Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Bruckner M, Wyckoff MH, and Smölzer GM have all published studies regarding neonatal cardiac compressions. 2 reviewers were used to select or exclude each paper for this scoping review and no reviewer was allowed to determine inclusion or exclusion of their own publications.
Task Force Scoping Review Citation
Ramachandran S, Bruckner M, Wyckoff MH, Smölzer GM on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Neonatal Cardiac Compressions Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2022, Dec 20. Available from: http://ilcor.org
Methodological Preamble
The continuous evidence evaluation process started with a scoping review of neonatal cardiac compressions literature conducted by the ILCOR NLS Task Force and Content Expert Scoping Review Team comprised of Shalini Ramachandran, MD, Marlies Bruckner, MD, Myra Wyckoff MD, Georg M. Schmölzer MD, PhD. Neonatal cardiac compression literature was sought via a structured search strategy with the help of an information specialist, Ms. Helen Mayo from University of Texas Southwestern Medical Center. Studies identified were evaluated using Covidence. This allowed independent title and abstract review by two authors (SR and MB) to see if full text review was warranted. When MB was an author on a study under consideration, she was recused from the decision and MW gave the second opinion. Abstracts put forward by both reviewers were included for full text review. Conflicting opinions were reviewed, discussed and resolved with the help of MW and GS as long as they were not authors on the paper under consideration. The Neonatal Life Support Task Force considered the findings for each included PICOST and developed Task Force insights regarding the compiled literature for each PICOST.
Studies screened by title / abstract, those undergoing full text review and those extracted for data analysis for the scoping review are shown in the PRISMA diagram below.
PRISMA: NLS 5504 PRISMA
Link to Published Scoping Review
Ramachandran S, Bruckner M, Wyckoff MH, Schmölzer GM. Chest compressions in newborn infants: a scoping review. Arch Dis Child Fetal Neonatal Ed. 2022 Dec 1:fetalneonatal-2022-324529. doi: 10.1136/archdischild-2022-324529.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In neonates receiving cardiac compressions
Intervention: does use of any other compression to ventilation ratio (5:1, 9:3,15:2, synchronous, etc)
Comparators: versus the standard 3:1 compression to ventilation ratio
Outcomes: impact any short or long term outcomes (survival rates, time to return of spontaneous circulation (ROSC), hemodynamic parameters, tissue oxygenation, lung/brain inflammatory markers, compressor fatigue).
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), and case series were eligible for inclusion. Manikin, computer model and animal studies were eligible for inclusion. Conference abstracts and unpublished studies (e.g. trial protocols) were excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to Nov 22, 2021.
Search Strategies: NLS 5504 Search Strategies
Data Table: NLS 5504 Data Table
Task Force Insights
- Why this topic was reviewed
- The 2015 ILCOR CoSTR suggested use of the 3:1 compression to ventilation (C:V) ratio during neonatal chest compressions (weak recommendation, very-low-quality evidence).{Perlman 2015 S204; Perlman 2015 S120; Wyllie 2015 e169} There was no clinical evidence for this suggestion and it was based on animal and manikin studies. Use of the 3:1 C:V ratio was reaffirmed in 2020 after a brief evidence update.{Wyckoff 2020 S185; Wyckoff 2020 A156, Wyckoff 2020 e2020038505C} Because the 2020 evidence update identified multiple new manikin studies, several animal studies, and one clinical pilot trial, the task force felt an in depth scoping review was warranted.
- Narrative summary of evidence identified
- This scoping review identified 23 (7 manikin,15 animal and 1 clinical) studies examining different C:V ratios, CCaV or CC+SI with mixed results (shown in table).
- Other C:V ratios (i.e., 2:1, 4:1, 9:3, 15:2) did not improve time to ROSC or survival.
- In manikins, CCaV compared to 3:1 C:V ratio increased fatigue { Li 2015 142; Boldingh 2015 1; Boldingh 2016 910}. One study using a transitional lamb model compared continuous chest compressions with asynchronized ventilation (CCaV) to 3:1 C:V ratio and reported improved carotid blood flow and cerebral oxygen delivery {Vali 2021, 752}. Another animal study in piglets showed significant improvement in time to ROSC and survival in piglets resuscitated with CCaV,{Aggelina 2021,60} while others reported no difference in time to ROSC and survival {Schmölzer 2014 270; Mendler 2015 22; Patel 2020 357}
- In newborn piglet models of asphyxial cardiac arrest, providing cardiac compressions while providing a sustained inflation resulted in faster time to ROSC {Schmölzer 2013 2495; Li 2017 337; Mustofa 2018 82} but this was not seen when studied in the transitional lamb model {Vali 2017 e370}. A pilot trial randomized nine preterm infants <33 weeks’ gestation to CC+SI using SI of 20 s per SI (n=5) or 3:1 C:V (n=4) reported faster time to ROSC with CC+SI and similar survival.
3. Narrative Reporting of the task force discussions
• The information from the studies identified was considered insufficient to alter existing recommendations.
- The CC+SI data is interesting and the task force is aware a larger trial was undertaken and will be awaiting the results.
Knowledge Gaps
- The gaps in knowledge regarding optimal compression to ventilation ratios are immense. Additional research is required, particularly clinical neonatal studies
References
Aggelina A, Pantazopoulos I, Giokas G, et al. Continuous chest compressions with asynchronous ventilation improve survival in a neonatal swine model of asphyxial cardiac arrest. Am J Emerg Medicine 2021;48:60–6.
Boldingh AM, Jensen TH, Bjørbekk AT, et al. Rescuers’ physical fatigue with different chest compression to ventilation methods during simulated infant cardiopulmonary resuscitation. J Maternal-fetal Neonatal Medicine 2015;29:1–6.
Boldingh AM, Solevåg A, Aasen E, et al. Resuscitators who compared four simulated infant cardiopulmonary resuscitation methods favoured the three-to-one compression-to-ventilation ratio. Acta paediatrica (Oslo, Norway : 1992) 2016;105:910–6.
Dannevig I, Solevåg A, Saugstad OD, et al. Lung injury in asphyxiated newborn pigs resuscitated from cardiac arrest - the impact of supplementary oxygen, longer ventilation intervals and chest compressions at different compression-to-ventilation. Open Respiratory Medicine Journal 2012;6:89–96.
Dannevig I, Solevåg A, Sonerud T, et al. Brain inflammation induced by severe asphyxia in newborn pigs and the impact of alternative resuscitation strategies on the newborn central nervous system. Pediatric Research 2013;73:163–70.
Dellimore K, Scheffer C, Smith J, et al. Evaluating the influence of ventilation and ventilation-compression synchronization on chest compression force and depth during simulated neonatal resuscitation. J Maternal-fetal Neonatal Medicine 2016;30:1–18.
Hemway RJ, Christman C, Perlman J. The 3:1 is superior to a 15:2 ratio in a newborn manikin model in terms of quality of chest compressions and number of ventilations. Archives Dis Child - Fetal Neonatal Ed 2013;98:F42.
Li ES, Cheung P-Y, O’Reilly M, et al. Rescuer fatigue during simulated neonatal cardiopulmonary resuscitation. J Perinatol 2015;35:142–5.
Li ES, Görens I, Cheung P-Y, et al. Chest Compressions during Sustained Inflations Improve Recovery When Compared to a 3:1 Compression:Ventilation Ratio during Cardiopulmonary Resuscitation in a Neonatal Porcine Model of Asphyxia. Neonatology 2017;112:337–46.
Mendler MR, Maurer M, Hassan MA, et al. Different Techniques of Respiratory Support Do Not Significantly Affect Gas Exchange during Cardiopulmonary Resuscitation in a Newborn Piglet Model. Neonatology 2015;108:73–80.
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Mustofa J, Cheung P-Y, Patel S, et al. Effects of different durations of sustained inflation during cardiopulmonary resuscitation on return of spontaneous circulation and hemodynamic recovery in severely asphyxiated piglets. Resuscitation 2018;129:82–9.
Pasquin MP, Cheung P-Y, Patel S, et al. Comparison of Different Compression to Ventilation Ratios (2: 1, 3: 1, and 4: 1) during Cardiopulmonary Resuscitation in a Porcine. Neonatology 2018;114:37–45.
Patel S, Cheung P-Y, Lee T-F, et al. Asynchronous ventilation at 120 compared with 90 or 100 compressions per minute improves haemodynamic recovery in asphyxiated newborn piglets. Archives Dis Child - Fetal Neonatal Ed 2020;105:357–63.
Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim H-S, Liley HG, Mildenhall L, Simon WM, et al. Part 7: Neonatal Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132:S204–S241.
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Schmölzer GM, O’Reilly M, LaBossiere J, et al. Cardiopulmonary resuscitation with chest compressions during sustained inflations: a new technique of neonatal resuscitation that improves recovery and survival in a neonatal porcine model. Circulation 2013;128:2495–503.
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Srikantan SK, Srikantan SK, Berg RA, et al. Effect of one-rescuer compression/ventilation ratios on cardiopulmonary resuscitation in infant, pediatric, and adult manikins. Pediatric Critical Care Medicine 2005;6:293–7.
Vali P, Chandrasekharan PK, Rawat M, et al. Continuous Chest Compressions During Sustained Inflations in a Perinatal Asphyxial Cardiac Arrest Lamb Model. Pediatric Critical Care Medicine 2017;18:e370–7.
Vali P, Lesneski A, Hardie M, et al. Continuous chest compressions with asynchronous ventilations increase carotid blood flow in the perinatal asphyxiated lamb model. Pediatr Res 2021;90:752–8.
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