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.


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.


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