Combination of active compression decompression cardiopulmonary resuscitation and the inspiratory impedance threshold device: State of the art

Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota, USA.
Current Opinion in Critical Care (Impact Factor: 2.62). 06/2004; 10(3):193-201. DOI: 10.1097/01.ccx.0000126089.40242.a9
Source: PubMed


Over the past decade, the combination of active compression decompression (ACD) cardiopulmonary resuscitation (CPR) and an impedance threshold device (ITD) has been shown to significantly increase vital organ perfusion pressures and survival rates in animals and humans. The purpose of this review article is to summarize the recent advances with this new technology.
Building upon animal studies that demonstrated the benefit of the ITD used with either ACD CPR or standard CPR (S-CPR), four prospective, randomized clinical trials with ACD/ITD CPR have been recently completed. One blinded, out-of-hospital cardiac arrest trial (n = 21 patients) demonstrated that systemic blood pressures and coronary perfusion pressures were markedly higher when ACD/ITD CPR was used when compared directly with ACD CPR alone. The second blinded trial demonstrated that the combination of ACD/ITD CPR was effective with both a facemask and an endotracheal tube (n = 15 patients). A third randomized clinical trial (n = 210 patients) demonstrated that 24-hour survival rates for out-of-hospital cardiac arrest were more than 65% higher with ACD/ITD CPR than with S-CPR (P < 0.01). Neurologic function after cardiac arrest trended higher in patients with witnessed arrest who received ACD/ITD CPR than in those who received S-CPR(P < 0.07). In addition, when ACD/ITD CPR was applied later in the course of treatment, short-term survival rates were threefold higher in patients receiving ACD/ITD CPR (44%) than in those receiving S-CPR (14%)(P < 0.05). In that study, patients with the greatest chance for survival-those with witnessed cardiac arrest and an initial rhythm of ventricular fibrillation-had a 23% 24-hour survival rate with S-CPR versus a 58% 24-hour survival rate with ACD/ITD CPR (P < 0.01). It should be noted that this trial was performed in a city where an earlier study found no difference in outcomes between ACD CPR alone and S-CPR. The fourth clinical trial was a randomized, double-blinded study of 400 patients with out-of-hospital cardiac arrest treated by advanced life support personnel. All patients received ACD CPR: half were treated with a sham ITD and the other half were treated with an active ITD. Twenty-four hour survival, the primary endpoint, was 32% in the active ITD group versus 22% in the sham group (P < 0.05).
On the basis of the cumulative findings of these studies, it is concluded that ACD/ITD CPR provides superior vital organ blood flow and results in significantly higher short-term survival rates than do ACD CPR alone or S-CPR. Use of the ACD/ITD CPR technology optimizes perfusion of the heart and brain during cardiac arrest and results in the highest reported survival rates of any CPR device technology. Use of this technology should be encouraged while additional studies are under way to examine the potential long-term impact of this new technology.

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Available from: Keith Geoffrey Lurie
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    • "Experimental studies in animals and humans have suggested that it can increase both myocardial and cerebral perfusion, passively exploiting the forces generated during cardiac massage, especially when combined with an active compression-decompression-CPR (ACD-CPR) method [4, 6,7,8]. Most recent data suggest that ITD could be beneficial even in conscious yet hypotensive patients, thus supporting its overall efficacy and safety profile [9]. "
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    ABSTRACT: Introduction Uncertainty persists on the clinical impact of impedance threshold devices in out-of-hospital cardiac arrest. We conducted an updated systematic review on impedance threshold devices. Methods Several databases were searched for studies testing the effectiveness of impedance threshold devices in patients with cardiac arrest. The primary endpoint was long-term survival. Results Seven trials (11,254 patients) were included. In 4 studies (2,284 patients) impedance threshold devices were used with active compression-decompression-cardiopulmonary resuscitation, and in the others alone. Overall, impedance threshold devices did not impact on the rate of return of spontaneous circulation (odds ratio=1.17 [0.96-1.43], p=0.114), favorable neurologic outcome (odds ratio=1.56 [0.97-2.50], p=0.065), or long-term survival (odds ratio=1.22 [0.94-1.58], p=0.127). These analyses were fraught with heterogeneity (respectively, p=0.055, p=0.236, and p=0.011) and inconsistency (respectively, I-squared=51% , I-squared=27% , and I-squared=67%). Exploratory analysis showed that combined use of impedance threshold devices with active compression-decompression significantly increased the likelihood of return of spontaneous circulation (odds ratio=1.19 [1.00-1.40], p=0.045), favorable neurologic outcome (odds ratio=1.60 [1.14-2.25], p=0.006), and long-term survival (odds ratio=1.52 [1.11-2.08], p=0.009). The favorable impact of the interaction between impedance threshold devices and active compression-decompression was also confirmed at meta-regression analysis (respectively, b=0.195 [0.004-0.387], p=0.045, b=0.500 [0.079-0.841], p=0.018, b=0.413 [0.063-0.764], p=0.021). Conclusions The evidence base on impedance threshold devices is apparently inconclusive, with a neutral impact on clinically relevant outcomes. However, exploratory analysis focusing on the combined use of impedance threshold devices with active compression-decompression suggests that this combo treatment may be useful to improve patient prognosis.
    Full-text · Article · Mar 2014
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    • "During active compression, there is increase in the intrathoracic pressure, which is conveyed to the cardiac chambers and vascular compartments as well as to the arterial system. In opposition, during decompression the chest recoils back, affecting a decrease in intrathoracic pressure to levels less than the extrathoracic venous pressure, which then causes a return of the blood flow to the thorax [12] [13]. "
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    ABSTRACT: Cardiac arrest is a major concern in health care, owing to its high incidence and mortality rates. Since the development of external cardiopulmonary resuscitation (CPR), there has been little advancement in nonpharmacologic therapies that have increased survival rates associated with cardiac arrest. Consequently, there has been much interest in the development of new techniques to improve the efficacy of CPR, particularly in the development of devices. Initially, many of the devices developed were not considered functional and failed to gain acceptance in the clinical setting. Recently, however, several devices have been developed which have progressed the administration of CPR and garnered acceptance in the clinical setting. In this article we will briefly review some of the more common mechanical devices developed to increase the safety and efficacy of CPR administration.
    Full-text · Article · Nov 2008 · The American journal of emergency medicine

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