Standard Cardiopulmonary Resuscitation Versus Active Compression-Decompression Cardiopulmonary Resuscitation With Augmentation of Negative Intrathoracic Pressure for Out-of-Hospital Cardiac Arrest - Standard CPR vs. Active Compression-Decompression CPR With Augmentation of Negative Intrathoracic Pressure for Out-of-Hospital Cardiac Arrest

Jan 30, 2011
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
National Institutes of Health, and Advanced Circulatory Systems
Date Published:
01/01/2011
Date Updated:
01/30/2011
Original Posted Date:
01/30/2011
References

Description:

The goal of the trial was to compare treatment with standard cardiopulmonary resuscitation (CPR) compared with active compression-decompression CPR with augmented negative intrathoracic pressure among patients with an out-of-hospital cardiac arrest.

Hypothesis:

Active compression-decompression CPR will be more effective at improving survival.

Study Design

  • Randomized
  • Parallel
  • Crossover

Patient Populations:

  • Patients presumed to be at least 18 years of age with an out-of-hospital cardiac arrest

    Number of screened applicants: 2,470
    Number of enrollees: 1,653
    Duration of follow-up: 1 year
    Mean patient age: 67 years
    Percentage female: 34%

Exclusions:

  • Arrest due to trauma or noncardiac causes
  • Pre-existing do-not-resuscitate orders
  • Signs of obvious clinical death
  • Any condition that precluded the use of CPR (for example, recent sternotomy with incompletely healed wound)
  • Patient had received <1 minute of CPR by emergency medical service personnel
  • Complete and non-removable airway obstruction
  • Intubation with a leaky airway, or presence of a stoma, tracheostomy, or tracheotomy

Primary Endpoints:

  • Survival to hospital discharge with favorable neurological function

Secondary Endpoints:

  • Major adverse events (death, cerebral bleeding, transfusion, surgical intervention for bleeding, seizures, re-arrest, pulmonary edema, chest fractures, internal thoracic and abdominal injuries, and device malfunction or defects) to hospital discharge

Drug/Procedures Used:

Patients with an out-of-hospital nontraumatic cardiac arrest were randomized to standard CPR (n = 813) versus active compression-decompression CPR with augmented negative intrathoracic pressure (n = 840).

Active CPR consisted of a suction cup device that attached to the chest and enabled the operator to administer compressions via a handle (ResQPump or CardioPump). An impedance threshold device was attached to the facemask or advanced airway, which lowered intrathoracic pressure during decompressions (ResQPOD).

Principal Findings:

Overall, 1,653 patients were randomized. In the active CPR group, the mean age was 67 years, 34% were women, initial recorded rhythm was ventricular fibrillation in 35%, asystole in 45%, and pulseless electrical activity in 20%, emergency call to CPR start time was 6.7 minutes, mean duration of CPR was 28 minutes, and 28% of patients were admitted to the hospital.

The primary outcome, survival to hospital discharge with good neurological function, occurred in 9% of the active CPR group versus 6% of the standard CPR group (p = 0.019). Survival did not appear to be influenced by the initial cardiac rhythm. Overall survival to hospital discharge was 12% versus 10% (p = 0.12), and 1-year survival was 9% versus 6% (p = 0.03), respectively.

Pulmonary edema occurred in 11% versus 8% (p = 0.015), chest fractures in 1% versus 2% (p = 0.56), and pneumothorax in 1% versus <1% (p = 0.63), respectively.

Interpretation:

Among individuals who suffered an out-of-hospital cardiac arrest, the use of active CPR was beneficial. Compared with standard CPR, active CPR with a suction cup device attached to the chest, and an impedance device attached to the facemask or advanced airway improved survival with good neurological function. Pulmonary edema occurred more frequently in the active CPR group. Despite benefit, survival in the intervention group remained dismal (9% survival to hospital discharge with good neurological function). Replication of this study is needed before adoption.

References:

Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomized trial. Lancet 2011;377:301-11.

Keywords: Pulmonary Edema, Follow-Up Studies, Out-of-Hospital Cardiac Arrest, Suction, Electric Impedance, Cardiopulmonary Resuscitation, Pneumothorax, Ventricular Fibrillation, Heart Arrest, Hospitalization


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