Active chest compression-decompression for cardiopulmonary resuscitation
Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, AP-HP, Université Pierre et Marie Curie (Paris 6), Service de Gériatrie à Orientation Cardiologique et Neurologique, Ivry-sur-Seine, Ile-de-France, France
Carmelo Lafuente-Lafuente, Service de Gériatrie à Orientation Cardiologique et Neurologique, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, AP-HP, Université Pierre et Marie Curie (Paris 6), 7 Avenue de la République, Ivry-sur-Seine, Ile-de-France, 94205, France. email@example.com. firstname.lastname@example.org.
Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid-sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials testing this device have shown discordant results.
To determine the effect of active chest compression-decompression CPR compared to standard chest compression CPR on mortality and neurological function in adults with cardiac arrest treated either in-hospital or out-of-hospital.
We updated the searches of CENTRAL in The Cochrane Library (Issue 12 of 12, 2012), MEDLINE (OVID, 1946 to January week 1 2013), and EMBASE (OVID, 1980 to week 1 2013) on 14 January 2013. We checked the reference list of retrieved articles, contacted experts in the field, and searched ClinicalTrials.gov.
All randomised or quasi-randomised studies comparing active compression-decompression with standard manual chest compression in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team.
Data collection and analysis
We independently extracted data on an intention-to-treat basis. When needed, we contacted the authors of the primary studies. If appropriate, we cumulated studies and pooled relative risk (RR) estimates. We predefined subgroup analyses according to setting (out-of-hospital or in-hospital) and attending team composition (with physician or paramedic only).
In this update, 27 new related publications were found, but they did not all fulfil inclusion criteria or concerned participants already reported in previous publications. In the end, we included 10 trials in this review: Eight were in out-of-hospital settings; one was set in-hospital only; and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in four studies. The two in-hospital studies were different in quality and size (773 and 53 participants). Both found no differences between ACDR CPR and STR in any outcome.
Out-of-hospital trials cumulated 4162 participants. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98, 95% confidence interval (CI) 0.94 to 1.03) or at hospital discharge (RR 0.99, 95% CI 0.98 to 1.01). The pooled RR of neurological impairment of any severity was 1.71 (95% CI 0.90 to 3.25), with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11, 95% CI 0.98 to 9.83). However, assessment of neurological outcome was limited, and few participants had neurological damage.
There was no difference between ACDR CPR and STR with regard to complications such as rib or sternal fractures, pneumothorax, or haemothorax (RR 1.09, 95% CI 0.86 to 1.38). Skin trauma and ecchymosis were more frequent with ACDR CPR.
Active chest compression-decompression in people with cardiac arrest is not associated with any clear benefit.
Compression-décompression active de la poitrine dans la réanimation cardio-respiratoire
La réanimation cardio-respiratoire par compression-décompression active (RCR-CDA) utilise un dispositif d'aspiration portable appliqué au milieu du sternum pour comprimer la poitrine puis la décomprimer activement après chaque compression. Les essais contrôlés randomisés testant ce dispositif rapportaient des résultats contradictoires.
Déterminer l'effet de la compression-décompression active de la RCR par rapport à la compression thoracique standard RCR sur la mortalité et la fonction neurologique chez les adultes atteints d'un arrêt cardiaque traités soit à l'hôpital soit en dehors de l'hôpital.
Stratégie de recherche documentaire
Nous avons mis à jour les recherches de CENTRAL dans La Bibliothèque Cochrane (numéro 12 sur 12, 2012), MEDLINE (OVID, de 1946 à la semaine 1 de janvier 2013) et EMBASE (OVID, de 1980 à la semaine 1 2013) le 14 janvier 2013. Nous avons vérifié les références bibliographiques des articles identifiés, contacté des experts dans le domaine et consulté ClinicalTrials.gov.
Critères de sélection
Toutes les études randomisées ou quasi-randomisées comparant une compression-décompression active à une compression thoracique manuelle standard chez des adultes atteints d'un arrêt cardiaque qui recevaient une réanimation cardio-respiratoire par une équipe médicale ou paramédicale formée à cet effet.
Recueil et analyse des données
Nous avons indépendamment extrait les données en intention de traiter. En cas de besoin, nous avons contacté les auteurs des études primaires. Si cela était approprié, nous avons regroupé les études et combiné les estimations du risque relatif (RR). Nous avions prédéfinis, les analyses en sous-groupes en fonction de l'environnement (soit à l'hôpital soit en dehors de l'hôpital) et la composition de l'équipe soignante (avec un médecin ou uniquement un auxilliaire médical).
Dans cette mise à jour, 27 nouvelles publications pertinentes ont été identifiées, mais elles n'ont pas toutes rempli les critères d'inclusion ou portaient sur des participants déjà mentionnés dans les précédentes publications. Finalement, nous avons inclus 10 essais dans cette revue : Huit étaient dans un environnement non hospitalier ; un dans un environnement hospitalier uniquement ; et un avait à la fois des composants hospitaliers et non hospitaliers. L'Allocation assignation secrète était adéquate dans quatre études. Les deux études en milieu hospitalier présentaient des variations en termes de qualité et de taille (773 et 53 participants). Aucune ne rapportait de différence entre la RCR-CDA et la RCR-ST pour aucun critère de jugement.
Les essais en extra-hospitalier cumulaient 4162 participants. Il N'y avait aucune différence entre la RCR-CDA et la RCR-ST pour la mortalité, soit immédiatement (RR 0,98, intervalle de confiance (IC) à 95 % 0,94 à 1,03) ou à la sortie d'hôpital (RR 0,99, IC à 95 % 0,98 à 1,01). Le RR combiné de troubles neurologiques de n'importe quelle gravité était de 1,71 (IC à 95 % 0,90 à 3,25), avec une tendance non signicative à une plus grande fréquence des dommages neurologiques graves chez les survivants de la RCR-CDA (RR de 3,11, IC à 95%, entre 0,98 et 9,83). Cependant, l'évaluation du critère de jugement neurologique était limitée, et peu de participants présentaient des dommages neurologiques.
Il n'y a aucune différence entre la RCR-CDA et la RCR-ST en ce qui concerne les complications telles que des fractures des côtes ou du sternum, un pneumothorax, ou un hémothorax (RR 1,09, IC à 95 % 0,86 à 1,38). Les Traumatismes cutanés et les ecchymoses étaient plus fréquents avec la RCR-CDA.
Conclusions des auteurs
La Compression-décompression active de la poitrine chez les personnes atteintes d'un arrêt cardiaque n'est associée à aucun bénéfice évident.
Active compression-decompression using a hand-held device for emergency heart massage
During standard cardiopulmonary resuscitation (heart massage) for cardiac arrest (arrest of the heart), the chest is compressed manually and repeatedly by hand. This is a temporary method that pumps blood and oxygen to the brain via the heart. During standard cardiopulmonary resuscitation, the chest is not manually decompressed. Active chest compression-decompression is an alternative method of heart massage and uses a hand-held suction device to compress the chest, then decompress the chest after each compression. Comparison of these techniques showed active chest compression-decompression to have no advantage and some drawbacks compared to standard cardiopulmonary resuscitation.
Compression-décompression active à l'aide d'un dispositif portable pour le massage cardiaque d'urgence
Pendant la réanimation cardio-respiratoire standard (massage cardiaque) pour un arrêt cardiaque (arrêt du cœur), on comprime manuellement la poitrine et de manière répétée avec la main. Ceci est une méthode ponctuelle qui permet de faire circuler le sang et l'oxygène vers le cerveau via le cœur. Pendant la réanimation cardio-respiratoire standard, la poitrine n'est pas, manuellement décompressée. La Compression-décompression active de la poitrine est une méthode alternative de massage cardiaque qui utilise un dispositif d'aspiration portable pour comprimer la poitrine, puis la décomprimer après chaque compression. La comparaison de ces techniques a montré que la compression-décompression active n'avait aucun avantage et avait certains inconvénients par rapport à la réanimation cardio-respiratoire standard.
Notes de traduction
Translated by: French Cochrane Centre
Translation supported by: Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux
Резюме на простом языке
Использование ручных устройств для активной компрессии-декомпрессии грудной клетки при массаже сердца для неотложной помощи
Во время стандартной сердечно-легочной реанимации (массаж сердца) при остановке сердца, выполняются повторяющиеся нажатия на грудную клетку руками. Это временный способ, который проталкивает (нагнетает) кровь (насыщенную кислородом) и кислород к мозгу через сердце. Во время стандартной сердечно-легочной реанимации, проводимой руками, декомпрессия грудной клетки не осуществляется. Активная компрессия-декомпрессия грудной клетки является альтернативным способом массажа сердца и использует ручное всасывающее устройство для нажатия на грудную клетку и для ее декомпрессии после каждого нажатия. Сравнение этих методов показало, что активная компрессия-декомпрессия груди не имеет преимуществ, а имеет некоторые недостатки по сравнению со стандартным способом сердечно-легочной реанимации.
Заметки по переводу
Перевод: Страту Вячеслав Фёдорович. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Казанский федеральный университет. По вопросам, связанным с этим переводом, пожалуйста, свяжитесь с нами по адресу: email@example.com
Streszczenie prostym językiem
Czynne uciskanie i rozprężanie klatki piersiowej z użyciem przenośnego urządzenia do masażu serca.
W trakcie standardowej resuscytacji krążeniowo-oddechowej (masażu serca), prowadzonej w stanach nagłego zatrzymania krążenia (zatrzymania czynności serca), wielokrotnie uciska się klatkę piersiową przy użyciu rąk. Metoda ta umożliwia pompowanie krwi zawierającej tlen do mózgu za pośrednictwem serca w czasie gdy serce nie pracuje. W trakcie standardowej resuscytacji krążeniowo-oddechowej klatka piersiowa rozpręża się samoistnie (biernie) po zwolnieniu ucisku. Czynne uciskanie i rozprężanie klatki piersiowej stanowi alternatywną metodę masażu serca z wykorzystaniem przenośnego urządzenie ssącego, za pomocą którego naprzemiennie uciska się klatkę piersiową i czynnie ją rozpręża po każdym uciśnięciu. Wykazano, że czynne uciskanie i rozprężanie klatki piersiowej nie przynosi dodatkowych korzyści i posiada pewne wady w porównaniu ze standardową resuscytacją krążeniowo-oddechową.
Aktive Kompression-Dekompression mit einem Hand-Gerät für die Notfallherzmassage
Während einer standardmäßigen kardiopulmonalen Reanimation (Herzmassage) bei Herzstillstand, wird die Brust manuell und wiederholt mit der Hand zusammengedrückt. Dies ist eine temporäre Methode, die Blut und Sauerstoff über das Herz zum Gehirn pumpt. Während einer Standard-Reanimation wird die Brust nicht manuell dekomprimiert. Aktive Brustkompression-Dekompression ist eine alternative Methode der Herzmassage und verwendet eine tragbare Absaug-Vorrichtung um die Brust zusammenzudrücken und dann die Brust nach jeder Kompression zu dekomprimieren. Beim Vergleich dieser Techniken zeigte sich bei der aktiven Brust Kompression-Dekompression im Vergleich zur Standard-Reanimation kein Vorteil sondern eher einige Nachteile.
Anmerkungen zur Übersetzung
K. Kunzweiler, Koordination durch Cochrane Schweiz
Active compression-decompression resuscitation (ACDR CPR) uses a hand-held device with a suction cup to perform cardiac massage during cardiopulmonary resuscitation. The operator applies this device mid-sternum to compress the chest as in standard manual cardiopulmonary resuscitation (STR). The operator then uses the device to actively decompress the chest after each compression (Cohen 1992). This differs from STR, which allows passive relaxation of the chest after each compression. A pressure gauge in the device measures both compression and decompression forces and can be used to adjust the effort.
ACDR CPR was designed to increase the pump action of closed chest massage. Indeed, experimental studies have shown that ACDR CPR, in comparison to STR, increases venous return and left ventricular filling in the decompression phase, leading to improved stroke volume (Tucker 1993), cardiac output (Orliaguet 1995), and arterial pressures (Shultz 1994) in the compression phase. Only one study, involving participants after prolonged resuscitation, found no differences in haemodynamics (Malzer 1996).
Disadvantages of ACDR CPR include the requirement for more training than STR, more physical effort (Shultz 1995), and the fact that it can be more difficult to apply in certain clinical situations. Increased frequency of sternal and rib fractures with ACDR CPR has been reported (Baubin 1999).
The improved haemodynamic associated with ACDR CPR was expected to reduce mortality or neurological damage, or both, when applied to people in cardiac arrest. However, results from clinical trials have been variable and contradictory. The first clinical trials comparing ACDR CPR to STR included small groups of participants, in-hospital, and showed promising results with the newer technique (Cohen 1993; Tucker 1994). Later randomised controlled trials involving a greater number of participants, mostly in out-of-hospital settings, often showed negative effects for the ACDR CPR method (Schwab 1995; Stiell 1996).
Mauer et al combined individual participant data of 2866 participants from seven separate out-of-hospital randomised controlled trials (Mauer 1999). Pooled data showed in participants treated with ACDR CPR a significant improvement in one-hour survival (23.8% versus (vs) 20.6% in ACDR CPR and STR groups, respectively) and a trend, which was not significant, towards a better survival to hospital discharge (7% vs 5.8%). Mauer et al found that ACDR CPR neither improved nor impaired neurological outcomes and complication rates. After the publication of this meta-analysis, several new controlled trials comparing ACDR CPR and STR were done. Again, some showed a benefit using ACDR CPR (Plaisance 1999), and some did not (Skogvoll 1999).
A parallel Cochrane systematic review, which aimed to study the effectiveness of mechanical chest compression devices when compared with manual chest compressions for cardiopulmonary resuscitation, found that evidence from human studies was insufficient to conclude that mechanical chest compression is associated with benefit or harm (Brooks 2011). ACDR CPR is a passive tool, manually driven by the rescuer, who delivers all the energy needed to compress and decompress the chest, so it is as prone - or more - to fatigue as standard manual compression. The 2010 American Heart Association guidelines for cardiopulmonary resuscitation increased the focus on adequate chest compression as a critical component of high-quality cardiopulmonary resuscitation (American Heart Association 2010). Retrieving the ACDR CPR device might delay immediate application of chest compression, and early fatigue may reduce the performance of compressions performed with this device.
We decided to prepare and maintain a systematic review, analysing the effects of the use of ACDR CPR and STR in both out-of-hospital and in-hospital settings.
To determine the effect of active chest compression-decompression CPR compared to standard chest compression CPR on mortality and neurological function in adults with cardiac arrest treated either in-hospital or out-of-hospital.
Criteria for considering studies for this review
Types of studies
Randomised or quasi-randomised controlled trials comparing ACDR CPR to STR in the defined population and reporting at least one of the defined outcomes. We accepted quasi-randomised studies because it can be difficult to maintain the allocation process, as the time available for deciding treatment is very limited. Double-blinding is not possible for this intervention; blinded assessment of outcomes was desired, but we did not consider it a decisive requisite for inclusion of studies.
Types of participants
Adult patients (any age greater than 16 years old) suffering cardiac arrest and undergoing cardiopulmonary resuscitation efforts performed by a medical or paramedical trained team. We considered both out-of-hospital and in-hospital settings, but undertook separate analyses, as patients in these settings are usually different with regard to causes of cardiac arrest and comorbidity. For our purposes, we defined cardiac arrest as sudden presentation of unresponsiveness, absence of spontaneous pulse, and absence of spontaneous respiration in a person not having a known or evident terminal disease.
Types of interventions
Active chest compression-decompression using an appropriate device
Paramedical or medical teams participating in the study must have received specific training in ACDR CPR. Participants could receive STR by a witness (medical or not) until the arrival of the emergency team, but after that they must have received sustained ACDR CPR. We did not consider for inclusion trials alternating ACDR CPR and STR in the same participant.
Any intervention other than chest compression procedure, especially those interventions for basic and advanced life support, must have been applied equally in both intervention and control groups and should have been performed in accordance with the aforementioned recommendations. Time response from cardiac arrest to the beginning of resuscitation by the paramedical or medical team was assumed to be equal between treatment groups as a result of the randomisation procedure. If there were imbalances between the groups, this was dealt with by stratification or logistic regression analysis.
Types of outcome measures
Immediate: participants not recovering spontaneous circulation in spite of resuscitation efforts.
To hospital discharge: participants not surviving long enough to be discharged from the hospital where they were first admitted.
Long-term: at three, six, or 12 months, or a combination of the aforementioned, when data were available.
Frequency of resultant neurological impairment in participants surviving until hospital discharge
This was classified as follows:
Moderate: impaired functionality or quality of life, but participant self-sufficient for basic needs of daily life. This corresponds to the Glasgow-Pittsburgh Cerebral Performance category 2 (moderate disability).
Severe: dependency for one or several basic needs of daily life. This corresponds to the Glasgow-Pittsburgh Cerebral Performance categories 3 and 4 (severe disability, vegetative state).
Any resultant neurologic impairment.
If data were available, we also assessed this outcome in the long-term (three, six, or 12 months, or a combination of the aforementioned).
Relevant complications derived from the applied technique.
Sternal and rib fractures.
Haemothorax or pneumothorax.
Internal organ damage.
We did not consider minor complications such as superficial trauma to the skin.
Search methods for identification of studies
The following electronic databases were searched last on 14 January 2013:
the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 12 of 12, December 2012;
MEDLINE on Ovid (1946 to January week 1 2013); and
The RCT filters used for MEDLINE and EMBASE have been updated (Lefebvre 2011).
Searching other resources
We checked the reference list of all identified primary studies and review articles for other potential relevant citations. We contacted the sole company that manufactures ACDR CPR devices (Ambu International A/S) and colleagues working in the field of cardiopulmonary resuscitation for other published and unpublished studies. A search of the clinical trials registry ClinicalTrials.gov was conducted. There was no language restriction.
Data collection and analysis
Selection of studies
Two authors (CL-L, MM-B) selected trials for inclusion or exclusion after reading titles and abstracts of studies identified using the search strategy. We compared the selected trials and resolved any discrepancy by discussion and consensus. Using a predefined form, two authors independently read the full text of retained studies and included trials that met the above stated criteria. We checked the articles finally selected for the review to avoid including data published in duplicate.
Data extraction and management
Using a predefined form, two authors (CL-L, MM-B) independently extracted data. We checked the forms for agreement and decided differences by discussion and consensus. We extracted all data on the basis of intention-to-treat. When needed, we contacted authors of primary studies for additional information or data.
Assessment of risk of bias in included studies
Two authors (CL-L, MM-B) independently assessed the methodological quality of the selected studies, addressing adequacy of allocation concealment for randomised trials, which we ranked as yes (low risk of bias), unclear, or no (high risk of bias), following the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008; Higgins 2011). We resolved any differences of opinion by discussion and consensus.
Assessment of heterogeneity
We tested homogeneity between included studies using a fixed-effect or random-effects model, as appropriate. If significant heterogeneity was present, we attempted to explain the differences based on the clinical characteristics of the included studies. If a clinically dissimilar study existed, we did not combine it statistically.
Assessment of reporting biases
We carried out a funnel plot to test for the presence of publication bias, based on the data for the primary outcome of immediate mortality.
We pooled trials using Review Manager 5 (RevMan) software and pooled relative risk calculated for all outcomes. If results for any outcome were significant, we also expressed them as number needed to treat (NNT) to prevent one adverse outcome.
Subgroup analysis and investigation of heterogeneity
We considered predefined subgroups for out-of-hospital studies. Personnel within the resuscitation teams were thought to have a possible effect on outcome because ACDR CPR requires more training than standard chest compression, and this could influence its performance. Therefore, we proposed subgroup analyses for studies where the resuscitation team included physicians and paramedics and for studies where resuscitation teams consisted of paramedics without a physician.
We performed sensitivity analyses by selectively pooling the following:
studies having the best methodological quality (allocation concealment adequate (A)); and
studies including the greatest number of participants (i.e. > 500 participants).
Description of studies
Results of the search
Our searches identified 231 references in total. We found 27 new publications for this update, of which we assessed two in detail, but none fulfilled our inclusion criteria.
We were aware of two additional controlled trials conducted in Brussels (Belgium) and Thessaloniki (Greece), which were cited as having contributed to the combined analysis of individual participant data performed by Mauer et al (Mauer 1999). However, this analysis offered no separate data from the individual trials. We were unable to obtain any published data and did not receive responses to our letters to the respective main authors.
After reading titles and abstracts, we retained 27 articles for detailed assessment. We excluded 10 articles reporting nine studies: five because they were not randomised (Arai 2001; Gueugniaud 1998; Lefrançois 1998; Panzer 1996; Rivers 1993); one because it included a large proportion of participants with pre-existing terminal disease (Cohen 1993); two because they combined ACDR CPR with other interventions not performed in controls (an inspiratory impedance threshold device in both cases) (Aufderheide 2011; Wolcke 2003); and one study (two references) because ACDR CPR was applied to all participant groups (Plaisance 2004). We present further details of the excluded studies in the 'Characteristics of excluded studies' section. One further article is a publication in Chinese, which is waiting for translation of the full text.
Most trials (eight) included only out-of-hospital cardiac arrests; one included both out-of- and in-hospital cardiac arrests (Stiell-Prehospital 1996, n = 1011; Stiell-Inhospital 1996, n = 773), and one included only in-hospital participants (Tucker 1994, n = 53). The trials were conducted between 1993 and 1999 in Europe (France, Germany, Norway, United Kingdom) and North America (Canada, United States).
Stiell et al reported and analysed separately data from the two different settings of their trial: out-of-hospital and in-hospital participants. Schwab et al also reported and analysed separately data from the two cities where they conducted their study: Fresno and San Francisco (USA). We maintained the same pattern and pooled each of Stiell and Schwab's trials as two independent substudies.
All trials excluded people with a terminal disease or evidence of irreversible (i.e. brain) death. Most trials excluded also witnessed arrests, pregnant women, trauma victims, people in hypothermia, and intoxications. Three studies applied additional exclusion criteria: primary respiratory arrest, drowning, airway obstruction, and recent sternotomy.
The mean age of included participants was wide-ranging: between 65 and 71 years in eight studies, and lower in Goralski 1998 (61.5 years) and Plaisance 1999 (58.5 years). Two trials (Lurie 1994; Nolan 1998) stated that they could include young participants (> eight years old), but the mean age of the participants actually included was 67 years in both studies. Males predominated in all trials (57% to 73%) but one (Tucker 1994), where women represented 57%.
Five studies reported participant medical antecedents, presumed aetiology of the arrest, or both. Antecedents of heart disease (23% to 58%) and suspected cardiac aetiology (40% to 70%) were the most common conditions, followed by respiratory diseases (8% to 16%). Demographic and clinical characteristics were comparable between the ACDR CPR and STR groups in every trial.
Mean time from call to arrival of the rescue team ranged from 5.2 to 16 minutes in the out-of-hospital studies, depending on geographic and emergency system characteristics. In the two in-hospital studies, mean response time was only 1.4 and 2 minutes. Mean adrenaline dose used varied from 2.7 mg to 14.3 mg in the different trials. Response times and adrenaline doses were not significantly different between ACDR CPR and STR groups in any individual trial.
No study was blinded to the intervention applied, as it is impossible to mask the use of the ACDR device. In four studies, authors conducted explicit intention-to-treat analysis. In the remaining six studies, we could extract - from the published data or after contacting authors - data as intention-to-treat. No outcome data were missing for the outcomes from each study that were pooled in the review. (Six of the studies did not report useable data on neurological outcomes.)
There were few disagreements between the reviewers in selecting primary studies, assessing quality, or extracting data, and they were easily resolved by consensus. The funnel plot graphic was symmetrical, indicating that this test detected no publication bias or other bias.
We gave all results as pooled relative risk (RR) and its 95% confidence interval (CI) (ACDR CPR participants versus STR participants).
We found only two in-hospital studies fulfilling inclusion criteria (Stiell-Inhospital 1996; Tucker 1994). The best was the Stiell study, a good-quality trial (A) that included 733 in-hospital participants. This trial did not find any significant difference between ACDR CPR and STR groups neither in mortality, immediate (RR 1.01, 95% CI 0.91 to 1.12), or at hospital discharge (RR 1.01, 95% CI 0.96 to 1.06), nor in neurologic impairment in survivors (RR 1.14, 95% CI 0.46 to 2.87) or in complications (RR 0.97, 95% CI 0.49 to 1.93). The Tucker trial was a quality C study, with only 53 participants. No significant difference appeared in this study in any outcome either. Despite the differences in size and quality, the findings of the two in-hospital studies were similar.
All the out-of-hospital studies (cumulating 4162 participants) reported data for immediate mortality. Borderline heterogeneity between studies was found for this outcome (Chi² statistic = 14.81, df = 9, P = 0.10). This heterogeneity was largely due to Plaisance 1999 and disappeared when we removed this study (Chi² statistic = 8.38, df = 8, P = 0.40). We found no effect of ACDR CPR on immediate mortality either using a random-effects model (RR 0.98, 95% CI 0.94 to 1.03) or a fixed-effect model (RR 0.98, 95% CI 0.94 to 1.01) or after removing Plaisance 1999 (RR 1.00, 95% CI 0.96 to 1.04).
Eight trials (3412 participants) reported mortality at hospital discharge. They were homogeneous. We found no effect of ACDR CPR on mortality at hospital discharge (RR 0.99, 95% CI 0.98 to 1.01).
No study reported long-term mortality. Plaisance 1999 followed for one year a specific subgroup of participants discharged without neurological damage, but the study did not follow up all the survivors of each treatment group. After contacting the author, further information about participants having neurological injury was not available.
Data on neurological outcome in survivors were available from five trials (cumulating 144 survivors) at hospital discharge. There was no heterogeneity between studies. Frequency of severe neurological damage showed a clear trend, without reaching statistical significance, being higher in the ACDR CPR group (RR 3.11, 95% CI 0.98 to 9.83), while moderate neurological damage did not differ between intervention groups (RR 0.98, 95% CI 0.34 to 2.79). The pooled relative risk of neurological impairment of any severity was 1.71 (95% CI 0.90 to 3.25). No study reported long-term neurological outcomes.
Six studies (3032 participants) provided data on complications related to treatment. Studies were homogenous. Relevant observed complications (rib or sternal fractures, pneumothorax or haemothorax, internal organ damage) were comparable with both resuscitation techniques (RR 1.09, 95% CI 0.86 to 1.38). Skin trauma or ecchymosis were more frequent with ACDR CPR in all studies.
Subgroup analysis (out-of-hospital studies only)
Results for mortality were unchanged when pooling separately trials with and without a physician in the first attending team. The trend toward more frequent neurological damage (of any severity) in the ACDR CPR group was apparent in those studies with only paramedics (RR 2.19, 95% CI 0.93 to 5.13) and disappeared when a physician directed the rescue team (RR 1.14, 95% CI 0.59 to 2.21). However, there were few participants in each subgroup, and it was not possible to analyse neurological outcome by degree of severity given the number of participants.
All results were unchanged when selectively pooling the best-quality studies (adequate allocation concealment; four studies) or largest studies (those including > 500 participants: four studies).
Summary of main results
This systematic review found no evidence of benefit on mortality with the use of active compression-decompression cardiopulmonary resuscitation (ACDR CPR) compared with standard manual cardiopulmonary resuscitation (STR) for cardiopulmonary resuscitation. Confidence intervals were small with the trial evidence excluding a benefit greater than 6% relative risk reduction and a harm as big as 3% relative risk increase attributable to ACDR CPR.
With regard to neurologic outcome, a non-significant difference between treatment groups was observed in out-of-hospital studies, with the rate of neurologic impairment of severe degree and any severity tending to be higher in those treated with ACDR CPR. In subgroup analysis, this trend appeared in studies with attending teams comprising paramedics alone, and not in those with paramedics and physicians. However, this difference was not statistically significant, and the assessment of this outcome was limited: The number of participants with neurological impairment was small, assessors were often not blinded to the study intervention applied, and the Glasgow-Pittsburgh Cerebral Performance Scale is not a precise measure of neurologic function. Also, perceived differences between studies with and without physicians in rescue teams could merely reflect the overall numbers or rescuers attending the participant. These trials did not assess late neurological complications.
Complications were similar with both treatments. Some studies on autopsies of patients after unsuccessful resuscitation found more chest fractures, specifically sternal fractures, with ACDR CPR than with STR, and also a higher risk of iatrogenic cardiac injury (Baubin 1999; Rabl 1996). The clinical trials included in this review were not specifically designed to study complications. Nevertheless, in several of them, autopsies were done in a number of non-survivors (Stiell-Inhospital 1996; Schwab-Fresno 1995; Tucker 1994). In all the studies included in this review and in the pooled results, the observed complications were very similar with both techniques, with the exception of skin trauma or ecchymosis, which were more frequent with ACDR CPR.
Potential biases in the review process
The objective of this systematic review was to assess the overall effectiveness of ACDR CPR in the wide spectrum of clinical practice. A possible limitation of this approach is to pool together trials conducted in different clinical conditions and emergency medical systems. Percentage of participants in ventricular fibrillation, time to receive life support, composition, and training of medical teams are all factors that varied from study to study. Possible benefits of ACDR CPR, or conversely potential dangers, in specific subgroups of people or specific emergency medical systems might have been missed by being diluted in the global pool.
However, results seem to be consistent. Combining the included studies in different ways, by size, quality, team composition, and setting, did not change the main findings. Also, statistically significant heterogeneity between studies was not found, with the only exception of one outcome, immediate mortality, due to one study (Plaisance 1999). Neither the exclusion nor the inclusion (using both fixed- and random-effects models for statistics) of this study modified the results.
Plaisance 1999 showed better results for immediate mortality than the other trials. This difference could be explained by several reasons. It could be due to a bias in participant selection, as allocation concealment was clearly inadequate. But it could be due also to a better performance of the ACDR CPR technique. In this study, practitioners were experienced in ACDR CPR, and frequent retraining was performed, with rapid rotation of staff to avoid fatigue and conduct of the entire cardiopulmonary resuscitation at the scene of cardiac arrest directed by a physician. It was not possible to compare the outcomes of this study with the other included trials, other than immediate mortality, because not all the participants were assessed until hospital discharge. Participants were followed to discharge only if they had no neurological impairment.
Agreements and disagreements with other studies or reviews
Our results are different from the meta-analysis by Mauer 1999 with regard to immediate mortality, where they found a significant reduction (odds ratio 0.83, 95% CI 0.695 to 0.99). The main difference seems to be that we pooled more studies than Mauer: the studies by Schwab, Goralski, and Skogvoll, leading to 1296 more participants. All these trials had negative results for ACDR CPR. Mauer et al used individual participant data and analysed one-hour mortality while we recorded the immediate mortality as defined by authors of each trial, usually in the first minutes after resuscitation. However, the differences are limited to results for early mortality; Mauer and colleagues found no significant difference in mortality at hospital discharge neither.
Difficulty in applying optimal ACDR CPR in clinical settings, reported by several studies, reveal that this procedure, while seemingly relatively simple, is in fact much more complex than STR. This complexity could limit its effectiveness in real practice. In studies on transducer-equipped manikins, ACDR CPR required a higher physical effort than STR (Shultz 1995). Staff fatigue led to a significant reduction of compression rate and depth, as well as decompression force, after only two minutes in one study (Skogvoll 1997). ACDR CPR mechanical performance was also worse than STR during patient transport (Sunde 1997). In some of the clinical trials included in this review, they had limited available personnel to sustain chest massage, chest massage was performed during transport, or both (Nolan 1998; Schwab-Fresno 1995; Schwab-S.Francisco 1995; Stiell-Prehospital 1996).
The 2010 American Heart Association guidelines for cardiopulmonary resuscitation increased the focus on adequate chest compression as a critical component of high-quality cardiopulmonary resuscitation, specifically in minimising interruptions in chest compressions, providing compressions of adequate rate and depth, and avoiding leaning between compressions (American Heart Association 2010). The difficulty of applying ACDR CPR during transport and the reduced performance of ACDR CPR observed in some trials because of early fatigue may hinder in real practice the theoretical advantages of ACDR CPR over manual compression.
There are several important determinants of survival following cardiac arrest that are independent of the technique used. Time from arrest to basic and advanced life support, specially to defibrillation, is a well-characterised major factor (Eisenberg 1979; Mullie 1989), most important in out-of-hospital arrests (Becker 1991; Nichol 1996). Other major factors influencing survival are patient-intrinsic: primary cause of arrest, initial heart rhythm (Pepe 1993; Zoch 2000), coexisting diseases, and age (de Vos 1999; Ebell 1992).
Most experimental studies concluded that ACDR CPR, compared to STR, improved haemodynamics during cardiopulmonary resuscitation. Despite this physiological advantage, this does not appear to be sufficient to modify the natural evolution of cardiac arrest.
Implications for practice
There is no clear evidence of benefits from the use of active compression-decompression compared to standard manual chest compression in people with cardiac arrest occurring in different settings and different emergency medical systems. In the light of these results, ACDR CPR may not have a place in routine clinical practice. If performed, it should be by a well-trained, regularly re-trained team and ideally in the context of controlled clinical trials.
Implications for research
It is possible that changes in the design of the ACDR CPR device, particularly to improve adherence to the chest wall, could make it more efficient in practice. Combination of ACDR CPR with other devices designed to further increase negative intrathoracic pressures, e.g. an impedance threshold device, might improve the effectiveness of ACDR CPR. A large randomised controlled trial has found a significant increase in short- and long-term survival with the combination of ACDR CPR combined with augmented negative intrathoracic pressure via an impedance threshold device (Aufderheide 2011). Ideally, other studies should confirm these results.
In new clinical trials studying ACDR CPR, special attention to complications would be desirable, as well as long-term follow up of neurological outcomes.
Professor Shah Ebrahim and Dr Jonathon Sterne made valuable comments. Dr Plaisance helped us to locate primary studies. Ms Margaret Burke updated our searches for primary studies. Ms Theresa Moore reviewed and improved our English wording.
We thank the Cochrane Heart Group for their support in updating this review (2013).
#1 MeSH descriptor heart arrest explode all trees #2 heart next arrest* in All Text #3 cardiac next arrest* in All Text #4 sudden next death in All Text #5 MeSH descriptor Cardiopulmonary Resuscitation this term only #6 resuscitation in All Text #7 (#1 or #2 or #3 or #4 or #5 or #6) #8 active next compression in All Text #9 acdr in All Text #10 acd-cpr in All Text #11 acd in All Text #12 decompression in All Text #13 CardioPump in All Text #14 (#8 or #9 or #10 or #11 or #12 or #13) #15 (#7 and #14)
MEDLINE (Ovid) 1966 to May 2008
1 exp Heart Arrest/ 2 heart arrest$.tw. 3 cardiac arrest$.tw. 4 sudden death.tw. 5 Cardiopulmonary Resuscitation/ 6 resuscitation.tw. 7 or/1-6 8 active compression.tw. 9 acdr.tw. 10 acd-cpr.tw. 11 acd.tw. 12 decompression.tw. 13 cardiopump.tw. 14 or/8-13 15 7 and 14 16 randomized controlled trial.pt. 17 controlled clinical trial.pt. 18 Randomized controlled trials/ 19 random allocation/ 20 double blind method/ 21 single-blind method/ 22 or/16-21 23 exp animal/ not humans/ 24 22 not 23 25 clinical trial.pt. 26 exp Clinical trials/ 27 (clin$ adj25 trial$).ti,ab. 28 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab. 29 placebos/ 30 placebo$.ti,ab. 31 random$.ti,ab. 32 research design/ 33 or/25-32 34 33 not 23 35 34 or 24 36 35 and 15
#1 MeSH descriptor Heart Arrest explode all trees #2 heart next arrest* #3 cardiac next arrest* #4 sudden next death #5 MeSH descriptor Cardiopulmonary Resuscitation, this term only #6 resuscitation #7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6) #8 active next compression #9 acdr #10 acd-cpr #11 acd #12 decompression #13 CardioPump #14 (#8 OR #9 OR #10 OR #11 OR #12 OR #13) #15 (#7 AND #14)
1. exp Heart Arrest/ 2. heart arrest$.tw. 3. cardiac arrest$.tw. 4. sudden death.tw. 5. Cardiopulmonary Resuscitation/ 6. resuscitation.tw. 7. or/1-6 8. active compression.tw. 9. acdr.tw. 10. acd-cpr.tw. 11. acd.tw. 12. decompression.tw. 13. cardiopump.tw. 14. or/8-13 15. 7 and 14 16. randomized controlled trial.pt. 17. controlled clinical trial.pt. 18. randomized.ab. 19. placebo.ab. 20. drug therapy.fs. 21. randomly.ab. 22. trial.ab. 23. groups.ab. 24. 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 25. exp animals/ not humans.sh. 26. 24 not 25 27. ((2008$ not (200801$ or 200802$ or 200803$ or 200804$)) or 2009$ or 2010$).ed. 28. 15 and 26 and 27
1. resuscitation/ 2. heart arrest/ 3. heart arrest$.tw. 4. sudden death.tw. 5. resuscitation.tw. 6. cardiac arrest$.tw. 7. or/1-6 8. active compression.tw. 9. acdr.tw. 10. acd-cpr.tw. 11. acd.tw. 12. decompression.tw. 13. cardiopump.tw. 14. or/8-13 15. 7 and 14 16. random$.tw. 17. factorial$.tw. 18. crossover$.tw. 19. cross over$.tw. 20. cross-over$.tw. 21. placebo$.tw. 22. (doubl$ adj blind$).tw. 23. (singl$ adj blind$).tw. 24. assign$.tw. 25. allocat$.tw. 26. volunteer$.tw. 27. crossover procedure/ 28. double blind procedure/ 29. randomized controlled trial/ 30. single blind procedure/ 31. 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 32. (animal/ or nonhuman/) not human/ 33. 31 not 32 34. 15 and 33 35. ((2008$ not ("200801" or "200802" or "200803" or "200804" or "200805" or "200806" or "200807" or "200808" or "200809" or "200810" or "200811" or "200812" or "200813" or "200814" or "200815" or "200815" or "200816" or "200817")) or 2009$ or 2010$).em. 36. 34 and 35
10 November 2014
Review declared as stable
Since 2004 there have been no new studies found for inclusion. On this basis the decision has been taken to stop updating this review.
4 September 2013
New citation required but conclusions have not changed
No new trials were located.
16 April 2013
New search has been performed
Searches were re-run: 27 new publications were found, but none fulfilled the inclusion criteria. No new trial was included, and conclusions did not change.
29 June 2010
New search has been performed
Searches were re-run for this update in June 2010. 8 new publications were found, but none included. The conclusion remains unchanged
13 May 2009
No changes - republished to fix technical problem
21 May 2008
New search has been performed
In the current update, we reran the search to May 2008. 4 new publications found and assessed, but none included. Conclusions unchanged
16 May 2008
Converted to new review format.
30 January 2004
New search has been performed
In this update, we reran the search for primary studies up to January 2004. 2 new studies were found, assessed and excluded from the review. The studies were excluded because 1 study was not randomised, and the other treated the intervention, active chest compression-decompression (ACDR CPR) and the control groups differently. The conclusions were unchanged
31 May 2002
New search has been performed
In this update, we reran the search for randomised controlled trials up to May 2002. No new trials were found. The conclusions were unchanged
Contributions of authors
Carmelo Lafuente-Lafuente: conception and design of the review, draft of the protocol, search for primary studies, assessing papers for inclusion and quality, extracting data, analysis and interpretation of data, writing the review.
María Melero-Bascones: draft of the protocol, screening search results, retrieval of papers, assessing papers for inclusion and quality, extracting data from papers, writing the review.
Declarations of interest
Sources of support
Complejo Hospitalario Universitario de Albacete, Spain.
Hôpital Charles Foix, groupe hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France.
Allocating time to the main author to allow them to do this work
No sources of support supplied
Differences between protocol and review
There were none; we applied the protocol as initially defined.
Characteristics of studies
Characteristics of included studies [ordered by study ID]
n = number of participants included in the study. VF = presenting ventricular fibrillation or ventricular tachycardia as initial electrical rhythm. ACDR = active chest compression-decompression resuscitation. STR = standard resuscitation (manual chest compression).
Randomised controlled trial
n = 53
Mean age: 71 years
Exclusions: trauma victims, pregnancy
Cardiac antecedents: 58%
ACDR vs STR
Physician in responder team
Mean response time: 2 minutes
Adrenaline dose: ?
Immediate and at-hospital discharge mortality
Intention-to-treat analysis was explicitly done
In-hospital San Francisco (USA) 1992 to 1993
Risk of bias
Support for judgement
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Incomplete outcome data (attrition bias) All outcomes
Selective reporting (reporting bias)
All outcomes analysed in the review had been reported adequately
Blinding of participants and personnel (performance bias) All outcomes
Blinding of outcome assessment (detection bias) Mortality
Blinding of outcome assessment (detection bias) Neurological status
Characteristics of excluded studies [ordered by study ID]
Participants were allocated to ACD-CPR or standard CPR randomly (no details known)
92 participants with cardiac arrest occurring out-of-hospital in Sichuan, China
ACDR CPR (cardio pump) or standard CPR
Return of spontaneous circulation and admission to hospital
Only data from abstract known. No figures given. It is said that "On arriving to the hospital, the survival rate was higher in the ACD-CPR group, but of no statistical significance." The full text of this publication is awaiting translation from Chinese