Rescuer Fatigue in CC Only CPR (BLS #349): Scoping Review

profile avatar

ILCOR staff

Commenting on this CoSTR is no longer possible

To read and leave comments, please scroll to the bottom of this page.

This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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)

Task Force Scoping Review Citation

Raffay V, Semeraro F, Avis S, Brooks S, Castren M, Chung S, Considine J, Hung K, Kudenchuk P, Mancini MB, Nishiyama C, Perkins GD, Ristagno G, Smith C, Smyth M, Morley PT, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Rescuer fatigue in CC Only CPR - Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Feb 11th. Available from:

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of Rescuer fatigue in chest compression (CC) Only CPR by the ILCOR BLS Task Force Scoping Review team. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force.


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

Population: In rescuers performing CPR on adult or paediatric patients

Intervention: compression only CPR

Comparators: traditional CPR

Outcomes: increase in rescuer fatigue with resulting decrease in CPR quality

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.

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 October 29th, 2019.

Search Strategies

Pubmed (712 records)

Cardiopulmonary resuscitation OR CPR AND fatigue

Cardiopulmonary resuscitation OR CPR AND quality

Chest compression AND fatigue

Chest compression AND quality

Chest compression AND continuous

Embase (441 records)

Cardiopulmonary resuscitation OR CPR AND fatigue

Cardiopulmonary resuscitation OR CPR AND quality

Chest compression AND fatigue

Chest compression AND quality

Chest compression AND continuous

Inclusion and Exclusion criteria

Inclusion Criteria: human and manikin studies.

Exclusion Criteria: animal studies or those that did not have a comparator group of 30:2 or 15:2 CPR.

Data tables







Heidenreich 2006


(cross-over), manikin

Medical students

9 minutes of continuous compressions

9 minutes of 15:2 CPR

More ‘adequate compressions’ with CCC in the first 2 min with

NO difference between CCC and 15:2 in the third minute

Less 'adequate compressions' by the ninth minute.

Odegaard 2006

RCT, manikin

Travellers at Oslo Airport

5 min of continuous chest compression.

5 min of 15:2 or 30:2 CPR

A marked decrease in quality with time for continuous chest compressions indicated that rescuer fatigue adversely affects the quality of chest compressions

Trowbridge 2009

RCT (cross-over), manikin

Twenty lay female volunteers

10 min continuous compression

10 in 30:2 CPR

Lactate levels used to assess fatigue.

Significant reduction in depth of compression during continuous compressions

No significant change in compression rate.

Yuksen 2017


80 participants in the study; 39 in the manual group and 41 in the device group

The manual group performed standard chest compression, while the device group performed chest compression using the CPR RAD with a set rate of 100 times/minute.

Chest compression outcome

Compression depth after 2 minute, mm

Overall compression depth, mm

Duration of chest compression was significantly higher in device users

During the first and second minutes, compression rate was higher in cases of standard compression

The CPR RAD use led to better results in terms of fatigue reduction

Ashton A 2002

Comparative study


( 20 males 20 females) performed continuous chest compressions on a Laerdal Skillmeter Resusci-Anne manikin for two consecutive periods of 3 min separated by 30 s.

3 min of continuous chest compressions on the manikin aiming for a rate of 100/min. After a 30 s interval representing a maximal period during which the pulse, ECG electrodes, ECG lead and gain settings would be checked during an actual cardiac arrest, a further 3 min of chest compressions were performed as before.

For each subject the following demographic parameters were recorded: rescuer gender, age, weight, height, profession (doctor or nurse) and whether or not the subject was a certified advanced life support (ALS) provider.

The total number of compressions attempted was well maintained at approximately 100 /min throughout the period of study. However, the number of satisfactory chest compressions performed decreased progressively during resuscitation (P < 0.001) as follows: first min, 82 min(-1); second, 68 min(-1); third, 52 min(-1); fourth, 70 min(-1); fifth, 44 min(-1); sixth, 27 min(-1). Authors observed significant correlations between the number of satisfactory compressions performed and both height and weight of the rescuer. Female subjects achieved significantly fewer satisfactory compressions compared with males (P = 0.03). Seven subjects (five female, two male) were unable to complete the second 3-min period because of exhaustion.

Rescuer fatigue adversely affects the quality of chest compressions without interruption a 3-min

This effect may be greater in females due to their smaller stature

Consider to rotating the rescuer performing chest compressions after 1 min intervals

Hightower 1995

Prospective manikin study

11 experienced nursing assistants who regularly provide CPR in the ED/Major resuscitation room in rural university hospital emergency department.

Each study participant performed 5 minutes of closed-chest compressions. Compression adequacy (for placement and depth) was assessed with the mannequin and reported on an attached monitor out of view of the study subjects. Subjects were asked to verbally indicate the point during their 5-minute compression period at which they felt too fatigued to provide effective compressions (arbitrarily defined as a minimum of 90% of all compressions being judged correct by the mannequin).

Authors used one-way repeated-measures ANOVA and regression analysis to determine whether compression adequacy diminished over time. ANOVA was also used to determine whether the total compressions performed per minute diminished over time.

-The percentage of correct chest compressions decreased significantly after 1 minute.

-CPR providers could not recognize their inability to provide proper compressions.,[ cardiac arrest team leaders should carefully monitor compression adequacy during CPR to assure maximally effective care for patients receiving CPR]

Study subjects did not accurately identify the point during their 5-minute sessions at which their fatigue caused compressions to become impaired.

Huseyin 2002

Comparative study

21 participants in this study, 8 doctors (6 male 2 female) and 13 nurses (9 female and 4 male)

The continuing effectiveness of chest compressions was compared.

The continuing effectiveness of chest compressions was compared between groups of 2 or 3 rescuers performing chest compressions for 1, 2 or 3 min during scenarios lasting 18 min.

  • a three-person team delivering 1 min periods of chest compressions in rotation is significantly better than other sequences at 5 min and beyond.
  • no significant difference between the first and final set of chest compressions.

[Continuous CC for 1 min, preferably by three rescuers in rotation, maintain a high level of effectiveness. ]

Lucia 1999

Observational study


Two study groups were established: group P (n=14), composed of sedentary, professional CPR rescuers (mean [+/-SD]; age, 34+/-6 years; VO2max, 32.5+/-5.5 mL/kg/min), and group Ex (n=14), composed of physically active, nonexperienced subjects (age, 34+/-6 years; VO2max, 44.5+/-8.5 mL/kg/min).

Each subject was required to perform an 18-min CPR session, which involved manual external cardiac compressions (ECCs) on an electronic teaching mannequin following accepted standard CPR guidelines.

  • Subjects’ gas exchange parameters and heart rates (HRs) were monitored throughout the trial.
  • Fatigue prevented four subjects from group P from completing the trial.
  • the physiologic responses to CPR differed between groups.

Manders 2009


40 pairs of rescuers were randomly assigned to either scenario. (nurses, certified BLS providers)

the number of effective chest compressions over 8 min

The number of effective chest compressions over 8 min

when alternating tworescuers every 1min versus every 2min.

The main outcome measure was the number of effective compressions and to indicate fatigue.

In the 1min scenario, there is a gradual increase with every minute in the number of rescuers indicating fatigue; in the 2 min scenario, there are large leaps in the second and fourth minutes.

No increase in the number of rescuers indicating fatigue in the third minute of the 2 min scenario. After 4 min, 44.4% of rescuers in the 2 min scenario had indicated fatigue, versus 27.8% in the 1 min scenario.

Ochoa 1998

Observational manikin study

N=38 (doctors and nurses who work in the Intensive Care and Emergency departments, with an age ranging from 25 to 45 years and trained in CPR)

Each participant gave up to 5 min of external chest compressions

The rescuers had to inform the investigator at the precise moment when they believed that fatigue was affecting the quality or the number of their chest compressions, although they had to continue for 5 min of resuscitation (or until they noticed great fatigue or pain).

  • The mean interval until rescuers noticed that their fatigue affected their performance was 186 s (SD= 84.1), with a minimum of 60 s and a maximum of 300 s
  • no significant differences in the time interval before fatigue affected performance between professions

Riera 2007

Observational manikin study

23 healthy volunteers, nurses and doctors of the Intensive Care Unit (ICU), members of the hospital cardiac arrest team, were enrolled in the study.

Chest compressions for 2 min on manikin

The oxygen saturation and cardiac rate of the subjects were monitored using pulse oximetry before and after one and 2 min performing chest compressions. The percentage of the maximal heart rate of the rescuer over the theoretical maximum allowed in a conventional stress test was calculated, taking into account age and body mass index (BMI) of the subjects.

Fatigue was measured using a visual analogical scale (VAS).

  • None of the subjects had difficulties to complete the test.
  • All subjects recovered their basal values in less than 2min

Heidenreich 2012

Randomized cross-over manikin study

17 elderly volunteers performed both HO-CPR and STD-CPR, separated by at least 2 days, on a manikin model for 9 min each

9 minutes of continuous compressions

9 minutes of continuous compressions

separated by at least 2 days, on a manikin model for 9 min each.

  • No difference was observed in the number of adequate compressions between groups in the first minute;
  • the total number of compressions delivered was significantly greater in the HO-CPR when considering the entire resuscitation period.
  • Related to the fatigue, a significantly greater number of rescuers took breaks for rest during HO-CPR than STD-CPR.

Skulec 2016

Randomized cross-over manikin study

10 healthy volunteers

Standard BLS vs compression only BLS

to compare the energy expenditure of standard
BLS with a compression-ventilation ratio
of 30:2 (S-BLS) and compression-only
BLS (CO-BLS) and assess the sensation of
fatigue and perceived exertion associated
with these activities

Maximal VO2/kg (23.16±3.94
vs. 20.17±2.14 ml/kg/min, p=0.049)
and AUCVO2/kg min (18.90±3.13 vs.
15.91±2.07 ml/min3; p=0.021) during SBLS were significantly higher compared to
CO-BLS. Conversely, a more intense rate of
perceived exertion (16.6±2.0 vs. 13.8±1.2,
p=0.001) and sensation of general fatigue
(86.5±10.8 vs. 75.0±14.3, p=0.058) were associated with CO-BLS. Neither sensation of general fatigue, nor perceived exertion correlated with energy expenditure.

Shin J &2014

Randomized cross-over manikin study

36 volunteers (laypersons; 18 men and 18 women)

Standard BLS vs compression only BLS

ST-CPR or CO-CPR at first, and then each CPR technique was performed for 8 minutes with a 3-hour rest interval

The rate and number of adequate CCs were significantly lower with the CO-CPR than with the ST-CPR after 2 and 6 minutes, respectively, and performer fatigue was higher with the CO-CPR than with the ST-CPR during 8 minutes of CPR.

Min 2013

Randomized cross-over manikin study

63 trainees of EMT's. In this study, three different ways of CCC-CPR was performed each for 10mins; The first method is general CCC-CPR without a break(CCC); The second method is that there is 10 seconds break after 200 chest compressions(10/200); The third method is that there is 10 seconds break after 100 chest compressions(10/100).

10 minutes of CCC-CPR

10 minutes of CCC-CPR:

  1. general CCC-CPR without a break(CCC);
  2. a 10 seconds break after 200 chest compressions(10/200);
  3. a 10 seconds break after 100 chest compressions(10/100).

The method that showed the deepest ---Until 4 minutes, there was no statistically difference among three methods.

The method that showed the highest percentage of adequate compression was the 10/100.

Fatigue as measured by the VAS was very low with the 10/100 method.

These results mean that 10-second break improve the quality of CPR to some extent.

Task Force Insights

1. Why this topic was reviewed.

This topic was prioritized for an updated evidence review as this topic had not been reviewed by ILCOR since 2005.

2. Narrative summary of evidence identified

Fifteen manikin studies evaluating fatigue at various compression to ventilation ratios were identified. These studies compared fatigue and its effects on CPR quality in volunteers performing continuous compressions and 30:2 or 15:2 CPR.(Trowbridge 2009 6, Heidenreich 2006 1020, Odegaard 2006 335, Yuksen 2017 63, Manders 2009 1015, Skulec 2016 58, Shin 2014 59, Heidenreich 2012 88, Min 2013 1279, Ashton 2002 151, Huseyin 2002 57, Hightower 1995 300, Lucia 1999 158, Ochoa 1998 149, Riera 2007 108)

Three RCTs investigated compared 5, 9 and 10 minutes of continuous chest compressions to 15:2 and 30:2 and reported that more ‘adequate compressions’ were observed in the first 2 min with continuous compressions but with no difference after the third minute. Measured lactate levels were used to assess fatigue. Significant reduction in compression depth was observed during continuous compressions, but without significant change in compression rate. Overall, CPR quality parameters decreased with time during continuous chest compressions indicating rescuer fatigue adversely affects the quality of chest compressions (Trowbridge 2009 6, Heidenreich 2006 1020, Odegaard 2006 335).

Four randomized cross-over manikin studies investigated the effectiveness of 8, 9 and 10 minutes of continuous chest compressions compared to 30:2. The first study investigated the energy expenditure and assessed the sensation of fatigue and perceived exertion associated with these activities. Neither sensation of general fatigue, nor perceived exertion correlated with energy expenditure.(Skulec 2016 58) The second study compared rescuer fatigue and CPR quality with CPR performed for 8 minutes on a realistic manikin. The compression rate and number of adequate compressions were significantly lower and rescuer fatigue higher with continuous compressions after 2 and 6 minutes.(Shin 2014 59). The third study assessed elderly rescuers' ability to maintain adequate compression rate and depth during a 9 min scenario. While total number of compressions delivered was significantly greater in the continuous compression group, rescuers had to take more breaks due to fatigue. (Heidenreich 2012 88). The fourth study found 10 second rest periods to reduce fatigue and improve CPR quality during a 10 minute scenario.(Min 2013 1279).

Three studies explored the temporal trends of fatigue during continuous compressions. Two of these studies indicated fatigue affects CPR quality after as little as 1 minute,(Ashton 2002 151, Huseyin 2002 57) while the third study indicated rescuers would not be able to accurately identify the time point when their fatigue would impact on their CPR performance.(Hightower 1995 300).

Three studies explored how rescuer characteristics might influence fatigue and CPR performance during 2, 5, and 18 minutes of continuous compressions. The first study evaluated the influence of rescuer physical fitness,(Lucia 1999 158) the second assessed the influence of the rescuer’s gender, age, weight, height or professional status,(Ochoa 1998 149) while the third analyzed rescuer tolerate to performing continuous compressions measuring oxygen saturation, heart rate and fatigue using a visual analogical scale.(Riera 2007 108).

One RCT investigated the effects of standard manual compressions vs. compressions performed using a compression device (CPR RsQ Assist®), and found less fatigue and higher CPR quality in the device group. (Yuksen 2017 63) Another RCT evaluated the number of effective chest compressions and self-reported fatigue over 8 min in scenarios where two rescuers alternated between changing “compressor” every 1min vs. every 2 min. After 4 min self-reported rescuer fatigue 44% vs. 28% for the 2 and 1 min scenarios, respectively.(Manders 2009 1015).

In conclusion, evidence from manikin studies comparing fatigue and effects on CPR quality suggest that CCC is effective in the first 2 minutes regarding the depth and frequency, and there are indications that rest reduces rescuer fatigue and increase CPR quality as rescuer fatigue adversely affects the quality of chest compressions after 2 minutes

3. Narrative Reporting of the task force discussions

Continuous compression strategies have been increasingly advocated in an effort to increase overall bystander CPR rates. Evidence reviews evaluating the effect of continuous chest compressions vs. standard CPR on critical outcomes such as long-term survival has been performed by the Basic Life Support Task Force in a separate evidence review. Although the BLS Task Force regards rescuer fatigue as an important barrier to high quality bystander CPR, a higher value is placed on patient cantered outcomes.

Knowledge Gaps

Only simulation manikin data were identified. Insights into the effects of compression only on bystander fatigue and CPR quality in actual cardiac arrests is not known.


Heidenreich JW, Berg, RA, Higdon TA, Ewy GA, Kern KB, Sanders AB. Rescuer Fatigue: Standard versus Continuous Chest-Compression Cardiopulmonary Resuscitation. Academic Emerg Med 2006; 13: 1020-1026.

Odegaard S, Saether E, Steen PA, Wik L. Quality of lay person CPR performance with compression:ventilation ratios 15:2, 30:2 or continuous chest compressions without ventilations on manikins. Resuscitation 2006; 71: 335-340.

Trowbridge C, Parekh JN, Ricard MD, Potts J, Patrickson WC, Cason CL. A randomized cross-over study of the quality of cardiopulmonary resuscitation among females performing 30:2 and hands-only cardiopulmonary resuscitation. BMC Nursing 2009; 8: 6-18.

Yuksen C, Prachanukool T, Aramvanitch K, Thongwichit N, Sawanyawisuth K, Sittichanbuncha Y. Is a mechanical-assist device better than manual chest compression? A randomized controlled trial. Open Access Emerg Med. 2017 Aug 29;9:63-67. doi: 10.2147/OAEM.S133074.

Ashton A, McCluskey A, Gwinnutt CL, Keenan AM. Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min. Resuscitation. 2002 Nov;55(2):151-5.

Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in quality of closed-chest compressions over time. Ann Emerg Med. 1995 Sep;26(3):300-3.

Huseyin TS, Matthews AJ, Wills P, O'Neill VM. Improving the effectiveness of continuous closed chest compressions: an exploratory study. Resuscitation. 2002 Jul;54(1):57-62.

Lucía A, de las Heras JF, Pérez M, Elvira JC, Carvajal A, Alvarez AJ, Chicharro JL. The importance of physical fitness in the performance of adequate cardiopulmonary resuscitation. Chest. 1999 Jan;115(1):158-64.

Manders S, Geijsel FE. Alternating providers during continuous chest compressions for cardiac arrest: every minute or every two minutes? Resuscitation. 2009 Sep;80(9):1015-8. doi:10.1016/j.resuscitation.2009.05.014.

Ochoa FJ, Ramalle-Gómara E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions. Resuscitation. 1998 Jun;37(3):149-52.

Riera SQ, González BS, Alvarez JT, Fernández Mdel M, Saura JM. The physiological effect on rescuers of doing 2min of uninterrupted chest compressions. Resuscitation. 2007 Jul;74(1):108-12.

Heidenreich JW, Bonner A, Sanders AB. Rescuer fatigue in the elderly: standard vs. hands-only CPR. J Emerg Med. 2012 Jan;42(1):88-92. doi: 10.1016/j.jemermed.2010.05.019.

Skulec R, Truhlar A,Vondruska V,Parizkova R,Dudakova J,Astapenko D,Suchy T,Lehmann C,Cerny V Rescuer fatigue does not correlate to energy expenditure during simulated basic life support Fewer. Signa Vitae (2016) 12(1) 58-62

Shin J, Hwang SY, Lee HJ, Park CJ, Kim YJ, Son YJ, Seo JS, Kim JJ, Lee JE, Lee IM, Koh BY, Hong SG. Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial. Scand J Trauma Resusc Emerg Med. 2014 Oct 28;22:59. doi: 10.1186/s13049-014-0059-x.

Min MK, Yeom SR, Ryu JH, Kim YI, Park MR, Han SK, Lee SH, Cho SJ. A 10-s rest improves chest compression quality during hands-only cardiopulmonary resuscitation: a prospective, randomized crossover study using a manikin model. Resuscitation. 2013 Sep;84(9):1279-84.

Scoping Review


Виктория Антонова
(397 posts)
Dear Ms. Raffay et al, Thank you very much for creating this task force scoping review. With the increase of scientific literature about effect of physical fatigue on CPR quality, this review becomes strongly necessary. Maybe studies with feedback devices were not considered, but there is a recent publication that, a priori, might be included in the PICO question proposed: PLoS One. 2018 Sep 19;13(9):e0203576. Doi: 10.1371/journal.pone.0203576. Fatigue was assessed in terms of muscle activity and CPR quality was also measured. Thank you for your attention. Yours sincerely, Cristian Abelairas-Gómez

Sort by

Time range




Review Type