CPR by rescuers wearing PPE: BLS Evidence Update; Systematic Review

Evidence Update 10/8/2024

PICOST / Research Question:

Year of last full review: 2023 COSTR

Current ILCOR Consensus on Science and Treatment Recommendation for this PICOST:

We recommend monitoring for fatigue in all rescuers performing CPR (good practice statement).

We suggest increased vigilance for fatigue in rescuers wearing PPE (weak recommendation, very low–certainty evidence).

Current Search Strategy (for an existing PICOST): See appendix below

Database searched: Medline Embase Cochrane

Time Frame: (existing PICOST) – updated from end of last search (please specify): 25 May 2022 – 9 Aug 2024

Date Search Completed: 9 Aug 2024

Search Results: 64 identified, but no relevant study found.

Another hand search identified 4 relevant studies: 2 compared PPE vs no PPE (Sellmann 2022, Tangpaisarn 2023) 2 compared alternative types of PPEs (Starosolski 2022, Cheng 2023).

Summary of Evidence Update:

• Relevant Guidelines or Systematic Reviews: none

• RCT:

• Nonrandomized Trials, Observational Studies

Reviewer Comments:

Four studies have been published during two years since the previous SR. All studies were based on simulation and CPR quality was set as the primary outcome. There is no evidence to change the current 2023 COSTR.

Even if wearing PPE reduces CPR quality, we should wear appropriate PPE during CPR. Because CPR is considered as an aerosol generating procedure. It would be good to conduct a scoping review of studies on the most efficient CPR methods while wearing PPE in the future.

Since relevant studies were not searched in the existing search strategy, the search strategy needs to be re-generated during the next evidence update.

References

• Cheng CH, Cheng YY, Yuan MK, Juang YJ, Zeng XY, Chen CY, Foo NP. Impact of Personal Protective Equipment on Cardiopulmonary Resuscitation and Rescuer Safety. Emerg Med Int. 2023 Nov 30;2023:9697442.
• Sellmann T, Nur M, Wetzchewald D, Schwager H, Cleff C, Thal SC, Marsch S. COVID-19 CPR-Impact of Personal Protective Equipment during a Simulated Cardiac Arrest in Times of the COVID-19 Pandemic: A Prospective Comparative Trial. J Clin Med. 2022 Oct 5;11(19):5881.
• Starosolski M, Zysiak-Christ B, Kalemba A, Kapłan C, Ulbrich K. A Simulation Study Using a Quality Cardiopulmonary Resuscitation Medical Manikin to Evaluate the Effects of Using Personal Protective Equipment on Performance of Emergency Resuscitation by Medical Students from the University of Silesia, Katowice, Poland and Non-Medical Personnel. Med Sci Monit. 2022 Jul 2;28:e936844.
• Tangpaisarn T, Chaiyakot N, Saenpan K, Sriphrom S, Owattanapanich N, Kotruchin P, Phungoen P. Surgical mask-to-mouth ventilation as an alternative ventilation technique during CPR: A crossover randomized controlled trial. Am J Emerg Med. 2023 Oct;72:158-163.

Appendix 1. Search strategy

Original CoSTR 1/9/2023

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 were recused from the discussion as they declared a conflict of interest: None applicable.

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: None applicable.

CoSTR Citation

Chung SP, Nehme Z, Lagina A, Johnson N, Bray J. on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. CPR by rescuers wearing PPE vs no PPE for Cardiac Arrest in Adults and Children Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, November 30, 2022. Available from: http://ilcor.org

Methodological Preamble

There are two published systematic reviews investigating the impact of PPE on CPR quality. One review suggested the use of PPE significantly compromises the quality of chest compression during CPR (Sahu 2021 190), while the other review showed that the use of PPE was not associated with a reduced rate or depth of chest compressions (Cui 2021 733724). However, since these two reviews there have been more studies published.

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support conducted by Sung Phil Chung, Ziad Nehme, Anthony Lagina and Nicholas Johnson with involvement of clinical content experts. Evidence for adult literature was sought and considered by the Basic Life Support Task Force. This review is focused on comparing outcomes of survival, CPR quality, time to procedure of interest, rescuer fatigue, and neuropsychiatric performance rather than infection risk (which is covered in other ILCOR reviews [Couper 2020 59, Perkins 2020 145, Wyckoff 2021 229]). The time to procedure outcomes were limited to basic life support interventions.

PICOST

Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest (including simulated cardiac arrest).

Intervention: CPR by rescuers wearing personal protective equipment (PPE)

Comparators: CPR by rescuers not wearing PPE or wearing an alternative strategy of PPE

Outcomes: Critical: Survival to discharge, ROSC; Important: CPR quality, time to procedure of interest, and rescuer’s fatigue and neuropyschiatric performance such as concentration and dexterity

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to May 23, 2022.

PROSPERO Registration CRD42022347746

Consensus on Science

The comprehensive search strategy resulted in one clinical study and 17 simulation studies (11 RCTs and 6 non-RCTs) being included. A meta-analysis was performed when there were two or more studies reporting the same outcome. In the case of studies comparing different types of PPE, meta-analysis was not performed because the types of PPE varied according to each study.

Clinical studies

For the critical outcome of survival to hospital discharge/one-month survival we identified very-low certainty evidence (downgraded for risk of bias) from one before-and-after observational study comparing conventional PPE (before period, n=73) vs enhanced PPE (after period, n=57) in an emergency department setting (Ko 2021 1291). Conventional PPE means wearing surgical mask, glove and gown, while enhanced PPE included complete bodysuit, boots, N95 respirator, and PAPR (powered air-purifying respirator). This study reported no difference in 1-month survival in an unadjusted (8.2% vs. 3.5%; p = 0.47) or adjusted multivariable logistic regression analyses(adjusted OR = 0.38, 95% CI: 0.07–2.10; p = 0.27).

For the critical outcome of ROSC we identified very-low certainty evidence (downgraded for risk of bias) from one clinical study reported no difference in the rate of ROSC in the ED between conventional and enhanced PPE groups (49.3% vs. 43.8%; p = 0.60; adjusted OR = 0.79, 95% CI: 0.38–1.67; p = 0.54).

Simulation RCT studies

For the important outcome of chest compression depth, we identified very low-certainty evidence (downgraded for risk of bias, impresicion and indirectness) from 5 randomised studies (Kienbacher 2021 79, Mormando 2021 e200, Rauch 2021 1728, Chen 2016 e3262, Kim 2016 893) enrolling 178 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 1.8mm; 95% CI, −4.3 to 0.8mm).

For the important outcome of chest compression rate, we identified low-certainty evidence (downgraded for risk of bias and indirectness) from 5 randomised studies (Kienbacher 2021 79, Mormando 2021 e200, Rauch 2021 1728, Chen 2016 e3262, Kim 2016 893) enrolling 178 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 1.0/min; 95% CI, −5.8 to 3.7/min).

For the important outcome of appropriate chest compression depth, we identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 4 randomised studies (Fernández-Méndez 2021 7093, Rauch 2021 1728, Chen 2016 e3262, Kim 2016 893) enrolling 114 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 6.5%; 95% CI, −25.3 to 12.2%).

For the important outcome of appropriate chest compression rate, we identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 3 randomised studies (Fernández-Méndez 2021 7093, Chen 2016 e3262, Kim 2016 893) enrolling 80 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 3.7%; 95% CI, −18.3 to 10.9%).

For the important outcome of hands-off time, we identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 2 randomised studies (Fernández-Méndez 2021 7093, Kim 2016 893) enrolling 40 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 5.1sec; 95% CI, −1.7 to 11.8sec).

For the important outcome of appropriate chest recoil, we identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 2 randomised studies (Fernández-Méndez 2021 7093, Mormando 2021 e200) enrolling 58 simulated out-of-hospital cardiac arrests, which showed benefit from the use of the PPE compared with no PPE (absolute risk reduction [ARR], 4.3%; 95% CI, 0.8 to 7.8%).

Simulation non-RCT studies

For the important outcome of chest compression depth, we identified very low-certainty evidence (downgraded for risk of bias, inconsistency and indirectness) from 4 observational studies (Hacımustafaoğlu 2021 385, Serin 2021 292, Donoghue 2020 267, Shin 2015 19) enrolling 252 simulated out-of-hospital cardiac arrests, which showed no difference in rescuers wearing PPE compared with no PPE (absolute risk reduction [ARR], 4.4mm; 95% CI, −8.9 to 0.1mm).

For the important outcome of chest compression rate, we identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 4 observational studies (Hacımustafaoğlu 2021 385, Serin 2021 292, Donoghue 2020 267, Shin 2015 19) enrolling 252 simulated out-of-hospital cardiac arrests, which showed no difference between rescuers wearing PPE compare with no PPE (absolute risk reduction [ARR], 2.4/min; 95% CI, −5.9 to 1.2/min).

For the important outcome of rescuer’s fatigue, we have identified very low-certainty evidence (downgraded for risk of bias and indirectness) from 2 observational studies (Hacımustafaoğlu 2021 385, Serin 2021 292) enrolling 124 simulated out-of-hospital cardiac arrests, which showed increased fatigue of rescuer from the use of the PPE compared with no PPE (absolute risk reduction [ARR], 2.7 VAS score out of 10; 95% CI, 1.4 to 4.0).

Treatment Recommendations

We recommend monitoring for fatigue in all rescuers performing CPR (Good Practice Statement). Rescuers wearing personal protective equipment (PPE) may have greater fatigue, so we suggest increased vigilance for fatigue in these circumstances (Weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

In making this treatment recommendation, we put a high value on protecting healthcare professionals from potential infection transmission and consistency with current recommendations on using PPE during resuscitation.

The delivery of chest compressions is physically tiring. In the two studies reporting greater fatigue in the groups wearing PPE, CPR was performed in pairs and the person performing chest compressions was changed every two minutes. Although both of these studies reported worse CPR quality with PPE, the overall results show no effect on CPR quality. Furthermore, there was a lack of clinical studies examining the impact of PPE on patient outcomes. The Task Force considered a treatment recommendation that included an option to shorten CPR cycles while wearing PPE; however, we decided against this as there was no overall evidence that PPE influenced CPR quality, and a shorter CPR cycle may also increase hands-off-chest time (Jo 2015 539). A recent systematic review (Hung 2019) also suggested against pausing chest compressions at intervals other than every two minutes to assess the cardiac rhythm.

Knowledge Gaps

The studies included in this review were predominately simulation manikin-based studies and varied significantly in the procedures used, including the type of PPE, the design of simulated scenarios, the duration of CPR performed, and the measures of CPR quality used. As such, results should be interpreted carefully and may not be generalizable to the clinical setting.

Current knowledge gaps include but are not limited to:

• Clinical studies examining the effect of PPE on patient outcome.
• Clinical studies examining the effect of PPE on CPR quality.
• The relationship between PPE use, CPR duration and rescuer fatigue.

Clinical studies considering the best type of PPE or appropriate modification strategies to mitigate rescuer fatigue.

Attachments:

PPE CPR Et D

PPE CPR forest plots

References

Chen J, Lu KZ, Yi B, Chen Y. Chest Compression With Personal Protective Equipment During Cardiopulmonary Resuscitation: A Randomized Crossover Simulation Study. Medicine (Baltimore). 2016 Apr;95(14):e3262.

Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R, Mehrabian A, Morley PT, Nolan JP, Soar J, et al. COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review. Resuscitation. 2020;151:59–66.

Cui Y, Jiang S. Influence of Personal Protective Equipment on the Quality of Chest Compressions: A Meta-Analysis of Randomized Controlled Trials. Front Med (Lausanne). 2021 Nov 26;8:733724.

Donoghue AJ, Kou M, Good GL, Eiger C, Nash M, Henretig FM, Stacks H, Kochman A, Debski J, Chen JY, Sharma G, Hornik CP, Gosnell L, Siegel D, Krug S, Adler MD; Best Pharmaceuticals for Children Act – Pediatric Trials Network. Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance: A Controlled Trial. Pediatr Emerg Care. 2020 Jun;36(6):267-273.

Fernández-Méndez M, Otero-Agra M, Fernández-Méndez F, Martínez-Isasi S, Santos-Folgar M, Barcala-Furelos R, Rodríguez-Núñez A. Analysis of Physiological Response during Cardiopulmonary Resuscitation with Personal Protective Equipment: A Randomized Crossover Study. Int J Environ Res Public Health. 2021 Jul 2;18(13):7093.

Hacımustafaoğlu M, Çağlar A, Öztürk B, Kaçer İ, Öztürk K. The effect of personal protective equipment on cardiac compression quality. Afr J Emerg Med. 2021 Dec;11(4):385-9.

Hung K, Castren M, Kudenchuk P, Mancini MB, Avis S, Brooks S, Chung S, Considine J, Hatanaka T, Nishiyama C, Perkins G, Ristagno G, Semeraro F, Smith C, Smyth M, Morley P, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force. Timing of CPR cycles (2 min vs other) Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2019 Jan 1. Available from: http://ilcor.org

Jo CH, Cho GC, Ahn JH, Park YS, Lee CH. Rescuer-limited cardiopulmonary resuscitation as an alternative to 2-min switched CPR in the setting of inhospital cardiac arrest: a randomised cross-over study. Emerg Med J. 2015 Jul;32(7):539-43.

Kienbacher CL, Grafeneder J, Tscherny K, Krammel M, Fuhrmann V, Niederer M, Neudorfsky S, Herbich K, Schreiber W, Herkner H, Roth D. The use of personal protection equipment does not impair the quality of cardiopulmonary resuscitation: A prospective triple-cross over randomised controlled non-inferiority trial. Resuscitation. 2021 Mar;160:79-83.

Kim TH, Kim CH, Shin SD, Haam S. Influence of personal protective equipment on the performance of life-saving interventions by emergency medical service personnel. Med Simul. 2016;92(10):893-8.

Ko HY, Park JE, Jeong DU, Shin TG, Sim MS, Jo IJ, Lee GT, Hwang SY. Impact of Personal Protective Equipment on Out-of-Hospital Cardiac Arrest Resuscitation in Coronavirus Pandemic. Medicina (Kaunas). 2021 Nov 24;57(12):1291.

Mormando G, Paganini M, Alexopoulos C, Savino S, Bortoli N, Pomiato D, Graziano A, Navalesi P, Fabris F. Life-Saving Procedures Performed While Wearing CBRNe Personal Protective Equipment: A Mannequin Randomized Trial. Simul Healthc. 2021 Dec 1;16(6):e200-e205.

Perkins GD, Morley PT, Nolan JP, Soar J, Berg K, Olasveengen T, Wyckoff M, Greif R, Singletary N, Castren M, et al. International Liaison Committee on Resuscitation: COVID-19 consensus on science, treatment recommendations and task force insights. Resuscitation. 2020;151:145–147.

Rauch S, van Veelen MJ, Oberhammer R, Dal Cappello T, Roveri G, Gruber E, Strapazzon G. Effect of Wearing Personal Protective Equipment (PPE) on CPR Quality in Times of the COVID-19 Pandemic-A Simulation, Randomised Crossover Trial. J Clin Med. 2021 Apr 16;10(8):1728.

Sahu AK, Suresh S, Mathew R, Aggarwal P, Nayer J. Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis. Am J Emerg Med. 2021 Jan;39:190-196.

Serin S, Caglar B. The Effect of Different Personal Protective Equipment Masks on Health Care Workers' Cardiopulmonary Resuscitation Performance During the Covid-19 Pandemic. J Emerg Med. 2021 Mar;60(3):292-8.

Shin DM, Kim SY, Shin SD, Kim CH, Kim TH, Kim KY, Kim JH, Hong EJ. Effect of wearing personal protective equipment on cardiopulmonary resuscitation : Focusing on 119 emergency medical technicians. Korean J Emerg Med Ser 2015;19(3):19-32.

Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM; COVID-19 Working Group. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation. 2021 Dec;169:229-311.