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Mechanical CPR Devices

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting  (P), does do automated mechanical chest compression devices  (I), compared with compared with standard manual chest compressions  (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?
Consensus on Science:
For the critical outcome of survival to 1 year, we identified moderate-quality evidence (downgraded for serious risk of bias) from 1 cluster RCT(Perkins 2015, 947) using the Lund University Cardiac Arrest System (LUCAS) device showing no benefit or harm when compared with manual chest compressions (5.4% versus 6.2%; RR, 0.87; 95% CI, 0.68–1.11). For the critical outcomes of survival at 180 days with good neurologic outcome and survival at 30 days with favorable neurologic outcome, we identified moderate-quality evidence (downgraded for serious risk of bias) from one RCT(Rubertsson 2014, 53) using a LUCAS device and enrolling 2589 OHCA patients that did not show benefit or harm when compared with manual chest compressions at 180 days (8.5% versus 7.6%; RR, 1.11; 95% CI, 0.86–1.45) or 30 days (7.3% versus 8.1%; RR, 1.11; 95% CI, 0.84–1.45). For the critical outcome of survival to 180 days, we identified moderate-quality evidence (downgraded for serious risk of bias) from 1 RCT(Rubertsson 2014, 53) using a LUCAS device enrolling 2589 OHCA patients showing no benefit or harm when compared with manual chest compressions where quality of chest compressions in the manual arm was not measured (8.5% versus 8.1%; RR, 1.06; 95% CI, 0.81–1.41). For the critical outcome of survival to hospital discharge with favorable neurologic outcome (defined as CPC 1–2 or mRS 0–3), we have identified moderate-quality evidence (downgraded for serious risk of bias) from 3 RCTs enrolling 7582 OHCA patients showing variable results.(Hallstrom 2006, 2620; Rubertsson 2014, 53; Wik 2014, 741) One study(Hallstrom 2006, 2620-2628) (n=767) showed harm with the use of a load-distributing band mechanical chest compression device compared with manual chest compressions (7.5% of patients in the control group versus 3.1% in the intervention group; P=0.006; RR, 0.41; 95% CI, 0.21–0.79). Two other RCTs(Rubertsson 2014, 53; Wik 2014, 741) (n=6820), one using a load-distributing band and the other using a LUCAS, did not show benefit or harm when compared with manual chest compressions: load-distributing band study: 4.14% survival in the intervention group versus 5.25% for manual compressions (RR, 0.79; 95% CI, 0.60–1.03); LUCAS: 8.31% intervention versus 7.76% manual compressions (RR, 1.07; 95% CI, 0.83–1.39). For the critical outcome of survival to hospital discharge, we identified moderate-quality evidence (downgraded for serious risk of bias) from 5 RCTs(Hallstrom 2006, 2620; Lu 2010, 496; Smekal 2011, 702; Rubertsson 2014, 53; Wik 2014, 741) enrolling 7734 OHCA patients and 150 IHCA patients showing heterogeneous results. One study of patients with IHCAs(Lu 2010, 496) (n=150) showed benefit with use of a piston device compared with manual chest compressions (32.9% versus 14.7%; P=0.02; RR, 2.21; 95% CI, 1.17–4.17). Two other RCTs(Smekal 2011, 702; Rubertsson 2014, 53) of LUCAS did not show benefit or harm (9.0% versus 9.15%; RR, 0.98; 95% CI, 0.77–1.25 and 8.0% versus 9.72%; RR, 0.82; 95% CI, 0.29–2.33, respectively, for LUCAS versus manual compressions). One large RCT(Wik 2014, 741-748) (n=4231) using a load-distributing–band device showed equivalence when compared with high-quality manual chest compressions (9.34% versus 10.93%; RR, 0.85; 95% CI, 0.71–1.02). For the critical outcome of survival to 30 days, we identified moderate-quality evidence (downgraded for serious risk of bias) from 2 RCTs(Rubertsson 2014, 53; Perkins 2015, 947) (n=7060) using the LUCAS device showing no benefit or harm when compared with manual chest compressions and where quality of compressions in the manual arm was not measured (6.3% versus 6.85%; RR, 0.92; 95% CI, 0.73–1.16 and 8.82% versus 8.07%; RR, 1.02; 95% CI, 0.97–1.31, respectively). For the important outcome of ROSC, we identified low-quality evidence (downgraded for serious risk of bias and serious inconsistency) from 7 RCTs enrolling 11 638 cardiac arrest patients (IHCA and OHCA).(Halperin 1993, 762; Dickinson 1998, 289; Lu 2010, 496; Smekal 2011, 702; Rubertsson 2014, 53; Wik 2014, 741; Perkins 2015, 947) Two studies(Dickinson 1998, 289; Lu 2010, 496) (n=167) showed benefit with mechanical chest compression devices compared with manual compressions: 14.29% versus 0% (RR, not applicable) and 55.26% versus 37.84% (RR, 1.46; 95% CI, 1.02–2.08), respectively. One study(Wik 2014, 741) (n=4231) showed harm with mechanical devices; however, there was no adjustment for interim analyses: 28.59% versus 32.32% (RR, 0.88; 95% CI, 0.81–0.97). Four studies(Halperin 1993, 762; Smekal 2011, 702; Rubertsson 2014, 53; Perkins 2015, 947) (n=7240) did not show benefit or harm when compared with manual chest compressions: 47.06% versus 17.75% (RR, 2.67; 95% CI, 0.85–8.37), 31.60% versus 31.39% (RR, 1.01; 95% CI, 0.92–1.10), 35.38% versus 34.60% (RR, 1.02; 95% CI, 0.92–1.14), and 40.54% versus 31.94% (RR, 1.27; 95% CI, 0.82–1.96), respectively.
Treatment Recommendation:
We suggest against the routine use of automated mechanical chest compression devices to replace manual chest compressions (weak recommendation, moderate-quality evidence). We suggest that automated mechanical chest compression devices are a reasonable alternative to high-quality manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety (weak recommendation, low-quality evidence). Values, Preferences, and Task Force Insights The task force placed value on ensuring high-quality chest compressions with adequate depth, rate, and minimal interruptions, regardless of whether they are delivered by machine or human. The task force also considered that application of a mechanical chest compression device without a focus on minimizing interruptions in compressions and delay to defibrillation could cause harm. In making a recommendation for mechanical compression devices for use in some settings, we place value on the results from a large, high-quality RCT(Wik 2014, 741) showing equivalence between very-high-quality manual chest compressions and mechanical chest compressions delivered with a load-distributing band in a setting with rigorous training and CPR quality monitoring. Also, the task force acknowledges the existence of situations where sustained high-quality manual chest compressions may not be practical. Examples include CPR in a moving ambulance where provider safety is at risk, the need for prolonged CPR where provider fatigue may impair high-quality manual compressions (eg, hypothermic arrest), and CPR during certain procedures (eg, coronary angiography or preparation for ECPR). Our task force agreed that there was an adequate amount of data generated from RCTs for the systematic review to exclude observational studies. We agreed that despite the availability of several observational studies comparing manual and mechanical chest compressions, the inherent risk of bias related to patient selection, group allocation, and uncontrolled confounders supports a decision to exclude them from the process of developing this CoSTR statement. We conducted a universal literature search for RCTs studying any type of automated mechanical chest compression device. Prior to initiating the review, we planned to parse the data by device type if an effect specific to device was observed in the analysis. Although we did not undertake a formal analysis by device, there were no obvious device-specific effects observed. The task force did consider some data that are not included in the evidence profile tables or CoSTR statement. Specifically, the PARAMEDIC (prehospital randomized assessment of a mechanical compression device in cardiac arrest) study(Perkins 2015, 947-955) showed an association between mechanical chest compressions and worse survival with good neurologic outcome (CPC 1–2) at 3 months (adjusted OR, 0.72; 95% CI, 0.52–0.99). This was not included in our consensus on science, because survival with good neurologic outcome at 90 days was not an a priori outcome identified by the group. After assessing the evidence, there was much debate over the ultimate wording of our recommendation. Some members thought a weak recommendation supporting mechanical chest compression devices as a reasonable alternative to manual chest compressions was most appropriate, whereas others thought a recommendation against the routine use of mechanical chest compression devices was more appropriate. There was general agreement that the bulk of evidence reviewed suggests no significant difference or equivalence between mechanical and manual chest compressions related to critical and important clinical outcomes. The task force weighed this with the data from a few studies suggesting a negative association between mechanical chest compression and outcomes as well as the potential resource implications associated with implementation of mechanical devices in any setting. With these factors in mind, the task force concluded that available clinical evidence did not support a recommendation for broad and universal implementation of mechanical chest compression devices across all clinical settings in favor of high-quality manual chest compressions. Public comments provided online were reviewed by the task force. Comments suggested that we consider special circumstances where mechanical chest compressions may be more practical than the continued provision of high-quality chest compression and circumstances where provider safety might be improved with the use of mechanical versus manual chest compressions. Delivery of manual compressions in a moving ambulance by an unrestrained provider was seen as a particularly unsafe situation. Mechanical devices may allow providers to remain seated and restrained in this situation while chest compressions continue. Accordingly, we have included a treatment recommendation to address these situations not directly addressed in the literature reviewed but deemed to represent reasonable situations for the use of this technology.
CoSTR Attachments:
MEch CPR ev profile table Jan 22 2015 updated feb 4 corrected.docx    

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