Trial of Continuous or Interrupted Chest Compressions during CPR.

BACKGROUND During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital cardiac arrest, the interruption of manual chest compressions for rescue breathing reduces blood flow and possibly survival. We assessed whether outcomes after continuous compressions with positive-pressure ventilation differed from those after compressions that were interrupted for ventilations at a ratio of 30 compressions to two ventilations. METHODS This cluster-randomized trial with crossover included 114 emergency medical service (EMS) agencies. Adults with non-trauma-related cardiac arrest who were treated by EMS providers received continuous chest compressions (intervention group) or interrupted chest compressions (control group). The primary outcome was the rate of survival to hospital discharge. Secondary outcomes included the modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3 indicating favorable neurologic function). CPR process was measured to assess compliance. RESULTS Of 23,711 patients included in the primary analysis, 12,653 were assigned to the intervention group and 11,058 to the control group. A total of 1129 of 12,613 patients with available data (9.0%) in the intervention group and 1072 of 11,035 with available data (9.7%) in the control group survived until discharge (difference, -0.7 percentage points; 95% confidence interval [CI], -1.5 to 0.1; P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in the control group survived with favorable neurologic function at discharge (difference, -0.6 percentage points; 95% CI, -1.4 to 0.1, P=0.09). Hospital-free survival was significantly shorter in the intervention group than in the control group (mean difference, -0.2 days; 95% CI, -0.3 to -0.1; P=0.004). CONCLUSIONS In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions. (Funded by the National Heart, Lung, and Blood Institute and others; ROC CCC ClinicalTrials.gov number, NCT01372748.).

[1]  Dana M. Zive,et al.  Association between hospital post-resuscitative performance and clinical outcomes after out-of-hospital cardiac arrest. , 2015, Resuscitation.

[2]  P. Kudenchuk,et al.  A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. , 2015, American heart journal.

[3]  R. Bellomo,et al.  HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility trial. , 2014, Resuscitation.

[4]  Monique L. Anderson,et al.  Abstract 86: Association Between Hospital Postresuscitative Performance and Clinical Outcomes in Patients with Out-of-Hospital Cardiac Arrest , 2014 .

[5]  P. Kudenchuk,et al.  Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial. , 2014, American heart journal.

[6]  C. Callaway,et al.  Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest. , 2014, Resuscitation.

[7]  R. Berg,et al.  Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies. , 2013, Resuscitation.

[8]  M. Copass,et al.  Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest. , 2012, The American journal of cardiology.

[9]  Judy Powell,et al.  The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. , 2011, Resuscitation.

[10]  Henry E. Wang,et al.  A trial of an impedance threshold device in out-of-hospital cardiac arrest. , 2011, The New England journal of medicine.

[11]  Daniel Davis,et al.  Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. , 2011, The New England journal of medicine.

[12]  C. Callaway,et al.  Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster-randomised trial , 2011, BMJ : British Medical Journal.

[13]  Roger D. White,et al.  Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[14]  Robin Hemphill,et al.  Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[15]  Roger D. White,et al.  Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[16]  Mark Terry,et al.  Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[17]  D. Angus,et al.  Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. , 2010, JAMA.

[18]  R. Berg,et al.  Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. , 2009, Annals of emergency medicine.

[19]  Judy Powell,et al.  Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation , 2009, Circulation.

[20]  M. Gratton,et al.  Improved Patient Survival Using a Modified Resuscitation Protocol for Out-of-Hospital Cardiac Arrest , 2009, Circulation.

[21]  G. Jacquet.  Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest , 2008 .

[22]  R. Agarwal.  The low-flow or high-flow oxygen delivery system and a low-flow or high-flow nonrebreather mask. , 2006, American journal of respiratory and critical care medicine.

[23]  R. Clark.  Faculty Opinions recommendation of Normoxic resuscitation after cardiac arrest protects against hippocampal oxidative stress, metabolic dysfunction, and neuronal death. , 2006 .

[24]  G. Ewy,et al.  Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. , 2006, The American journal of medicine.

[25]  P. Hof,et al.  Normoxic Resuscitation after Cardiac Arrest Protects against Hippocampal Oxidative Stress, Metabolic Dysfunction, and Neuronal Death , 2005, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[26]  P. Steen,et al.  Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. , 2005, JAMA.

[27]  T. Aufderheide,et al.  Death by hyperventilation: A common and life-threatening problem during cardiopulmonary resuscitation , 2004, Critical care medicine.

[28]  Nicole A. Lazar,et al.  Statistical Analysis With Missing Data , 2003, Technometrics.

[29]  Roderick J. A. Little,et al.  Statistical Analysis with Missing Data: Little/Statistical Analysis with Missing Data , 2002 .

[30]  Robert A. Berg,et al.  Importance of Continuous Chest Compressions During Cardiopulmonary Resuscitation: Improved Outcome During a Simulated Single Lay-Rescuer Scenario , 2002, Circulation.

[31]  Robert A. Berg,et al.  Adverse Hemodynamic Effects of Interrupting Chest Compressions for Rescue Breathing During Cardiopulmonary Resuscitation for Ventricular Fibrillation Cardiac Arrest , 2001, Circulation.

[32]  R. Berg,et al.  "Bystander" chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless "cardiac arrest". , 2000, Circulation.

[33]  W A Watson,et al.  Hawthorne effect: implications for prehospital research. , 1995, Annals of emergency medicine.

[34]  D. Rubin,et al.  Statistical Analysis with Missing Data. , 1989 .

[35]  Barbara T. Unger,et al.  Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. , 2014, Resuscitation.

[36]  J. Stockman,et al.  Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest , 2012 .

[37]  S. Trzeciak,et al.  Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest , 2009 .

[38]  H. White.  Maximum Likelihood Estimation of Misspecified Models , 1982 .

[39]  P. J. Huber.  The behavior of maximum likelihood estimates under nonstandard conditions , 1967 .