Cardiac & Resuscitation, Exclusives, Heart of America, Patient Care, Top Story

Active Compression-Decompression CPR Plus an Impedance Threshold Device

Although conventional closed-chest manual CPR has been the standard of care for over 60 years,1 its limitations have resulted in new CPR techniques.2–6 Conventional, standard CPR provides only about 20–30% of normal blood flow to the heart and brain, which in many cases is insufficient to enable a return of spontaneous circulation (ROSC).7–10 In addition, it’s difficult to perform correctly and consistently.11–14

Over the past 25 years, a new method of CPR called “active compression-decompression (ACD) CPR plus an impedance threshold device (ITD)” has been developed as a superior alternative to standard CPR.15–19 ACD+ITD CPR has been tested in multiple animal20–24 and human studies,15–19 and it has been found to provide significantly higher rates of survival with favorable neurological function compared with standard CPR.15–24

ACD+ITD CPR is performed with tools that work synergistically to more than double the blood flow to the heart and brain vs. standard CPR.25,26 ACD+ITD CPR relies on a suction cup to actively lift the chest during the recoil phase5,6 and an ITD to impede air from rushing into the lungs during the recoil phase.2,3,27 This device combination lowers intrathoracic pressure during the CPR decompression phase, which in turn draws more venous blood back into the heart, refilling it more efficiently than is possible with standard CPR.3,4,18

Perhaps most importantly, during the active recoil phase, the biophysics of ACD+ITD CPR causes more venous blood flow from the brain to the heart, thereby lower intracranial pressures. This results in less resistance to forward blood flow to the brain and an overall increase in brain flow.28–30

The ACD+ITD CPR device provides guidance to help minimize common errors during CPR, such as such as compressions that are too fast or too slow, incomplete chest wall recoil, inadequate or too much compression depth, and excessive ventilation rates.12,15–19 (See Figure 1.)

Based upon multiple animal studies20–24 and four European studies15–18 demonstrating superior hemodynamics and short-term survival rates with ACD+ITD CPR vs. ACD CPR alone or standard CPR, a large NIH-funded trial was performed from 2005–2010. It showed that ACD+ITD CPR was superior to standard CPR when ACD+ITD CPR was started as a BLS therapy and continued for at least 30 minutes or until ROSC. Fifty percent more patients with a non-traumatic cardiac arrest of cardiac etiology were alive and with good neurological function a year after cardiac arrest with ACD+ITD CPR vs. standard CPR controls.19

The ACD+ITD CPR combination, called ResQCPR, is the first and only CPR technology ever approved by the FDA that’s indicated to increase the likelihood of survival after a cardiac arrest compared with standard CPR.19,31,32

Since FDA approval, ACD+ITD CPR has been introduced into a number of different EMS systems and hospitals. Like any new technique, training is required as is regular follow-up to assure rescue personnel are using the system correctly. In some places, the ACD+ITD CPR devices have been co-packaged with an AED, a face mask and a resuscitator bag for use by police and other first responders. This new CPR technique is becoming more widely used.

Recommendation

Based upon the strong science generated over the past 25 years and proven improved hemodynamics, survival and neurological outcome, ACD+ITD CPR should be the new standard of care for all BLS and ALS providers, as well as an essential element of any lifesaving bundle of care. ACD+ITD CPR should be the hemodynamic platform upon which all new cardiac arrest therapeutic interventions should be tested.

To further enhance outcome from cardiac arrest, an automated ACD+ITD CPR system is needed that can be easily integrated with other recent advances, including use of head-up CPR, prolonged CPR, integration with ECMO/ECPR, ongoing CPR in the cardiac catheterization laboratory, and ways to monitor, record and optimize CPR quality throughout the course of the resuscitation effort.

References

1. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173:1064–1067.

2. Lurie KG, Nemergut EC, Yannopoulos D, et al. The physiology of cardiopulmonary resuscitation. Anesth Analg. 2016;122(3):767–783.

3. Pirrallo RG, Aufderheide TP, Provo TA, et al. Effect of an inspiratory impedance threshold device on hemodynamics during conventional manual cardiopulmonary resuscitation. Resuscitation. 2005;66(1):13–20.

4. Aufderheide TP, Pirrallo RG, Provo TA, et al. Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest. Crit Care Med. 2005;33(4):734–740.

5. 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. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group. N Engl J Med. 1999;341(8):569–575.

6. Plaisance P, Adnet F, 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.

7. Duggal C, Weil MH, Gazmuri RJ, et al. Regional blood flow during closed-chest cardiac resuscitation in rats. J Appl Physiol (1985). 1993;74(1):147–152.

8. Niemann JT. Cardiopulmonary resuscitation. N Engl J Med. 1992;327(15):1075–1080.

9. Eisenberg MS, Horwood BT, Cummins RO, et al. Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med. 1990;19(2):179–186.

10. Becker L, Ostrander M, Barrett J, et al. Outcome of cardiopulmonary resuscitation in a large metropolitan area: Where are the survivors? Ann Emerg Med. 1991;20(4):355–361.

11. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293(3):299–304.

12. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417–435.

13. Olasveengen TM, Tomlinson AE, Wik L, et al. A failed attempt to improve quality of out-of-hospital CPR through performance evaluation. Prehosp Emerg Care. 2007;11(4):427–433.

14. Abella BS. The importance of cardiopulmonary resuscitation quality. Curr Opin Crit Care. 2013;19(3):175–180.

15. Plaisance P, Lurie KG, Payen D. Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: A randomized evaluation in patients in cardiac arrest. Circulation. 2000;101(9):989–994.

16. Wolcke BB, Mauer DK, Schoefmann MF, et al. Comparison of standard cardiopulmonary resuscitation versus the combination of active compression-decompression cardiopulmonary resuscitation and an inspiratory impedance threshold device for out-of-hospital cardiac arrest. Circulation. 2003;108(18):2201–2205.

17. Plaisance P, Lurie KG, Vicaut E, et al. Evaluation of an impedance threshold device in patients receiving active compression-decompression cardiopulmonary resuscitation for out of hospital cardiac arrest. Resuscitation. 2004;61(3):265–271.

18. Plaisance P, Soleil C, Lurie KG, et al. Use of an inspiratory impedance threshold device on a facemask and endotracheal tube to reduce intrathoracic pressures during the decompression phase of active compression-decompression cardiopulmonary resuscitation. Crit Care Med. 2005;33(5):990–994.

19. 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.

20. Debaty G, Metzger A, Rees J, et al. Enhanced perfusion during advanced life support improves survival with favorable neurologic function in a porcine model of refractory cardiac arrest. Crit Care Med. 2015;43(5):1087–1095.

21. Lurie KG, Coffeen P, Shultz J, et al. Improving active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve. Circulation. 1995;91(6):1629–1632.

22. Aufderheide TP, Lurie KG. Vital organ blood flow with the impedance threshold device.

Crit Care Med. 2006;34(12 Suppl):S466–S473.

23. Lurie KG, Voelckel WG, Zielinski T, et al. Improving standard cardiopulmonary resuscitation with an inspiratory impedance threshold valve in a porcine model of cardiac arrest. Anesth Analg. 2001;93(3):649–655.

24. 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.

25. Lurie KG, Coffeen P, Shultz J, et al. Improving active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve. Circulation. 1995;91(6):1629–1632.

26. Lurie KG, Lindner KH. Recent advances in cardiopulmonary resuscitation. J Cardiovasc Electrophysiol. 1997;8(5):584–600.

27. Thayne RC, Thomas DC, Neville JD, et al. Use of an impedance threshold device

improves short term outcomes following out-of-hospital cardiac arrest. Resuscitation. 2005;67(1):103–108.

28. Yannopoulos D, Aufderheide T, Gabrielli A, et al. Clinical and hemodynamic comparison of 15:2 and 30:2 compression-to-ventilation ratios for cardiopulmonary resuscitation. Crit Care Med. 2006;34(5):1444–1449.

29. Yannopoulos D, Sigurdsson G, McKnite S, et al. Reducing ventilation frequency combined with an inspiratory impedance device improves CPR efficiency in a swine model of cardiac arrest. Resuscitation. 2004;61(1):75–82.

30. Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2005;64(3):363–372.

31. 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.

32. Summary of Safety and Effectiveness Data (SSED): Combination compression/decompression manual chest pump with impedance respiratory valve. (March 6, 2015.) U.S. Food and Drug Administration. Retrieved Jan. 21, 2019, from www.accessdata.fda.gov/cdrh_docs/pdf11/P110024b.pdf.