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《心肺复苏指南》参考资料（英文版）Part 6：CPR Techniques and devices

Circulation 2005; 112: 47-50; originally published online Nov 28, 2005 DOI: 10.1161/CIRCULATIONAHA. 105.166555 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, Tx 72514 Copyright o 2005 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online

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Part 6: CPR Techniques and devices O the past 25 years a variety of alternatives to standard the abdomen(midway between the xiphoid and the umbili- manual CPR have been developed in an effort to cus) during the relaxation phase of chest improve ventilation or perfusion during cardiac arrest and purpose is to enhance venous return during CPR. 10.II When ultimately to improve survival. Compared with standard IAC-CPR performed by trained providers was compared with CPR, these techniques and devices typically require more standard CPR for cardiac arrest in the in-hospital setting, personnel, training, or equipment, or they apply to a specific IAC-CPR c and short-term survival in 2 setting Maximum benefits are reported when adjuncts are randomized trials (LoE 1)2.13 and improved survival to begun early in the treatment of cardiac arrest, so that the use hospital discharge in I study. 3 The data from these studies of these alternatives to CPR is often limited to the hospital was combined in 2 positive meta-analyses (LOE 1). 14, I5 setting. To date no adjunct has consistently been shown to be Evidence from I randomized controlled trial of out-of- superior to standard manual CPR for out-of-hospital basic life hospital cardiac arrest(LOE 2), 6 however, did not show any support, and no device other than a defibrillator has consis- survival advantage to IAC-CPR. Although there is I pediatric tently improved long-term survival from out-of-hospital car- case report 7 of complications, no harm was reported in the diac arrest. The data reported here is limited to clinical trials, other studies, which involved a total of 426 patients o most animal data is excluded from this section IAC-CPR may be considered during in-hospital resuscita- tion when sufficient personnel trained in its use are available CPR Techniques Class IIb). There is insufficient evidence to recommend for ligh-Frequency Chest Compressions or against the use of IAC-CPR in the out-of-hospital setting High-frequency (>100 per minute) manual or mechanical Class Indeterminate) chest compressions have been studied as a technique for “ Cough”CPR mproving resuscitation from cardiac arrest I-4 The sparse "Cough"CPR is not useful for the treatment of an unrespon- mal and human data available show mixed results. one clinical trial of 9 patients showed that high-frequency(120 sive victim, 8-23 and it should not be taught to lay rescuers per minute)chest compressions improved hemodynamics Human" cough"CPR has been reported only in awake, monitored patients who developed ventricular fibrillation compressions for cardiac arrest by adequately trained rescue (VF)or rapid ventricular tachycardia(VT). 20.22,24 Several personnel can be considered, but there is insufficient evidence to recommend for or against its use(Class Indeterminate) the cardiac catheterization suite suggest that repeated cough ing every I to 3 seconds during episodes of VF or rapid VT Open-Chest CPR by conscious, supine, monitored patients trained in the No prospective randomized studies of open-chest CPR for technique can maintain a mean arterial pressure resuscitation have been published. Four relevant human >100 mm Hg and can maintain consciousness for up to 90 studies were reviewed: 2 were performed to treat in-hospital seconds cardiac arrest following cardiac surgery (LOE 46; LOE 57), The increase in intrathoracic pressure that occurs with and 2 were performed after out-of-hospital cardiac arrest coughing generates blood flow to the brain and helps main (LOE 48: LOE 5%). The observed benefits of open-chest tain consciousness. Coughing every I to 3 seconds for up to cardiac massage were improved coronary perfusion pressure% 90 seconds after the onset of vF or pulseless VT is safe and Open-chest CPR should be considered Class a)for ously trained to perform this maneuver(Class Ib), Detian previ and increased return of spontaneous circulation(ROSC). effective only in conscious, supine, monitored patients previ- patients with cardiac arrest in the early postoperative period remains the treatment of choice for Ve or pulseless v? lation after cardiothoracic surgery or when the chest or abdomen already open(eg, in trauma surgery). For further information CPR Devices bout trauma resuscitation, see Part 10.7: Special Resusci Devices to assist ventilation tation Situations: Cardiac arrest associated with trauma utomatic and Mechanical Transport Ventilators Automatic transport ventilators (ATVs). One prospective Interposed Abdominal Compression The interposed abdominal compression(IAC)-CPR techniq cohort study of 73 intubated patients, most of whom were in cardiac arrest, in an out-of-hospital urban setting showed no uses a dedicated rescuer to provide manual compression of difference in arterial blood gas parameters between those ventilated with an atv and those ventilated with a bag-mask (Circulation. 2005: 112: IV-47-IV-50) o 2005 American Heart Associa device(LOE 4. 25 Disadvantages of ATVs include the need This special supplement to Circulation is freely available at for an oxygen source and electric power. Thus, providers http://www.circulationaha.org should always have a bag-mask device available for manual backup. Some ATVs may be inappropriate for use in children DOI: 10.1161/CIRCULATIONAHA 105. 166555 <5 years of age lv-47

Part 6: CPR Techniques and Devices Over the past 25 years a variety of alternatives to standard manual CPR have been developed in an effort to improve ventilation or perfusion during cardiac arrest and ultimately to improve survival. Compared with standard CPR, these techniques and devices typically require more personnel, training, or equipment, or they apply to a specific setting. Maximum benefits are reported when adjuncts are begun early in the treatment of cardiac arrest, so that the use of these alternatives to CPR is often limited to the hospital setting. To date no adjunct has consistently been shown to be superior to standard manual CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest. The data reported here is limited to clinical trials, so most animal data is excluded from this section. CPR Techniques High-Frequency Chest Compressions High-frequency (100 per minute) manual or mechanical chest compressions have been studied as a technique for improving resuscitation from cardiac arrest.1– 4 The sparse animal and human data available show mixed results. One clinical trial of 9 patients showed that high-frequency (120 per minute) chest compressions improved hemodynamics over standard CPR (LOE 4).5 The use of high-frequency chest compressions for cardiac arrest by adequately trained rescue personnel can be considered, but there is insufficient evidence to recommend for or against its use (Class Indeterminate). Open-Chest CPR No prospective randomized studies of open-chest CPR for resuscitation have been published. Four relevant human studies were reviewed: 2 were performed to treat in-hospital cardiac arrest following cardiac surgery (LOE 46; LOE 57), and 2 were performed after out-of-hospital cardiac arrest (LOE 48; LOE 59). The observed benefits of open-chest cardiac massage were improved coronary perfusion pressure9 and increased return of spontaneous circulation (ROSC).8 Open-chest CPR should be considered (Class IIa) for patients with cardiac arrest in the early postoperative period after cardiothoracic surgery or when the chest or abdomen is already open (eg, in trauma surgery). For further information about trauma resuscitation, see Part 10.7: “Special Resuscitation Situations: Cardiac Arrest Associated With Trauma.” Interposed Abdominal Compression The interposed abdominal compression (IAC)-CPR technique uses a dedicated rescuer to provide manual compression of the abdomen (midway between the xiphoid and the umbilicus) during the relaxation phase of chest compression. The purpose is to enhance venous return during CPR.10,11 When IAC-CPR performed by trained providers was compared with standard CPR for cardiac arrest in the in-hospital setting, IAC-CPR improved ROSC and short-term survival in 2 randomized trials (LOE 1)12,13 and improved survival to hospital discharge in 1 study.13 The data from these studies was combined in 2 positive meta-analyses (LOE 1).14,15 Evidence from 1 randomized controlled trial of out-ofhospital cardiac arrest (LOE 2),16 however, did not show any survival advantage to IAC-CPR. Although there is 1 pediatric case report17 of complications, no harm was reported in the other studies, which involved a total of 426 patients. IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb). There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting (Class Indeterminate). “Cough” CPR “Cough” CPR is not useful for the treatment of an unresponsive victim,18 –23 and it should not be taught to lay rescuers. Human “cough” CPR has been reported only in awake, monitored patients who developed ventricular fibrillation (VF) or rapid ventricular tachycardia (VT).20,22,24 Several small case series (LOE 5)18,20,22,24 reporting experiences in the cardiac catheterization suite suggest that repeated coughing every 1 to 3 seconds during episodes of VF or rapid VT by conscious, supine, monitored patients trained in the technique can maintain a mean arterial pressure 100 mm Hg and can maintain consciousness for up to 90 seconds. The increase in intrathoracic pressure that occurs with coughing generates blood flow to the brain and helps maintain consciousness. Coughing every 1 to 3 seconds for up to 90 seconds after the onset of VF or pulseless VT is safe and effective only in conscious, supine, monitored patients previously trained to perform this maneuver (Class IIb). Defibrillation remains the treatment of choice for VF or pulseless VT. CPR Devices Devices to Assist Ventilation Automatic and Mechanical Transport Ventilators Automatic transport ventilators (ATVs). One prospective cohort study of 73 intubated patients, most of whom were in cardiac arrest, in an out-of-hospital urban setting showed no difference in arterial blood gas parameters between those ventilated with an ATV and those ventilated with a bag-mask device (LOE 4).25 Disadvantages of ATVs include the need for an oxygen source and electric power. Thus, providers should always have a bag-mask device available for manual backup. Some ATVs may be inappropriate for use in children 5 years of age. (Circulation. 2005;112:IV-47-IV-50.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166555 IV-47

Circulation December 13. 2005 In both the out-of-hospital and in-hospital settings, ATVs increased incidence of sternal fractures in the ACD-CPR re useful for ventilation of adult patients with a pulse who group have an advanced airway (eg, endotracheal tube, esophageal ACD-CPR may be considered for use in the in-hospital tracheal combitube [Combitube], or laryngeal mask airway etting when providers are adequately trained(Class llb). [LMA)in place(Class Ila). For the adult cardiac arrest There is insufficient evidence to recommend for or against patient who does not ha ve an advan the use of ACD-CPR in the prehospital setting(Class ATV may be useful if tidal volumes are delivered by a Indeterminate) flow-controlled, time-cycled ventilator without positive end- Impedance Threshold Device expiratory pressure(PEEP). If the ATV has adjustable output The impedance threshold device(ITD) is a valve that limits control valves, tidal volume should be adjusted to make the chest rise(approximately 6 to 7 mL/kg or 500 to 600 mL), air entry into the lungs during chest recoil between chest with breaths delivered over I second. Until an advanced compressions. It is designed to reduce intrathoracic pressure airway is in place, an additional rescuer should provide and enhance venous return to the heart in initial studies the cricoid pressure to reduce the risk of gastric inflation. Once ITD was used with a cuffed endotracheal tube during bas an advanced airway is in place, the ventilation rate should be tube ventilation and acd-cPr 42-44 The itd and acd 8 to 10 breaths per minute during CPR device are thought to act synergistically to enhance venous Manually triggered, oxygen-powered, flow-limited resus- return during active decompression. In recent reports the ItD has been used during conven citator. In a study of 104 anesthetized nonarrest patients tional CPR4546 with an endotracheal tube or face mask without an advanced airway in place (ie, no endotracheal tube; patients were ventilated through a mask), patients Studies suggest that when the ItD is used with a face mask, it may create the same negative intratracheal pressure as use ventilated by firefighters with manually triggered, oxygen- of the Itd with an endotracheal tube if rescuers can maintain powered, flow-limited resuscitators had less gastric inflation than those ventilated with a bag-mask device (LOE 5). 26 a tight face mask seal. 43, 45, 46 In 2 randomized studies(LOE 1)4447 of 610 adults in Manually triggered, oxygen-powered, flow-limited resuscita cardiac arrest in the out-of-hospital setting, use of ACD-CPR tors may be considered for the management of patients who plus the ITD was associated with improved ROSC and do not have an advanced airway in place and for whom a 24-hour survival rates when compared with use of standard mask is being used for ventilation during CPR. Rescuers CPR alone. A randomized study of 230 adults documented should avoid using the automatic mode of the oxygen- increased admission to the intensive care unit and 24-hour powered, flow-limited resuscitator because it applies contin- survival(LOE 2)45 when an ITD was used during standard uous PEEP that is likely to impede cardiac output during CPR in patients in cardiac arrest (pulseless electrical activity chest compressions( Class In) only) in the out-of-hospital setting. The addition of the ITD Devices to Support Circulation was associated with improved hemodynamics during stan- dard CPR in I clinical study(LOE 2) Active Compression-Decompression CPR Although increased long-term survival rates have not been to actively lift the anterior chest during decompression. It is can improve nemo o tubule s used by trained personnel as an Active compression-decompression CPR(ACD-CPR)is per- documented, when the ITD formed with a hand-held device equipped with a suction cup adjunct to CPR in int adult cardiac arrest patients, it parameters and rosC(Class lla) thought that decreasing intrathoracic pressure during the of 2onmpression phase enhances venous return to the heart. As Mechanical Piston Device The mechanical piston device depresses the sternum via a and Drug Administration for sale in the United States. compressed gas-powered plunger mounted on a backboard. In Results from the use of acd-cpr have been mixed. in 4 I prospective randomized study and 2 prospective random- randomized studies(LOE 127.2, LOE 229. 30) ACD-CPR ized crossover studies in adults(LOE 2), mechanical improved long-term survival rates when it was used by piston CPR used by medical and paramedical personnel adequately trained providers for patients with cardiac arrest in improved end-tidal CO, and mean arterial pressure in patients the out-of-hospital272 and in- hospital,30 settings. In 5 other in cardiac arrest in both the out-of-hospital and in-hospital randomized studies (LOE 131-: LOE 235),however, ne settings. effects were observed. In 4 clinical Mechanical piston CPR may be considered for patients in studies(LOE 3)0.,36-38 ACD-CPR improved hemodynamics cardiac arrest in circumstances that make manual resuscita- over standard CPR, and in I clinical study(Loe 3)39 did not tion difficult(Class Ib). The device should be programmed Frequent training seems to be a significant factor in achie to deliver standard CPR with adequate compression depth at icac. 28 the rate of 100 compressions per minute with a compression ventilation ratio of 30: 2(until an advanced airway is in place) A meta-analysis of 10 trials involving 4162 patients in the and a compression duration that is 50% of the compression- out-of-hospital setting (LOE 1)o and a meta-analysis of 2 decompression cycle length. The device should allow co trials in the in-hospital setting(826 patients) o failed document any early or late survival benefit of ACD- CPR over plete chest wall recoil conventional CPR. The out-of-hospital meta-analysis found Load-Distributing Band CPR or Vest CPR large but nonsignificant worsening in neurologic outcome The load-distributing band (LDB) is a circumferential chest survivors in the ACD-CPR group, and I small study showed compression device composed of a pneumatically or electri-

In both the out-of-hospital and in-hospital settings, ATVs are useful for ventilation of adult patients with a pulse who have an advanced airway (eg, endotracheal tube, esophagealtracheal combitube [Combitube], or laryngeal mask airway [LMA]) in place (Class IIa). For the adult cardiac arrest patient who does not have an advanced airway in place, the ATV may be useful if tidal volumes are delivered by a flow-controlled, time-cycled ventilator without positive endexpiratory pressure (PEEP). If the ATV has adjustable output control valves, tidal volume should be adjusted to make the chest rise (approximately 6 to 7 mL/kg or 500 to 600 mL), with breaths delivered over 1 second. Until an advanced airway is in place, an additional rescuer should provide cricoid pressure to reduce the risk of gastric inflation. Once an advanced airway is in place, the ventilation rate should be 8 to 10 breaths per minute during CPR. Manually triggered, oxygen-powered, flow-limited resuscitators. In a study of 104 anesthetized nonarrest patients without an advanced airway in place (ie, no endotracheal tube; patients were ventilated through a mask), patients ventilated by firefighters with manually triggered, oxygenpowered, flow-limited resuscitators had less gastric inflation than those ventilated with a bag-mask device (LOE 5).26 Manually triggered, oxygen-powered, flow-limited resuscitators may be considered for the management of patients who do not have an advanced airway in place and for whom a mask is being used for ventilation during CPR. Rescuers should avoid using the automatic mode of the oxygenpowered, flow-limited resuscitator because it applies continuous PEEP that is likely to impede cardiac output during chest compressions (Class III). Devices to Support Circulation Active Compression-Decompression CPR Active compression-decompression CPR (ACD-CPR) is performed with a hand-held device equipped with a suction cup to actively lift the anterior chest during decompression. It is thought that decreasing intrathoracic pressure during the decompression phase enhances venous return to the heart. As of 2005 no ACD-CPR devices have been cleared by the Food and Drug Administration for sale in the United States. Results from the use of ACD-CPR have been mixed. In 4 randomized studies (LOE 127,28; LOE 229,30) ACD-CPR improved long-term survival rates when it was used by adequately trained providers for patients with cardiac arrest in the out-of-hospital27,28 and in-hospital29,30 settings. In 5 other randomized studies (LOE 131–34; LOE 235), however, no positive or negative effects were observed. In 4 clinical studies (LOE 3)30,36 –38 ACD-CPR improved hemodynamics over standard CPR, and in 1 clinical study (LOE 3)39 did not. Frequent training seems to be a significant factor in achieving efficacy.28 A meta-analysis of 10 trials involving 4162 patients in the out-of-hospital setting (LOE 1)40 and a meta-analysis of 2 trials in the in-hospital setting (826 patients)40 failed to document any early or late survival benefit of ACD-CPR over conventional CPR. The out-of-hospital meta-analysis found a large but nonsignificant worsening in neurologic outcome in survivors in the ACD-CPR group, and 1 small study41 showed increased incidence of sternal fractures in the ACD-CPR group. ACD-CPR may be considered for use in the in-hospital setting when providers are adequately trained (Class IIb). There is insufficient evidence to recommend for or against the use of ACD-CPR in the prehospital setting (Class Indeterminate). Impedance Threshold Device The impedance threshold device (ITD) is a valve that limits air entry into the lungs during chest recoil between chest compressions. It is designed to reduce intrathoracic pressure and enhance venous return to the heart. In initial studies the ITD was used with a cuffed endotracheal tube during bagtube ventilation and ACD-CPR.42– 44 The ITD and ACD device are thought to act synergistically to enhance venous return during active decompression. In recent reports the ITD has been used during conventional CPR45,46 with an endotracheal tube or face mask. Studies suggest that when the ITD is used with a face mask, it may create the same negative intratracheal pressure as use of the ITD with an endotracheal tube if rescuers can maintain a tight face mask seal.43,45,46 In 2 randomized studies (LOE 1)44,47 of 610 adults in cardiac arrest in the out-of-hospital setting, use of ACD-CPR plus the ITD was associated with improved ROSC and 24-hour survival rates when compared with use of standard CPR alone. A randomized study of 230 adults documented increased admission to the intensive care unit and 24-hour survival (LOE 2)45 when an ITD was used during standard CPR in patients in cardiac arrest (pulseless electrical activity only) in the out-of-hospital setting. The addition of the ITD was associated with improved hemodynamics during standard CPR in 1 clinical study (LOE 2).46 Although increased long-term survival rates have not been documented, when the ITD is used by trained personnel as an adjunct to CPR in intubated adult cardiac arrest patients, it can improve hemodynamic parameters and ROSC (Class IIa). Mechanical Piston Device The mechanical piston device depresses the sternum via a compressed gas-powered plunger mounted on a backboard. In 1 prospective randomized study and 2 prospective randomized crossover studies in adults (LOE 2),48 –50 mechanical piston CPR used by medical and paramedical personnel improved end-tidal CO2 and mean arterial pressure in patients in cardiac arrest in both the out-of-hospital and in-hospital settings. Mechanical piston CPR may be considered for patients in cardiac arrest in circumstances that make manual resuscitation difficult (Class IIb). The device should be programmed to deliver standard CPR with adequate compression depth at the rate of 100 compressions per minute with a compressionventilation ratio of 30:2 (until an advanced airway is in place) and a compression duration that is 50% of the compressiondecompression cycle length. The device should allow complete chest wall recoil. Load-Distributing Band CPR or Vest CPR The load-distributing band (LDB) is a circumferential chest compression device composed of a pneumatically or electriIV-48 Circulation December 13, 2005

Part 6: CPR Techniques and Devices /v-49 cally actuated constricting band and backboard. Evidence pression rate on initial success of resuscitation and 24 hour survival after from a case control study of 162 adults (LOe 4)51 docu- ed manual cardiopulmonary resuscitation in dogs. Circulation. mented improvement in survival to the emergency depart 1988:77:240-250. 2. Halperin HR, Tsitlik JE, Guerci AD, Mellits ED, Levin HR, Shi AY. ment when LDB-CPR was administered by adequately Chandra n, weisfeldt ml. Determinants of blood flow to vital organs trained rescue personnel to patients with cardiac arrest in the during cardiopulmonary resuscitation in dogs. Circulation. 1986:73 out-of-hospital setting. The use of LDB-CPR improve 539-5 modynamics in I in-hospital study of end-stage patients 3. Kern KB, Sanders AB, Raife J, Milander MM, Otto Cw, Ewy GA. A (LOE 3)2 and 2 laboratory studies (LOE 6).53.54 LDB-CPR tudy of chest compression rates during cardiopulmonary resuscitation in humans: the importance of rate-directed chest compressions. Arch intern may be considered for use by properly trained personnel as ar Med.1992;152:145-149 adjunct to CPR for patients with cardiac arrest in the 4. Omato JP, Gonzalez ER, Garnett AR. Levine RL, McClung BK. Effect of out-of-hospital or in-hospital setting( Class IIb). cardiopulmonary resuscitation compression rate on end-tidal carbon dioxide concentration and arterial pressure in man. Crit Care Med. 1988 Phased Thoracic-Abdominal Compression-Decompression 16:241-245. CPR With a Hand-Held Device 5. Swenson RD, Weaver WD, Niskanen RA, Martin J, Dahlberg s Hemo- Phased thoracic-abdominal compression-decompression CPR pulmonary resuscitation. Circulation. 1988: 78: 630-6 (PTACD-CPR) combines the concepts of IAC-CPR and 6. Anthi A, Tzelepis GE, Alivizatos P, Michalis A, Palatianos GM, ACD-CPR. A hand-held device alternates chest compression Geroulanos S. Unexpected cardiac arrest after cardiac surgery: incidence, and abdominal decompression with chest decompression and and outcome of open chest cardiopulmonary resus- tation. Chest. 1998: 113: 15-19 abdominal compression. Evidence from I prospective ran- domized clinical study of adults in cardiac arrest (LOE 2)55 7. Pottle A, Bullock I, Thomas J, Scott L. Survival to discharge following open chest cardiac compression(OCCC): a 4-year retrospective audit documented no improvement in survival rates with use of PTACD-CPR for assistance of circulation during advanced Trust, United Kingdom. Resuscitation. 2002: 52: 269-272. cardiovascular life support(ACLS) in the out-of-hospital and 8. Takino M, Okada Y. The optimum timing of resuscitative thoracotomy for non-traumatic out-of-hospital cardiac arrest. Resuscitation. 1993: 26: in-hospital settings. Thus, there is insufficient evidence to support the use of PTACD-CPR outside the research settin 9. Boczar ME. Howard MA, Rivers EP. Martin GB, Horst HM. Lewan- Class Indeterminate). dowski C, Tomlanovich MC, Nowak RM. A technique revisited: hemo- dynamic comparison of closed- and open-chest cardiac massage during Med.1995:23:498-503 Extracorporeal Techniques and Invasive 10. Beyar R, Kishon Y, Kimmel E, Neufeld H, Dinnar U Intrathoracic and Perfusion Devices abdominal pressure variations as an efficient method for cardiopulmonary Much of the literature showing the effectiveness of extracor resuscitation: studies in compared with computer model results poreal CPR(ECPR) includes patients with cardiac disease Cardiovasc Res. 1985: 19: 335-34 ECPR is more successful in postcardiotomy patients than in I1. Voorhees WD, Niebauer MJ, Babbs CF. Improved oxygen delivery those with cardiac arrest from other causes(LOE 5).56 ECPR Med.1983:12:128-135. may be particularly effective for these patients because they 12. Sack JB, Kesselbrenner MB, Jarrad A. Interposed abdominal are more likely to have a reversible(ie, surgically correctable mpression-cardiopulmonary resuscitation and resuscitation outcome or short-term) cause of cardiac arrest, and typically they uring asystole and electromechanical dissociation. Circulation. 1992: 86: 1692-1700 suffer cardiac arrest without preceding multisystem organ 13. Sack JB, Kesselbrenner MB. Bregman D. Survival from in-hospital failure cardiac arrest with interposed abdominal counterpulsation during cardio- ECPR for induction of hypothermia has been shown to pulmonary resuscitation. JAMA. 1992: 267: 379-385. improve survival rates in a small study of patients who 14. Babbs CF. Interposed abdominal compression CPR: a comprehensive evidence based review. Resuscitation. 2003: 59: 71-82 arrived at the ED in cardiac arrest and failed to respond to 15. Babbs CF. Simplified meta-analysis of clinical trials in resuscitation. standard ACLS techniques(LOE 5).57 Resuscitation. 2003: 57: 245-255 ECPR should be considered for in-hospital patients 16. Mateer JR, Stueven HA, Thompson BM, Aprahamian C, Darin JC cardiac arrest when the duration of the no-flow arrest is brief Pre-hospital IAC-CPR versus standard CPR: paramedic resuscitation of and the condition leading to the cardiac arrest is reversible 17. Waldman P, Walters BL, Grunau CF Pancreatic injury associated with (eg, hypothermia or drug intoxication) or amenable to heart interposed abdominal compressions in pediatric cardiopulmonary resus- transplantation or revascularization( Class Ib).58 59 tion. Am J Emerg Med. 1984: 2: 510-512 8. Criley JM, Blaufuss AH, Kissel GL Cough-induced cardiac compression If-administered from of cardiopulmonary resuscitation. JAMA. 1976 Summary A variety of CPR techniques and devices may improve en RA. Alferness C, Criley JM hemodynamics or short-term survival when used by well- Mechanical"cough" cardiopulmonary resuscitation during cardiac ar trained providers in selected patients. To date no adjunct has dogs. Am J Cardiol. 1985: 55: 199-204 consistently been shown to be superior to standard manual 20. Miller B, Cohen A, Serio A, Bettock D. Hemodynamics of cough ca diopulmonary resuscitation in a patient with sustained torsades de for out-of-hospital basic life support, and no device pointes/ventricular flutter. J Emerg Med. 1994: 12: 627-632 than a defibrillator has consistently improved long-term Rieser M. The use of cough-CPR in patients with acute myocardial rival from out-of-hospital cardiac arrest. 22. Miller B, Lesnefsky E, Heyborne T, Schmidt B, Freeman K, Breckinridge S, Kelley K, Mann D, Reiter M. Cough-cardiopulmonary resuscitation in References the cardiac catheterization laboratory: hemodynamics during an episode I. Feneley MP, Maier Gw, Kern KB, Gaynor JW, Gall SA Jr, Sanders AB of prolonged hypotensive ventricular tachycardia. Cathet Cardiovasc Raessler K, Muhlbaier LH, Rankin JS, Ewy GA. Influence of com Diagn.1989:18:168-171

cally actuated constricting band and backboard. Evidence from a case control study of 162 adults (LOE 4)51 documented improvement in survival to the emergency department when LDB-CPR was administered by adequately trained rescue personnel to patients with cardiac arrest in the out-of-hospital setting. The use of LDB-CPR improved hemodynamics in 1 in-hospital study of end-stage patients (LOE 3)52 and 2 laboratory studies (LOE 6).53,54 LDB-CPR may be considered for use by properly trained personnel as an adjunct to CPR for patients with cardiac arrest in the out-of-hospital or in-hospital setting (Class IIb). Phased Thoracic-Abdominal Compression-Decompression CPR With a Hand-Held Device Phased thoracic-abdominal compression-decompression CPR (PTACD-CPR) combines the concepts of IAC-CPR and ACD-CPR. A hand-held device alternates chest compression and abdominal decompression with chest decompression and abdominal compression. Evidence from 1 prospective randomized clinical study of adults in cardiac arrest (LOE 2)55 documented no improvement in survival rates with use of PTACD-CPR for assistance of circulation during advanced cardiovascular life support (ACLS) in the out-of-hospital and in-hospital settings. Thus, there is insufficient evidence to support the use of PTACD-CPR outside the research setting (Class Indeterminate). Extracorporeal Techniques and Invasive Perfusion Devices Much of the literature showing the effectiveness of extracorporeal CPR (ECPR) includes patients with cardiac disease. ECPR is more successful in postcardiotomy patients than in those with cardiac arrest from other causes (LOE 5).56 ECPR may be particularly effective for these patients because they are more likely to have a reversible (ie, surgically correctable or short-term) cause of cardiac arrest, and typically they suffer cardiac arrest without preceding multisystem organ failure. ECPR for induction of hypothermia has been shown to improve survival rates in a small study of patients who arrived at the ED in cardiac arrest and failed to respond to standard ACLS techniques (LOE 5).57 ECPR should be considered for in-hospital patients in cardiac arrest when the duration of the no-flow arrest is brief and the condition leading to the cardiac arrest is reversible (eg, hypothermia or drug intoxication) or amenable to heart transplantation or revascularization (Class IIb).58,59 Summary A variety of CPR techniques and devices may improve hemodynamics or short-term survival when used by welltrained providers in selected patients. To date no adjunct has consistently been shown to be superior to standard manual CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest. References 1. Feneley MP, Maier GW, Kern KB, Gaynor JW, Gall SA Jr, Sanders AB, Raessler K, Muhlbaier LH, Rankin JS, Ewy GA. Influence of compression rate on initial success of resuscitation and 24 hour survival after prolonged manual cardiopulmonary resuscitation in dogs. Circulation. 1988;77:240 –250. 2. Halperin HR, Tsitlik JE, Guerci AD, Mellits ED, Levin HR, Shi AY, Chandra N, Weisfeldt ML. Determinants of blood flow to vital organs during cardiopulmonary resuscitation in dogs. Circulation. 1986;73: 539 –550. 3. Kern KB, Sanders AB, Raife J, Milander MM, Otto CW, Ewy GA. A study of chest compression rates during cardiopulmonary resuscitation in humans: the importance of rate-directed chest compressions. Arch Intern Med. 1992;152:145–149. 4. Ornato JP, Gonzalez ER, Garnett AR, Levine RL, McClung BK. Effect of cardiopulmonary resuscitation compression rate on end-tidal carbon dioxide concentration and arterial pressure in man. Crit Care Med. 1988; 16:241–245. 5. 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A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation. Crit Care Med. 1995;23:498 –503. 10. Beyar R, Kishon Y, Kimmel E, Neufeld H, Dinnar U. Intrathoracic and abdominal pressure variations as an efficient method for cardiopulmonary resuscitation: studies in dogs compared with computer model results. Cardiovasc Res. 1985;19:335–342. 11. Voorhees WD, Niebauer MJ, Babbs CF. Improved oxygen delivery during cardiopulmonary resuscitation with interposed abdominal compressions. Ann Emerg Med. 1983;12:128 –135. 12. Sack JB, Kesselbrenner MB, Jarrad A. Interposed abdominal compression-cardiopulmonary resuscitation and resuscitation outcome during asystole and electromechanical dissociation. Circulation. 1992;86: 1692–1700. 13. Sack JB, Kesselbrenner MB, Bregman D. Survival from in-hospital cardiac arrest with interposed abdominal counterpulsation during cardiopulmonary resuscitation. JAMA. 1992;267:379 –385. 14. Babbs CF. Interposed abdominal compression CPR: a comprehensive evidence based review. Resuscitation. 2003;59:71– 82. 15. Babbs CF. Simplified meta-analysis of clinical trials in resuscitation. Resuscitation. 2003;57:245–255. 16. Mateer JR, Stueven HA, Thompson BM, Aprahamian C, Darin JC. Pre-hospital IAC-CPR versus standard CPR: paramedic resuscitation of cardiac arrests. Am J Emerg Med. 1985;3:143–146. 17. Waldman PJ, Walters BL, Grunau CF. Pancreatic injury associated with interposed abdominal compressions in pediatric cardiopulmonary resuscitation. Am J Emerg Med. 1984;2:510 –512. 18. Criley JM, Blaufuss AH, Kissel GL. Cough-induced cardiac compression: self-administered from of cardiopulmonary resuscitation. JAMA. 1976; 236:1246 –1250. 19. Niemann JT, Rosborough JP, Niskanen RA, Alferness C, Criley JM. Mechanical “cough” cardiopulmonary resuscitation during cardiac arrest in dogs. Am J Cardiol. 1985;55:199 –204. 20. Miller B, Cohen A, Serio A, Bettock D. Hemodynamics of cough cardiopulmonary resuscitation in a patient with sustained torsades de pointes/ventricular flutter. J Emerg Med. 1994;12:627– 632. 21. Rieser MJ. The use of cough-CPR in patients with acute myocardial infarction. J Emerg Med. 1992;10:291–293. 22. Miller B, Lesnefsky E, Heyborne T, Schmidt B, Freeman K, Breckinridge S, Kelley K, Mann D, Reiter M. Cough-cardiopulmonary resuscitation in the cardiac catheterization laboratory: hemodynamics during an episode of prolonged hypotensive ventricular tachycardia. Cathet Cardiovasc Diagn. 1989;18:168 –171. Part 6: CPR Techniques and Devices IV-49

lV-50 Circulation December 13, 2005 23. Bircher N, Safar P, Eshel G, Stezoski w. Cerebral and hemodynamic 4 Rabl w, Pfeiffer KP, Benzer A, Gilly H. Chest injuries after variables durin ing cough-induced CPR in dogs. Crit Care Med. 1982: 10 104-10 Palance CPR)in cadavers. Resuscitation. 1999: 43: 9-15 24. Saba SE. David Sw. Sustained consciousness during ventricular fibril- 42. ce P, Lurie KG, Payen D. Inspiratory imped of cough cardiopulmonary resuscitation. Cathet Car- diovasc Diagn. 1996: 37: 47-48 ompression-decompression cardiopulmonary resuscitation: a ra 25. Johannigman JA. Branson RD, Johnson DJ, Davis K Jr, Hurst JM. 989-994 43. Plaisance P, Soleil C, Lurie KG, Vicat E, Ducros L, Payen D. Use of Acad Emerg Med. 1995: 2: 719-724 aspiratory impedance threshold device on a facemask and endotrac 6. Noordergraaf GJ, van Dun PJ, Kramer BP, Schors MP, Homman HP, de ube to reduce intrathoracic pressures during the decompression phase Jong w, Noordergraaf A. Can first responders achieve and ma normocapnia when sequentially ve with a bag-valve device and wo oxygen-driven resuscitators? A controlled clinical xH. Care Med. 2005: 3:90- ression cardiopulmonary resuscitation. Crit Wolcke BB. Mauer DK. Schoefmann ann H. Provo TA Lindner KH, Dick WF, Aeppli D, Lurie KG. Comparison of standard 27. Lurie KG. Shultz JJ. Callaham ML, Schwab TM. Gisch T, Rector T cardiopulmonary resuscitatio the combination of active Frascone R, Long L. Evaluation of active compression-decompr ompression-decompression cardiopulmonary resuscitation and an CPR in victims of out-of-hospital cardiac arrest. JAMA. 199 spiratory impedance threshold device for out-of-hospital cardiac arrest. 1405-1411 irculation.2003:108:2201-2205 28. Plaisance P, Lurie KG, Vicat E, Adnet F, Petit JL, Epain D, Ecollan P 45. Aufderheide TP, Pirrallo RG. Provo TA, Lurie KG. Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmo- cardiopulmonary resuscitation and active compression-decompression nary resuscitation in patients with out-of-hospital cardiac arrest. Crit Care resuscitation for out-of-hospital cardiac arrest. French Active Med.2005:33:734-740 Compression-Decompression Cardiopulmonary Resuscitation Study 46. Pirrallo RG, Aufderheide TP. Provo TA, Lurie KG. Effect of ar Group. N Engl J Med. 1999: 341: 569-575. inspiratory impedance threshold device on hemodynamics during con- Cohen TJ, Goldner BG, Maccaro PC, Ardito AP, T S Cohen mB ventional manual cardiopulmonary resuscitation. Resuscitation. 2005: 66 Dibs s omparison of active compression-decompression cardiopul- monary resuscitation with standard card onary resuscitation fo 47. Plaisance P, Lurie KG, Vicat E, Martin D, Gueugniaud PY, Petit JL, cardiac arrests occurring in the hospital. N Engl J Med. 1993:329 Payen D. 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23. Bircher N, Safar P, Eshel G, Stezoski W. Cerebral and hemodynamic variables during cough-induced CPR in dogs. Crit Care Med. 1982;10: 104 –107. 24. Saba SE, David SW. Sustained consciousness during ventricular fibrillation: case report of cough cardiopulmonary resuscitation. Cathet Cardiovasc Diagn. 1996;37:47– 48. 25. Johannigman JA, Branson RD, Johnson DJ, Davis K Jr, Hurst JM. Out-of-hospital ventilation: bag–valve device vs transport ventilator. Acad Emerg Med. 1995;2:719 –724. 26. Noordergraaf GJ, van Dun PJ, Kramer BP, Schors MP, Hornman HP, de Jong W, Noordergraaf A. Can first responders achieve and maintain normocapnia when sequentially ventilating with a bag-valve device and two oxygen-driven resuscitators? A controlled clinical trial in 104 patients. Eur J Anaesthesiol. 2004;21:367–372. 27. Lurie KG, Shultz JJ, Callaham ML, Schwab TM, Gisch T, Rector T, Frascone RJ, Long L. Evaluation of active compression-decompression CPR in victims of out-of-hospital cardiac arrest. 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A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. JAMA. 1995;273: 1261–1268. 32. Stiell I, H’ebert P, Well G, Laupacis A, Vandemheen K, Dreyer J, Eisenhauer M, Gibson J, Higginson L, Kirby A, Mahon J, Maloney J, Weitzman B. The Ontario trial of active compression-decompression cardiopulmonary resuscitation for in-hospital and prehospital cardiac arrest. JAMA. 1996;275:1417–1423. 33. Mauer D, Schneider T, Dick W, Withelm A, Elich D, Mauer M. Active compression-decompression resuscitation: a prospective, randomized study in a two-tiered EMS system with physicians in the field. Resuscitation. 1996;33:125–134. 34. Nolan J, Smith G, Evans R, McCusker K, Lubas P, Parr M, Baskett P. The United Kingdom pre-hospital study of active compression-decompression resuscitation. Resuscitation. 1998;37:119 –125. 35. Luiz T, Ellinger K, Denz C. 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Timerman S, Cardoso LF, Ramires JA, Halperin H. Improved hemodynamic performance with a novel chest compression device during treatment of in-hospital cardiac arrest. Resuscitation. 2004;61:273–280. 53. Halperin H, Berger R, Chandra N, Ireland M, Leng C, Lardo A, Paradis N. Cardiopulmonary resuscitation with a hydraulic-pneumatic band. Crit Care Med. 2000;28:N203–N206. 54. Halperin HR, Paradis N, Ornato JP, Zviman M, Lacorte J, Lardo A, Kern KB. Cardiopulmonary resuscitation with a novel chest compression device in a porcine model of cardiac arrest: improved hemodynamics and mechanisms. J Am Coll Cardiol. 2004;44:2214 –2220. 55. Arntz HR, Agrawal R, Richter H, Schmidt S, Rescheleit T, Menges M, Burbach H, Schroder J, Schultheiss HP. Phased chest and abdominal compression-decompression versus conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Circulation. 2001;104:768 –772. 56. Chen Y-S, Chao A, Yu H-Y, Ko W-J, Wu I-H, Chen RJ-C, Huang S-C, Lin F-Y, Wang S-S. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation. J Am Coll Cardiol. 2003;41:197–203. 57. Nagao K, Hayashi N, Kanmatsuse K, Arima K, Ohtsuki J, Kikushima K, Watanabe I. Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital. J Am Coll Cardiol. 2000;36:776 –783. 58. Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med. 1999;6:700 –707. 59. Martin GB, Rivers EP, Paradis NA, Goetting MG, Morris DC, Nowak RM. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest. 1998;113:743–751. IV-50 Circulation December 13, 2005

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