressure and breath duration that minimize gastric inflation. It remains unclear if breath delivery should be fast or slow, and how inflation time affects the division of gas flow between the lungs and esophagus.

METHODS: A physiological model was used to predict and compare rates of gastric inflation and to determine ideal ventilation duration. Gas flow equations were based on standard pulmonary physiology. Gastric inflation was assumed to occur whenever mouth pressure exceeded lower esophageal sphincter pressure. Mouth pressure profiles that approximated mouth-to-mouth ventilation and bag-valve-mask ventilation were investigated. Target tidal volumes were set to 0.6 and 1.0 L. Compliance and airway resistance were varied.

RESULTS: Rapid breaths shorter than 1 s required high mouth pressures, up to 25 cm H₂O to achieve the target lung volume, which thus promotes gastric inflation. Slow breaths longer than 1 s permitted lower mouth pressures but increased time over which airway pressure exceeded lower esophageal sphincter pressure. The gastric volume increased with breath durations that exceeded 1 s for both mouth pressure profiles. Breath duration of ∼1.0 s caused the least gastric inflation in most scenarios. Very low esophageal sphincter pressure favored a shift toward 0.5 s. High resistance and low compliance each increased gastric inflation and altered ideal breath times.

CONCLUSIONS: The model illustrated a general theory of optimal rescue ventilation. Breath duration with an unprotected airway should be 1 s to minimize gastric inflation. Short pressure-driven and long duration-driven gastric inflation regimens provide a unifying explanation for results in past studies.