Mechanical Chest Compression Devices: Historical Evolution, Classification and Current Practices, A Short Review: [1]

Abstract

The standard treatment of cardiac arrest is cardiopulmonary resuscitation (CPR), performed with effective manual chest compressions. Although current CPR was developed 50 years ago, cardiac arrest still has a high mortality rate and manual chest compressions have some potential limitations. Because of these limitations, mechanical chest compression devices were developed to improve the efficiency of CPR. This CPR technology includes devices such as the mechanical piston load-distributing band, active compression-decompression CPR, simultaneous sterno-thoracic CPR, impedance threshold valve, phased thoracic-abdominal active compression-decompression CPR and active compression-decompression CPR with enhanced external counterpulsation, and the impedance threshold valve. The purpose of this manuscript was to draw attention to developments in this medical area and to examine studies on the effectiveness of these devices.

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Review

Mechanical Chest Compression Devices: Historical Evolution, Classication and Current Practices, A Short Review

Mahmure Aygn1, Hacer Erten Yaman2, Asl Gen1, Funda Karadal1, Nadiye Bar Eren1

1Department of Nursing, stanbul Geliim University College of Health Science, stanbul, Turkey

2Department of Nursing, stanbul Maltepe University College of Health Science, stanbul, Turkey

Abstract

The standard treatment of cardiac arrest is cardiopulmonary resuscitation (CPR), performed with eective manual chest compressions. Although current CPR was developed 50 years ago, cardiac arrest still has a high mortality rate and manual chest compressions have some potential limitations. Because of these limitations, mechanical chest compression devices were developed to improve the efficiency of CPR. This CPR technology includes devices such as the mechanical piston load-distributing band, active compressiondecompression CPR, simultaneous sterno-thoracic CPR, impedance threshold valve, phased thoracic-abdominal active compressiondecompression CPR and active compression-decompression CPR with enhanced external counterpulsation, and the impedance threshold valve. The purpose of this manuscript was to draw attention to developments in this medical area and to examine studies on the eectiveness of these devices. (Eurasian J Emerg Med 2016; 15: 94-104)

Keywords: Cardiac arrest, cardiopulmonary resuscitation, mechanical chest compression devices

Introduction

Standard cardiopulmonary resuscitation (S-CPR) refers to the entire body of techniques of external chest compression and securing positive pressure ventilation for the purpose of achieving adequate blood and oxygen ow into vital organs such as the heart and brain following cardiac arrest (1). The current application of S-CPR is based on the technique of external chest compression that was defined by Kouwenhoven in 1960 and comprises the phases of active compression and passive decompression. Despite the evolution of resuscitation medicine, the limited improvement in survival rates following cardiac arrest has led researchers to explore the possibility of dierent CPR techniques and also to develop devices that support ventilation and circulation (2-6). This manuscript was prepared to review the experimental and clinical studies conducted on the historical progress and eectiveness of mechanical chest compression devices (MCCD).

Limitations of S-CPR

The fundamental goal of eective CPR applications is to achieve return of spontaneous circulation (ROSC) and a good neurological outcome and the return of the patient to the patients previous qu-

ality of life and functional level of health. Guidelines emphasize the importance of eective chest compression for successful CPR. The eectiveness of chest compressions depends on a couple of parameters (such as application of compressions to the right place, at an adequate depth and rate, on a regular and uninterrupted basis; letting the chest to fully recoil after each compression; avoiding over-ventilation; and maintaining a balance between compression and ventilation) (1, 5, 7, 8).

One of the basic problems related to S-CPR techniques is that even in the most eective chest compressions, a physiologically adequate amount of cardiac output may not be reached and because the quality of compression may change over time, this may cause cerebral and coronary blood ow to reduce even further as a result of the interruptions (9-11). If the chest compressions could reach the needed depth, as it does in infants and children, a higher intrathoracic pressure and cardiac output would be possible (12, 13). Another problem is that the quality of CPR is limited to the degree of knowledge, experience, and endurance of the rescuer (9, 14-17). Transferring the patient into an ambulance, discontinuing CPR prior to defibrillation, the diiculty of eectively applying the technique in a moving ambulance, failure to maintain the relationship between compression and ventilation, and reduced elastic recoil of the chest

Correspondence to: Mahmure Aygn e-mail: [email protected]

Received: 18.11.2015 Accepted: 02.03.2016

Copyright 2016 by Emergency Physicians Association of Turkey - Available online at www.eajem.com DOI: 10.5152/eajem.2016.74936

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Mechanical Chest Compression Devices 95

wall in prolonged CPR applications could all have an adverse eect on the success of CPR (5, 7, 13-17).

When the importance of chest compression is considered and in the light of the issues experienced in currently employed techniques and the low survival rates following cardiac arrest, the necessity of further developing S-CPR techniques and increasing the eectiveness of chest compression becomes clear.

Mechanical Chest Compression Devices: Definition, History, and Classification

Definition

MCCDs are noninvasive circulation support devices that function manually, pneumatically, or electrically and in accordance with CPR guidelines, provide uninterrupted and eective external chest compression to achieve an adequate blood ow to the heart and other vital organs during non-traumatic adult cardiac arrest. MCCDs can be used as an alternative to S-CPR in cases that may hinder eective compressions such as prolonged CPR during the transport of the patients or in the shortage of personnel (2, 6, 10, 18, 19).

These devices are included in the guidelines of the American Heart Association (AHA) under the heading circulatory support devices (6). They are described by the U.S. Food and Drug Administration (FDA) as External cardiac compressors (19). In the literature, the nomenclature varies, and external cardiac compression devices, automatic chest-compression devices, and mechanical CPR devices are some of the terms of reference (2, 10, 13, 18).

History

The advent of MCCDs is not new. These devices began to be developed in the beginning of the 1960s, when resuscitation medicine was merely in its infancy. Chronologically speaking, the electro-pneumatic machine developed by Harkins and Bramson (20) in 1961; the portable pneumatic pump developed by Nachlas and Siedband (21) in 1962; the Beck-Rand external cardiac compression machine developed by Safar et al. (22) in 1963; the cardiac massage machine developed by Bailey and Browse in 1964 (23); and the hospital mechanical pump developed by Nachlas and Siedband (21) in 1965 were the first MCCDs to be invented. In later years, experiments were conducted with many manually operated devices such as the cardio-massager, cardio-pulser, pneumatical iron heart, and Travenol LR50-90 (13, 24).

Many of the first developed and tested of these devices were very complex, too heavy, or ineective for use in CPR; therefore, they were found to be nonfunctional and unacceptable for the clinical setting. On the other hand, since the 2000s, many devices have begun to be developed and have found a clinical area of use, and the literature of the eects of these devices on CPR outcomes are steadily increasing.

Classification

These devices are dierent from one another in terms of their working principles, the energy they consume, and their electronic features. MCCDs used currently can be classified as follows:1. Piston-driven CPR devices (PD-CPR),2. Load-distributing band CPR devices (LDB-CPR).

In addition to these two fundamental groups, third-generation

devices, which combine dierent working mechanisms and dierent

CPR techniques, have been used in recent years, aiming to increase the hemodynamic eects of S-CPR. These are as follows:3. Active compressiondecompression CPR devices (ACD-CPR),4. Simultaneous sterno-thoracic cardiopulmonary resuscitation devices (SST-CPR/S-CPR/X CPR),

5. Inspiratory impedance threshold valve/devices and ResQCPR (ACD + ITD CPR),

6. Phased thoracic-abdominal active compressiondecompression CPR devices (PTACD-CPR), and

7. Active compressiondecompression CPR with enhanced external counterpulsation and the inspiratory impedance threshold valve (AEI-CPR) (2, 6, 13, 25-29).

The devices in these groups and their working principles have

been discussed below.

1. Piston-driven devices (PD-CPR)

These are based on the cardiac pump theory and are first-generation mechanical devices that use a piston to exert single-point compression on the sternum. One of the first examples in this group was the Pneumatically Run Thumper. A more developed model of this device is the Thumper Mechanical CPR Device Model 1007 and its updated model the Life-Stat. The Life-Stat consists of a backboard attached to a column and operates pneumatically with a piston. It has a ventilator that is meant to be used in conjunction with chest compression (Figure 1a) (Michigan Instruments, USA). Mechanical piston-driven devices that are operated manually work with a lever system and are marketed under brand names such as the Animax Mono (Figure 1b) (AAT Alber Antriebstechnik GmbH, Albstadt, Germany) and the CPR RsQAssist, which employs an audio-visual metronome (10, 13, 24, 26, 29).

2. Load-distributing band devices (LDB-CPR)

Load-distributing band devices are based on the thoracic pump theory and represent second-generation mechanical chest compression technology. These devices exert thoracic compression on the anterior-anterolateral thorax using a wide pneumatic band that wraps around the chest, inating and deating at cyclically. The basic equipment in these devices consists of a backboard, a chest compression band (load-distributing Life Band), and a power system. The first example of this type of device was the Vest-CPR. Currently, devices that work with this mechanism are marketed under commercial names such as the pneumatic Automated CPR Vest (Reax resuscitation device) and the pneumatic or electrical AutoPulse (Figure 2). Studies show that the chest compression achieved all around the chest with the AutoPulse creates higher coronary perfusion pressure than sternal pressure (13, 24, 25, 29-33).

3. Active compressiondecompression CPR devices (ACD-CPR)

ACD-CPR devices are third-generation devices that work on the piston principle. These devices were developed based on a news article published in 1990 about a successful resuscitation attempt of a lay person performed with a toilet plunger to his father (34, 35). As is known, in S-CPR, the return of blood to the heart is dependent only on the passive recoil of the chest wall. The principle behind this technique may be summarized as the pumping of blood outside of the thorax through positive pressure in the active compression phase and then exerting an external negative vacu-

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um, creating an intrathoracic negative pressure during the active decompression phase to increase the venous return of blood to the heart. Thus, in the next compression phase, an increase is achieved in cardiac output, coronary and cerebral blood ow, and in arterial blood pressure. The most widely known and commonly used of the ACD-CPR devices is the LUCAS (Lund University Cardiac Assist System). The original LUCAS 1 was a pneumatic device that was developed in Sweden by Steen in 2002. The new model of the device, introduced in 2010 under its new name LUCAS 2 (LUCAS 2 Chest Compression System), runs on electricity and consists of a piston for compression, a silicone suction cup for decompression, a rechargeable battery, a backboard, and connecting legs (Figure 3a). The device allows defibrillation without interrupting compression, and its X-ray translucent capability makes cardiac catheterization possible. The ACDC Thumper is another pneumatic device. The manual devices that operate with the ACD-CPR technique are marketed under trade names such as CardioPump, ResQPump, and Ambu Cardio Pump (Figure 3b) (6, 13, 24, 29, 36-40).

4. Simultaneous sterno-thoracic CPR devices (SST-CPR / X-CPR)

These devices were designed to benefit from both the cardiac pump and thoracic pump theories. These devices have two components: a piston (which depresses the sternum in the compression phase) and a circumferential band (which constricts the thorax simultaneously compressions).The Life Belt is a device that is operated manually using the SST-CPR principle. Another such device is the pneumatic Weil Mini Chest Compressor (Figure 4) (Resuscitation International, USA) (13, 41-44).

5. Inspiratory Impedance Threshold Device (ITD) and ResQCPR (ACD+ITD CPR)

The inspiratory ITD is a pressure-sensitive one-way valve system that can be connected to a face mask or to any developed airways equipment such as endotracheal tubing. The valve closes in the decompression phase of CPR, temporarily blocking the more than necessary passage of passive air through the open airway into the patients lungs, thus decreasing intrathoracic pressure and creating a small vacuum. This increases the ow of venous blood to the heart, and the increased venous return increases cardiac output in the next compression. ITD are marketed under the trademark ResQPOD ITD 16. ITD can be used alone during S-CPR as well as it may be used in combination with manual ACD-CPR devices such as the CardioPump and the ResQPump. This system is known as ResQCPR. ResQCPR=ACD-CPR (ResQPUMP)+ITD (ResQPOD) (Figure 5a) (6, 27, 45-47).

a

b

Figure 1. a, b. Piston-driven CPR devices (a) Pneumatic: Thumper (LifeStat) (https://www.michiganinstruments.com). (b) Manual: Animax Mono (http://www.aat-online.de/)

Figure 2. Load-distributing band CPR devices Auto Pulse (69)

Figure 3. a, b. Active compressiondecompression CPR devices. (a) Pneumatic/electrically driven ACD-CPR devices: LUCAS 2 (36). (b) Manual driven ACD-CPR devices: ResQPump (18).

a

b

Figure 4. Simultaneous sterno-thoracic cardiopulmonary resuscitation devices

Weil Mini Chest Compressor (http://www.resusintl.com/)

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a

b

Figure 5. a, b. Other CPR devices. (a) Impedance threshold device (ITD) and ResQCPR: ResQPod+ResQPump (46). (b) Phased thoracic-abdominal compressiondecompression CPR: Lifestick (48)

6. Phased thoracic-abdominal active compression decompression CPR devices (PTACD-CPR)

Interposed abdominal compression CPR (IAC-CPR) activates the abdominal venous reservoir by increasing abdominal pressure; this CPR technique is based on forcing venous return, thereby increasing venous return to the heart. Abdominal compression is applied to the area midpoint between the xiphoid and umbilicus in the relaxation phase of chest compression. Phased thoracic-abdominal active compressiondecompression CPR constitutes the working principle behind ACD-CPR and IAC-CPR and is a new method that combines the two techniques. PTACD-CPR is applied by simultaneous chest compression (positive intrathoracic pressure) and active abdominal decompression and then following this phase, simultaneous active chest decompression (negative intrathoracic pressure) and abdominal compression. The Lifestick was developed for use in this technique; it is a manually controlled device. The device consists of a rigid central bar and two arms with adhesive pads that are connected to this rigid bar. The larger adhesive pad is placed over the abdomen and the smaller over the anterior chest wall. An implementer compresses the two sides of the device just like a seesaw, applying pressure both on the chest and the abdomen alternately (Figure 5b) (11, 27, 48-50).

7. Active compressiondecompression CPR with Enhanced External Counterpulsation and the Inspiratory Impedance Threshold Valve (AEI-CPR)

Enhanced external counterpulsation (EECP) is a circulatory support system that achieves increased cardiac output using a method whereby cus applied to the lower extremities are inated during diastole to increase coronary blood circulation and deated at the early systole to reduce afterload and increase venous return. AEI-CPR is another experimental technique, which is a combination of active

compressiondecompression CPR, EECP, and Inspiratory impedance threshold valve, aiming to improve CPR hemodynamics and increase survival rates. This technique, which is still in its theoretical and experimental stage, is simply expressed as AEI-CPR=ACD-CPR+EECP+ITV (51, 52).

Studies Conducted on the Eectiveness of MCCDs

Theoretically, MCCDs appear to provide many practical advantages, such as the mechanical devices deliver compressions at the same frequency and depth which are recommended in the guidelines, as opposed to the inter-rescuer variations and fatigue factors that aect the quality of chest compression; these devices allow the rescuers to perform other tasks (cannulation, airway, etc.) and defibrillation without the need of interruption in CPR; and they provide consistent rate and depth of chest compressions during transport of the patient.

However, the main issue is to what degree these devices have an impact on survival in cardiac arrest, on hemodynamic parameters, and on the survival neurologically intact and whether they produce a significant dierence in in-hospital and out-of-hospital cardiac arrests (IHCA and OHCA, respectively) compared to S-CPR. Experimental studies conducted with some mechanical chest compression devices developed in recent years present strong evidence that these devices increase the eectiveness and quality of CPR. Moreover, although they were first developed to achieve uninterrupted CPR, particularly in cases of OHCA, the studies on the use of these devices in IHCAs help to expand their clinical usage area. This section will review some of the results of some MCCD-related experimental or clinical studies on in-hospital and out-of-hospital cases.

Experimental studies with LUCAS-CPR have shown that the device enables significantly higher cerebral blood circulation than S-CPR as well as higher rates of cardiac output, carotid artery blood

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Table 1. Studies with LUCAS-CPR

Title

Study design

Results

Conclusion

1. Rubertsson S (2005).

Experimental: pigs:

Mean cortical cerebral blood flow and

L-CPR generated higher cerebral

Increased cortical cerebral

VF was induced (n=14),

ETCO2 was significantly higher in

blood flow and cardiac output

blood flow with LUCAS;

L-KPR (n=7), S-KPR (n=7)

L- CPR than in S-CPR (in order of;

than S-CPR. The results strongly

a new device for mechanical

p=0.041 and p=0.009).

support prospective

chest compressions compared

randomized studies in patients

to standard external

to evaluate the effects of this

compressions during

device in clinical practice.

experimental cardiopulmonary

resuscitation (9)

2.Steen S (2002). Evaluation of

Experimental: In an

n thorax model: Superior pressure and

LUCAS gave significantly better

LUCAS, a new device for automatic

artificial thorax model

flow were obtained with L-CPR

circulation during ventricular

mechanical compression and active

and pigs: VF was induced

compared with S-CPR

fibrillation than manual chest

In pigs: higher CO, carotid artery blood

compressions. flow, ETCO2, and CPP were obtained

with L-CPR (83% ROSC) than with S-CPR (0% ROSC).

decompression resuscitation (36)

3. Liao Q (2010). Manuel versus

Experimental: pigs: VF

ROSC: LCPR (n=8), S-CPR (n=3),

L-CPR generated higher CPP

mechanical cardiopulmonary

was induced (n=16),

The mean CPP: L-CPR 20, S-CPR 5 mmHg,

than S-CPR.

resuscitation. An experimental

L-KPR (n=8), S-KPR (n=8)

p<0.01, ETCO2; higher in the

study in pigs (53)

LCPR group (p<0.05).

4. Larsen A (2007). Cardiac arrest

Clinical study:

The device allowed visualization of the

Coronary angiography and

with continuous mechanical chest

IHCA: LUCAS has been

coronary arteries in all patients,

coronary intervention may be

compression during percutaneous

used During PCI (n=13)

PCI was successfully performed in

successfully performed in

coronary intervention. A report on

eight patients.

patients with cardiac arrest

the use of the LUCAS device (54)

using the LUCAS device

5. Bonnemeier H (2009).

Clinical study: IHCA, LUCAS

The device allows for uninterrupted chest

LUCAS may significantly

Automated continuous chest

has been used During

compressions during angiography and

improve the chain of survival

compression for in-hospital

PCI (n=5)

angioplasty.

and clinical outcome in patients

cardiopulmonary resuscitation

CT evidences show that L-CPR may also

with IHCA.

of patients with pulseless electrical

provide additional therapeutic effects

in those patients with PEA due to PE, mechanical thrombus fragmentation, and increase pulmonary artery flow after LUCAS-compression.

activity: A report of five cases (55)

6. Bonnemeier H (2011).

Clinical study: IHCA,

ROSC: n=27, Dying within the first hour

Continuous chest compression

Continuous Mechanical chest

L-CPR, patients with PEA

(n=10), 24 h (n=3) after CPR, Discharged

with LUCAS seems to be

compression during in hospital

(n=28)

from hospital CPC 1 and 2: n=13,

feasible, safe, and might

cardiopulmonary resuscitation of

L-CPR, During coronary

PE (n=14), did not undergo thrombolytic

improve outcomes after IHCA of

patients with pulseless electrical

angiography and

therapy (n=6/14), CT angiography in these

PEA cardiac arrest.

activity (56)

pulmonary angiography

patients showed fragmentation of the

Patients with PE may benefit

(n=21),

thrombus.

probably because of thrombus

fragmentation and increased pulmonary artery blood flow.

7. Wagner H (2010). Cardiac arrest in

Clinical study: Retrospective

The PCI procedures were successfully

Discharge CPC 1: >25% (n=11)

the catheterization laboratory:

2004-2008, IHCA: During

performed during mechanical chest

Mechanical chest compressions

a 5-year experience of using

PCI using LUCAS (n=43)

compressions (n=36) and pericardiocentesis

devices enable continued chest

mechanical chest compressions

(n=1).

compressions during PCI with

to facilitate PCI during prolonged

maintained circulation, which

may reduce mortality in patients with cardiac arrest, requiring lengthy

CPR, in the catheterization

resuscitation efforts (57)

laboratory,

8. Fidler R (2014). Three modes of

Case report: Post-CABG

S-CPR (8 min): Average arterial

LUCAS-2 could provide superior

cardiac compressions in a single

patient receiving three

pressures=65/10 mmHg

arterial blood pressure

patient: A comparison of usual

modes of cardiac

L-CPR (10 min): Average arterial

compared to S-CPR and open

manual compressions, automated

compressions S-CPR,

pressures=100/60 mmHg.

cardiac massage.

compressions, and open cardiac

L-CPR, and open cardiac

Open cardiac massage: Average arterial

massage (58)

massage

pressures=70/15 mmHg

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Mechanical Chest Compression Devices 99

Table 1. Studies with LUCAS-CPR (Continued)

Title

Study design

Results

Conclusion

9. Axelssona C (2006).

OHCA, Non-randomized,

No significant difference in ROSC

No sufficient evidence to

Clinical consequences of the

Sweden, 2003-2005,

(51% in both groups),

support that mechanical CPR

introduction of mechanical chest

L-CPR (n=159),

Survival to hospital admission:

would improve outcomes. It is

compression in the EMS system for

S-CPR (n=169)

L-CPR (38%) and S-CPR (37%),

important to perform further

treatment of out-of-hospital cardiac

Hospital discharge: L-CPR 8% and S-CPR 10%

randomized trials to investigate

arrest- A pilot study (60)

Discharge CPC 1: L-CPR 83%, S-CPR 76%.

how to use mechanical chest

(device was used in only 105 cases (66%)

compressions in accordance with pre-hospital standards

10. Smekal D (2011). A pilot study of

OHCA, prospective pilot

ROSC with a palpable pulse: L-CPR 41%,

Discharged: L-CPR 8%,

mechanical chest compressions

study, Sweden, 2005-2007

S-CPR 32 (p=0.30),

S- CPR 10% (p=0.78).

with the LUCAS device in

L-CPR (n=75), S- CPR (n=73)

ROSC with BP >80/50 mmHg > 5 min:

In this pilot study, there was no

cardiopulmonary resuscitation (61)

L-CPR 31%, S-CPR 26%, p=0.59

difference in early survival

Hospitalized alive >4 h: L-CPR 24%,

between L-CPR and S-CPR.

S-CPR 21%, p=0.69

11. Axelssona C (2009). Mechanical

OHCA, a prospective pilot

ETCO2 was significantly higher in L- CPR

L-CPR performed better than

active compressiondecompression

study, Sweden, 2003-2005

than in S- CPR according to initial (p=0.01),

S-CPR regarding cardiac output.

cardiopulmonary resuscitation

L-CPR (n=64), S- CPR (n=62)

average (p=0.04), and minimum (p=0.01).

(ACD-CPR) versus manual CPR

No differences in survival outcomes.

according to pressure of end tidal

carbon dioxide (PETCO2) during

CPR in out-of-hospital cardiacj arrest (62)

12. Rubertsson S (2014). Mechanical

OHCA, randomized,

ROSC:L-CPR 35.4%, S-CPR 34.6%, p: 0.68,

There was no significant

Chest Compressions and

multicenter (Sweden,

Four-hour survival: L-CPR 23.6%,

difference between the two

Simultaneous Defibrillation vs

Netherlands, England),

S-CPR 23.7%, p>0.99,

groups. In clinical practice,

Conventional Cardiopulmonary

20082012

Discharge with a CPC score of 1-2:

mechanical CPR using the

Resuscitation in Out-of-Hospital

L-CPR (n=1300)

L-CPR 8.3%, S-CPR 7.8%, p:0.61

presented algorithm did not

Cardiac Arrest: The LINC

S-CPR (n=1289)

Surviving at 6 months with a CPC score

result in improved effectiveness

Randomized Trial (63)

of 1-2: L-CPR 8.5%, S-CPR 8.1%, p:0.67

compared with manual CPR.

13. Perkins G (2015). Mechanical

OHCA, randomized,

ROSC (survived event): L-CPR 23%,

There was no significant

versus manual chest compression

England, 2010-2013,

S-CPR 23%,

difference between two groups.

for out-of-hospital cardiac arrest

L-CPR (n=1652)

30 day survival: L-CPR 6%, S-CPR 7%, p: 0.86,

This trial was unable to show

(PARAMEDIC): a pragmatic cluster

S-CPR (n=2819)

Survival with CPC 12: L-CPR 5%, S-CPR 6%,

any superiority of mechanical

randomized controlled trial (64)

p: 0.72

CPR.

[device was used in only 985 cases (60%)]

14. Blomberg H (2011). Poor chest

Experimental, evaluated the

Adequate compressions: L-CPR 58%,

The performance of trained

compression quality with

CPR performance of

S-CPR 88%,

ambulance crews (which uses

mechanical compressions in

ambulance crews

The median compression depth:

LUCAS) was found to be

simulated cardiopulmonary

(L-CPR and S-CPR) in a

L-CPR 3.8 cm, S-CPR 4.7 cm

remarkably poor.

resuscitation: A randomized,

manikin setup

Only 12 out of the 21 ambulance crews

Poor chest compressions due to

cross-over manikin study (65)

(n=21)

(57%) applied the mandatory stabilization

failure in recognizing and

correcting a malposition of the device reduced a potential benefit of mechanical chest

strap on the LUCAS device.

compressions.

VF: ventricular fibrillation; CO: cardiac output; CPP: coronary perfusion pressures; PCI: percutaneous coronary intervention; IHCA: in-hospital cardiac arrest;

OHCA: out -hospital cardiac arrest; ROSC: return of spontaneous circulation; PE: pulmonary emboli; PEA: pulseless electrical activity; CPC: cerebral performance category; CABG: coronary artery bypass grafting; ETCO2: end-tidal CO2; L-CPR: LUCAS KPR; BP: blood pressure

ow, end tidal CO2 (ETCO2), aortic and coronary perfusion pressure, and ROSC (9, 36, 53). The LUCAS device has been used in IHCA situations, in cardiac catheterization laboratories, and intensive care units. Studies show that the LUCAS device is functional during percutaneous coronary interventions (54-58). The findings reported in the mentioned studies have been summarized in Table 1. The use and eectiveness of mechanical chest compression devices such as LUCAS in organ transplants from non-heart-beating donors, in situations where a decision to terminate life and execute an organ

transplant has been made, and where CPR is continued until the start of extracorporeal oxygenation (ECMO) are the subjects of ongoing studies (59).

Details of LUCAS-CPR studies with nontraumatic adult OHCA patients are shown in Table 1. Axelsson et al. (60) and Smekal et al. (61) have reported no significant dierences in their studies when compared with S-CPR, whereas the same team in another study (62) revealed that ETCO2 values, which are a prognostic value for cardiac output and survival, were significantly higher in the LUCAS group

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than in the S-CPR group. In two large randomized studies (LINC-LUCAS in Cardiac Arrest and PARAMEDIC-The Prehospital Randomised Assessment of a Mechanical Compression Device In Cardiac Arrest), no significant dierence was found between LUCAS-CPR and S-CPR in terms of ROSC and survival with good neurological outcomes (63, 64). In another study in which the skills of healthcare personnel in using LUCAS were evaluated, it was determined that the rate and depth of compressions applied to a manikin using LUCAS were inadequate compared with S-CPR (65).

Table 2 displays the findings of studies conducted on the effectiveness of AutoPulse in CPR (A-CPR). A study conducted with IHCA patients where AutoPulse was used reported that A-CPR produced higher coronary perfusion pressure than S-CPR (66). In two non-randomized studies using AutoPulse in OHCA patients, it was shown that A-CPR produced better results than S-CPR (32, 67). In a multi-center randomized study, the results of the ASPIRE Trial (Assisted Prehospital International Resuscitation Research) indicated that survival to hospital discharge and good neurological outcomes were lower in A-CPR than in S-CPR (68). The results of two nonrandomized, small sample size studies support the effectiveness of A-CPR (69, 70). Another large, randomized study (30) reports that survival rates with ROSC and satisfactory neurological outcomes were better with A-CPR than with S-CPR. A review of the results of the Circulation-Improving Resuscitation Care (CIRC) Trial, another multicenter randomized study conducted with AutoPulse, revealed that A-CPR is equal to S-CPR in terms of ROSC and survival rates (71).

Table 3 presents the results of some studies that have reported on other MCCDs and techniques. Some trials on ResQCPR (ACD+ITD CPR) have reported short- and long-term survival rates to be higher than those for S-CPR (47, 72, 73). The results of trials with simultaneous sterno-thoracic CPR devices (SST-CPR/X-CPR) reveal hope for the future of these devices. In a study that consisted of a small series of cases, X-CPR produced higher coronary perfusion pressure than S-CPR (42). In a study with the Lifestick, a phased thoracic-abdominal active compressiondecompression CPR device, no dierence was detected compared with S-CPR in terms of ROSC, but it was reported that this technique could be advantageous for patients with asystole or pulseless electrical activity (48). Another study conducted with a small sample (49) did not report any statistically significant dierence between using the Lifestick and applying S-CPR.

In the literature, there are also simulation studies where CPR devices and techniques were compared. Zhang et al. (11) used a circulation computer model in an experimental study to compare five ITD-supported techniques (S-CPR, ACDCPR, IACCPR, LifestickCPR, and EECPCPR) in terms of their hemodynamic eects, and they found Lifestick-CPR to be the most eective. A similar simulation study of five CPR techniques [S-CPR, ACD-CPR, IAC-CPR, ACD-CPR+External counterpulsation (ECP), and S-CPR+ECP] had made a comparison and found that cardiac output, cerebral blood ow, coronary blood ow, and mean coronary perfusion pressure to be the lowest in S-CPR and highest in IAC-CPR, with ACD-CPR+ECP exhibiting values close to this (51).

MCCDs in the Guidelines

An evaluation was made of the recommendations for use and the levels of evidence cited in the AHA 2010 and 2015 guidelines based on large randomized trials. In the case of automatic ACD-CPR

devices such as LUCAS and LDB-CPR devices such as Autopulse, the guidelines state that the evidence to support or reject the routine use of these devices in the treatment of cardiac arrest is not suicient and that manual chest compressions remain as the standard treatment of cardiac arrest; however, these devices may be a reasonable alternative for use by properly trained personnel (AHA 2015: Class IIb, LOE B-R). Furthermore, the guidelines state that the use of mechanical piston devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider [e.g., limited rescuers available and prolonged CPR during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, and during preparation for extracorpo-real CPR (ECPR)], provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices (AHA 2015: Class IIb, LOE C-EO) (6, 74).

The AHA 2010 guideline states with regard to manual ACD-CPR devices that there is no adequate evidence to either recommend or reject the routine use of these devices and that the use of the devices may be considered in the event of properly trained personnel. The AHA 2015 guideline has not made any revision with regard to these devices, maintaining the same recommendations and evidence level specified in the 2010 guideline (Class IIb, LOE B) (6, 74).

With respect to the sole use of the ITD-CPR device, the AHA 2010 guidelines recommendation and evidence level places the device in Class IIb, LOE B, whereas the AHA 2015 guideline has changed the recommendation and evidence level, placing it in the category of Not recommended for routine use S-CPR (Class III: No benefit, LOE A) (6, 74).

There appears to be no evaluation in the AHA 2010 guideline for ITD+ACD-CPR (RESQCPR). In the 2015 guideline, however, it is stated that this combination is not recommended for routine use as an alternative for S-CPR but may be considered as an alternative only in the presence of available equipment and trained personnel (Class IIb, LOE C-LD) (6, 74).

It can be seen that the AHA 2010 and 2015 guidelines do not include information and data on CPR devices and combinations such as the SST-CPR, PTACD-CPR, and AEI-CPR because these are still in the experimental stage and are not supported by adequate clinical research (6, 74).

Conclusion

In a general assessment, it may be stated that although large randomized trials have as yet highlighted the superiority of these devices over S-CPR in OHCA, they have at the same time not produced any evidence to prove their failure or harm.

The possibilities to be created by the harmonious cooperation of the disciplines of mathematics, biology, medicine, engineering, and the physical sciences in the process of developing biomedical equipment technologies and the role technology will play in constructing the future cannot be ignored. Therefore, an increase in the number of experimental and clinical research on CPR technologies and the evaluations & revisions performed according to the results of these studies will pave the way for the development of changes with respect to the application methods and areas of these devices. Ensuring that these devices become more functional, effective, and reliable will improve the effectiveness of CPR and may reduce the incidence of morbidity and mortality accompanying cardiac arrest.

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Mechanical Chest Compression Devices 101

Table 2. Studies with Autopulse

Title

Study design

Results

Conclusion

1. Timerman S (2004). Improved

IHCA (at ICU), Brazil,

Peak aortic pressure: A-CPR153,

A-CPR demonstrated a clinically

hemodynamic performance with a

2000-2001, A-CPR (n=8),

S-CPR 115 mmHg, p<0.0001

significant improvement in

novel chest compression device

S-CPR (n=8)

Peak right atrial pressure: A-CPR=129,

hemodynamics compared to

during treatment of in-hospital

S-CPR=83 mmHg, p<0.0001 CPP: A-CPR=20

manual chest compressions.

cardiac arrest (66)

mmHg, S-CPR=15 mmHg, p<0.015

2. Hock Ong ME (2006). Use of an

OHCA, observational,

ROSC: A-CPR 34.5%, S-CPR 20.2%

A-CPR is better. AutoPulse was

automated, load-distributing band

A-CPR (n=284), (2003-2005)

Survival to hospital admission: A-CPR 20.9%,

improved survival to hospital

chest compression device for

S-CPR (n=499) (2001-2003)

S-CPR 11.1%

discharge when compared to

out-of-hospital cardiac arrest

device was used in only

Survival to hospital discharge:

S- CPR

resuscitation (32)

210 cases

A-CPR 9.7%, S-CPR 2.9%

No difference in CPC (p=0.360)

(device was used in only 210 cases)

3. Casner M (2005). The impact of

OHCA, Retrospective,

Arrival to an emergency department with

A-CPR may improve ROSC and

a new CPR device on rate of

A-CPR (n=69), S-CPR (n=93)

measurable spontaneous pulses:

may particularly benefit patients

spontaneous circulation in out-of

A-CPR 39%, manual 29%, p: 0.003,

with no shockable rhythms.

hospital cardiac arrest (67)

At shockable rhythms: A-CPR 44%, manual 50%, p: 0.340,

At asystole: A-CPR 37%, manual 22%, p: 0.008, At PEA: A-CPR 38%, manual 23%, p: 0.079).

4. Hallstrom A (2006). Manual chest

OHCA, randomized,

Survival to 4 h: A-CPR 29.5%,

Use of an automated LDB-CPR

compression vs. use of an

multicenter (US, Canada)

S-CPR 28.5%, p=0.74

device as implemented in this

automated chest compression

2004-2005

Survival to hospital discharge: A-CPR 5.8%,

study was associated with

device during resuscitation

A-CPR (n=554),

S-CPR 9.9%, p=0.060

worse neurological outcomes

following out-of-hospital cardiac

S-CPR (n=517)

CPC 12 at hospital discharge: A-CPR 3.1%,

and a trend toward worse

arrest: A randomized trial

S-CPR 7.5%, p=0.006

survival compared with manual

(ASPRE) (68)

CPR.

5. Krep H (2007). Out-of-hospital

OHCA, prospective,

ROSC: 54.3% (n=25/46), chest compression

The AutoPulse is an effective

cardiopulmonary resuscitation with

Germany, 2004-2005

device (69)

and safe mechanical CPR device

the AutoPulseTM system:

A-CPR (n=46),

Admitted to ICU: 39.1% (n=18/46),

useful in OHCA

A prospective observational study

ACD-CPR (n=48)

Discharged from ICU: 21.8% (n=10/46)

Discharged CPC 1=2; CPC 2=1; CPC 3= 7 patient (n=10)

ROSC ACD-CPR with use cardio pump: 52% (n=48)

with a new load-distributing band

6. Duchateau F-X (2010). Effect of

OHCA, prospective,

Median diastolic BP: A-CPR 23 mmHg,

The use of the AuotoPulse is

the AutoPulse automated band

France (2008)

S-CPR 17 mmHg, p<0.001

associated with increased

chest compression device on

A-CPR (n=29) (first S-CPR

Median systolic BP: A-CPR 106 mmHg,

diastolic BP compared to S-CPR.

hemodynamics in out-of-hospital

and then A-CPR same

S-CPR 72 mmHg, p<0.02,

cardiac arrest resuscitation (70)

groups)

Mean BP: A-CPR 36 mmHg,

S-CPR 29 mmHg, p<0.002,

ETCO2: did not increase with Autopulse

(from 21 to 22 mmHg, p=0.80)

7. Jennings PA (2012). An automated

OHCA, retrospective,

Survival to hospital : A-CPR 26% (17/66),

Further research is warranted,

CPR device compared with standard

Australia, 2006-2010

S-CPR 20% (43/220), p=0.23

which involves randomization

chest compressions for

A-CPR (n=66),

Survived to hospital discharge: A-CPR 3%

and larger number of cases to

investigate the potential benefits of A-CPR, including survival to hospital discharge.

out-of-hospital resuscitation (25)

S-CPR (n=220)

(n=2/66), S-CPR 7% (15/220), p=0.38

8. Hock Ong ME (2012). Improved

OHCA, multicenter,

ROSC: A-CPR 35.3% (n=195),

The AutoPulse improved

neurologically intact survival with

randomized, Singapore

S-CPR 22.4% (n=103)

survival with intact neurological

the use of an automated, load-

S-CPR (n=459, 2004-2007)

Survival to hospital discharge: A-CPR 3.3%,

status on discharge in adults

distributing band chest compression

A-CPR (n=522, 2007-2009)

S-KPR 1.3%

with non-traumatic cardiac

device for cardiac arrest presenting

CPC 1 -2 at hospital discharge: A-CPR 81.3%

arrest.

to the emergency department (30)

(n=13/16), S-CPR 33.3% (n=2/6).

9. Wik L (2014). Manual vs. integrated

OHCA, multicenter

ROSC: A-CPR 28.6%, S-CPR 32.3%,

CIRC Trial: Compared to high-

automatic load-distributing band

(US, Europe), randomized,

no different

quality A-CPR, S-CPR resulted in

CPR with equal survival after out of

(2009-2011),

24-h survival: A-CPR 21.8%, S-CPR 25%,

statistically equivalent survival

hospital cardiac arrest. The

A-CPR (n=2099),

no different survival to hospital discharge:

to hospital discharge.

S-CPR (n=2132)

A-KPR 9.4%, S-KPR 11%, no different

CO: cardiac output; CPP: coronary perfusion pressure; IHCA: in-hospital cardiac arrest; OHCA: out -hospital Cardiac arrest; ROSC: return of spontaneous circulation;

PEA: pulseless electrical activity; CPC: cerebral performance category; ETCO2: end-tidal CO2; A-KPR : AutoPulse CPR; ICU: intensive care unit; BP: blood pressure

randomized CIRC trial (71)

102

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Mechanical Chest Compression Devices

Eurasian J Emerg Med 2016; 15: 94-104

Table 3. Studies wth other devices

Title

Study design

Results

Conclusion

Plaisance P (2004). Evaluation of

OHCA, multicenter,

24-h survival: ACD-KPR+ active ITD 32%,

ACD-KPR+active ITD

an impedance threshold device

randomized, prospective,

ACD-KPR+sham ITD 22%,p = 0.02

significantly improved

in patients receiving active

France, 1999-2000

ROSC: ACD-KPR+active ITD:48%, ACD-KPR+

24-h survival rates.

compression decompression

ACD-KPR+ active ITD

sham ITD:39%, p=0.05

cardiopulmonary resuscitation

(n=200)

Survival ICU admission: ACD-CPR+active

for out of hospital cardiac

ACD-KPR + sham ITD

ITD 40%, ACD-CPR+sham ITD 29% (p=0.02)

arrest (72)

(n=200)

Hospital discharge: ACD-CPR+active

ITD: 5%, ACD-KPR+sham ITD:4% (p:0.02)

Impedance threshold device (ITD+ACD-KPR) Simultaneous Sterno thoracic Phased Chest and Abdominal

Wolcke BB (2003). Comparison

OHCA, prospective,

ROSC: ACD-CPR+ITD 55%, S-CPR 37%,

Compared with S-CPR,

of standard cardiopulmonary

Germany, 1999-2002

p:0.016

ACD- CPR+ITD

resuscitation versus the

ACD-CPR+ITD (n=103)

1-hour survival: ACD-CPR+ITD 51%,

significantly improved

combination of active

S-CPR (n=107)

S-CPR 32%, p:0.006

short-term survival

compressiondecompression

24-h survival: ACD-CPR+ITD 37%,

rates

cardiopulmonary resuscitation

S-CPR 22%, p:0,033

and an inspiratory impedance

Hospital discharge: ACD-CPR+ITD 18%,

threshold device for out-of-

S-CPR 13%, p:0.41

hospital cardiac arrest (73)

Frasconea RJ (2013).Treatment

ResQTrial; OHCA,

Survival with good neurologic outcomes:

ResQCPR showed

of non-traumatic out-of-hospital

randomized, prospective,

ResQCPR 7.9%, S-CPR 5.7%, p:0.027,

significant increase in

cardiac arrest with active

multicenter (US, 2005-

1-year survival: ResQCPR 7.9, S-CPR 5.7%,

survival to hospital

compression decompression

2009)

p: 0.026

discharge with

cardiopulmonary resuscitation

ResQCPR (n=1403)

favorable neurological

plus an impedance threshold

S-CPR (n=1335)

function compared

device (47)

with S-CPR

Cha KC (2014). Hemodynamic

OHCA,

Right atrial pressures during compression

X-KPR demonstrated

Effects of an Automatic

X CPR (n=11)

and relaxation and

higher coronary

Simultaneous Sterno thoracic

S-CPR (n=14)

ETCO2 were not different between two

perfusion pressure

CPR Device in Patients with

groups.

than standard CPR

Cardiac Arrest (42)

Femoral arterial pressures during relaxation and CPP were higher in X-CPR (p=0.017).

Yang Z (2014). Similar

Experimental, pigs: VF was

There were no differences in CPP, ETCO2, and

Similar hemodynamic

Hemodynamic Efficacy Between

induced, MCC compression

carotid blood flow between the two groups

efficacy was observed

30-mm and 50-mm Compression

depth: 30 mm (n=5) and

A significantly less rib fracture was observed

between 30- and

Depth During Mechanical Chest

50 mm (n=5)

in the 30-mm group, p<0.05.

50-mm compression

Compression with Weil Mini

depth with the Weil

Chest Compressor (43)

Mini Chest Compressor.

Chen W (2012). The effects of

Experimental, pigs: VF was

MCC generated significantly greater CPP,

MCC may provide a

a newly developed miniaturized

induced (n=30)

ETCO2, carotid blood flow, and intrathoracic

new option for

mechanical chest compressor on

MCC and (LUCAS or

negative pressure, with significantly lower

cardiopulmonary

outcomes of cardiopulmonary

Thumper)

compression depth and fewer rib fractures

resuscitation.

resuscitation in a porcine model (44)

than both the LUCAS and Thumper devices

Arntz HR (2001). Phased Chest

OHCA, Germany,

ROSC: S-CPR 50% (13/26), Lifestick-CPR 38%

Lifestick resuscitation is

and Abdominal Compression

Lifestick (n=24),

(9/24), p:0.55,

feasible and safe and

Decompression Versus

S-CPR (n=28),

ROSC at VF: S-CPR 68% (13/19), Lifestick

may be advantageous

Conventional Cardiopulmonary

44% (4/9), p:0.43,

in patients with asystole

Resuscitation in Out-of-Hospital

ROSC at NEA/ asystole: S-CPR 0%,

or pulseless electric

Cardiac Arrest (48)

Lifestick-CPR 33% (5/15), p:0.23

activity.

Survival 1h: S-CPR 46% (12/26),

Lifestick 25% (6/24)

Hospital discharge: S-CPR 7/26, Lifestick 0 Autopsy: Sternal or rib fractures were found more frequently with S-CPR, p<0.05)

Havel C (2008). Safety, feasibility,

OHCA, Prospective, single-

Thumper device, they were not significantly

Lifestick is safe and

and hemodynamic and blood

center, phase II study,

different between Lifestick and Thumper in

beneficial,

flow effects of active

Lifestick (n=20)

resuscitations.

The small number of

compressiondecompression of

Thumper (n=11)

patients included in the

thorax and abdomen in patients

Although Lifestick seemed

study limits the

with cardiac arrest (49)

to improve hemodynamic

conclusions about the

effects compared with the

hemodynamic effects of the Lifestick.

CO: cardiac output; CPP: coronary perfusion pressure; IHCA: in-hospital cardiac arrest; OHCA: out -hospital Cardiac arrest; ROSC: return of spontaneous circulation; PEA: pulseless electrical activity; CPC: cerebral performance category; ETCO2: end-tidal CO2; A-KPR : AutoPulse CPR; ICU: intensive care unit; BP: blood pressure

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Aygn et al.

Mechanical Chest Compression Devices 103

Peer-review: Externally peer-reviewed.

Conict of Interest: No conict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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