Clinical paperMechanical active compression-decompression versus standard mechanical cardiopulmonary resuscitation: A randomised haemodynamic out-of-hospital cardiac arrest study
Introduction
During cardiopulmonary resuscitation with active compression-decompression (ACD-CPR) the chest wall is actively lifted with a suction cup between compressions. This creates lower intrathoracic pressures in the decompression phase and improves cardiac output, via increased venous return, and perfusion to heart and brain tissue.1., 2. Clinical studies on manually-administered ACD-CPR have shown equal or improved end tidal carbon dioxide (EtCO2) and survival results.3., 4., 5., 6., 7., 8., 9. However, a Cochrane group suggested that the physical demands required to achieve effective ACD-CPR “may hinder in real practice the theoretical advantages of ACD-CPR over manual compressions”.8., 10.
A mechanical ACD-CPR device could overcome the issues with provider exhaustion.11., 12. In a porcine study Steinberg et al. used a modified piston-based device to compare standard mechanical CPR to mechanical ACD-CPR.13 They found that mechanical ACD-CPR improved cardiac output and cerebral blood flow, with a trend towards improved coronary perfusion pressures, despite similar capnometric readings.1., 13. While they used a 20 mm active decompression (AD) height above the sternal resting position, the optimal methods of delivering AD during ACD-CPR are not well defined in humans.14., 15.
We hypothesised that mechanical ACD-CPR (Intervention) with a device providing AD height up to 30 mm, would improve multi-modal haemodynamic measurements and provide a similar safety profile compared to standard mechanical piston-based CPR (Control) (both devices; Stryker, Lund, Sweden).
Section snippets
Study design and setting
This trial was prospective, cluster-randomised and un-blinded. All included patients were treated by the rapid response car (RRC) crew, covering an area of 822 km2 with 878,139 inhabitants. The RRC is manned 24/7 by an anaesthetist and a critical care paramedic, in the tiered response system of the emergency medical service (EMS) of Oslo and Akershus (Oslo University Hospital, Division of Prehospital Services, Norway).
Inclusion and exclusion
The RRC-crew identified inclusion and exclusion criteria and initiated the
Results
Between April 2015 and April 2017, the RRC-crew attended 722 of the 943 OHCA patients in the region. Of these, 221 met the inclusion criteria and were treated with either the Control or the Intervention device, while 501 did not met the inclusion criteria due to ROSC or CPR stopped due to futility. Eleven patients were subsequently excluded, leaving 210 in the intention to treat (ITT) groups: Control 109 and Intervention 101 (Fig. 1).
Main findings
This is the first clinical trial of mechanical ACD-CPR. In 210 patients with OHCA, the haemodynamic measures and clinical outcomes were not significantly different between the Control and Intervention groups. No difference in injuries was found. Not all Intervention patients received Complete AD, and this may have affected overall results. An exploratory analysis found that, within the Intervention group, Complete AD provided significantly higher SctO2 and CBPpeak and lower pMTCO2 and DBPnadir
Conclusions
This first study of mechanical ACD-CPR found no overall difference in haemodynamic readings, clinical outcomes, or frequency of CPR-related injuries compared with standard mechanical CPR. The Intervention device provided inconsistent delivery of the intended ACD-CPR pattern, and this may have influenced results. A study with an optimised device is feasible and warranted to investigate the clinical impact of mechanical ACD-CPR on ROSC and survival.
Funding
This trial was funded by a grant from Stryker (formerly Physio-Control), the manufacturer of the study devices, to cover Oslo University Hospital salary for a study coordinator (50% during the data collection period), the research devices and development and cost for CRF and data handling. The PI developed the LUCAS 2-AD trial protocol in consultation with Physio-Control, staff at the data coordinating centre, and the statistician. Norwegian National Advisory Unit on Prehospital Emergency
CRediT authorship contribution statement
Per Olav Berve: Data curation, Formal analysis, Investigation, Software, Supervision, Visualisation, Writing - original draft. Bjarne Madsen Hardig: Data curation. Tore Skålhegg: Data curation. Håvard kongsgaard: Formal analysis. Jo kramer Johansen: Writing - original draft. Lars Wik: Conceptualization, Funding acquisition, Methodology, Project administration.
Declaration of Competing Interest
LW was PI in the Zoll Medical funded CIRC study and holds patents via Oslo University Hospital (Inven2). He is a member of the medical advisory board of Stryker/Physio-Control. At the time of the study, BMH was employed by Stryker/Jolife AB, which manufactures the LUCAS device, LIFEPAK 15 and CODE-STAT. In addition, JC did analysis and data work for the study that was funded by Stryker/Jolife AB. POB, TS, HK and JKJ declare no conflicts of interests.
References (45)
- et al.
Active compression-decompression CPR improves vital organ perfusion in a dog model of ventricular fibrillation
Chest
(1994) - et al.
End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: comparison of active compression-decompression and standard CPR
Ann Emerg Med
(1995) - et al.
Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial
Lancet
(2011) - et al.
Active compression-decompression resuscitation: a prospective, randomized study in a two-tiered EMS system with physicians in the field
Resuscitation
(1996) - et al.
Comparison of exertion required to perform standard and active compression-decompression cardiopulmonary resuscitation
Resuscitation
(1995) - et al.
Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest (OHCA)
Resuscitation
(2009) - et al.
The first European pre-hospital active compression-decompression (ACD) cardiopulmonary resuscitation workshop: a report and a review of ACD-CPR
Resuscitation
(1995) - et al.
Effect of different compression–decompression cycles on haemodynamics during ACD-CPR in pigs
Resuscitation
(1998) - et al.
European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary
Resuscitation
(2015) - et al.
Force and depth of mechanical chest compressions and their relation to chest height and gender in an out-of-hospital setting
Resuscitation
(2015)
Chest compressions induce errors in end-tidal carbon dioxide measurement
Resuscitation
Influence of chest compression artefact on capnogram-based ventilation detection during out-of-hospital cardiopulmonary resuscitation
Resuscitation
Capnography and chest-wall impedance algorithms for ventilation detection during cardiopulmonary resuscitation
Resuscitation
Feasibility of the capnogram to monitor ventilation rate during cardiopulmonary resuscitation
Resuscitation
Using generalized additive (mixed) models to analyze single case designs
J Sch Psychol
Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest
Resuscitation
Comparison of manual and mechanical chest compression techniques using cerebral oximetry in witnessed cardiac arrests at the emergency department: A prospective, randomized clinical study
Am J Emerg Med
Cerebral oximetry versus end tidal CO2 in predicting ROSC after cardiac arrest
Am J Emerg Med
Simultaneous beat-to-beat assessment of arterial blood pressure and quality of cardiopulmonary resuscitation in out-of-hospital and in-hospital settings
Resuscitation
Coronary blood flow and perfusion pressure during coronary angiography in patients with ongoing mechanical chest compression: a report on 6 cases
Resuscitation
No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device–a pilot study
Resuscitation
Comparison of computed tomography and autopsy in detection of injuries after unsuccessful cardiopulmonary resuscitation
Resuscitation
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2022, Resuscitation PlusCitation Excerpt :Experimental studies, investigating the effect of active decompression on pigs’ hemodynamics, found a higher cerebral blood flow and cardiac output compared with a non-active decompression approach14,19,20. A human study comparing a modified LUCAS 2 device with an active decompression feature vs a standard LUCAS 2 device found a better cerebral oxygen saturation when the active decompression was correctly administered15. Even if CPR-related chest collapse has not been measured in humans before, the changes in chest compliance during CPR have been demonstrated by a previous cadaver study: the elastic recoil of the human thorax decreases over time13, which could negatively affect the heart refilling.
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2022, ResuscitationCitation Excerpt :A further randomised trial, during OHCA compared a modified mechanical chest compression device which provided active decompression as well as chest compression with standard mechanical compressions. The study found no differences in physiological end-points (maximal end-tidal carbon dioxide, cerebral oxygen saturations and invasive blood pressure) or injuries between devices.52 Exploratory analyses revealed that active decompression occurred less frequently than expected, potentially because of the suction cup becoming detached from the chest wall, which may have influenced the study findings.
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