Mechanical CPR Devices: ALS 3002 TF SR

Conflict of Interest

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

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: Helen Pocock and Keith Couper were both involved in clinical trials included in the review. Bias assessments and decisions about inclusion were completed by task force members not involved in those trials.

CoSTR Citation

Insert citation for ILCOR.org posting of CoSTR

Pocock H, Nicholson T, Szarpak L, Soar J, Berg KM on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force. Mechanical CPR Devices, Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, November 1, 2024. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) on mechanical CPR began with an updated systematic review (PROSPERO registration CRD42024537440). This review updated the prior ILCOR review, which was based on a 2014 Cochrane systematic review.^1-3 All evidence identified was considered by the Advanced Life Support Task and is described here. Discussion points and highlights of the evidence-to-decision process are also included. All data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest and resuscitation attempted by trained medical personnel

Intervention: Any type of powered automated mechanical chest compression

Comparators: Manual chest compression

Outcomes: Any clinical outcome including the critical outcomes of survival with favorable neurologic outcome, survival, and quality of life, and the important outcomes of ROSC and adverse events related to resuscitation.

Study Designs: All randomized, quasi-randomized and cluster-randomized trials from all years comparing any type of powered, mechanical chest compression device to standard manual chest compressions which report at least one of the outcomes defined below will be considered for inclusion in the review.

Timeframe: All years and all languages were included; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to 14 May 2024. All dates up to May 14 2024 were included, in spite of the prior review being conducted in 2014, due to minor modifications to the search strategy.

PROSPERO Registration: CRD42024537440

Consensus on Science

Of 3910 studies identified, 14 papers reporting results from 11 trials were included.^4-17 Six of these trials were included in the 2014 systematic review that informed the 2015 CoSTR, and 5 new trials were identified.^7,12,14-16 Due to significant changes to CPR and cardiac arrest treatment over time, for this review studies conducted prior to the year 2000 were excluded. Due to significant heterogeneity in study design, including in mechanical CPR device, cardiac arrest population and setting, timing of intervention and nature of co-interventions, meta-analysis was not thought advisable. Results of individual studies are summarized below, group by mechanical CPR mechanism and cardiac arrest setting. This consensus on science focuses on the key outcomes of ROSC, survival to hospital discharge or longer, survival with favorable neurologic outcome, and adverse effects of resuscitation.

Does mechanical CPR with a load-distributing band device, compared with manual CPR, change outcome for out-of-hospital cardiac arrest (OHCA)?

For the critical outcome of favourable neurological outcome at hospital discharge, we identified low certainty evidence (downgraded for serious risk of bias and serious inconsistency) from 3 randomized controlled trials (RCTs)^4,13,15 enrolling 5131 patients. The first RCT⁴ enrolling 767 patients found worse outcome using a mechanical CPR device compared with manual CPR (RR 0.41 [95% CI 0.21 to 0.79]; 45 fewer per 1,000 patients [95% CI from 17 fewer to 329 more]. The second study¹³ enrolled 4231 patients and found no benefit when using a mechanical CPR device compared with manual CPR (RR 0.79 [95% CI 0.60 to 1.03]; 11 fewer per 1,000 patients survived with good neurological outcome (mRS 0-3) at hospital discharge [95% CI from 21 fewer to 2 more]. The third RCT¹⁵ enrolling 133 patients showed no benefit from using a mechanical CPR device compared with manual CPR (RR 2.32 [95% CI 0.47 to 11.53]; 41 more per 1,000 patients survived with good neurological outcome (CPC 1-2) at discharge [95% CI from 17 fewer to 329 more.

For the critical outcome of survival to hospital discharge we identified low certainty evidence (downgraded for serious risk of bias and serious inconsistency) from 3 RCTs^4,13,15 enrolling 5131 patients. The first RCT⁴ enrolling 767 patients found worse outcome from using a load-distributing band-mechanical CPR device compared with manual CPR (RR 0.59 [95% CI, 0.36 to 0.97]; 41 fewer survivors per 1,000 patients [95% CI, from 63 fewer to 3 fewer]). The second study¹³ including 4231 patients found no benefit from using a load-distributing band-mechanical CPR device compared with manual CPR (RR 0.85 [95% CI, 0.71 to 1.02]; 16 fewer survivors per 1,000 patients [95% CI from 32 fewer to 2 more]). The third RCT¹⁵ enrolling 133 patients found benefit from using a load-distributing band-mechanical CPR device compared with manual CPR (RR 3.01 [95% CI, 1.04 to 8.77]; 126 more survived per 1,000 patients [95% CI, from 3 more to 486 more]).

For the important outcome of ROSC we identified low certainty evidence (downgraded for serious risk of bias and serious inconsistency) from two RCTs^4,13,15 enrolling 4364 patients.

The first RCT¹³ enrolling 4231 patients found worse outcome using a load-distributing band-mechanical CPR device compared with manual CPR (RR 0.88 [95% CI 0.81 to 0.97]; 39 fewer patients achieving ROSC per 1,000 patients [95% CI, from 61 fewer to 10 fewer]). The second small RCT¹⁵ enrolling 133 patients found benefit from using a load-distributing band-mechanical CPR device compared with manual CPR (RR 1.92 [95% CI, 1.15 to 3.21]; 216 more patients achieved ROSC per 1,000 patients [95% CI, from 35 more to 518 more]).

For the important outcome of resuscitation related injury, we identified low certainty evidence (downgraded for serious risk of bias and serious inconsistency) from two RCTs^13,14 enrolling 4323 patients. The first RCT¹³ included 4231 patients and found no difference in injuries associated with the use of a load-distributing band-mechanical CPR device compared with manual CPR (RR 1.09 [95% CI 0.92 to 1.30]; 9 more per 1,000 patients had post-resuscitation injuries with a load-distributing band-mechanical CPR device [95% CI from 8 fewer to 32 more]. The second RCT¹⁴enrolling 92 patients also found no difference in injuries associated with the use of a load-distributing band-mechanical CPR device compared with manual CPR (RR 3.27 [95% CI 0.70 to 15.38]; 95 more had evidence of serious resuscitation-related structural visceral damage per 1,000 patients [95% CI from 13 fewer to 599 more]).

Does mechanical CPR with a load-distributing band device, compared with manual CPR, change outcome for in-hospital cardiac arrest (IHCA)?

For the important outcome of serious resuscitation-related injury, we identified very low certainty evidence (downgraded for very serious risk of bias and serious imprecision) from one RCT¹⁴ enrolling 137 patients and finding no difference (RR 1.32 [95% CI 0.45 to 3.89]; 25 more per 1,000 patients had evidence of serious resuscitation-related injury with a load-distributing band-mechanical CPR device [95% CI from 42 fewer to 222more ]).

Does mechanical CPR using a piston-based device, compared with manual CPR, improve outcomes from OHCA?

For the critical outcome of favourable neurologic outcome at six months, we identified low certainty evidence (downgraded for very serious risk of bias) from one RCT⁵ enrolling 2549 patients of no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.11 [95% CI 0.86 to 1.45]; 8 more per 1000 survivors with good neurologic outcome (CPC 1-2) [95% CI from 11 fewer to 34 more]).

For the critical outcome of favourable neurologic outcome at 3 months we identified moderate certainty evidence (downgraded for serious risk of bias) from one RCT¹⁰ enrolling 4471 patients and finding no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 0.78 [95% CI 0.60 to 1.02]; 13 fewer per 1,000 survivors with good neurologic outcome (CPC 1-2) [95% CI from 24 fewer to 1 more]).

For the critical outcome of favourable neurologic outcome at hospital discharge we identified low certainty evidence (downgraded for very serious risk of bias) from one RCT⁵ enrolling 2589 patients and finding no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.07 [95% CI 0.87 to 1.39]; 5 more per 1,000 survivors with good neurologic outcome (CPC 1-2) [95% CI from 10 fewer to 30 more]). The same study also found no benefit for favourable neurological outcome at 30 days, RR 1.11 [95% CI 0.84 to 1.45]; 8 more per 1,000 survivors with good neurologic outcome [95% CI from 12 fewer to 33 more]).

For the critical outcome of survival at one year we identified moderate certainty evidence (downgraded for serious risk of bias) from one RCT¹⁰ enrolling 4471 patients finding no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 0.87 [95% CI 0.68 to 1.11]; 8 fewer survivors per 1,000 patients [95% CI from 20 fewer to 7 more]).

For the critical outcome of survival at six months, we identified low certainty evidence (downgraded for very serious risk of bias) from one RCT⁵ enrolling 2589 patients and finding no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.06 [95% CI 0.82 to 1.37]; 5 more survivors per 1,000 patients at 6 months [95% CI from 15 fewer to 30 more]).

For the critical outcome of survival to 90 days, we identified moderate certainty evidence (downgraded for serious risk of bias) from one RCT¹⁰ enrolling 4471 patients finding no benefit from a piston-based mechanical CPR device compared with manual CPR (RR 0.90 [95% CI 0.71 to 1.14]; 6 fewer survivors per 1,000 patients to 90 days [95% CI from 19 fewer to 9 more]).

For the critical outcome of survival at 30 days we identified low certainty evidence (downgraded for very serious risk of bias) from one 3 RCTs^5,10,12 enrolling 8251 patients. One study enrolled 4471 patient and found no benefit from a piston-based mechanical CPR device compared with manual CPR (RR 0.92 [95% CI 0.73 to 1.16]; 5 fewer survivors per 1,000 patients [95% CI from 18 fewer to 11 more]). Another RCT⁵ enrolling 2589 patients found no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.02 [95% CI 0.79 to 1.31]; 2 more survivors per 1,000 patients [95% CI from 18 fewer to 26 more]). A third RCT¹² enrolling 1191 patients found no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 1.31 [95% CI 0.67 to 2.55]; 9 more survivors per 1,000 patients [95% CI from 10 fewer to 47 more]).

For the critical outcome of survival to hospital discharge, we identified very low certainty evidence (downgraded for very serious risk of bias and serious imprecision) from 3 RCTs^5,6,12 enrolling 3927 patients. One RCT⁶ enrolling 147 patients found no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 0.82 [95% CI 0.29 to 2.33]; 18 fewer survivors per 1,000 patients [95% CI from 69 fewer to 129 more]). Another RCT¹² enrolling 1191 patients found no difference using a piston-based mechanical CPR device compared with manual CPR (RR 1.20 [95% CI 0.64 to 2.25]; 21 fewer survivors per 1000 patients [95% CI from 13 fewer to 45 more]). An additional RCT⁵enrolling 2589 patients found no difference using a piston-based mechanical CPR device compared with manual CPR (RR 0.98 [95% CI 0.77 to 1.25]; 2 fewer survivors per 1,000 patients [95% CI from 21 fewer to 23 more])

For the important outcome of sustained ROSC we identified low certainty evidence (downgraded for very serious risk of bias) from 3 RCTs^5,10,12 enrolling 8251 patients. One study¹² enrolling 1191 patients found no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.06 [95% CI 0.87 to 1.30]; 18 more per 1,000 patients [95% CI from 38 fewer to 88 more]). Another RCT⁵ enrolling 2589 patients found no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.02 [95% CI 0.92 to 1.14; 7 more per 1,000 patients achieved ROSC [95% CI from 28 fewer to 48 more]). A third RCT¹⁰ enrolling 4471 patients found no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 1.01 [95% CI 0.92 to 1.10; 3 more per 1,000 patients achieved ROSC [95% CI from 25 fewer to 31 more]). For the important outcome of ROSC with a palpable pulse, one RCT⁶ enrolling 158 patients provided very low certainty evidence (downgraded for very serious risk of bias and serious imprecision) of no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 1.27 [95% CI 0.82 to 1.96]; 86 more per 1,000 patients [95% CI from 58 fewer to 307 more]).

For the important outcome of serious resuscitation-related injury, we identified very low certainty evidence (downgraded for very serious risk of bias, serious indirectness and very serious imprecision) from a single RCT¹⁴enrolling 94 patients and finding no significant difference using a piston-based mechanical CPR device compared with manual CPR (RR 1.57 [95% CI 0.27 to 8.94]; 24 more per 1000 patients with serious injuries [95% CI, from 30 fewer to 331 more]).

Does mechanical CPR using a piston-based device, compared with manual CPR, improve outcomes from IHCA?

For the critical outcome of favourable neurologic outcome at discharge we identified very low certainty evidence (downgraded for serious risk of bias and very serious imprecision) from a single RCT⁷ enrolling 127 patients, finding no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.13 [95% CI 0.13 to 9.72]; 5 more with good neurological outcome per 1,000 patients [95% CI from 31 fewer to 311 more]).

For the critical outcome of survival to hospital discharge we identified very low certainty evidence (downgraded for very serious risk of bias, inconsistency and very serious imprecision) from 2 RCTs^7,17 enrolling 277 patients. One trial⁷enrolling 127 patients found no benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.13 [95% CI 0.13 to 9.72]; 5 more survivors per 1,000 patients [95% CI from 31 fewer to 311 more]). Another RCT¹⁷ enrolling 150 patients found benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 2.21 [95% CI 1.17 to 4.17]; 180 more survivors per 1,000 patients [95% CI from 25 more to 471 more survivors]).

For the important outcome of ROSC we identified low certainty evidence (downgraded for very serious risk of bias, inconsistency and very serious imprecision) from 3 RCTs^7,16,17 enrolling 352 patients. One trial⁷ found no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 1.13 [95% CI 0.55 to 2.31]; 32 more per 1,000 patients with ROSC [95% CI from 112 fewer to 328 more]). Another RCT¹⁶ enrolling 75 patients found no benefit using a piston-based mechanical CPR device compared with manual CPR (RR 0.80 [95% CI 0.55 to 1.17]; 131 fewer per 1,000 patients with ROSC [95% CI from 296 fewer to 112 more]). A third RCT¹⁷ enrolling 150 patients found benefit from using a piston-based mechanical CPR device compared with manual CPR (RR 1.46 [95% CI 1.02 to 2.08]; 174 more per 1,000 patients with ROSC [95% CI from 8 more to 409 more]).

For the important outcome of serious resuscitation-related injury we identified very low certainty evidence (downgraded for very serious risk of bias and very serious imprecision) from one RCT¹⁴ enrolling 140 patients and finding no additional serious or life threatening injury from using a piston-based mechanical CPR device compared with manual CPR (RR 1.05 [95% CI 0.34 to 3.27]; 4 more injuries per 1,000 patients [95% CI from 51 fewer to 175 more]).

Treatment Recommendations

We suggest against the routine use of automated mechanical chest compression devices to replace manual chest compressions for out-of-hospital cardiac arrest (weak recommendation, low certainty evidence).

We suggest against the routine use of automated mechanical chest compression devices to replace manual chest compressions for in-hospital cardiac arrest (weak recommendation, very low certainty evidence).

Automated mechanical chest compression devices may be a reasonable alternative to manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety (good practice statement).

Justification and Evidence to Decision Framework Highlights

This topic was prioritized by the ALS Task Force due to awareness of a marked increase in the use of mechanical CPR in several countries since the COVID-19 pandemic, and because the Task Force was aware of new trials. Although there have now been several trials, the Task Force agreed that meta-analysis would not provide clinically reliable information, due to the heterogeneity of the trials available. Discussion and rationale for the treatment recommendations included the following:

• The 3 largest trials, which provide the highest-certainty evidence, were all neutral overall when reporting risk ratios, showing no benefit or harm from mechanical CPR, compared with manual CPR. One of these trials found a small significant different in neurological outcome when using an adjusted odds ratio (aOR), with worse outcome in the group assigned to piston-based mechanical CPR, compared with those assigned to manual CPR.¹⁰ The authors reported this result as both an unadjusted OR (0.77 [0.59-1.02]) and an aOR (0.72 [0.52-0.99]), and it was not clear which of these was primary. We therefore chose to report the RR for the main result. All of these results are very similar. A fourth large trial was stopped early due to decreased survival to discharge with favorable neurologic outcome.⁴
• Lower-certainty evidence from other smaller trials was conflicting, with some showing benefit and some showing harm from mechanical CPR.
• Most trials were done in the out-of-hospital setting. The more limited data for IHCA is also inconsistent. Both trials were small, with one designed to test feasibility and one to look at adverse effects; thus neither was designed to compare critical clinical outcomes. Treatment recommendations are the same, but the Task Force thought it was important to separate them to highlight the lower certainty of evidence for in-hospital cardiac arrest.
• The task force discussed the pros and cons of pooling studies in meta-analysis extensively, in the end deciding that heterogeneity was too marked (including devices used, timing of use, and protocols included with use of mechanical CPR) that pooling results could be misleading.
• One trial conducted subgroup analyses by initial rhythm, finding that patients with an initial shockable rhythm had lower survival at 30 days if they were randomized to mechanical CPR with a piston-based device, compared with manual CPR.¹⁰ A second trial that looked at results by initial rhythm found no difference in any of the subgroups, although there was a nonsignificant trend toward benefit from mechanical CPR in the asystole and PEA groups that was not seen in the group with ventricular fibrillation.¹²
• The Task Force discussed concern about the potential for delays in initial defibrillation when attempting to use mechanical CPR for cardiac arrest with shockable rhythm. This concern could be avoided by not deploying a mechanical device until after a first shock (if indicated) is delivered.
• The task force discussed the lack of justification for the cost of mechanical CPR devices and the training required for their use to be implemented, in light of the evidence suggesting no benefit. However, as there is also no convincing evidence for, there is insufficient evidence to suggest that healthcare systems already using mechanical CPR routinely need to change practice.
• The Task Force was in agreement that mechanical CPR is useful in settings where manual CPR either risks provider safety (eg during transport) or interferes with other potentially life-saving procedures (eg in the cardiac catheterization lab or during ECMO cannulation).
• There are several mechanical CPR devices available currently, and there is no evidence to favor one over the other at present.
• The Task Force discussed the importance of training when mechanical CPR devices are used, to minimize pauses in compressions during placement and to ensure proper placement so that visceral injuries are minimized.

Knowledge Gaps

• Whether mechanical CPR improves outcome from IHCA.
• Whether the possible benefit of mechanical CPR depends on timing of use, cardiac arrest rhythm, or setting.
• Whether one mechanical CPR device is superior to another
• Whether rates of CPR-related injuries from mechanical CPR vary by patients size and age
• The optimal approach to defibrillation (ie whether to pause the device for defibrillation, vs other approaches such as timing defibrillation with compression phase) when mechanical CPR devices are used

ETD summary tables: ALS 3002 Mech CPR ETD IHCA; ALS 3002 Mech CPR Et D OHCA; ALS 3002 Mech CPR Et D OHCA PISTON;ALS 3002 Mech CPR ETD PISTON IHCA

References

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