ANNALS OF EMERGENCY MEDICINE
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2013
Systematic Review Snapshot TAKE-HOME MESSAGE There is no clear benefit from active compression-decompression cardiopulmonary resuscitation (CPR) in out-of-hospital or inhospital cardiac arrest. METHODS DATA SOURCES MEDLINE, EMBASE, and the Cochrane Library were searched on January 14, 2013. References of relevant articles were searched for additional studies. Expert contact and a review of ClinicalTrials.gov were also conducted. STUDY SELECTION All randomized or quasirandomized trials comparing active compression-decompression with standard manual chest compression in adult patients with cardiac arrest who received CPR by a trained medical or paramedical team. DATA EXTRACTION AND SYNTHESIS Data were extracted on an intention-to-treat basis by 2 investigators, who assessed quality of study methodology and risk of bias. Pooled relative risk was calculated for each outcome. Two predefined subgroup analyses examined cardiac arrest setting and resuscitation team leadership.
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Does Active Chest Compression-Decompression Cardiopulmonary Resuscitation Decrease Mortality, Neurologic Impairment, or Cardiopulmonary Resuscitation–Related Complications After Cardiac Arrest? EBEM Commentator
Joshua C. Reynolds, MD, MS Department of Emergency Medicine Michigan State University College of Human Medicine Grand Rapids, MI
Results Selected results of pooled individual patient data. Outcome Measures Out-of-hospital cardiac arrest Mortality at hospital discharge Neurologic impairment* Inhospital cardiac arrest Mortality at hospital discharge Neurologic impairment*
Studies, n
Participants, n
RR (95% CI)
9 5
3,412 385
0.99 (0.98–1.01) 1.74 (1.06–2.83)
2 2
826 279
1.00 (0.95–1.05) 1.19 (0.63–2.25)
RR, Relative risk; CI, confidence interval. *Neurologic impairment was defined as any cerebral performance category score greater than 1 (5-point scale; 1¼good cerebral performance; 5¼brain death).
The search identified 231 potential studies, of which 10 met inclusion criteria: 8 were in out-of-hospital settings, 1 was inhospital, and 1 had both inhospital and out-of-hospital components. Most trials excluded witnessed arrests, pregnant women, trauma victims, and victims of hypothermia or intoxication; a few trials additionally excluded primary respiratory arrest, drowning, airway obstruction, and recent sternotomy. In
all trials, responders were trained in active compression-decompression CPR. Response times and epinephrine dosing did not differ between groups in any trial. Allocation concealment was adequate in 4 studies, but no study was blinded to the intervention, given the inherent use of the active compressiondecompression device. Pooled relative risks of morality at hospital discharge and neurologic Annals of Emergency Medicine 1
Systematic Review Snapshot impairment for patients with out-ofhospital (n3,412) and inhospital (n826) cardiac arrest are presented in the Table. There were also no differences in return of spontaneous circulation or CPR-related complications (eg, sternal and rib fracture, hemothorax or pneumothorax, internal organ damage). Further subgroup analyses of physician-led versus paramedic-led response teams in the out-of-hospital cardiac arrest setting did not reveal any significant difference in any outcome. All results were unchanged when the best-quality or largest studies were selectively pooled in sensitivity analyses.
Commentary Active compression-decompression CPR uses a handheld device with a suction cup to perform closed-chest cardiac massage. The operator applies a device to the midsternum to compress the chest and then uses the same device to actively decompress the chest after each compression. This differs from traditional manual CPR, in which the chest is allowed to passively recoil. Active compressiondecompression CPR was originally designed to augment the pump action of closed-chest cardiac massage. Preclinical work demonstrated increased venous return and left ventricular filling in the active decompression phase, leading to increased stroke volume,1 cardiac output,2 and systemic arterial pressure3 in the compression phase. The improved hemodynamic profile associated with active compression-decompression CPR was expected to reduce mortality or neurologic insult in victims of cardiac arrest. Indeed, initial small studies demonstrated promising results,4,5 but
2 Annals of Emergency Medicine
larger randomized trials have not lived up to these expectations. The results of this Cochrane review differ from those of a previous metaanalysis; Mauer et al6 found a significant reduction in immediate mortality (odds ratio 0.83; 95% confidence interval 0.70 to 0.99). This Cochrane review has since included 3 additional studies consisting of 1,296 additional subjects. These 3 trials all demonstrated negative results for active compressiondecompression CPR. Several studies report difficulty in applying active compression-decompression CPR in clinical settings, rescuer fatigue after several minutes of active compressiondecompression CPR, and nonadherence of the device to the chest wall, which could limit its effectiveness. Additional efforts to combine an active compression-decompression CPR device with another device to further increase negative intrathoracic pressure (impedance threshold device) are under way. Although neither device appears to be beneficial in isolation,7 one trial combining the 2 devices found a small but significant increase in neurologically favorable survival to hospital discharge (9% versus 6%; odds ratio 1.58; 95% confidence interval 1.07 to 2.36; P¼.02) among patients with a presumed cardiac cause of cardiac arrest.8 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2013;(9):CD002751. http://dx.doi.org/10. 1002/14651858.CD002751.pub3.
1. Tucker KJ, Redberg RF, Schiller NB, et al. Active compression-decompression resuscitation: analysis of transmitral flow and left ventricular volume by transesophageal echocardiography in humans. Cardiopulmonary Resuscitation Working Group. J Am Coll Cardiol. 1993;22:1485-1493. 2. Orliaguet GA, Carli PA, Rozenberg A, et al. End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: comparison of active compressiondecompression and standard CPR. Ann Emerg Med. 1995;25:48-51. 3. Shultz JJ, Coffeen P, Sweeney M, et al. Evaluation of standard and active compression-decompression CPR in an acute human model of ventricular fibrillation. Circulation. 1994;89:684-693. 4. Cohen TJ, Goldner BG, Maccaro PC, et al. A comparison of active compressiondecompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital. N Engl J Med. 1993;329: 1918-1921. 5. Tucker KJ, Galli F, Savitt MA, et al. Active compression-decompression resuscitation: effect on resuscitation success after inhospital cardiac arrest. J Am Coll Cardiol. 1994;24:201-209. 6. Mauer DK, Nolan J, Plaisance P, et al. Effect of active compression-decompression resuscitation (ACD-CPR) on survival: a combined analysis using individual patient data. Resuscitation. 1999;41:249-256. 7. Aufderheide TP, Nichol G, Rea TD, et al; Resuscitation Outcomes Consortium (ROC) Investigators. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011;365: 798-806. 8. Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compressiondecompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011;377:301-311.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
Volume
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no.
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2013
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2013
Systematic Review Snapshot TAKE-HOME MESSAGE There is no clear benefit from active compression-decompression cardiopulmonary resuscitation (CPR) in out-of-hospital or inhospital cardiac arrest. METHODS DATA SOURCES MEDLINE, EMBASE, and the Cochrane Library were searched on January 14, 2013. References of relevant articles were searched for additional studies. Expert contact and a review of ClinicalTrials.gov were also conducted. STUDY SELECTION All randomized or quasirandomized trials comparing active compression-decompression with standard manual chest compression in adult patients with cardiac arrest who received CPR by a trained medical or paramedical team. DATA EXTRACTION AND SYNTHESIS Data were extracted on an intention-to-treat basis by 2 investigators, who assessed quality of study methodology and risk of bias. Pooled relative risk was calculated for each outcome. Two predefined subgroup analyses examined cardiac arrest setting and resuscitation team leadership.
Volume
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no.
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:
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2013
Does Active Chest Compression-Decompression Cardiopulmonary Resuscitation Decrease Mortality, Neurologic Impairment, or Cardiopulmonary Resuscitation–Related Complications After Cardiac Arrest? EBEM Commentator
Joshua C. Reynolds, MD, MS Department of Emergency Medicine Michigan State University College of Human Medicine Grand Rapids, MI
Results Selected results of pooled individual patient data. Outcome Measures Out-of-hospital cardiac arrest Mortality at hospital discharge Neurologic impairment* Inhospital cardiac arrest Mortality at hospital discharge Neurologic impairment*
Studies, n
Participants, n
RR (95% CI)
9 5
3,412 385
0.99 (0.98–1.01) 1.74 (1.06–2.83)
2 2
826 279
1.00 (0.95–1.05) 1.19 (0.63–2.25)
RR, Relative risk; CI, confidence interval. *Neurologic impairment was defined as any cerebral performance category score greater than 1 (5-point scale; 1¼good cerebral performance; 5¼brain death).
The search identified 231 potential studies, of which 10 met inclusion criteria: 8 were in out-of-hospital settings, 1 was inhospital, and 1 had both inhospital and out-of-hospital components. Most trials excluded witnessed arrests, pregnant women, trauma victims, and victims of hypothermia or intoxication; a few trials additionally excluded primary respiratory arrest, drowning, airway obstruction, and recent sternotomy. In
all trials, responders were trained in active compression-decompression CPR. Response times and epinephrine dosing did not differ between groups in any trial. Allocation concealment was adequate in 4 studies, but no study was blinded to the intervention, given the inherent use of the active compressiondecompression device. Pooled relative risks of morality at hospital discharge and neurologic Annals of Emergency Medicine 1
Systematic Review Snapshot impairment for patients with out-ofhospital (n3,412) and inhospital (n826) cardiac arrest are presented in the Table. There were also no differences in return of spontaneous circulation or CPR-related complications (eg, sternal and rib fracture, hemothorax or pneumothorax, internal organ damage). Further subgroup analyses of physician-led versus paramedic-led response teams in the out-of-hospital cardiac arrest setting did not reveal any significant difference in any outcome. All results were unchanged when the best-quality or largest studies were selectively pooled in sensitivity analyses.
Commentary Active compression-decompression CPR uses a handheld device with a suction cup to perform closed-chest cardiac massage. The operator applies a device to the midsternum to compress the chest and then uses the same device to actively decompress the chest after each compression. This differs from traditional manual CPR, in which the chest is allowed to passively recoil. Active compressiondecompression CPR was originally designed to augment the pump action of closed-chest cardiac massage. Preclinical work demonstrated increased venous return and left ventricular filling in the active decompression phase, leading to increased stroke volume,1 cardiac output,2 and systemic arterial pressure3 in the compression phase. The improved hemodynamic profile associated with active compression-decompression CPR was expected to reduce mortality or neurologic insult in victims of cardiac arrest. Indeed, initial small studies demonstrated promising results,4,5 but
2 Annals of Emergency Medicine
larger randomized trials have not lived up to these expectations. The results of this Cochrane review differ from those of a previous metaanalysis; Mauer et al6 found a significant reduction in immediate mortality (odds ratio 0.83; 95% confidence interval 0.70 to 0.99). This Cochrane review has since included 3 additional studies consisting of 1,296 additional subjects. These 3 trials all demonstrated negative results for active compressiondecompression CPR. Several studies report difficulty in applying active compression-decompression CPR in clinical settings, rescuer fatigue after several minutes of active compressiondecompression CPR, and nonadherence of the device to the chest wall, which could limit its effectiveness. Additional efforts to combine an active compression-decompression CPR device with another device to further increase negative intrathoracic pressure (impedance threshold device) are under way. Although neither device appears to be beneficial in isolation,7 one trial combining the 2 devices found a small but significant increase in neurologically favorable survival to hospital discharge (9% versus 6%; odds ratio 1.58; 95% confidence interval 1.07 to 2.36; P¼.02) among patients with a presumed cardiac cause of cardiac arrest.8 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2013;(9):CD002751. http://dx.doi.org/10. 1002/14651858.CD002751.pub3.
1. Tucker KJ, Redberg RF, Schiller NB, et al. Active compression-decompression resuscitation: analysis of transmitral flow and left ventricular volume by transesophageal echocardiography in humans. Cardiopulmonary Resuscitation Working Group. J Am Coll Cardiol. 1993;22:1485-1493. 2. Orliaguet GA, Carli PA, Rozenberg A, et al. End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: comparison of active compressiondecompression and standard CPR. Ann Emerg Med. 1995;25:48-51. 3. Shultz JJ, Coffeen P, Sweeney M, et al. Evaluation of standard and active compression-decompression CPR in an acute human model of ventricular fibrillation. Circulation. 1994;89:684-693. 4. Cohen TJ, Goldner BG, Maccaro PC, et al. A comparison of active compressiondecompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital. N Engl J Med. 1993;329: 1918-1921. 5. Tucker KJ, Galli F, Savitt MA, et al. Active compression-decompression resuscitation: effect on resuscitation success after inhospital cardiac arrest. J Am Coll Cardiol. 1994;24:201-209. 6. Mauer DK, Nolan J, Plaisance P, et al. Effect of active compression-decompression resuscitation (ACD-CPR) on survival: a combined analysis using individual patient data. Resuscitation. 1999;41:249-256. 7. Aufderheide TP, Nichol G, Rea TD, et al; Resuscitation Outcomes Consortium (ROC) Investigators. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011;365: 798-806. 8. Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compressiondecompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011;377:301-311.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
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