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Original Contribution |

Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest:  A Randomized Trial FREE

Al Hallstrom, PhD; Thomas D. Rea, MD, MPH; Michael R. Sayre, MD; James Christenson, MD; Andy R. Anton, MD; Vince N. Mosesso, MD; Lois Van Ottingham, BSN; Michele Olsufka, RN; Sarah Pennington, RN; Lynn J. White, MS; Stephen Yahn, EMT-P; James Husar, EMT-P; Mary F. Morris; Leonard A. Cobb, MD
[+] Author Affiliations

Author Affiliations: Departments of Biostatistics (Dr Hallstrom and Mss Van Ottingham and Morris) and Medicine (Drs Rea and Cobb and Ms Olsufka), University of Washington, Seattle; Department of Emergency Medicine, Ohio State University, Columbus (Dr Sayre and Ms White); British Columbia Ambulance Service, Vancouver (Dr Christenson); Calgary Emergency Medical Services, Calgary, Alberta (Dr Anton and Mr Yahn); Department of Emergency Medicine (Dr Mosesso and Mr Husar), School of Medicine, University of Pittsburgh, Pittsburgh, Pa; and St Paul's Hospital, Vancouver, British Columbia (Ms Pennington).

More Author Information
JAMA. 2006;295(22):2620-2628. doi:10.1001/jama.295.22.2620.
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Published online

Context High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes.

Objective To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR.

Design, Setting, and Patients Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005.

Intervention Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517).

Main Outcome Measures The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors.

Results Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006).

Conclusions Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation.

Trial Registration clinicaltrials.gov Identifier: NCT00120965

Out-of-hospital cardiac arrest claims hundreds of thousands of lives annually in North America. Successful resuscitation depends on a coordinated set of actions including early cardiopulmonary resuscitation (CPR). High-quality CPR may be important for both cardiac and brain resuscitation.13 In animal investigations, fewer interruptions of CPR before and after defibrillation have improved cardiac and neurological outcomes.47 The order of resuscitation interventions may also be important, eg, survival may be improved by performing CPR by emergency medical services (EMS) personnel prior to defibrillation.8,9

Observations of rescue personnel indicate that maintaining consistent compressions is a difficult task.10 In the laboratory, trained paramedics provide shallower and slower compressions over time without noticing.11,12 Chest compressions often do not achieve guideline recommendations with regard to depth, rate, and hands-off time.13,14

The desire to provide optimal chest compressions led to the development of automated mechanical chest compression devices. The AutoPulse Resuscitation System (ZOLL Circulation, Sunnyvale, Calif) is a load-distributing band (LDB) circumferential chest compression device with an electrically actuated constricting band on a short backboard and has been approved by the US Food and Drug Administration for use in attempted resuscitation of cardiac arrest. In pig models and in-hospital cardiac arrest in humans, this LDB-CPR device produces greater blood flow to the heart and brain than manual CPR by trained individuals or the automated mechanical piston CPR device.15,16 Animal investigation has demonstrated a greater likelihood of neurologically intact survival in prolonged ventricular fibrillation cardiac arrest with LDB-CPR.17

In this study, the AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) trial, we compared LDB-CPR with manual CPR during out-of-hospital cardiac arrest. We hypothesized that 4-hour survival would be greater among patients randomized to LDB-CPR compared with those randomized to manual CPR. Secondary outcomes were survival to hospital discharge and neurological function at hospital discharge.

Corresponding Author: Al Hallstrom, PhD, Department of Biostatistics, University of Washington, 1107 NE 45th St, Suite 505, Seattle, WA 98105 (aph@u.washington.edu).

Author Contributions: Dr Hallstrom had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Hallstrom, Rea, Sayre, Christenson, Anton, Mosesso, Van Ottingham, Cobb.

Acquisition of data: Rea, Sayre, Christenson, Anton, Mosesso, Olsufka, Pennington, White, Yahn, Husar, Cobb.

Analysis and interpretation of data: Hallstrom, Rea, Sayre, Christenson, Anton, Mosesso, Van Ottingham, Morris, Cobb.

Drafting of the manuscript: Hallstrom, Rea, Sayre.

Critical revision of the manuscript for important intellectual content: Hallstrom, Rea, Sayre, Christenson, Anton, Mosesso, Van Ottingham, Olsufka, Pennington, White, Yahn, Husar, Morris, Cobb.

Statistical analysis: Hallstrom, Morris.

Obtained funding: Hallstrom.

Administrative, technical, or material support: Hallstrom, Van Ottingham.

Study supervision: Hallstrom, Rea, Sayre, Christenson, Anton, Mosesso, Van Ottingham, Olsufka, Pennington, White, Yahn, Husar, Cobb.

Financial Disclosures: Dr Mosesso reported receiving equipment and supplies for the AED clinical trial from the ZOLL Corporation.

Funding/Support: This study was sponsored by Revivant Corporation, now part of the ZOLL Corporation.

Role of the Sponsor: The funding organization provided the automated devices, assisted with training, and attended some of the investigator meetings, but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript. The sponsor was provided a 1-month period to review and comment on the manuscript prior to submission. The investigators were under no obligation to incorporate any such input.

Acknowledgment: The data and safety monitoring board consisted of Lawrence Brown, EMT-P, Department of Emergency Medicine, Upstate Medical University, Syracuse, NY; David Goff, Jr, MD, PhD, Wake Forest University School of Medicine, Winston-Salem, NC; Joel Singer, PhD, St Paul's Hospital, Vancouver, British Columbia; and Terence Valenzuela, MD, University of Arizona College of Medicine, Tucson. Each data and safety monitoring board member received a fixed amount of money ($3000) independent of how many times the board would need to meet. We acknowledge the dedicated efforts of the following emergency medical service agencies and their personnel: British Columbia Ambulance Service, Baldwin EMS, Calgary EMS, Eastern Area Prehospital Services, McKeesport Ambulance Rescue Service, Medical/Rescue Team South Authority, Northwest EMS, Ross-West View EMS Authority, Seattle Fire Department, Tri-Community South EMS, Columbus Division of Fire EMS, Upper Arlington Fire Division, and Worthington Fire and EMS.

Stiell I, Nichol G, Wells G.  et al.  Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation.  Circulation. 2003;108:1939-1944
PubMed   |  Link to Article
Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation.  Circulation. 2005;111:2134-2142
PubMed   |  Link to Article
Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitiation and survival following out-of-hospital cardiac arrest.  JAMA. 1995;274:1922-1925
PubMed   |  Link to Article
Niemann JT. Cardiopulmonary resuscitation.  N Engl J Med. 1992;327:1075-1080
PubMed   |  Link to Article
Yu T, Weil MH, Tang W.  et al.  Adverse outcomes of interrupted precordial compression during automated defibrillation.  Circulation. 2002;106:368-372
PubMed   |  Link to Article
Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario.  Circulation. 2002;105:645-649
PubMed   |  Link to Article
Steen S, Liao Q, Pierre L, Paskevicius A, Sjoberg T. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation.  Resuscitation. 2003;58:249-258
PubMed   |  Link to Article
Cobb LA, Fahrenbruch CE, Walsh TR.  et al.  Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA. 1999;281:1182-1188
PubMed   |  Link to Article
Wik L, Hansen TB, Fylling F.  et al.  Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;289:1389-1395
PubMed   |  Link to Article
Huseyin TS, Matthews AJ, Wills P, O'Neill VM. Improving the effectiveness of continuous closed chest compressions: an exploratory study.  Resuscitation. 2002;54:57-62
PubMed   |  Link to Article
Ochoa FJ, Ramalle-Gomara E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions.  Resuscitation. 1998;37:149-152
PubMed   |  Link to Article
Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in quality of closed-chest compressions over time.  Ann Emerg Med. 1995;26:300-303
PubMed   |  Link to Article
Abella BS, Alvarado JP, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.  JAMA. 2005;293:305-310
PubMed   |  Link to Article
Wik L, Kramer-Johansen J, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.  JAMA. 2005;293:299-304
PubMed   |  Link to Article
Timmerman S, Cardoso LF, Ramires JA. Improved hemodynamics with a novel chest compression device during treatment of in-hospital cardiac arrest.  Prehosp Emerg Care. 2003;7:162
Halperin HR, Paradis NA, Omato JP. Improved hemodynamics with a novel chest compression device during a porcine model of cardiac arrest.  Circulation. 2002;106:538
PubMed
Ikeno F, Kaneda H, Hongo Y.  et al.  Augmentation of tissue perfusion by a novel compression device increases neurologically intact survival in a porcine model of prolonged cardiac arrest.  Resuscitation. 2006;68:109-118
PubMed   |  Link to Article
Hallstrom AP, Paradis NA. Pre-randomization and de-randomization in emergency medical research: new names and rigorous criteria for old methods.  Resuscitation. 2005;65:65-69
PubMed   |  Link to Article
 Protection of Human Subjects, 45 CFR §46.116 (1997) 
 Protection of Human Subjects, 21 CFR §50.23 (1979) 
Herlitz J, Ekstrom L, Wennerblom B, Axelsson A, Bang A, Holmberg S. Prognosis among survivors of prehospital cardiac arrest.  Ann Emerg Med. 1995;25:58-63
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).  Circulation. 2004;110:3385-3397
PubMed   |  Link to Article
Connelly LB. Balancing the number and size of sites: an economic approach to the optimal design of cluster samples.  Control Clin Trials. 2003;24:544-559
PubMed   |  Link to Article
Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest.  Prehosp Emerg Care. 2005;9:61-67
PubMed   |  Link to Article
 East Version 3.0: Software for the Design, Simulation and Interim Monitoring of Flexible Clinical Trials User Manual. Cambridge, Mass: Cytel Software Corp; 2003
Chen YH, DeMets DL, Lan KK. Increasing the sample size when the unblinded interim result is promising.  Stat Med. 2004;23:1023-1038
PubMed   |  Link to Article
Venables WN, Ripley BD. Modern Applied Statistics With S. 4th ed. New York, NY: Springer Publishing Co; 2002
Rogers WH. Regression standard errors in clustered samples.  Stata Tech Bull Rep. 1993;3:88-94
Williams RL. A note on robust variance estimation for cluster-correlated data.  Biometrics. 2000;56:645-646
PubMed   |  Link to Article
Wooldridge JM. Econometric Analysis of Cross Section and Panel Data. Cambridge, Mass: MIT Press; 2002
Vukmir RB. Survival and outcome from prehospital cardiac arrest. http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijrdm/vol4n1/survival.xml. Accessibility verified May 15, 2006
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective.  Circulation. 2003;107:2780-2785
PubMed   |  Link to Article
Lairet J, Lee M. A comparison of standard manual cardiopulmonary resuscitation versus the AutoPulse mechanical cardiopulmonary resuscitation device.  Ann Emerg Med. 2005;46:S114
Link to Article
Ornato J. An emergency medical services system resuscitation strategy: using AutoPulse™ as the primary method for delivering chest compressions improves survival from out-of-hospital cardiac arrest (late-breaking trial presentation). Presented at: American Heart Association Resuscitation Science Symposium; November 11-12, 2005; Dallas, Tex
Campbell JP, Maxey VA, Watson WA. Hawthorne effect: implications for prehospital research.  Ann Emerg Med. 1995;26:590-594
PubMed   |  Link to Article
Anderson T, Vanden Hoek TL. Preconditioning and the oxidants of sudden death.  Curr Opin Crit Care. 2003;9:194-198
PubMed   |  Link to Article
Blackstone E, Morrison M, Roth MB. H2S induces a suspended animation-like state in mice.  Science. 2005;308:518
PubMed   |  Link to Article
Hart AP, Azar VJ, Hart KR, Stephens BG. Autopsy artifact created by the Revivant AutoPulse resuscitation device.  J Forensic Sci. 2005;50:164-168
PubMed
Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;288:3035-3038
PubMed   |  Link to Article

Figures

Tables

References

Stiell I, Nichol G, Wells G.  et al.  Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation.  Circulation. 2003;108:1939-1944
PubMed   |  Link to Article
Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation.  Circulation. 2005;111:2134-2142
PubMed   |  Link to Article
Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitiation and survival following out-of-hospital cardiac arrest.  JAMA. 1995;274:1922-1925
PubMed   |  Link to Article
Niemann JT. Cardiopulmonary resuscitation.  N Engl J Med. 1992;327:1075-1080
PubMed   |  Link to Article
Yu T, Weil MH, Tang W.  et al.  Adverse outcomes of interrupted precordial compression during automated defibrillation.  Circulation. 2002;106:368-372
PubMed   |  Link to Article
Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario.  Circulation. 2002;105:645-649
PubMed   |  Link to Article
Steen S, Liao Q, Pierre L, Paskevicius A, Sjoberg T. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation.  Resuscitation. 2003;58:249-258
PubMed   |  Link to Article
Cobb LA, Fahrenbruch CE, Walsh TR.  et al.  Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA. 1999;281:1182-1188
PubMed   |  Link to Article
Wik L, Hansen TB, Fylling F.  et al.  Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;289:1389-1395
PubMed   |  Link to Article
Huseyin TS, Matthews AJ, Wills P, O'Neill VM. Improving the effectiveness of continuous closed chest compressions: an exploratory study.  Resuscitation. 2002;54:57-62
PubMed   |  Link to Article
Ochoa FJ, Ramalle-Gomara E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions.  Resuscitation. 1998;37:149-152
PubMed   |  Link to Article
Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in quality of closed-chest compressions over time.  Ann Emerg Med. 1995;26:300-303
PubMed   |  Link to Article
Abella BS, Alvarado JP, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.  JAMA. 2005;293:305-310
PubMed   |  Link to Article
Wik L, Kramer-Johansen J, Myklebust H.  et al.  Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.  JAMA. 2005;293:299-304
PubMed   |  Link to Article
Timmerman S, Cardoso LF, Ramires JA. Improved hemodynamics with a novel chest compression device during treatment of in-hospital cardiac arrest.  Prehosp Emerg Care. 2003;7:162
Halperin HR, Paradis NA, Omato JP. Improved hemodynamics with a novel chest compression device during a porcine model of cardiac arrest.  Circulation. 2002;106:538
PubMed
Ikeno F, Kaneda H, Hongo Y.  et al.  Augmentation of tissue perfusion by a novel compression device increases neurologically intact survival in a porcine model of prolonged cardiac arrest.  Resuscitation. 2006;68:109-118
PubMed   |  Link to Article
Hallstrom AP, Paradis NA. Pre-randomization and de-randomization in emergency medical research: new names and rigorous criteria for old methods.  Resuscitation. 2005;65:65-69
PubMed   |  Link to Article
 Protection of Human Subjects, 45 CFR §46.116 (1997) 
 Protection of Human Subjects, 21 CFR §50.23 (1979) 
Herlitz J, Ekstrom L, Wennerblom B, Axelsson A, Bang A, Holmberg S. Prognosis among survivors of prehospital cardiac arrest.  Ann Emerg Med. 1995;25:58-63
PubMed   |  Link to Article
Jacobs I, Nadkarni V, Bahr J.  et al.  Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).  Circulation. 2004;110:3385-3397
PubMed   |  Link to Article
Connelly LB. Balancing the number and size of sites: an economic approach to the optimal design of cluster samples.  Control Clin Trials. 2003;24:544-559
PubMed   |  Link to Article
Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest.  Prehosp Emerg Care. 2005;9:61-67
PubMed   |  Link to Article
 East Version 3.0: Software for the Design, Simulation and Interim Monitoring of Flexible Clinical Trials User Manual. Cambridge, Mass: Cytel Software Corp; 2003
Chen YH, DeMets DL, Lan KK. Increasing the sample size when the unblinded interim result is promising.  Stat Med. 2004;23:1023-1038
PubMed   |  Link to Article
Venables WN, Ripley BD. Modern Applied Statistics With S. 4th ed. New York, NY: Springer Publishing Co; 2002
Rogers WH. Regression standard errors in clustered samples.  Stata Tech Bull Rep. 1993;3:88-94
Williams RL. A note on robust variance estimation for cluster-correlated data.  Biometrics. 2000;56:645-646
PubMed   |  Link to Article
Wooldridge JM. Econometric Analysis of Cross Section and Panel Data. Cambridge, Mass: MIT Press; 2002
Vukmir RB. Survival and outcome from prehospital cardiac arrest. http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijrdm/vol4n1/survival.xml. Accessibility verified May 15, 2006
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective.  Circulation. 2003;107:2780-2785
PubMed   |  Link to Article
Lairet J, Lee M. A comparison of standard manual cardiopulmonary resuscitation versus the AutoPulse mechanical cardiopulmonary resuscitation device.  Ann Emerg Med. 2005;46:S114
Link to Article
Ornato J. An emergency medical services system resuscitation strategy: using AutoPulse™ as the primary method for delivering chest compressions improves survival from out-of-hospital cardiac arrest (late-breaking trial presentation). Presented at: American Heart Association Resuscitation Science Symposium; November 11-12, 2005; Dallas, Tex
Campbell JP, Maxey VA, Watson WA. Hawthorne effect: implications for prehospital research.  Ann Emerg Med. 1995;26:590-594
PubMed   |  Link to Article
Anderson T, Vanden Hoek TL. Preconditioning and the oxidants of sudden death.  Curr Opin Crit Care. 2003;9:194-198
PubMed   |  Link to Article
Blackstone E, Morrison M, Roth MB. H2S induces a suspended animation-like state in mice.  Science. 2005;308:518
PubMed   |  Link to Article
Hart AP, Azar VJ, Hart KR, Stephens BG. Autopsy artifact created by the Revivant AutoPulse resuscitation device.  J Forensic Sci. 2005;50:164-168
PubMed
Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;288:3035-3038
PubMed   |  Link to Article
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