By David P.

Keseg, MD, FACEP | From the EMS State of the Science 2012 Issue

Approximately 460,000 individuals die every year from out-of-hospital cardiac arrest (OHCA). Studies
have consistently shown only an average of 5–15% of patients treated with standard CPR survive cardiac
arrest, and providing optimal blood flow to a patient in cardiac arrest by performing quality,
uninterrupted CPR is uniformly thought to have a positive impact on improving overall survival.

The quality of CPR has been an underappreciated factor and is only now beginning to emerge as an
important aspect of successful resuscitation. Manual chest compressions are often done incorrectly,
especially in the back of a moving ambulance, and incorrect chest compression can negatively impact
survival.

Fortunately, there are tools that hold promise for helping providers overcome these inaccuracies:
mechanical CPR devices.

The Problem with Manual CPR

The quality of CPR is an important factor that contributes to survival in sudden cardiac arrest. In one
experimental study, pigs received 4 minutes of VF and then 9 minutes of CPR before defibrillation. In the
group that received suboptimal compressions (1.5 inches depth and 80 per minute), two out of nine pigs
survived; in the group that received optimal compressions (2 inches depth and 100 per minute), eight of
nine pigs survived.

The study of adult patients from the Resuscitation Outcomes Consortium Cardiac Arrest Epistry with
confirmed ventricular fibrillation (VF) or ventricular tachycardia (VT) has shown that increasing chest
compression fraction (hands-on time) during out-of-hospital resuscitation of patients with VF/VT is an
independent determinant of survival to hospital discharge. However, three human observational studies
showed that interruptions of chest compressions were common, averaging 24% to 57% of the total
arrest time.

Interrupting CPR can result in precious seconds lost in trying to “reprime” the pump and results in
pooling of blood in the right ventricle. In a study looking at this important element of the
pathophysiology of cardiac arrest, VF was induced in air-ventilated pigs, after which ventilation was
withdrawn. During the first 3 minutes of VF, arterial blood was transported to the venous circulation,
with the consequence that the left ventricle emptied and the right ventricle became greatly distended.

It took 2 minutes of mechanical CPR to re-establish an adequate coronary perfusion pressure, which was
lost when interrupted. In this pig model, VF caused venous congestion, an empty left heart, and a
greatly distended right heart within 3 minutes. Adequate heart massage before and during defibrillation
greatly improved the likelihood of return of spontaneous circulation (ROSC).

It is widely accepted that one of the best predictors of ROSC is attaining a coronary perfusion pressure
(CPP) of more than 15 mm Hg in animals and humans. Every interruption of CPR causes the CPP to drop
immediately. In the same pig study referenced above, when VF was induced, CPP fell from 60 mmHg to
15 mmHg in 15 seconds and continued to plummet into negative numbers. After CPR was restarted, the
CPP remained negative for the first minute; it took 90 seconds for it to get back up to 15 mmHg.

Another pig study demonstrated that mean CPP was 20 mmHg in the mechanical group compared to
around 5 mmHg in the manual group. All eight pigs in the mechanical group achieved ROSC, as
compared with just three pigs in the manual group.

With manual CPR, many factors come into play, including fatigue, physical abilities, focus on several
simultaneous tasks, poor-quality CPR during transportation on a stretcher and in the back of a transport
vehicle, interruptions during movement of patient and variations in technique and training.

Just maintaining the proper rate is a major challenge. In one study, it was demonstrated that manual
CPR resulted in a rate of less than 80 compressions/minute 37% of the time. Other studies looked at the
challenges in performing correct CPR in various settings. They found the following percentages of
correctly performed CPR:

54–78% on the floor;

• 46% in the back of a moving ambulance; and

• 21% while transporting on a stretcher.(21,22)

Besides the poor-quality CPR that occurs in the back of a moving ambulance, the risk of injury to the
crew members is unacceptable. It has been reported that ambulance personnel who perform CPR in a
moving ambulance are at least four times more like to have a fatal or incapacitating injury than
personnel who are restrained.

Mechanical CPR allows high-quality CPR to be performed while EMS personnel are restrained; this
reduces risk of injury to the crew. Restrained ambulance occupants involved in a crash have been shown
to have 3.77 times lower risk of fatality and 6.49 times lower risk of incapacitating injury than
unrestrained occupants.

Consistent-Quality CPR

The use of automatic mechanical CPR devices can provide a consistent rate and depth of compression
and is one way of improving the quality of chest compression and contributing to EMS personnel safety.

There is compelling physiological and animal data suggesting that mechanical chest-compression devices
are more effective than manual CPR. At best, standard manual CPR produces coronary and cerebral
perfusion that is just 30% of normal.

Some studies that demonstrate the advantages of mechanical CPR devices include:

• Increased brain flow by as much as 60% vs. manual measured in pigs.

• Adequate heart pressures—exceeding 15 mmHg in pigs19 and humans—significantly improved over

• Increased hands-on times to up to 90% of the time—significantly improved over manual.

A study from Kramer-Johansen et al states, “The poorer results with sinusoidal than trapezoidal chest
compressions add to the arguments that mechanical chest compressions can ensure better quality CPR
for more than short intervals of time, unless the logistics around applying a mechanical device has too
many negative effects.”

Another advantage of mechanical CPR: it can allow for defibrillation during compressions. In a study on
the LUCAS device, it showed that defibrillations did not compromise CPR and can be delivered during
ongoing mechanical compressions without any pauses.

These devices are also helpful in maintaining perfusion during cardiac arrest while undergoing a cardiac
catheterization interventional procedure. The AHA 2010 Guidelines (Part 12: Cardiac Arrest in Special
Situations) state: “Mechanical chest compression devices have been used successfully in an animal
model and adult humans to provide maintenance of circulation in cardiac arrest while continuing a
percutaneous coronary procedure. It is reasonable to use mechanical CPR during PCI (Class IIa, LOE C).”

Mechanical CPR Concerns

Mechanical CPR is a recent development and as such, the literature around its effect on outcomes is still
evolving. Not everyone is a fan of mechanical CPR. A recent systematic literature review of mechanical
CPR devices compared to manual CPR during OHCA and ambulance transport concluded that there was
insufficient evidence to support or refute the use of mechanical CPR devices in these settings. The study
also said that while there was some low-quality evidence suggesting that mechanical CPR can improve
consistency and reduce interruptions in chest compressions, there is no evidence that mechanical CPR
devices improve survival and may worsen neurological outcome.

One area of concern with mechanical CPR devices has been the time off the chest while applying the
device. However, in our experience with the LUCAS device in Columbus, Ohio, we have found that
application takes only 15–60 seconds and that the time off the chest is minimal. In addition, it is
important to take into account the total time on and off the chest. In a prehospital real-use study, the
hands-off ratio with manual CPR was on average 22%; however, with mechanical CPR it was just 9%, as
measured over the entire resuscitation episodes of approximately 33–40 minutes.

The interruptions in manual CPR increased from 19% on the scene to 27% during transport, whereas
those with the mechanical CPR device stayed at the same low ratio (8–10%) both on scene and during
transport.

Another more practical concern is the cost of these devices. They can cost nearly the same as a
monitor/defibrillator, a cost that many feel is too high for a mechanical device that is not as technology-
packed as a cardiac monitor. In addition, one unit sold in the U.S., the ZOLL AutoPulse, has a one-time
use band that must be replaced after each use; and this replacement cost is not currently reimbursed by
most insurance agencies.
Types of Mechanical CPR Devices

Piston CPR Devices: Piston compression devices use battery power (e.g., the LUCAS 2 from Physio-
Control) or pneumatic power derived from compressed oxygen (e.g., the LifeStat from Michigan
Instruments, which also features an associated integrated ventilator). Early studies found that
mechanical piston CPR improved hemodynamic parameters, but not survival. However, these studies
were performed prior to the latest AHA guidelines and before crews began using compressions-only
CPR, early adult IO (EZ-IO) establishment, impedance threshold devices (ResQPOD), therapeutic
hypothermia and a “pit crew” approach to resuscitation.

Piston chest compression devices have been shown to be actually less damaging than manual CPR.
Trauma, such as rib fractures, is an occasional occurrence in CPR and a complication of this and other
mechanical devices.

The 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Science state, “There is insufficient evidence to support or refute the routine use of mechanical piston
devices in the treatment of cardiac arrest. Mechanical piston devices may be considered for use by
properly trained personnel in specific settings for the treatment of adult cardiac arrest in circumstances
(e.g., during diagnostic and interventional procedures) that make manual resuscitation difficult (Class
IIb, LOE C).”

However, EMS insiders believe that the positive results being realized by EMS systems using mechanical
CPR devices applied early and efficiently; the move to compressiond-only CPR and its proven efficacy;
and the results of Dr. Idris’ study, which shows the need to keep compressions within a defined range of
100–120 compressions per minute, will result in a stronger position for mechanical CPR in the future.

Active Compression-Decompression (ACD) Devices: This piston technique, not yet approved for use in
the U.S., integrates a suction cup that allows for active return of the chest and provides both active
chest compression and active chest decompression (ACD-CPR).

A 2005 study demonstrated that incomplete chest recoil during CPR worsens hemodynamics. The study,
although performed in piglets, indicated that leaning on the chest during CPR and not allowing the chest
to fully expand on the upstroke led to worse systolic blood pressure, worse coronary perfusion pressure
and substantially reduced myocardial blood flow.

Load-Distributing Band (LDB): The ZOLL AutoPulse device uses a load-distributing band that is placed
around the patient’s chest and circumferentially tightens and loosens around the patient, distributing
the force evenly to generate changes in intrathoracic pressure.

Initial studies of the device had found improved hemodynamic parameters and coronary perfusion
pressures as well as improved prehospital survival to the emergency department. Recent trials showed
improved hemodynamics, with coronary perfusion pressures above the level generally associated with
improved survival, as well as improvement in survival to arrival at the emergency department when
compared with manual CPR.
A multi-site cluster-randomized trial (ASPIRE) that the Columbus (Ohio) Division of Fire participated in
was terminated early due to a lack of benefit and apparent harm. It is believed that site-specific factors
had led to the poorer results, and further clinical research is still ongoing.

However, in the 2006 JAMA article, the authors looked at 783 adults with non-traumatic cardiac arrest
in the prehospital setting. They compared resuscitation outcomes before and after switching over their
urban EMS system to a load-distributing band (LDB) CPR device. They compared 499 patients in the
manual CPR phase and 284 patients in the LDB CPR phase. The LDB device was placed on 210 out of the
284 patients in this last phase.

Rates for ROSC and survival were increased with LDB CPR compared with manual CPR. Survival to
hospital admission was 20.9% in the LDB CPR group vs. 11.1% in the manual CPR group, and survival to
hospital discharge was 9.7% vs 2.9% respectively.

In secondary analysis of the 210 patients on whom the LDB device was applied, 38 patients (18.1%)
survived to hospital admission (95% CI, 13.4%–23.9%) and 12 patients (5.7%) survived to hospital
discharge (95% CI, 3.0%–9.3%). Among patients in the manual CPR and LDB CPR groups who survived to
hospital discharge, there was no significant difference between groups in cerebral performance category
(P=.36) or overall performance category (P=.40).

Their final conclusion: Compared with resuscitation using manual CPR, a resuscitation strategy using LDB
CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-
hospital nontraumatic cardiac arrest.

According to the 2010 AHA Guidelines, “The LDB may be considered for use by properly trained
personnel in specific settings for the treatment of cardiac arrest (Class IIb, LOE B). However, there is
insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest.”

The Columbus Experience

The Columbus (Ohio) Division of Fire has had the opportunity to use and evaluate several types of
mechanical CPR devices. We used the Thumper devices in the 1970s and 1980s, and we were one of the
participating systems in the ASPIRE trial, which provided exposure to the Autopulse device.

In July 2011, we put LUCAS devices on three of our EMS officer vehicles. In the first six months of usage,
we used the devices 71 times. Although this was not a scientific study, our average ROSC rate with
manual CPR was 30.5% and our hospital discharge rate was just 11.1%. With the LUCAS device it was
19% and 2.3%.

During the first six months of 2012, the ROSC rate and hospital discharge rate with manual CPR was 33%
and 12% respectively and with the LUCAS it was 30% and 4%.

Our results are not as positive as some other systems that have mechanical CPR devices on all of their
ALS vehicles because the LUCAS devices were only available on our EMS officer vehicles. Although
manual CPR had been going on from the start of each arrest, the device was being applied late into most
cardiac arrests. It was also being applied to patients who had not quickly converted from a ventricular
fibrillation or ventricular tachycardia rhythm.

The Columbus Department of Fire EMS staff has a favorable attitude about mechanical CPR devices. The
advantages in terms of job enhancement have already been discussed. In a survey we conducted, our
EMS personnel reported the following:

• 60% of providers surveyed said application time for the LUCAS device was less than 30 seconds; 40%
said it was 30–60 seconds.

• 100% of providers surveyed said the LUCAS 2 device makes the treatment of cardiac arrest patients in
the field go smoother than with manual CPR.

• 100% of providers surveyed said they perceived that they obtain ROSC (pulses) more often on patients
that have the LUCAS device applied than with manual CPR.

• 100% of providers surveyed said they see no drawbacks to using mechanical CPR in the field.

• Responders identified the following advantages to using the LUCAS device in the field: It gives them
more time to focus on other skills and patient care; it is safer for transport in the back of the medic (no
one standing to perform CPR); it can be applied rapidly and, once applied, provides consistent CPR with
no interruptions.

Summary

In the Cochrane review, a large literature review of randomized controlled trials (RCTs), cluster RCTs and
quasi-randomized studies that compared mechanical chest compressions to manual chest compressions,
the authors conclude: “There is insufficient evidence from human RCTs to conclude that mechanical
chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit
or harm. Widespread use of mechanical devices for chest compressions during cardiac is not supported
by this review. More RCTs that measure and account for CPR process in both arms are needed to clarify
the potential benefit from this intervention.”

Further studies are needed to truly determine the efficacy of mechanical CPR devices. The LINC study, a
large RCT comparing LUCAS to manual CPR, is ongoing and expected to complete enrollment in the next
few months. The LINC trial is a prospective randomized multicenter study where LUCAS will be used with
simultaneous defibrillation compared to manual chest compressions. The study is being conducted in
first-tier systems, where LUCAS always will be placed in the first-arriving ambulance.

There also has been promising research showing benefit of Active Compression Decompression CPR and
it is expected that the LUCAS device and others will utilize this method of CPR in the future. Studies with
these devices will also be critical in assessing the overall survival of patients receiving combined
mechanical and ACD CPR.