RECOVER 2.0 Worksheet

QUESTION ID: BLS-06

PICO Question:
In cats and dogs in CPA (P), does active compression-decompression (I) compared to active compression / passive decompression chest compressions (C), improve ... (O)?

Outcomes:
Favorable neurologic outcome, Surrogate marker(s) of perfusion, Survival to discharge, ROSC

Prioritized Outcomes (1= most critical; final number = least important):

1. Favorable neurologic outcome
2. Survival to discharge
3. ROSC
4. Surrogate markers of perfusion

Domain chairs: Steve Epstein, Kate Hopper; final edits by Jamie Burkitt

Evidence evaluators: Matthew Turner, Rachel Halpin

Conflicts of interest: none

Search strategy: See attached document

Evidence Review:

Study Design

Reduced Quality Factors 0 = no serious, - = serious, - - = very serious

Positive Quality Factors 0 = none, + = one, ++ = multiple

Dichotomous Outcome Summary

Non-Dichotomous Outcome Summary Brief description

Overall Quality High, moderate, low, very low, none

No of studies

Study Type

RoB

Indirectness

Imprecision

Inconsistency

Large Effect

Dose-Response

Confounder

# Intervention with Outcome

# Control with Outcome

RR (95% CI)

Outcome: Favorable neurologic outcome
8	CT	-	- -	0	0	0	0	0				Of the 8 human clinical trials identified, only 1 supported a favorable neurologic outcome with ACD (RR = 2.5, 95%CI 1.03-5.85)	Very low
1	OBS	-	- -	0	0	0	0	0				36 human patients in 2 different cities showed no difference in neurologic outcome with ACD vs conventional CPR	Very low

Outcome: Survival to discharge
12	CT	-	- -	0	0	0	0	0				Of the 12 human clinical trials none found a difference in survival to discharge	Very low
1	OBS	-	-	0	0	0	0	0				36 human patients in 2 different cities showed no difference in survival to discharge with ACD vs conventional CPR	Very low

Outcome: ROSC
11	CT	-	- -	0	0	0	0	0				Of the 11 human clinical trials none found a difference in ROSC.	Very low
3	EX	-	-	0	0	0	0	0				3 experimental swine studies found no difference in ROSC with the use of ACD vs. conventional CPR	Very low
1	OBS	-	-	0	0	0	0	0				36 human patients in 2 different cities showed no difference in ROSC with ACD vs conventional CPR	Very low

Outcome: Surrogate Markers of Perfusion
15	EX	-	-	0	0	0	0	0				3 canine and 12 swine studies predominantly showed improved surrogate markers of perfusion with the use of ACD vs conventional CPR.	Very low

PICO Question Summary

Introduction

Active compression-decompression (ACD) CPR uses a handheld device with a suction cup applied to the midsternal region in human patients to allow active lifting of the chest wall during the chest decompression phase of CPR. This enhances negative intrathoracic pressure generated during chest recoil, augmenting venous return. This PICO question investigated the utility of ACD CPR in dogs and cats.

Consensus on science

Outcome 1: Favorable Neurologic Outcome: For the critical outcome of FNO, we identified 7 clinical trials (very low quality of evidence, downgraded for serious risk of bias and very serious indirectness) and 1 observational study (very low quality of evidence, downgraded for serious risk of bias and very serious indirectness) that addressed the PICO question.1–8 All studies were in people. One clinical trial showed improved FNO with ACD, but this was not repeatable in the other trials.1,3–8 The observational study failed to demonstrate a difference.2 Outcome 2: Survival to Discharge: For the next critical outcome of survival to discharge, we identified 12 clinical trials (very low quality of evidence, downgraded for serious risk of bias and very serious indirectness) and 1 observational study (very low quality of evidence, downgraded for serious risk of bias, and serious indirectness) that addressed the PICO question.2,4,5,7–13 All studies were in people. Of the relevant human clinical trials using ACD-CPR compared to standard CPR, none found a significant difference in survival to discharge.4,5(p9),7,8(p5),9–14 The observational study failed to demonstrate a difference.2 Outcome 3: ROSC: For the important outcome of ROSC, we identified 11 clinical trials (very low quality of evidence, downgraded for serious risk of bias and very serious indirectness), 3 experimental studies (very low quality of evidence, downgraded for serious risk of bias and serious indirectness), and 1 observational study (very low quality of evidence, downgraded for serious risk of bias and serious indirectness).4,5,7–17 Of the relevant human clinical trials evaluating the use of ACD-CPR compared to standard CPR, these studies yielded mixed results, but overall do not support that ACD-CPR improves ROSC.1,3,5–9,11–13,18 There are no relevant veterinary studies. Outcome 4: Surrogate markers of Perfusion: For the important outcome of surrogate markers of perfusion, we identified 15 experimental studies (very low quality of evidence, downgraded for serious risk of bias and serious indirectness).15–17,19–30 An experimental dog study provides evidence that ACD increases LV pressure/time, coronary perfusion, cardiac output, and pulmonary artery flow.23 Increased minute ventilation with ACD has also been shown.20 A study of 8 beagle dogs showed increased cerebral and pulmonary blood flow in dogs during ACD-CPR compared to conventional CPR.22 Several porcine experimental models show improvements in surrogate markers (cerebral, carotid, renal or myocardial blood flow, cardiac output, or blood pressure) with ACD-CPR.15–17,19,21,24–30

Treatment recommendation

We recommend against the use of active compression-decompression CPR in dogs and cats (strong recommendation, expert opinion).

Justification of treatment recommendation

The majority of the evidence evaluated did not support a benefit of ACD during CPR in human patients, despite the fairly consistent improvement in surrogate markers of perfusion found in experimental animal studies. In addition, adherence of the ACD device’s suction cup to the thoracic wall, and thus the applicability to dogs and cats in the clinical setting (i.e., those with full haircoats) is limited.

Knowledge gaps

Evaluation of prioritized outcomes (favorable neurological outcome, survival to discharge) for ACD-CPR versus conventional CPR in dogs and cats is needed to help determine whether clipping fur during CPR to apply an ACD would be worthwhile. Alternatively, development and evaluation of safe, clinically applicable ACD equipment in dogs and cats would be needed.

1. Plaisance P, Lurie KG, Vicaut E, et al. A comparison of standard cardiopulmonary resuscitation and active compression–decompression resuscitation for out-of-hospital cardiac arrest. New England journal of medicine. 1999;341(8):569-575.

2. Schwab TM, Callaham ML, Madsen CD, Utecht TA. A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. Jama. 1995;273(16):1261-1268.

3. Tucker KJ, Galli F, Savitt MA, et al. Active compression-decompression resuscitation: effect on resuscitation success after in-hospital cardiac arrest. Journal of the American College of Cardiology. 1994;24(1):201-209.

4. Stiell IG, Hébert PC, Wells GA, et al. The Ontario trial of active compression-decompression cardiopulmonary resuscitation for in-hospital and prehospital cardiac arrest. Jama. 1996;275(18):1417-1423.

5. Plaisance P, Adnet F de´ ric, Vicaut E, et al. Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support: a randomized multicenter study. Circulation. 1997;95(4):955-961.

6. Nolan J, Smith G, Evans R, et al. The United Kingdom pre-hospital study of active compression-decompression resuscitation. Resuscitation. 1998;37(2):119-125.

7. Mauer D, Schneider T, Dick W, et al. Active compression-decompression resuscitation: a prospective, randomized study in a two-tiered EMS system with physicians in the field. Resuscitation. 1996;33(2):125-134.

8. Lurie KG, Shultz JJ, Callaham ML, et al. Evaluation of active compression-decompression CPR in victims of out-of-hospital cardiac arrest. jama. 1994;271(18):1405-1411.

9. Skogvoll E, Wik L. Active compression-decompression cardiopulmonary resuscitation: a population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest. Resuscitation. 1999;42(3):163-172.

10. Mauer D, Schneider T, Elich D, Dick W. Carbon dioxide levels during pre-hospital active compression--decompression versus standard cardiopulmonary resuscitation. Resuscitation. 1998;39(1-2):67-74.

11. Luiz T, Ellinger K, Denz C. Active compression-decompression cardiopulmonary resuscitation does not improve survival in patients with prehospital cardiac arrest in a physician-manned emergency medical system. Journal of cardiothoracic and vascular anesthesia. 1996;10(2):178-186.

12. Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011;377(9762):301-311.

13. Gunaydin YK, Cekmen B, Akilli NB, et al. Comparative effectiveness of standard CPR vs active compression-decompression CPR with CardioPump for treatment of cardiac arrest. Am J Emerg Med. 2016;34(3):542-547.

14. Callaham ML. A randomized prospective trial of active compression-decompression CPR versus manuel CPR in prehospital cardiac arrest. Am Emerg Med. 1993;22:174.

15. Kern KB, Figge G, Hilwig RW, et al. Active compression-decompression versus standard cardiopulmonary resuscitation in a porcine model: no improvement in outcome. Am Heart J. 1996;132(6):1156-1162.

16. Bahlmann L, Klaus S, Baumeier W, et al. Brain metabolism during cardiopulmonary resuscitation assessed with microdialysis. Resuscitation. 2003;59(2):255-260.

17. Udassi JP, Udassi S, Shih A, et al. Novel adhesive glove device (AGD) for active compression-decompression (ACD) CPR results in improved carotid blood flow and coronary perfusion pressure in piglet model of cardiac arrest. Resuscitation. 2012;83(6):750-754.

18. Frascone RJ, Wayne MA, Swor RA, et al. Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device. Resuscitation. 2013;84(9):1214-1222.

19. Sunde K, Wik L, Naess PA, et al. Effect of different compression-decompression cycles on haemodynamics during ACD-CPR in pigs. Resuscitation. 1998;36(2):123-131.

20. Tucker KJ, Khan JH, Savitt MA. Active compression-decompression resuscitation: effects on pulmonary ventilation. Resuscitation. 1993;26(2):125-131.

21. Wik L, Naess PA, Ilebekk A, Steen PA. Simultaneous active compression-decompression and abdominal binding increase carotid blood flow additively during cardiopulmonary resuscitation (CPR) in pigs. Resuscitation. 1994;28(1):55-64.

22. Chang MW, Coffeen P, Lurie KG, et al. Active compression-decompression CPR improves vital organ perfusion in a dog model of ventricular fibrillation. Chest. 1994;106(4):1250-1259.

23. Tucker KJ, Khan J, Idris A, Savitt MA. The biphasic mechanism of blood flow during cardiopulmonary resuscitation: a physiologic comparison of active compression-decompression and high-impulse manual external cardiac massage. Ann Emerg Med. 1994;24(5):895-906.

24. Langhelle A, Stromme T, Sunde K, et al. Inspiratory impedance threshold valve during CPR. Resuscitation. 2002;52(1):39-48.

25. Voelckel WG, Lurie KG, Sweeney M, et al. Effects of active compression-decompression cardiopulmonary resuscitation with the inspiratory threshold valve in a young porcine model of cardiac arrest. Pediatr Res. 2002;51(4):523-527.

26. Raedler C, Voelckel WG, Wenzel V, et al. Vasopressor response in a porcine model of hypothermic cardiac arrest is improved with active compression-decompression cardiopulmonary resuscitation using the inspiratory impedance threshold valve. Anesth Analg. 2002;95(6):1496-1502, table of contents.

27. Metzger AK, Herman M, McKnite S, Tang W, Yannopoulos D. Improved cerebral perfusion pressures and 24-hr neurological survival in a porcine model of cardiac arrest with active compression-decompression cardiopulmonary resuscitation and augmentation of negative intrathoracic pressure. Crit Care Med. 2012;40(6):1851-1856.

28. Shih A, Udassi S, Porvasnik SL, et al. Use of impedance threshold device in conjunction with our novel adhesive glove device for ACD-CPR does not result in additional chest decompression. Resuscitation. 2013;84(10):1433-1438.

29. Kwon Y, Debaty G, Puertas L, et al. Effect of regulating airway pressure on intrathoracic pressure and vital organ perfusion pressure during cardiopulmonary resuscitation: a non-randomized interventional cross-over study. Scand J Trauma Resusc Emerg Med. 2015;23:83.

30. Steinberg MT, Olsen JA, Eriksen M, et al. Haemodynamic outcomes during piston-based mechanical CPR with or without active decompression in a porcine model of cardiac arrest. Scand J Trauma Resusc Emerg Med. 2018;26(1):31.