Background: Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).
Objectives: To assess the effectiveness of resuscitation strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.
Search methods: On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index-Expanded (SCI-EXPANDED) and Conference Proceedings Citation Index-Science databases. Biotechnology and Bioengineering Abstracts and Science Citation abstracts had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers.
Selection criteria: We included randomised controlled trials (RCTs), cluster-RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest.
Data collection and analysis: We used standard methodological procedures expected by Cochrane.
Main results: We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect.
AUTHORS'
Conclusions: The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high-quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.
Conclusion: The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high-quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.
Conclusion (proposition de traduction) : Les données disponibles ne suggèrent pas que les protocoles de RCP utilisant des dispositifs de compression thoracique mécaniques soient supérieurs à la prise en charge conventionnelle reposant uniquement sur les compressions manuelles. Sur la base de l’ensemble des preuves, les dispositifs mécaniques constituent une alternative raisonnable lorsqu’il est difficile ou dangereux pour les intervenants d’assurer des compressions manuelles de haute qualité de façon continue (par exemple en cas d’effectif limité, de RCP prolongée, d’arrêt cardiaque hypothermique, de transport en ambulance, en salle d’angiographie ou lors de la préparation d’une ECPR...). Les systèmes qui choisissent d’intégrer ces dispositifs doivent faire l’objet d’une surveillance étroite, certaines données suggérant un risque potentiel de préjudice. Une attention particulière doit être portée à la réduction des interruptions de compressions et des délais de défibrillation lors de la mise en place du dispositif.
Commentaire : Cette revue Cochrane, fondée sur 11 essais randomisés totalisant près de 13 000 patients, offre une analyse méthodologiquement rigoureuse de l’intérêt des dispositifs de compression thoracique mécaniques par rapport à la RCP manuelle. Les résultats montrent une absence de supériorité claire des dispositifs mécaniques sur les critères cliniquement pertinents, notamment la survie avec bon pronostic neurologique, la survie à la sortie d’hospitalisation et le RACS. Les études sont marquées par une forte hétérogénéité (types de dispositifs, contextes intra- et extrahospitaliers, protocoles de RCP) et par un risque de biais non négligeable, ce qui empêche toute méta-analyse quantitative robuste. Certains essais suggèrent même un possible effet délétère, en particulier lorsque la mise en place du dispositif entraîne des interruptions de compressions ou des retards à la défibrillation.
Sur le plan pratique, la revue soutient une utilisation ciblée et non systématique des dispositifs mécaniques, réservée aux situations où une RCP manuelle de qualité est difficilement maintenable ou dangereuse pour les soignants, comme lors du transport, des réanimations prolongées ou en contexte interventionnel. Le message central reste que la qualité, la continuité et la précocité des compressions, ainsi que la défibrillation rapide, demeurent les déterminants majeurs du pronostic, indépendamment du caractère manuel ou mécanique de la RCP.