Use of feedback CPR devices for neonatal cardiac arrest: NLS 5505 TF ScR

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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 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, 2023, Jan 14. Available from:

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.


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.


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

Population: In neonates receiving cardiac compressions

Intervention: does use of any feedback devices such as end-tidal carbon dioxide monitors, pulse oximeters or automated compression feedback devices

Comparators: compared with clinical assessments of compression efficacy

Outcomes: decrease hands-off time, decrease time to return of spontaneous circulation (ROSC), improve perfusion, increase survival rates or improve neurologic outcomes?

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 5505 Search Strategies

Data Table: NLS 5505 Data Table

Task Force Insights

  1. Why this topic was reviewed
  2. The 2015 ILCOR CoSTR suggested against the routine reliance on any single feedback device such as ETCO2 monitors or pulse oximeters for detection of ROSC during neonatal cardiac compressions until more evidence becomes available (weak recommendation, very-low-quality evidence).{Perlman 2015 S204; Perlman 2015 S120; Wyllie 2015 e169} Since the topic has not been reviewed since 2015, the task force felt a scoping review was justified to identify if there was sufficient new evidence to warrant a systematic review.
  3. Narrative summary of evidence identified
  4. Sixteen studies compared chest compression feedback devices including 12 manikin studies,{Andriessen 2012 274; Martin 2013 1125; Dold 2014 245; Roehr 2014 444; Fuerch 2015 52; Solevåg 2016 1; Austin 2017 1; Solevåg 2018 1; Kandasamy 2019 793; Kim 2019 795; Kim 2020 114; Jeon 2021 193} four animal studies,{Chalak 2011 401; Hamrick 2014 e000450; Hamrick 2017 e575; Chandrasekharan 2017 898} and two clinical studies{Maher 2009 662; Stine 2019 e01871}.
  5. Studies assessed auditory visual feedback devices,{Andriessen 2012 274; Austin 2017 1; Fuerch 2015 52; Kandasamy 2019 793; Martin 2013 1125} visual feedback alone,{Kim 2020 114} auditory feed forward devices,{Dold 2014 245; Roehr 2014 444; Solevåg 2016 1; Solevåg 2018 1; Kim 2019 795} haptic feedback device,{Jeon 2021 193} and real-time physiologic feedback using capnography{Chalak 2011 401; Hamrick 2014 e000450; Hamrick 2017 e575; Chandrasekharan 2017 898} or blood pressure monitoring {Maher 2009 662}. Overall, studies reported a significant improved chest compression depth,{Kandasamy 2019 793; Martin 2013 1125} chest compression rate,{Martin 2013 1125; Austin 2017 1; Kandasamy 2019 793} duty cycle,{Austin 2017 1;Kadasmay 2019 793; Martin 2013 1125} and percentage of correctly performed cycles{Andriessen 2012 274} when using an auditory-visual feedback device.
  6. One study reported improvement in release force in the feedback group,{Kandasamy 2019 793} whereas two studies reported similar recoil/release forces with and without a feedback device.{Martin 2013 1125; Austin 2017 1}
  7. Auditory and visual prompts from a decision support tool during simulated neonatal resuscitation resulted in higher adherence to the current neonatal resuscitation algorithm compared to performing resuscitation with cardiac compressions based on memory alone.{Fuerch 2015 52}
  8. In manikin studies, a metronome resulted in a more consistent chest compression rates but no difference in the average chest compression rate, or applied force and pressure was observed.{Solevåg 2016 1; Solevåg 2018 1; Kim 2019 795} Similarly, vibrations from a smartwatch as haptic feed-forward assistance resulted in a higher proportion of optimal cardiac compression duration, rate, and better chest compression depth over time.{Jeon 2021 193} Listening to a popular music piece with a beat of 120/min also significantly improved the number of delivered chest compressions and inflations compared to baseline.{Roehr 2014 444}
  9. Four animal studies compared end-tidal CO2 capnography to guide chest compression rate and depth during cardiopulmonary resuscitation using the 3:1 Compression:Ventilation ratio approach. End-tidal CO2 had high sensitivity and specificity for correlating with return of spontaneous circulation{Chalak 2011 401; Chandrasekharan 2017 898} but in randomized studies, did not improve time to return of spontaneous circulation or survival in randomized animal studies.{Hamrick 2014 e000450; Hamrick 2017 e575} The only available clinical data was an observational study of capnography values during CPR in 49 infants with a mean (SD) gestational age of 36±3 weeks and a median age (interquartile range) at the time of CPR of 30 (16–96) days.{Stine 2019 e01871} An end-tidal CO2 between 17 and 18 mmHg correlated with the highest sensitivity and specificity for heart rate to have recovered to greater than 60/min with the area under the curve for the receiver operator characteristic of 0.835.{Stine 2019 e01871}

3. Narrative Reporting of the task force discussions

The Task Force did not feel that the available studies would warrant a systematic review given the paucity of clinical data

Knowledge Gaps

  • The gaps in knowledge regarding chest compression feedback devices are immense. Additional research is required, particularly clinical studies
  • There is a need for large studies powered for important clinical outcomes to determine the role pf capnography in improving response to and outcomes of newborn cardiopulmonary resuscitation.
  • There is a need for specific research to determine whether continuous monitoring of flow and volume or exhaled CO2 levels compete with other essential auditory and visual cues that need to be appreciated and responded to by resuscitation teams.


Andriessen P, Oetomo SB, Chen W, et al. Efficacy of feed forward and feedback signaling for inflations and chest compression pressure during cardiopulmonary resuscitation in a newborn mannequin. Journal of clinical medicine research 2012;4:274–8.

Austin AL, Spalding CN, Landa KN, et al. A Randomized Control Trial of Cardiopulmonary Feedback Devices and Their Impact on Infant Chest Compression Quality: A Simulation Study. Pediatr Emerg Care 2017;:1.

Chalak LF, Barber CA, Barber CA, et al. End-tidal CO₂ detection of an audible heart rate during neonatal cardiopulmonary resuscitation after asystole in asphyxiated piglets. Pediatric Research 2011;69:401–5.

Chandrasekharan P, Vali P, Rawat M, et al. Continuous capnography monitoring during resuscitation in a transitional large mammalian model of asphyxial cardiac arrest. Pediatr Res 2017;81:898–904.

Dold SK, Schmölzer GM, Kelm M, et al. Training neonatal cardiopulmonary resuscitation: can it be improved by playing a musical prompt? A pilot study. American Journal of Perinatology 2014;31:245–8.

Fuerch JH, Yamada NK, Coelho PR, et al. Impact of a novel decision support tool on adherence to Neonatal Resuscitation Program algorithm. Resuscitation 2015;88:52–6.

Hamrick JL, Hamrick JT, Lee JK, et al. Efficacy of Chest Compressions Directed by End‐Tidal CO2 Feedback in a Pediatric Resuscitation Model of Basic Life Support. J Am Hear Assoc Cardiovasc Cerebrovasc Dis 2014;3:e000450.

Hamrick JT, Hamrick JL, Bhalala U, et al. End-Tidal Carbon Dioxide–Guided Chest Compression Delivery Improves Survival in a Neonatal Asphyxial Cardiac Arrest Model. Pediatr Crit Care Me 2017;18:e575–84.

Jeon SA, Chang H, Yoon SY, et al. Effectiveness of Smartwatch Guidance for High-Quality Infant Cardiopulmonary Resuscitation: A Simulation Study. Medicina 2021;57:193.

Kandasamy J, Theobald PS, Maconochie IK, et al. Can real-time feedback improve the simulated infant cardiopulmonary resuscitation performance of basic life support and lay rescuers? Arch Dis Child 2019;104:793.

Kim CW, Oh JH. Effect of metronome guidance on infant cardiopulmonary resuscitation. Eur J Pediatr 2019;178:795–801.

Kim KH, Kim CW, Oh JH. Effect of introducing a feedback device during adult and infant cardiopulmonary resuscitation training: A ‘before and after’ study. Hong Kong J Emerg Me 2020;27:114–7.

Maher KO, Berg RA, Lindsey CW, et al. Depth of sternal compression and intra-arterial blood pressure during CPR in infants following cardiac surgery. Resuscitation 2009;80:662–4.

Martin P, Theobald P, Kemp A, et al. Real-time feedback can improve infant manikin cardiopulmonary resuscitation by up to 79%—A randomised controlled trial. Resuscitation 2013;84:1125–30.

Roehr C-C, Schmölzer GM, Thio M, et al. How ABBA may help improve neonatal resuscitation training: auditory prompts to enable coordination of manual inflations and chest compressions. Journal of Paediatrics and Child Health 2014;50:444–8.

Solevåg A, Cheung P-Y, Li ES, et al. Chest Compression Quality in a Newborn Manikin: A Randomized Crossover Trial (August 2016). IEEE Journal of Translational Engineering in Health and Medicine 2018;6:1–5.

Solevåg AL, Cheung P-Y, Li E, et al. Quantifying force application to a newborn manikin during simulated cardiopulmonary resuscitation. J Maternal-fetal Neonatal Medicine 2016;29:1–3.

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.

Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, 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 (Reprint). Pediatrics. 2015;136 Suppl 2:S120-166.

Stine CN, Koch J, Brown LS, et al. Quantitative end-tidal CO2 can predict increase in heart rate during infant cardiopulmonary resuscitation. Heliyon 2019;5:e01871.

Wyllie J, Perlman JM, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, Kim HS, 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. Resuscitation. 2015;95:e169-201.


Racire Silva
In our service we never had access.
Norma Suely Oliveira
We don’t have feedback CPR device

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