CO-CPR

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Hüpfl M, Selig HF, Nagele P. "Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis". Lancet. 2010. 376(9752):1552-7.
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Clinical Question

In patients with out-of-hospital cardiac arrest, is compression-only CPR superior to standard CPR (chest compressions and rescue ventilation) in improving survival.

Bottom Line

With pooling of three RCT's with compression only CPR conducted by a bystander who was dispatcher-assisted demonstrating an absolute survival increase of 2.4% (NNT 41). When the analysis was expanded to include all comers with seven additional observational trials, no difference was seen between compression only CPR compare to standard CPR.

Major Points

This systematic review and two meta-analysis by Hüpfl et al. included over 3000 patients from three dispatcher-assisted RCT's and almost 14 000 patients combining seven prospective and retrospective observational trials. When pooled the RCT's showed a survival benefit for compression-only CPR with a NNT 41. This difference was lost when the observational trials were pooled. The RCT's preferentially included arrests from a cardiac cause making the findings unable to be applied to asphyxia-arrests. The current international guidelines recommends compressions given to for all patients and rescue breaths for to be delivered only when bystandards are trained and feel comfortable delivering them.

Guidelines

American Heart Association/International Liaison Committee on Resuscitation (AHA/ILCOR) 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations[1]

  • Chest compressions should be performed for all patients in cardiac arrest
    • strong recommendation, very-low-quality evidence
  • Those who are trained and willing to give rescue breaths do so for all adult patients in cardiac arrest
    • weak recommendation, very-low-quality evidence

Design

  • Primary Systematic review and Meta-analysis following PRISMA[2] for RCT's and secondary analysis following MOOSE[3] for observational trials.
  • Primary (RCT)
    • N=3033
      • Compression only CPR (n=1500)
      • Standard CPR (n=1533)
  • Secondary (Observational)
    • N=13883
      • Compression only CPR (n=2731)
      • Standard CPR (n=11152)
  • Search Dates: 1985 - August 2010
  • Databases: MEDLINE, EMBASE
  • Search terms: chest compression-only, compression alone, hands-only, bystander CPR
  • Analysis: Fixed effects model, inverse variance method for weighing studies
  • Primary outcome: Survival to discharge (or 30-day survival)

Studies Included

Search

  • MEDLINE and EMBASE
  • between 1985 and August 2010
  • Search Terms: chest compression-only, compression alone, hands-only, bystander CPR
  • Hand search bibliographies

Observational Study Inclusion Criteria

(1) observational cohort studies (no case series) (2) comparison between chest-compression-only CPR and standard CPR (3) survival data available (4) adult population (5) unstratified cohort (e.g., arrests of non-cardiac origin only) (6) bystander CPR (7) out-of-hospital arrest

Comparisons are Compression-Only vs. Standard CPR for Survival to Discharge

Primary (RCT)

  • Hallstrom et al. 2000[4]
    • 35/240(14.6%) vs. 29/278(10.4%)
  • Rea et al. 2010[5]
    • 122/978(12.5%) vs. 105/958(11.0%)
  • Svensson et al. 2010[6]
    • 54/282(19.1%) vs. 44/297(14.8%)

Secondary (Observational)

  • Prospective
    • Waalewijn et al. 2001[7]
      • 6/41(14.6%) vs. 61/437(14.0%)
    • SOS-Kanto Study Group 2007[8]
      • 38/439(8.7%) vs. 58/712(8.1%)
    • Iwami et al. 2007[9]
      • 52/544(9.6%) vs. 80/783(10.2%)
    • Ong et al. 2008[10]
      • 4/154(2.6%) vs. 8/287(2.8%)
  • Retrospective
    • Van Hoeyweghen et al. 1993[11]
      • 26/263(9.9%) vs. 71/443(16.0%)
    • Bohm et al. 2007[12]
      • 82/1145(7.2%) vs. 550/8209(6.7%)
    • Olasveegen et al. 2008[13]
      • 15/145(10.3%) vs. 35/281(12.5%)

Interventions

  • Compression-Only CPR vs. Standard CPR

Outcomes

Comparisons are Compression-Only vs. Standard CPR.

Presented as Risk Ratio; Lower limit - Upper limit (P-value)

Primary Outcomes

RCT Trials

Survival to Discharge (or 30-Days)
Hallstrom et al. 2000[4] 1.398; 0.8-2.2(NS)
Rea et al. 2010[5] 1.136; 0.9-1.5(NS)
Svensson et al. 2010[6] 1.293; 0.899-1.9(NS)
Overall 1.215; 1.009-1.5(0.04)

Secondary Outcomes

Observational Trials

Survival to 30-days
Iwami et al. 2007[9] 0.936; 0.6-1.3(NS)
Bohm et al. 2007[12] 1.069; 0.8-1.3(NS)
Ong et al. 2008[10] 0.932; 0.3-3.0(NS)
Waalewijn et al. 2001[7] 1.048; 0.4-2.3(NS)
Olasveegen et al. 2008[13] 0.831; 0.5-1.5(NS)
SOS-Kanto Study Group 2007[8] 1.063; 0.7-1.6(NS)
Van Hoeyweghen et al. 1993[11] 0.617; 0.4-0.9(0.025)
Overall 0.955; 0.8-1.1(NS)
Return of Spontaneous Circulation
Iwami et al. 2007[9] 0.991; 0.9-1.2(NS)
Ong et al. 2008[10] 1.048; 0.7-1.6(NS)
Waalewijn et al. 2001[7] 0.962; 0.6-1.5(NS)
Olasveegen et al. 2008[13] 0.978; 0.7-1.3(NS)
Overall 0.991; 0.9-1.1(NS)

Criticisms

  • Studies by Hallstrom et al.[4] and Rea et al.[5] only report in arrests from a cardiac cause, making external validity challenging for all comers[14]
  • Omitting rescue breaths in non-cardiac arrest may be detrimental to survival and good outcomes[14][15][16]
  • Missing patient survival data from Svensson et al.[6] should have been considered as mortality not missing[14]
  • Unclear in observational trials if CPR instruction was given by dispatcher or by-stander choice[17]
  • CO-CPR may allow more survival but conventional CPR with forced ventilation may be more protective for higher brain function but more study is needed.[18]
  • All RCT's using dispatcher-assisted CPR[4][5][6] used a compression:breath ratio of 15:2 instead of the current recommendation of 30:2[19]
  • Lay people should continue to be trained with standard CPR as they are unsuitable to determine the difference between cardiac or asphyxia arrest[19]

Funding

National Institutes of Health and American Heart Association

Further Reading

  1. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations http://circ.ahajournals.org/content/132/16_suppl_1/S51
  2. Moher D et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann. Intern. Med. 2009. 151:264-9, W64.
  3. Stroup DF et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000. 283:2008-12.
  4. 4.0 4.1 4.2 4.3 Hallstrom A et al. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N. Engl. J. Med. 2000. 342:1546-53.
  5. 5.0 5.1 5.2 5.3 Rea TD et al. CPR with chest compression alone or with rescue breathing. N. Engl. J. Med. 2010. 363:423-33.
  6. 6.0 6.1 6.2 6.3 Svensson L et al. Compression-only CPR or standard CPR in out-of-hospital cardiac arrest. N. Engl. J. Med. 2010. 363:434-42.
  7. 7.0 7.1 7.2 Waalewijn RA et al. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation 2001. 50:273-9.
  8. 8.0 8.1 SOS-KANTO study group Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 2007. 369:920-6.
  9. 9.0 9.1 9.2 Iwami T et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation 2007. 116:2900-7.
  10. 10.0 10.1 10.2 Ong ME et al. Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore. Resuscitation 2008. 78:119-26.
  11. 11.0 11.1 Van Hoeyweghen RJ et al. Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group. Resuscitation 1993. 26:47-52.
  12. 12.0 12.1 Bohm K et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation 2007. 116:2908-12.
  13. 13.0 13.1 13.2 Olasveengen TM et al. Standard basic life support vs. continuous chest compressions only in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2008. 52:914-9.
  14. 14.0 14.1 14.2 Rea T et al. Chest-compression-only versus standard CPR. Lancet 2011. 377:717; author reply 718-9.
  15. Böttiger BW et al. Chest-compression-only versus standard CPR. Lancet 2011. 377:716; author reply 718-9.
  16. Perkins GD & Handley AJ Chest-compression-only versus standard CPR. Lancet 2011. 377:716; author reply 718-9.
  17. Descatha A & Jost D Chest-compression-only versus standard CPR. Lancet 2011. 377:717-8; author reply 718-9.
  18. Abe T & Tokuda Y Chest-compression-only versus standard CPR. Lancet 2011. 377:718; author reply 718-9.
  19. 19.0 19.1 Nolan JP & Soar J Dispatcher-assisted bystander CPR: a KISS for a kiss. Lancet 2010. 376:1522-4.