Mechanical chest compression versus manual chest compression for cardiopulmonary resuscitation for cardiac arrest patients: A systematic review and meta‐analysis

Conventional cardiopulmonary resuscitation (CPR) consisting of manual chest compressions with rescue breaths is inherently inefficient with respect to generating cardiac output. A variety of alternatives and adjuncts to conventional CPR have been developed, with the aim of enhancing perfusion during resuscitation from cardiac arrest. Since the publication of the 2010 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care (ECC),1 a number of clinical trials have provided additional data on the effectiveness of these alternatives and adjuncts. Compared with conventional CPR, many of these techniques and devices require specialized equipment and training. Some have only been tested in highly selected subgroups of cardiac arrest patients; this context must be considered when rescuers or healthcare systems are considering implementation. ### Methodology The recommendations in this 2015 AHA Guidelines Update for CPR and ECC are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the ILCOR 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 2,3 and was completed in February 2015.4,5 In this in-depth evidence review process, the ILCOR Advanced Life Support (ALS) Task Force examined topics and then generated a prioritized list of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,6 search strategies and criteria for inclusion and exclusion of articles were defined, and then a search for relevant articles was performed. The evidence was evaluated by the ILCOR ALS Task Force by using the standardized methodological approach proposed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group.7 The quality of the evidence was categorized based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and …

HomeCirculationVol. 122, No. 16_suppl_2Part 7: CPR Techniques and Devices Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 7: CPR Techniques and Devices2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Michael Shuster, Swee Han Lim, Charles D. Deakin, Monica E. Kleinman, Rudolph W. Koster, Laurie J. Morrison, Jerry P. Nolan, Michael R. Sayre, CPR Techniques and Devices Collaborators Syed Sameer Ali, David G. Beiser, Pierre Carli, Suzanne R. Davies, Michael Holzer, Taku Iwami, Mark S. Link, Jim McKendry, Paul M. Middleton, Peter T. Morley, Chika Nishiyama, Giuseppe Ristagno, Sten Rubertsson and Kjetil Sunde Michael ShusterMichael Shuster , Swee Han LimSwee Han Lim , Charles D. DeakinCharles D. Deakin , Monica E. KleinmanMonica E. Kleinman , Rudolph W. KosterRudolph W. Koster , Laurie J. MorrisonLaurie J. Morrison , Jerry P. NolanJerry P. Nolan , Michael R. SayreMichael R. Sayre , CPR Techniques and Devices Collaborators , Syed Sameer AliSyed Sameer Ali , David G. BeiserDavid G. Beiser , Pierre CarliPierre Carli , Suzanne R. DaviesSuzanne R. Davies , Michael HolzerMichael Holzer , Taku IwamiTaku Iwami , Mark S. LinkMark S. Link , Jim McKendryJim McKendry , Paul M. MiddletonPaul M. Middleton , Peter T. MorleyPeter T. Morley , Chika NishiyamaChika Nishiyama , Giuseppe RistagnoGiuseppe Ristagno , Sten RubertssonSten Rubertsson and Kjetil SundeKjetil Sunde Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.971036Circulation. 2010;122:S338–S344Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, "Open-Chest CPRALS-CPR&A-004A, ALS-CPR&A-004B"). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.The success of any cardiopulmonary resuscitation (CPR) technique or device depends on the education and training of the rescuers as well as on resources (including personnel). In the hands of some groups, novel techniques and adjuncts may produce better short- or long-term outcomes than standard CPR. However, a device or technique that provides good-quality CPR when used by a highly trained team or in a test setting may show poor quality and create frequent interruptions in CPR when used in an uncontrolled clinical setting.1While no circulatory adjunct is currently recommended instead of manual CPR for routine use, some circulatory adjuncts are being routinely used in both out-of-hospital and in-hospital resuscitation. If a circulatory adjunct is used, rescuers should be well trained and a program of continuous surveillance should be in place to ensure that use of the adjunct does not adversely affect survival.The following CPR techniques and devices were reviewed during the 2010 International Consensus Conference. It should be noted that interposed abdominal compression (IAC) has not been studied in humans since 1994 and active compression-decompression (ACD) has not been studied in humans since 2003. Therefore these techniques have not been evaluated against the international resuscitation guideline changes of 2000 and 2005 for IAC and 2005 for ACD.Interposed Abdominal Compression (IAC)-CPRALS/BLS-CPR&A-082AConsensus on ScienceTwo randomized controlled trials in in-hospital cardiac arrests, showed improved return of spontaneous circulation (ROSC) and survival to hospital discharge when IAC-CPR was compared with standard CPR (LOE 12; LOE 23). However, there were no differences in neurologically intact survival.One randomized controlled trial in out-of-hospital cardiac arrest was unable to show any consistent benefits when IAC-CPR was compared with standard CPR (LOE 2).4Evidence from LOE 35,6 and LOE 57 in-hospital studies suggested better or neutral8,9 hemodynamics with IAC-CPR compared with standard CPR.Treatment RecommendationThere is insufficient evidence to support or refute the use of IAC-CPR.Active Compression-Decompression (ACD)-CPRALS/BLS-CPR&A-084AConsensus on ScienceFive randomized controlled trials (LOE 1)10–14 and 3 controlled trials (LOE 2)15–17 failed to show a difference in ROSC or survival with use of ACD-CPR compared with standard CPR.Six studies (LOE 2)18–23 demonstrated improved ROSC or survival to hospital discharge although there were no statistically significant differences in neurologically intact survival.A meta-analysis14 of 2 trials (826 patients) comparing ACD-CPR with standard CPR after in-hospital cardiac arrest (IHCA) did not detect a significant increase in rates of immediate survival or survival to hospital discharge.Treatment RecommendationThere is insufficient evidence to support or refute the use of ACD-CPR.Open-Chest CPRALS-CPR&A-004A, ALS-CPR&A-004BConsensus on ScienceThere are no published randomized controlled trials and very limited data in humans comparing open-chest CPR to standard CPR in cardiac arrest. One retrospective clinical trial (LOE 3)24 demonstrated that ROSC was improved by open-chest CPR in out-of-hospital cardiac arrest. One case series in victims of out-of-hospital cardiac arrest who had failed standard CPR (LOE 4)25 reported ROSC in 13 of 33 highly selected patients; 2 survived to hospital discharge.Multiple animal studies (LOE 5)26–44 using a variety of endpoints demonstrated benefit with open-chest CPR.Treatment RecommendationThere is insufficient evidence to support or refute the routine use of open-chest CPR in cardiac arrest.Load Distributing Band (LDB)–CPRALS/BLS-CPR&A-086A, ALS/BLS-CPR&A-086BConsensus on ScienceOne multicenter RCT in over 1000 adults documented no improvement in 4-hour survival and significantly worse neurologic outcome when LDB-CPR administered by EMS providers was compared with traditional CPR for out-of-hospital cardiac arrest of presumed cardiac origin (LOE 1).45 However, a posthoc analysis of this study revealed significant heterogeneity among study sites (LOE 1).46In one LOE 3 study,47 the use of LDB-CPR was associated with lower odds of 30-day survival (OR 0.4). However, when a smaller (77-patient) subgroup of LDB-CPR-treated patients was analyzed against concurrent controls, an increased rate of ROSC was noted.47Other nonrandomized human series (LOE 3) have reported increased rates of sustained ROSC48,49 and increased survival to discharge49 following out-of-hospital cardiac arrest and improved hemodynamics following failed resuscitation from in-hospital cardiac arrest (LOE 4).50 In a prospective before-and-after study (LOE 3),51 the mean no-flow ratio with manual CPR was 0.28 in the first 5 minutes of CPR compared with 0.40 with LDB-CPR. However between 5 and 10 minutes, no-flow time was 0.34 with manual CPR and 0.21 with LDB-CPR.Evidence from both clinical (LOE 1)45,46 and simulation (LOE 5)52 studies suggested that site-specific factors may influence resuscitation quality and device efficacy.A case report documented successful performance of a computed tomography (CT) scan while LDB-CPR was used (LOE 4).53Treatment RecommendationThere are insufficient data to support or refute the routine use of LDB-CPR instead of manual CPR. It may be reasonable to consider LDB to maintain continuous chest compression while undergoing CT scan or similar diagnostic studies, when provision of manual CPR would be difficult.Mechanical (Piston) CPRALS/BLS-CPR&A-083A, ALS/BLS-CPR&A-083BConsensus on ScienceWhen a piston-CPR device was compared with manual CPR, one RCT documented no improvement in ROSC or survival among adults in cardiac arrest (LOE 1).54Supportive data from 1 prospective, randomized crossover-design study (LOE 1)55 and 1 paired-cohort study (LOE 2)56 documented that the use of a piston-CPR device improved hemodynamics during CPR in adult cardiac arrest victims.One prospective pseudorandomized trial documented improvement in hemodynamic variables during CPR in adult cardiac arrest victims but no improvement in ROSC or survival (LOE 2).57Data from 1 prospective cohort study comparing the use of a piston-CPR device with manual CPR documented that the use of a piston-CPR device increased interruption in CPR because time was required to set up and remove the device from patients during transportation in adult OHCA (LOE 2).58Treatment RecommendationThere is insufficient evidence to support or refute the use of piston-CPR instead of manual CPR for adult victims of cardiac arrest.Lund University Cardiac Arrest System (LUCAS) CPRALS/BLS-CPR&A-085A, ALS/BLS-CPR&A-085BConsensus on ScienceThere are no RCTs evaluating the LUCAS device in human cardiac arrest.One study using concurrent controls in witnessed out-of-hospital cardiac arrest was unable to show any benefit (ROSC, survival to hospital, or survival to hospital discharge) with the use of the LUCAS device over the use of standard CPR (LOE 2).59One postmortem study showed similar injuries with LUCAS-CPR and standard CPR (LOE 2).60Six case series involving approximately 200 patients have reported variable success in use of the LUCAS device when implemented after an unsuccessful period of manual CPR (LOE 4).61–66Three adult human case reports (LOE 4),62,67,68 3 adult human case series (LOE 4),63,66,69 and 1 animal study (LOE 5)68 reported that the use of a mechanical chest-compression device in cardiac arrest during percutaneous coronary intervention (PCI) maintained circulation and enabled the procedure to be completed. A small number of patients in the case series survived.Two case reports demonstrated that a CT scan could be performed during CPR with the LUCAS device (LOE 4).53Treatment RecommendationThere are insufficient data to support or refute the use of LUCAS-CPR instead of manual CPR. It may be reasonable to consider LUCAS-CPR to maintain continuous chest compression while undergoing CT scan or similar diagnostic studies, when provision of manual CPR would be difficult.Impedance Threshold Device (ITD)ALS/BLS-CPR&A-081A, ALS/BLS-CPR&A-081BConsensus on ScienceOne meta-analysis that pooled the data from both conventional CPR and ACD-CPR RCTs demonstrated improved ROSC and short-term survival but no significant improvement in either survival to discharge or neurologically intact survival to discharge associated with the use of an ITD in the management of adult OHCA patients (LOE 1).70One RCT suggested that the use of an ITD in combination with ACD-CPR improved 24-hour survival and survival to intensive care unit (ICU) admission in adult out-of-hospital cardiac arrest patients, compared with ACD-CPR and a sham ITD (LOE 1).71 This contrasts with another RCT that compared ITD plus ACD-CPR with ACD-CPR plus a sham ITD, which did not show significant improvement in ROSC or 24-hour survival with use of the ITD (LOE 1).72One RCT reported that the use of an ITD in combination with standard CPR did not significantly improve ROSC, 24-hour survival, or survival to ICU admission in adult out-of-hospital cardiac arrest, compared with CPR and a sham ITD (LOE 1).73One RCT comparing ACD-CPR plus ITD with CPR in adult out-of-hospital cardiac arrest showed improved ROSC and 24-hour survival rates associated with ACD-CPR plus ITD, but no significant improvement in rates of hospital discharge or intact neurologic survival to hospital discharge (LOE 1).74One prospective cohort study (with historical control) of CPR plus ITD versus CPR without ITD in out-of-hospital cardiac arrest reported improved survival to emergency department (ED) admission for patients presenting in any rhythm (LOE 3).75Three cohort studies comparing CPR using the 2005 AHA Guidelines for CPR and ECC plus ITD, with historic controls of CPR using the 2000 AHA Guidelines for CPR and ECC, demonstrated improved survival to hospital discharge in out-of-hospital cardiac arrest (LOE 3).76–78 It was not possible to determine the relative contribution of the ITD to the improved outcome.In a porcine model of cardiac arrest, 8 studies demonstrated improved hemodynamic variables during CPR with use of the ITD (LOE 5).79–86 An additional 3 animal studies (LOE 5)87–89 showed no difference in survival or in any hemodynamic variable, and 2 animal studies (LOE 5)88,90 reported evidence of decreased ROSC, 20-minute survival, and arterial oxygen saturation associated with the use of an ITD.Treatment RecommendationThere are insufficient data to support or refute the use of the ITD.AcknowledgmentsWe thank the following individuals (the CPR Techniques and Devices Collaborators) for their collaborations on the worksheets contained in this section: Syed Sameer Ali; David G. Beiser; Pierre Carli; Suzanne R. Davies; Michael Holzer; Taku Iwami; Mark S. Link; Jim McKendry; Paul M. Middleton; Peter T. Morley; Chika Nishiyama; Giuseppe Ristagno; Sten Rubertsson; and Kjetil Sunde.DisclosuresCoSTR Part 7: Writing Group DisclosuresWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers' Bureau/HonorariaOwnership InterestConsultant/Advisory BoardOtherMichael ShusterSelf-employed—emergency physicianNoneNoneNoneNoneNoneNoneSwee Han LimSingapore General Hosp. Tertiary Healthcare; Sr ConsultantNoneNoneNoneNoneNoneNoneCharles D. DeakinSouthampton University Hospital NHS Trust—DoctorNoneNoneNoneNoneNoneNoneMonica E. KleinmanChildren's Hospital Anesthesia Foundation: Non-profit health care organization—Senior Associate in Critical Care MedicineNoneNoneNoneNoneNoneNoneRudolph W. KosterAcademic Medical Center—clinical staff cardiologist*Zoll Medical for study of the safety of the Autopulse automated chest compression device. Funded to the hospital and limited to direct study costs without any personal financial consequence. Jolife for the study of the Lucas automated chest compression device. Money is funded to the hospital and limited to direct study costs without any personal financial consequence*Zoll Medical: two Autopulse devices on loan to the hospital for safety study Jolife: two Lucas devices on loan to the hospital for safety study Phillips: one MRX chest compression feedback device on loan to the hospital for safety study purposesNoneNoneNoneNoneLaurie J. MorrisonSt. Michael's Hospital; clinician scientist*Laerdal Foundation Centre Grant—infrastructure support without salary supportNoneNoneNoneNoneNoneJerry P. NolanRoyal United Hospital NHS Trust: Consultant in Anaesthesia and Critical CareNoneNoneNoneNoneNoneNoneMichael R. SayreThe Ohio State University—Associate ProfessorNoneNoneNoneNoneNoneNoneThis table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.*Modest.†Significant.CoSTR Part 7: Worksheet Collaborator DisclosuresWorksheet CollaboratorEmploymentResearch GrantOther Research SupportSpeakers' Bureau/HonorariaOwnership InterestConsultant/Advisory BoardOtherSyed Sameer AliPenn State Hershey Medical Center—Critical Care/Resuscitation FellowNoneNoneNoneNoneNoneNoneDavid G. BeiserUniv. of Chicago, Associate ProfessorNoneNoneNoneNoneNoneNonePierre CarliAssistance Publique Hopitaux de Paris; Professor and chairman SAMUNoneNoneNoneNoneNoneNoneSuzanne R. DaviesAmbulance Research Institute (Government body—Division of the Ambulance Service of New South Wales) Paramedic Research FellowNoneNoneNoneNoneNoneNoneMichael HolzerDepartment of Emergency Medicine, Medical University of Vienna—Specialist in Internal Medicine, Emergency PhysicianNoneNoneNoneNoneNoneNoneTaku IwamiKyoto University Assistant Professor†Laerdal Foundation—Getting research grant †Sanofi Aventis Getting donation for clinical research on emergency careNoneNoneNoneNoneNoneMark S. LinkTufts Medical Center Hospital PhysicianNoneNoneNoneNoneNoneNoneJim McKendryCity of Winnipeg Training InspectorNoneNoneNoneNoneNoneNonePaul M. MiddletonAmbulance Service of NSW: Publicly funded ambulance service—Senior Med. Advisor/Director of ResearchNoneNoneNoneNoneNoneNonePeter T. MorleyRoyal Melbourne Hosp; Univ of Melbourne; Director of Medical Education; AHA EEENoneNoneNoneNoneNoneNoneChika NishiyamaPostgraduate—RN, MPHNoneNoneNoneNoneNoneNoneGiuseppe RistagnoWeil Institute of Critical Care Medicine Assistant Professor Mario Negri Institute for Pharmacological Researches ResearcherNoneNoneNoneNoneNoneNoneSten RubertssonUppsala University—Professor at the Department of Surgical Sciences/Anesthesiology & Intensive Care*I am receiving money from Jolife AB, Lund, Sweden as a consult dealing with their device LUCAS-mechanical chest compressions. I am also a PI for 'the multi-center LINC trial which is a study of out-of-hospital CA victims allocated to either standard ACLS or ACLS including mechanical chest compressionsNoneNoneNone*Advisory board for Covidean regarding VAPNoneKjetil SundeOslo University Hospital Ulleval Professor and Senior ConsultantNoneNoneNoneNoneNoneNoneThis table represents the relationships of worksheet collaborators that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all worksheet collaborators are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.*Modest.†Significant.AppendixCoSTR Part 7: Worksheet AppendixTask ForceWS IDxPICO TitleShort TitleAuthorsURLALS/BLSALS/BLS-CPR&A-081AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of a ITD (I) compared with no ITD (C), improve any outcomes (eg. ROSC, survival) (O)?Impedance threshold deviceSuzanne R. Davies, Paul M. Middletonhttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-081A.pdfALS/BLSALS/BLS-CPR&A-081BIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of a ITD (I) compared with no ITD (C), improve any outcomes (eg. ROSC, survival) (O)?Impedance threshold deviceSyed Sameer Alihttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-081B.pdfALS/BLSALS/BLS-CPR&A-082AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of Interposed abdominal compressions-CPR (I) compared with standard CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Interposed abdominal compression CPRMichael Holzer, Kjetil Sundehttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-082A.pdfALS/BLSALS/BLS-CPR&A-083AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of a piston CPR device (eg. Thumper) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Piston (thumper) device CPRGiuseppe Ristagnohttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-083A.pdfALS/BLSALS/BLS-CPR&A-083BIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of a piston CPR device (eg. Thumper) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Piston (thumper) device CPRJim McKendryhttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-083B.pdfALS/BLSALS/BLS-CPR&A-084AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of manual ACD-CPR (I) compared with standard CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Active compression decompression device (ACD) CPRPierre Carlihttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-084A.pdfALS/BLSALS/BLS-CPR&A-085AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of mechanical compression full (eg. Lucas) or partial decompression (eg. US version) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Lucas device CPRPeter T. Morleyhttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-085A.pdfALS/BLSALS/BLS-CPR&A-085BIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of mechanical compression full (eg. Lucas) or partial decompression (eg. US version) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Lucas device CPRTaku Iwami, Chika Nishiyamahttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-085B.pdfALS/BLSALS/BLS-CPR&A-086AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of load distributing band (eg. Autopulse) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Autopulse device CPRPeter T. Morleyhttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-086A.pdfALS/BLSALS/BLS-CPR&A-086BIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of load distributing band (eg. Autopulse) (I) compared with manual CPR (C), improve any outcomes (eg. ROSC, survival) (O)?Autopulse device CPRDavid G. Beiserhttp://circ.ahajournals.org/site/C2010/ALS-BLS-CPR-A-086B.pdfALSALS-CPR&A-004AIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P) including traumatic arrest, does the use of open-chest CPR (I) compared with standard CPR (C), improve any outcomes (eg. ROSC, survival) (O).Open-chest CPRSten Rubertssonhttp://circ.ahajournals.org/site/C2010/ALS-CPR-A-004A.pdfALSALS-CPR&A-004BIn adult cardiac arrest (prehospital [OHCA], in-hospital [IHCA]) (P) including traumatic arrest, does the use of open-chest CPR (I) compared with standard CPR (C), improve any outcomes (eg. ROSC, survival) (O).Open-chest CPRMark S. Linkhttp://circ.ahajournals.org/site/C2010/ALS-CPR-A-004B.pdfFootnotesThe American Heart Association requests that this document be cited as follows: Shuster M, Lim SH, Deakin CD, Kleinman ME, Koster RW, Morrison LJ, Nolan JP, Sayre MR; on behalf of the CPR Techniques and Devices Collaborators. Part 7: CPR techniques and devices: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122(suppl 2):S338–S344.*Co-chairs and equal first co-authors.© 2010 American Heart Association, Inc., European Resuscitation Council, and International Liaison Committee on Resuscitation.

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Background Mechanical cardiopulmonary resuscitation (CPR) devices are currently recommended when high-quality CPR could not be provided and only if used by trained rescuers. Guidelines are against their routinely use since clinical trials results are controversial, and solid evidence of improved survival are missing. Moreover, many studies compared these devices to very high-quality manual CPR, hardly replicable in a pre-hospital emergency setting. Nowadays, different machines are available but literature is poor in direct comparison studies. Purpose To assess whether the type of mechanical chest compressor could affect the probability of return of spontaneous circulation (ROSC) and of 30-days mortality after an out-of-hospital cardiac arrest (OHCA) as compared to manual standard CPR. Methods Data were prospectively collected from our Utstein-based cardiac arrest registry. We considered all OHCAs from January 1, 2015 to December 31, 2022 from 7 provinces covered by the same regional emergency system (population covered 4.2mln. inhabitants) but equipped with three different types of mechanical compressor: Autopulse®; LUCAS® and Easy Pulse®. Patients treated with mechanical CPR and manual CPR were randomly matched via a multivariable logistic regression propensity score considering age, gender, witnessed OHCA, presence of bystander CPR, first rhythm recorded, EMS arrival time and lay defibrillation before EMS arrival. Logistic regression and COX regression models were performed and adjusted for resuscitation duration to investigate the association between the type of CPR and the probability of ROSC and of 30-day mortality. Results Among 13,203 OHCAs with attempted CPR, 10,497 (79.5%) received manual CPR and in 2,405 (18.2%) mechanical CPR [Easy Pulse® in 1,102(45.8%), Autopulse® in 776 (32.3%) and LUCAS® in 521 (21.7%)]. ROSC before hospital admission was obtained in 1,712 patients (13.0%) and 762 (5.8%) were alive after 30 days. After propensity score matching two homogeneous groups of 1,946 patients each (manual and mechanical CRP) were identified. The rate of ROSC and of 30-day survival were lower in the mechanical CPR group (ROSC: 14.7% vs 24.1%; p<0.001; 30-day survival 6% vs 14%; p<0.001). The three devices showed an independent association with the probability of ROSC as compared to manual CPR [Autopulse®: OR 1.76, 95% CI (1.36-2.28) p<0.001; LUCAS®:OR 1.55, 95% CI (1.13-2.13), p=0.006 and Easy Pulse®:OR 0.49; 95% CI (0.37-0.65), p<0.001] (Figure 1A). Only Autopulse® was independently associated with 30-day mortality [AutoPulse HR 0.87, 95%CI (0.79-0.97), p=0.01; LUCAS®: HR 1.00, 95%CI (0.88-1.14), p=0.97) and Easy Pulse®: HR: 1.06, 95%CI (0.97-1.16), p=0.19] (Figure 1B). Conclusions This is the first study comparing the performance of three devices for mechanical chest compressions revealing that they differently affect the probability of ROSC and of 30-day survival.

Background and Objectives: This study analyzed the prognostic impact of mechanical cardiopulmonary resuscitation (CPR) devices in out-of-hospital cardiac arrest (OHCA) patients, in comparison to manual CPR. Materials and Methods: This study was a nationwide population-based observational study in South Korea. Data were retrospectively collected from 142,905 OHCA patients using the South Korean Out-of-Hospital Cardiac Arrest Surveillance database. We included adult OHCA patients who received manual or mechanical CPR in the emergency room. The primary outcome was survival at discharge and the secondary outcome was sustained return of spontaneous circulation (ROSC). Statistical analysis included propensity score matching and multivariate logistic regression. Results: A total of 19,045 manual CPR and 1125 mechanical CPR cases (671 AutoPulseTM vs. 305 ThumperTM vs. 149 LUCASTM) were included. In the matched multivariate analyses, all mechanical CPR devices were associated with a lower ROSC than that of manual CPR. AutoPulseTM was associated with lower survival in the multivariate analysis after matching (aOR with 95% CI: 0.57 (0.33–0.96)), but the other mechanical CPR devices were associated with similar survival to discharge as that of manual CPR. Witnessed arrest was commonly associated with high ROSC, but the use of mechanical CPR devices and cardiac origin arrest were associated with low ROSC. Only target temperature management was the common predictor for high survival. Conclusions: The mechanical CPR devices largely led to similar survival to discharge as that of manual CPR in OHCA patients; however, the in-hospital use of the AutoPulseTM device for mechanical CPR may significantly lower survival compared to manual CPR.

The Comparison of Manual and Mechanical Chest Compression on Survival and Long-Term Neurological Outcome of Nontraumatic Out-of-Hospital Cardiac Arrest Patients.

Early use of mechanical cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) may improve survival outcomes. Current evidence for such devices uses outcomes from an intention-to-treat (ITT) perspective. We aimed to determine whether early use of mechanical CPR using a LUCAS 2 device results in better outcomes. A prospective, randomised, multicentre study was conducted over one year with LUCAS 2 devices in 14 ambulances and manual CPR in 32 ambulances to manage OHCA. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were survival at 24 hours, discharge from hospital and 30 days. Of the 1,274 patients recruited, 1,191 were eligible for analysis. 889 had manual CPR and 302 had LUCAS CPR. From an ITT perspective, outcomes for manual and LUCAS CPR were: ROSC 29.2% and 31.1% (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82-1.45; p = 0.537); 24-hour survival 11.2% and 13.2% (OR 1.20, 95% CI 0.81-1.78; p = 0.352); survival to discharge 3.6% and 4.3% (OR 1.20, 95% CI 0.62-2.33; p = 0.579); and 30-day survival 3.0% and 4.0% (OR 1.32, 95% CI 0.66-2.64; p = 0.430), respectively. By as-treated analysis, outcomes for manual, early LUCAS and late LUCAS CPR were: ROSC 28.0%, 36.9% and 24.5%; 24-hour survival 10.6%, 15.5% and 8.2%; survival to discharge 2.9%, 5.8% and 2.0%; and 30-day survival 2.4%, 5.8% and 0.0%, respectively. Adjusted OR for survival with early LUCAS vs. manual CPR was 1.47 after adjustment for other variables (p = 0.026). This study showed a survival benefit with LUCAS CPR as compared to manual CPR only, when the device was applied early on-site.

Introduction: Mechanical chest compression (MCC) provides consistent pressure and timing of each chest compression in line with latest evidenced-based practice. However, there has been no evidence from large randomized trials about the effectiveness of the mechanical device compared with manual chest compression. Furthermore, few studies focused on cardiogenic shock and cardiac arrest related to heart disease. Hypothesis: The aim is to assess the effectiveness and safety of mechanical chest compressions versus manual chest compressions in patients with out of hospital cardiogenic shock and cardiac arrest due to heart disease. Methods: We conducted a retrospective observational study of comparing the outcomes of mechanical and manual chest compressions. A total of 69 consecutive patients with out of hospital cardiogenic shock and cardiac arrest were enrolled between April 2014 and May 2018. 39 patients of them received only manual cardiopulmonary resuscitation (CPR) and 30 utilized a mechanical CPR device. Baseline characteristics, resuscitation details, and outcomes were compared between patients who received manual (manual group) and mechanical compressions (MCC group). Results: There was no significant difference in age, gender, the rate of bystander CPR and arterial blood gases at baseline. No differences were found for the rate of ROSC and 30-day survival between two groups. However, MCC group had significantly higher rate of bleeding events than manual group. In addition, fifty-four patients of them were treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Among patients underwent VA-ECMO, the rate of 30-day survival was significantly lower in MCC group. (Figure 1). Conclusions: This study showed that mechanical chest compression increased bleeding events than manual chest compression. Furthermore, in the patients underwent ECMO, the use of mechanical chest compression might be associated with higher mortality.

ObjectiveSeveral studies have examined the impact of mechanical cardiopulmonary resuscitation (CPR) devices among multi-jurisdictional emergency medical services (EMS) systems; however, the variability across such systems can inject bias and confounding variables. We focused our investigation on the effect of introducing the Lund University Cardiac Assist System 2 (LUCAS-2) into a single basic life support (BLS) fire department first response jurisdiction served by a single private advanced life support (ALS) agency, hypothesizing that the implementation of the device would increase prehospital return of spontaneous circulation (ROSC) rates as compared with manual CPR. MethodsA retrospective observational analysis of adult non-traumatic prehospital cardiac arrest ALS agency records was conducted. Descriptive statistics were computed, and logistic regression was used to assess the impact of CPR method, response time, age, gender, CPR initiator, witnessed status, automated external defibrillator (AED) initiator, and presence of an initial shockable rhythm on ROSC rates. A Chi-square analysis was used to compare ROSC rates among compression modalities both before and after the implementation of LUCAS-2 on July 1, 2011. ResultsFrom an initial dataset of 857 cardiac arrest records, only 264 (74 pre-LUCAS period, 190 LUCAS-2 period) met inclusion criteria for the primary objective. The ROSC rates were 29.7% (22/74) and 29.5% (56/190), respectively, for manual-only and LUCAS-assisted CPR (p=0.9673). Logistic regression revealed a significant association between ROSC and two of the independent variables: arrest witnessed (OR 3.104; 95% CI 1.896-5.081; p<0.0001) and initial rhythm shockable (OR 2.785; 95% CI 1.492-5.199; p<0.0013). ConclusionsAnalyses support the null hypothesis that there is no difference in prehospital ROSC rates among adult non-traumatic cardiac arrest patients when comparing mechanical-assisted and manual-only CPR. These results are consistent with other larger multi-jurisdictional mechanical CPR studies. Systems with limited personnel might consider augmenting their resuscitations with a mechanical CPR device, although cost and system design should be factored into the decision. Secondary analysis of independent variables suggests that prehospital cardiac arrest patients with a witnessed arrest or an initial rhythm that is shockable have a higher likelihood of attaining ROSC. The power of our primary objective was limited by the sample size. Additionally, we were not able to adequately assess the quality of CPR among the two comparison groups with a lack of consistent end-tidal carbon dioxide (EtCO2) data.

IntroductionOur goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).MethodsWe searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.ResultsA total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.ConclusionMechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

Introduction: Mechanical chest compression (MCC) provides consistent pressure and timing of each chest compression in line with latest evidenced-based practice. However, there has few evidence about the effectiveness of the mechanical device compared with manual chest compression. Furthermore, few studies focused on cardiogenic shock and cardiac arrest related to heart disease. Hypothesis: The aim in this study is to assess the effectiveness and safety of resuscitation strategies using MCC versus resuscitation strategies using standard manual chest compressions in patients with out of hospital cardiogenic shock and cardiac arrest due to heart disease. Methods: We conducted a retrospective observational study of comparing the outcomes of mechanical and manual chest compressions at our hospital. A total of 69 consecutive patients with out of hospital cardiogenic shock and cardiac arrest were enrolled between April 2014 and May 2018. 39 patients of them received only manual cardiopulmonary resuscitation (CPR) and 30 utilized a mechanical CPR device (LUCAS® Lund University Cardiac Arrest System, USA) during the resuscitation. Baseline characteristics, resuscitation details, and outcomes were compared between patients who received manual (manual group) and mechanical compressions (MCC group). Results: There was no significant difference in age, gender, the rate of bystander CPR, and arterial blood gases at baseline. No differences were found for the rate of ROSC and 30-day survival between two groups (manual group 42.8% vs MCC group 50.1% p=0.13). However, MCC group had significantly higher rate of bleeding events than manual group. In addition, fifty-four patients of them were treated for cardiac arrest or refractory cardiogenic shock with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Among patients underwent VA-ECMO, the rate of 30-day survival was significantly lower in MCC group. (manual group 26.8% vs MCC group 39.1% p=0.014). Conclusions: This study showed that mechanical chest compression in cardiac arrest and cardiogenic shock increased bleeding events than manual chest compression. Furthermore, in the patients underwent ECMO, the use of mechanical chest compression might be associated with higher mortality.

BackgroundThe aim of this paper was to conduct a systematic review of the published literatures comparing the use of mechanical chest compression device and manual chest compression during cardiac arrest (CA) with respect to short-term survival outcomes and neurological function.MethodsDatabases including MEDLINE, EMBASE, Web of Science and the ClinicalTrials.gov registry were systematically searched. Further references were gathered from cross-references from articles by handsearch. The inclusion criteria for this review must be human prospective controlled studies of adult CA. Random effects models were used to assess the risk ratios and 95 % confidence intervals for return of spontaneous circulation (ROSC), survival to admission and discharge, and neurological function.ResultsTwelve trials (9 out-of-hospital and 3 in-hospital studies), involving 11,162 participants, were included in the review. The results of this meta-analysis indicated no differences were found in Cerebral Performance Category (CPC) scores, survival to hospital admission and survival to discharge between manual cardiopulmonary resuscitation (CPR) and mechanical CPR for out-of-hospital CA (OHCA) patients. The data on achieving ROSC in both of in-hospital and out-of-hospital setting suggested poor application of the mechanical device (RR 0.71, [95 % CI, 0.53, 0.97] and 0.87 [95 % CI, 0.81, 0.94], respectively). OHCA patients receiving manual resuscitation were more likely to attain ROSC compared with load-distributing bands chest compression device (RR 0.88, [95 % CI, 0.80, 0.96]). The in-hospital studies suggested increased relative harm with mechanical compressions for ratio of survival to hospital discharge (RR 0.54, [95 % CI 0.29, 0.98]). However, the results were not statistically significant between different kinds of mechanical chest compression devices and manual resuscitation in survival to admission, discharge and CPC scores for OHCA patients and survival to discharge for in-hospital CA patients.ConclusionsThe ability to achieve ROSC with mechanical devise was inferior to manual chest compression during resuscitation. The use of mechanical chest compression cannot be recommended as a replacement for manual CPR, but rather a supplemental treatment in an overall strategy for treating CA patients.

Objective. To compare the LifeBelt (Deca-Medica, Inc., Columbus, OH), a novel cardiopulmonary resuscitation (CPR) device, with manual CPR on the outcome of neurologically intact survival in a porcine model of cardiac arrest. Methods. Twenty-two adolescent swine were randomized by permuted block design to resuscitation using LifeBelt (n = 12) or manual CPR (n = 10). The animals were instrumented with right atrial and aortic pressure catheters while they were under general anesthesia with isoflurane and nitrous oxide. Ventricular fibrillation (VF) was induced with a bipolar pacing catheter placed in the right ventricle. After 7 minutes of untreated VF, chest compressions with either LifeBelt or manual CPR were initiated along with standard Advanced Cardiac Life Support. Survivors were assigned a neurologic score using the neurologic deficit score and the cerebral performance category (CPC) score at 24, 48, and 72 hours following resuscitation by a veterinarian blinded to treatment allocation. Results. There were no significant differences in prearrest hemodynamic parameters or in important resuscitation variables between the groups. One of 12 of the LifeBelt animals failed to achieve return of spontaneous circulation (0.08, 95% confidence interval [CI] 0.002–0.38). The remaining 11 had a neurologic deficit score of 0 and a CPC score of 1, indicating normal neurologic function. All of the manual CPR animals survived. One of 10 manual CPR survivors (0.10, 95% CI 0.003–0.45) had a neurologic deficit score of 260 and a CPC score of 3, indicating moderate disability, while the remaining animals had a neurologic deficit score of 0 and a CPC score of 1. Conclusions. In this porcine model of cardiac arrest, we did not detect significant differences in neurologically intact survival between LifeBelt CPR and manual CPR.

The objective of this study was to conduct a meta-analysis of literature examining rates of return of spontaneous circulation from load-distributing band and piston-driven chest compression devices as compared with manual cardiopulmonary resuscitation. Searches were conducted in MEDLINE, the ClinicalTrials.gov registry, and bibliographies on manufacturer websites for studies written in English. Selection criteria for the meta-analysis required that studies must be human controlled (randomized, historical, or case-control) investigations with confirmed out-of-hospital cases. A total of 12 studies (load-distributing band cardiopulmonary resuscitation versus manual cardiopulmonary resuscitation = 8, piston-driven cardiopulmonary resuscitation versus manual cardiopulmonary resuscitation = 4), comprising a total of 6,538 subjects with 1,824 return of spontaneous circulation events, met the selection criteria. Random effects models were used to assess the relative effect of treatments on return of spontaneous circulation. Compared with manual cardiopulmonary resuscitation, load-distributing band cardiopulmonary resuscitation had significantly greater odds of return of spontaneous circulation (odds ratio, 1.62 [95% CI, 1.36, 1.92], p < 0.001). The treatment effect for piston-driven cardiopulmonary resuscitation was similar to manual cardiopulmonary resuscitation (odds ratio, 1.25 [95% CI, 0.92, 1.68];p = 0.151). The corresponding difference in percentages of return of spontaneous circulation rates from cardiopulmonary resuscitation was 8.3% for load-distributing band cardiopulmonary resuscitation and 5.2% for piston-driven cardiopulmonary resuscitation. Compared with manual cardiopulmonary resuscitation, combining both mechanical cardiopulmonary resuscitation devices produced a significant treatment effect in favor of higher odds of return of spontaneous circulation with mechanical cardiopulmonary resuscitation devices (odds ratio, 1.53 [95% CI, 1.32, 1.78], p < 0.001). The ability to achieve return of spontaneous circulation with mechanical chest compression devices is significantly improved when compared with manual chest compressions. In the case of load-distributing band cardiopulmonary resuscitation, it was superior to manual cardiopulmonary resuscitation as the odds of return of spontaneous circulation were over 1.6 times greater. The robustness of these findings should be tested in large randomized clinical trials.

Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. We searched the Cochrane Central Register of Controlled Studies (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, Science Citation abstracts, Biotechnology and Bioengineering abstracts and Clinicaltrials.gov in November 2009. No language restrictions were applied. Experts in the field of mechanical chest compression devices and manufacturers were contacted. We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions to manual chest compressions during CPR for patients with atraumatic cardiac arrest. Two authors (SCB and LJM) abstracted data independently. Disagreement between reviewers was resolved by consensus and a third author (BB) if consensus could not be reached. The methodologies of selected studies were evaluated for risk of bias by a single author (SCB). The primary outcome was survival to hospital discharge with good neurologic outcome. We used the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for relative risk with 95% confidence intervals. Four trials, including data from 868 patients, were included in the review. The overall quality of included studies was poor and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurologic function (as defined as a Cerebral Performance Category score of 1 or 2), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41 (95% CI 0.21- 0.79). Data from other studies included in this review were used to calculate relative risks for having a return of spontaneous circulation (2 studies, N = 51, pooled RR 2.81, 95% CI 0.96 to 8.22) and survival to hospital admission (1 study, N = 17, RR 4.13, 95% CI 0.19 to 88.71) in patients who received mechanical chest compressions versus those who received manual chest compressions. There is insufficient evidence from human RCTs to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest is associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac is not supported by this review. More RCTs that measure and account for CPR process in both arms are needed to clarify the potential benefit from this intervention.