Mechanical Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest.

Abstract

HomeJournal of the American Heart AssociationAhead of PrintMechanical Cardiopulmonary Resuscitation During In‐Hospital Cardiac Arrest Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBMechanical Cardiopulmonary Resuscitation During In‐Hospital Cardiac Arrest Oscar J. L. Mitchell, MD, MSCE, Xinyi Shi, Benjamin S. Abella, MD, MPhil and Saket Girotra, MD, SM Oscar J. L. MitchellOscar J. L. Mitchell *Correspondence to: Oscar J. L. Mitchell, MD, MSCE, Division of Pulmonary, Allergy and Critical Care Hospital of the University of Pennsylvania 3400 Spruce Street, Philadelphia, PA 19104. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-5331-5562 , Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, , University of Pennsylvania, , Philadelphia, , PA, , USA, , Department of Emergency Medicine, Center for Resuscitation Science, , Philadelphia, , PA, , USA, , Leonard Davis Institute of Health Economics, University of Pennsylvania, , Philadelphia, , PA, , USA, Search for more papers by this author , Xinyi ShiXinyi Shi , Department of Emergency Medicine, Center for Resuscitation Science, , Philadelphia, , PA, , USA, Search for more papers by this author , Benjamin S. AbellaBenjamin S. Abella https://orcid.org/0000-0003-2521-0891 , Department of Emergency Medicine, Center for Resuscitation Science, , Philadelphia, , PA, , USA, Search for more papers by this author and Saket GirotraSaket Girotra https://orcid.org/0000-0002-4784-4513 , Division of Cardiovascular Medicine, Department of Internal Medicine, , University of Texas Southwestern Medical Center, , Dallas, , TX, , USA, Search for more papers by this author Originally published21 Mar 2023https://doi.org/10.1161/JAHA.122.027726Journal of the American Heart Association. 2023;0:e027726In‐hospital cardiac arrest (IHCA) strikes ≈300 000 hospitalized patients every year in the United States alone.1 High‐quality cardiopulmonary resuscitation (CPR) is a critical component of IHCA resuscitation care and is associated with higher rates of survival and reduced neurocognitive disability. As such, optimizing the quality of CPR during IHCA is a key priority emphasized in scientific statements from the American Heart Association and international cardiac arrest guidelines.2, 3 Despite these educational efforts, studies have shown that CPR quality during IHCA remains suboptimal, likely because of a range of factors including rescuer fatigue during prolonged resuscitation; interruptions in CPR during defibrillation, intubation, and other intra‐arrest interventions; and inadequate depth and rate of chest compressions.4, 5In contrast to conventional delivery of manual CPR, mechanical CPR devices represent a potentially appealing alternative as they can provide uninterrupted chest compressions at appropriate rate and depth and are not limited by human performance variability and fatigue. During prolonged resuscitation efforts, these devices can free team members for other tasks and potentially reduce room crowding. Currently available devices include the Lund University Cardiopulmonary Assist System (LUCAS, Stryker Medical, Kalamazoo, MI), the Autopulse (ZOLL Medical Corporation, Chelmsford, MA), and the Thumper (Michigan Instruments, Grand Rapids, MI). These devices use a piston, band, or vest to externally compress the thoracic cavity.6 However, the use of these devices is not without disadvantages, including the need to pause CPR for device deployment and a risk of traumatic injuries from the devices themselves. The majority of high‐quality studies comparing mechanical CPR to manual CPR have been performed in the setting of out‐of‐hospital cardiac arrest (OHCA) and have not found a benefit of mechanical CPR over manual CPR.7, 8, 9 The data comparing the effectiveness of mechanical CPR devices in IHCA are much more limited (Table 1).10, 11 In the absence of robust clinical trial data, members of hospital cardiac arrest committees must weigh the risks, benefits, and costs of whether, how, and when to integrate these technologies into their IHCA response. Given these data, the American Heart Association states that “the use of mechanical CPR devices by trained personnel may be beneficial in settings where reliable, high‐quality manual compressions are not possible or may cause risk to personnel,” but the guidelines do not give specific consideration for the use of mechanical CPR during IHCA.2 In this Perspective, we present a summary of current data on the use of mechanical CPR during IHCA to inform these decisions.Table 1. Summary of Three Randomized Controlled Trials of Mechanical Cardiopulmonary Resuscitation Use in In‐Hospital Cardiac ArrestAuthorYearDesignInterventionDeviceNumber of casesPrimary outcomeResultsCouper2021Multicenter, feasibility RCT3:1 Randomization mechanical vs manual CPRLund University Cardiopulmonary Assist System127 patients with IHCAProportion of eligible participants who were successfully randomized55% of eligible participants recruited.No difference when comparing rates of ROSC, survival to discharge, or survival with a good neurological outcome at 6 mo.Halperin1993Single‐center RCT1:1 Randomization mechanical vs manual CPRThoracic‐vest system34 patients with IHCAROSCROSC rate higher in mechanical vs manual CPR (47% vs 18%).Taylor1978Single‐center RCT1:1 Randomization mechanical vs manual CPRPiston‐driven CPR device30 patients with IHCA1‐hour survivalNo difference in 1‐hour survival between mechanical vs manual CPR (38% vs 42%)CPR indicates cardiopulmonary resuscitation; IHCA, in‐hospital cardiac arrest; RCT, randomized controlled trial; and ROSC, return of spontaneous circulation12, 13, 14Studies Comparing Survival After IHCA With Mechanical CPR Versus Conventional CPRFew studies have focused on barriers to high‐quality CPR during IHCA, where impediments are likely to differ substantially from those seen during OHCA. In addition to differences in the patient populations who experience IHCA compared with OHCA, the provider response to IHCA also differs considerably. Given the resources available in the hospital setting, CPR is typically started earlier than in OHCA, prolonged CPR by a single individual is unusual, and survival rates are often higher than in OHCA. Given these differences, the results from studies of mechanical CPR during OHCA may not be generalizable to cardiac arrests occurring in the in‐hospital environment.Few randomized controlled trials (RCTs) have examined whether mechanical CPR has a survival benefit over conventional manual CPR during IHCA. Most of these trials failed to demonstrate superiority of mechanical CPR over conventional CPR, consistent with OHCA trials of mechanical CPR. The most robust of these was COMPRESS‐RCT, an RCT that randomized 127 patients in a 3:1 ratio to mechanical CPR versus conventional CPR.12 Although mortality was not the primary outcome, no difference was found between mechanical CPR and conventional CPR when comparing rates of teturn of spontaneous circulation (ROSC; 28% versus 25%), survival to hospital discharge (4% versus 4%), or survival with a good neurological outcome at 6 months (1.0% versus 0%).12 However, this study was limited by low survival in both arms and lower‐than‐expected recruitment. There are 2 published prior RCTs of mechanical CPR use in IHCA, which served as preliminary efficacy studies describing novel mechanical CPR devices.13, 14 Neither of these trials found a difference in survival between mechanical CPR or manual CPR, although one study found that the use of mechanical CPR was associated with higher rates of ROSC and survival at 1 hour. However, no patients in this trial survived to hospital discharge.13, 14 Another RCT, performed by Lu and colleagues, enrolled only patients who experienced cardiac arrest in the emergency department and as such represented a very specific arrest population.10, 11, 15 Several observational studies have also been published comparing patients with IHCA who received mechanical CPR and those who received conventional CPR. However, these observational studies should be interpreted with caution because of the high risk of bias, particularly from confounding by indication as the responding providers may be unlikely to start mechanical CPR in cases of IHCA that they deem to be futile, and additional confounding from immortal time bias as patients who receive mechanical CPR have not attained ROSC by the time the responding team members apply mechanical CPR devices. Therefore, current evidence does not support routine use of mechanical CPR for all in‐hospital resuscitation events.Potential Benefits of Mechanical CPR During IHCA in Special SituationsIn‐hospital cardiac arrest teams can become large owing to the need to circulate compressors. Use of a mechanical CPR device can, in theory, allow for members of the team to leave the room, potentially requiring fewer individuals to be present during resuscitation efforts. This may be an important factor in settings where human resources might be limited. The issue of crowding became particularly relevant during the COVID‐19 pandemic, where viral aerosolization during CPR was a central concern during IHCA events. As such, many hospital systems acquired mechanical CPR devices during the pandemic to reduce exposure of health care workers.16IHCA During Cardiac ProceduresCardiac arrest can sometimes occur as a complication during cardiac catheterization procedures. The underlying cause of arrest in these situations could be acute myocardial infarction or a complication of the procedure itself (eg, coronary artery dissection), both of which require rapid intervention. Therefore, high‐quality resuscitative measures (CPR and defibrillation) need to be combined with immediate efforts to reestablish coronary blood flow (eg, angioplasty and stenting of the infarct related artery). Given these dual objectives, providing high‐quality CPR during a cardiac catheterization procedure can be especially challenging. Moreover, limited space around the fluoroscopy unit and radiation exposure also creates barriers for effective CPR. Mechanical CPR devices are attractive in this setting as they avoid radiation exposure to the team members and can ensure ongoing CPR while the underlying cause of the arrest can be promptly addressed.17 Several mechanical CPR devices have been designed to be partially radiolucent to facilitate such interventions.18 In recent years, there has been growing enthusiasm for extracorporeal membrane oxygenation (ECMO) for use in refractory cardiac arrest, largely based on the positive findings from the advanced reperfusion strategies for patients with out‐of‐hospital cardiac arrest and refractory ventricular fibrillation (ARREST) trial.19 Resuscitation in the ARREST trial was facilitated with the use of the Lund University Cardiopulmonary Assist System device to provide continuous CPR during prolonged transport and ECMO cannulation. Although the potential for ECMO as a strategy for refractory IHCA remains unclear, mechanical CPR devices could play an adjunctive role similar to OHCA, in selected patients considered for ECMO for refractory IHCA while the ECMO team is mobilized.Potential Risks of Mechanical CPRDelays in CPR for Device ApplicationThe use of mechanical CPR in IHCA does not come without risks. The time required to apply mechanical CPR devices can lead to delays in initiation of CPR during the early phase of cardiac arrest when the likelihood of achieving ROSC may be greatest. Prolonged pauses could potentially have a substantial impact on the likelihood of achieving ROSC but are not widely reported in the published literature. In the setting of RCTs, relatively short deployment times have been reported, highlighting that delays can be minimized with appropriate training. For example, in the COMPRESS‐RCT, the mean pause durations for backplate and upper portion deployment were 7.3 seconds and 9.8 seconds respectively, which highlights the importance of ongoing training of resuscitation teams in the use of mechanical CPR devices when such devices are used as a standard part of IHCA resuscitation practice.12Injuries From Mechanical CPRSeveral studies have demonstrated traumatic injuries associated with the use of mechanical CPR, which range from relatively benign injuries to life‐threatening or fatal ones. Such injuries are commonly caused by CPR, whether manual or mechanical and include fractures of ribs and sternum as well as damage to organs such as the liver, heart, and lungs. A recent meta‐analysis suggested that mechanical CPR may be associated with an increased risk of rib fractures as well as heart and liver injuries.20 Such injuries may be caused by poor placement or migration of the device during resuscitation. The risks of CPR pauses and injuries may be mitigated by ongoing high‐quality training of cardiac arrest teams in the correct use of mechanical CPR devices, although whether such training reduces such complications has not been rigorously studied.The efficacy of mechanical CPR for IHCA remains incompletely understood. Several knowledge gaps remain that, when answered, might help to clarify the population who should receive mechanical CPR, where in the hospital it should be used, and how best to implement a mechanical CPR program. Some of these are highlighted in Table 2.Table 2. Examples of Key Knowledge Gaps in the Use of Mechanical CPR During IHCA EventsKnowledge gapExample questionsWhich populations might benefit the most from mechanical CPR?Do outcomes from mechanical CPR use in IHCA differ between different inpatient settings or cardiac arrest rhythms? (eg, cardiac arrest in procedural settings, emergency department)Does use of mechanical CPR improve success of interventional procedures such as extracorporeal membrane oxygenation cannulation or coronary catheterization?Does deployment of mechanical CPR earlier during a resuscitation lead to better outcomes compared with manual CPR?Is mechanical CPR more useful in situations with limited human resources?High‐quality mechanical CPRWho should apply the mechanical CPR device?At what point during the resuscitation effort should the device be applied?Can the efficacy and safety of mechanical CPR devices be improved with simulation training or pit‐crew model of IHCA?IHCA dynamicsDoes use of mechanical CPR during IHCA improve team dynamics, communication, coordination, and leadership?Does use of mechanical CPR affect postevent attitudes of the resuscitation team?Implementation of mechanical CPRWhat barriers and facilitators exist to the implementation of mechanical CPR in the inpatient setting?Is mechanical CPR cost effective?CPR indicates cardiopulmonary resuscitation; and IHCA, in‐hospital cardiac arrest.ConclusionOptimizing the quality of CPR remains a crucial factor to improve survival rates from IHCA. Although an this is an attractive solution, studies have not demonstrated the superiority of mechanical CPR compared with conventional CPR during IHCA. Although use of these devices may have a place in specific resuscitation scenarios, the current evidence does not support a strategy for routine use of mechanical CPR devices for in‐hospital resuscitation. More research is needed to establish how the balance of risks and benefits of mechanical CPR use differs in IHCA when compared with OHCA.Sources of FundingDr. Girotra is currently supported the National Heart, Lung, and Blood Institute (R56HL158803, R01HL160734).DisclosuresDr Abella holds equity and research funding from VOC Health, a company developing novel COVID testing. He also holds research funding and has received speaking honoraria from Zoll and Becton Dickinson. For the remaining authors, no conflicts of interest were declared. Dr Girotra has received funding from the American Heart Association for editorial work.Footnotes*Correspondence to: Oscar J. L. Mitchell, MD, MSCE, Division of Pulmonary, Allergy and Critical Care Hospital of the University of Pennsylvania 3400 Spruce Street, Philadelphia, PA 19104. Email: oscar.[email protected]upenn.eduThis manuscript was sent to Daniel Edmundowicz, MD, Guest Editor, for review by expert referees, editorial decision, and final disposition.For Sources of Funding and Disclosures, see page 4.References1 Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval‐Arnould J, Grossestreuer AV, Yankama T, Donnino MW, Andersen LW. American Heart Association's get with the guidelines‐resuscitation I. Annual incidence of adult and pediatric In‐hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019; 12:e005580.LinkGoogle Scholar2 Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation.2020; 142:S366–S468. doi: 10.1161/CIR.0000000000000916LinkGoogle Scholar3 Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation.2013; 128:417–435. doi: 10.1161/CIR.0b013e31829d8654LinkGoogle Scholar4 Soar J, Edelson DP, Perkins GD. Delivering high‐quality cardiopulmonary resuscitation in‐hospital. Curr Opin in Crit Care.2011; 17:225–230. doi: 10.1097/MCC.0b013e3283468b5cCrossrefMedlineGoogle Scholar5 Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O'Hearn N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resuscitation during In‐hospital cardiac arrest. JAMA.2005; 293:305–310. doi: 10.1001/jama.293.3.305CrossrefMedlineGoogle Scholar6 Timerman S, Cardoso LF, Ramires JAF, Halperin H. Improved hemodynamic performance with a novel chest compression device during treatment of in‐hospital cardiac arrest. Resuscitation.2004; 61:273–280. doi: 10.1016/j.resuscitation.2004.01.025CrossrefMedlineGoogle Scholar7 Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out‐of‐hospital cardiac arrest: the LINC randomized trial. JAMA.2014; 311:53–61. doi: 10.1001/jama.2013.282538CrossrefMedlineGoogle Scholar8 Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, Lamb SE, Slowther A‐M, Woollard M, Carson A, et al. Mechanical versus manual chest compression for out‐of‐hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet.2015; 385:947–955. doi: 10.1016/S0140-6736(14)61886-9CrossrefMedlineGoogle Scholar9 Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN, Van Ottingham L, Olsufka M, Pennington S, White LJ, et al. Manual chest compression vs use of an automated chest compression device during resuscitation following out‐of‐hospital cardiac arrest: a randomized trial. JAMA.2006; 295:2620–2628. doi: 10.1001/jama.295.22.2620CrossrefMedlineGoogle Scholar10 Poole K, Couper K, Smyth MA, Yeung J, Perkins GD. Mechanical CPR: Who? When? How?Critical Care.2018; 22:140. doi: 10.1186/s13054-018-2059-0CrossrefMedlineGoogle Scholar11 Couper K, Yeung J, Nicholson T, Quinn T, Lall R, Perkins GD. Mechanical chest compression devices at in‐hospital cardiac arrest: a systematic review and meta‐analysis. Resuscitation.2016; 103:24–31. doi: 10.1016/j.resuscitation.2016.03.004CrossrefMedlineGoogle Scholar12 Couper K, Quinn T, Booth K, Lall R, Devrell A, Orriss B, Regan S, Yeung J, Perkins GD. Mechanical versus manual chest compressions in the treatment of in‐hospital cardiac arrest patients in a non‐shockable rhythm: a multi‐centre feasibility randomised controlled trial (COMPRESS‐RCT). Resuscitation.2021; 158:228–235. doi: 10.1016/j.resuscitation.2020.09.033CrossrefMedlineGoogle Scholar13 Halperin HR, Tsitlik JE, Gelfand M, Weisfeldt ML, Gruben KG, Levin HR, Rayburn BK, Chandra NC, Scott CJ, Kreps BJ. A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest. N Engl J Med.1993; 329:762–768. doi: 10.1056/NEJM199309093291104CrossrefMedlineGoogle Scholar14 Taylor GJ, Rubin R, Tucker M, Greene L, Rudikoff MT, Weifeldt ML. External cardiac compression: a randomized comparison of mechanical and manual techniques. JAMA.1978; 240:644–646. doi: 10.1001/jama.1978.03290070046013CrossrefMedlineGoogle Scholar15 Lu XG, Kang X, Gong DB. The clinical efficacy of thumper modal 1007 cardiopulmonary resuscitation: a prospective randomized control trial. Chinese Crit Care Med.2010; 22:496–497.Google Scholar16 Mitchell OJL, Doran O, Yuriditsky E, Root C, Teran F, Ma K, Shashaty M, Moskowitz A, Horowitz J, Abella BS. Rapid response system adaptations at 40 US hospitals during the COVID‐19 pandemic. Resuscitation Plus.2021; 6:100121. doi: 10.1016/j.resplu.2021.100121CrossrefMedlineGoogle Scholar17 Wagner H, Terkelsen CJ, Friberg H, Harnek J, Kern K, Lassen JF, Olivecrona GK. Cardiac arrest in the catheterisation laboratory: a 5‐year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts. Resuscitation.2010; 81:383–387. doi: 10.1016/j.resuscitation.2009.11.006CrossrefMedlineGoogle Scholar18 Remino C, Baronio M, Pellegrini N, Aggogeri F, Adamini R. Automatic and manual devices for cardiopulmonary resuscitation: a review. Adv Mech Eng.2018; 10:1687814017748749. doi: 10.1177/1687814017748749CrossrefGoogle Scholar19 Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, et al. Advanced reperfusion strategies for patients with out‐of‐hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open‐label, randomised controlled trial. Lancet.2020; 396:1807–1816. doi: 10.1016/S0140-6736(20)32338-2CrossrefMedlineGoogle Scholar20 Gao Y, Sun T, Yuan D, Liang H, Wan Y, Yuan B, Zhu C, Li Y, Yu Y. Safety of mechanical and manual chest compressions in cardiac arrest patients: a systematic review and meta‐analysis. Resuscitation.2021; 169:124–135. doi: 10.1016/j.resuscitation.2021.10.028CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics Copyright © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.122.027726PMID: 36942764 Originally publishedMarch 21, 2023 Keywordscardiopulmonary resuscitationmechanical CPRin‐hospital cardiac arrestcardiac arrestPDF download SubjectsCardiopulmonary ArrestCardiopulmonary Resuscitation and Emergency Cardiac CareQuality and Outcomes