Criteria
Judgement
s
○ No
○ Probably
no
Problem
Is there a
problem
priority?
What is
the overall
certainty
of this
evidence?
○ Uncertain
○ Probably
● Yes
○ Varies
Observational data shows that not allowing the chest to recoil
is common when delivering CPR.(Sutton, 2009, 494, Niles,
2009, 553, Fried, 2011, 1019) Improvement in chest wall
recoil has been shown to be possible through modification of
CPR technique and real-time feedback devices.(Niles, 2009,
553, Hostler, 2011, Aufderheide, 2005, 353) If chest wall
recoil does impact cardiac arrest survival, then improvements
may be achieved with minimal additional resources.
○ No
The relative importance or values of the main
outcomes of interest:
included
studies
● Very low
○ Low
○ Moderate
○ High
uncertainty
or variability
● Possibly
Is there
important
uncertaint
y about
how much
people
value the
main
outcomes?
CPR quality is an important determinant of outcome following
cardiac arrest. CPR quality metrics include chest compression
depth, rate, fraction, chest wall recoil, ventilation rate and
peri-shock pause. Large observational studies have
demonstrated a correlation between outcome and CPR quality
metrics.(Vadeboncoeur, 2014, 182, Vaillancourt, 2011, 1501,
Stiell, 2012, 1192, Idris, 2012, 3004, Christenson, 2009,
1241, Cheskes, 2011, 58) To date, chest wall recoil has not
been subject to the same analysis.
Ongoing observational
clinical studies are
attempting to measure
the effect of the chest
compression release
velocity on survival
outcomes in cardiac
arrest.
yes
○ Important
Benefits
& harms
of the
options
Additional
considerations
Research evidence
important
uncertainty
or variability
Outcome
Relative
importance
Survival with Favorable
neurological/functional
outcome
CRITICAL
Survival only at discharge
CRITICAL
Return of spontaneous
circulation
CRITICAL
Coronary perfusion
pressure
IMPORTANT
Cardiac output/ Cardiac
index
IMPORTANT
Certainty of
the evidence
(GRADE)
⨁◯◯◯
VERY LOW
○ Probably
no important
uncertainty
of variability
○ No
important
uncertainty
of variability
○ No known
undesirable
⨁◯◯◯
Outcome
With
maximizing
chest wall
recoil
Three studies were
identified. These
included two animal
studies(Yannopoulos,
2005, 363, Zuercher,
2010, 1141) and one
human non-cardiac
arrest study. (Glatz,
2013, 1674)
VERY LOW
Summary of findings: ignoring chest wall recoil
Without
maximizin
g chest
wall recoil
For the purposes of BLS
(i.e. not including
devices which actively
decompress), we
assessed the impact of
incomplete chest wall
recoil on outcomes.
There were no human
cardiac arrest studies
that met the review
inclusion criteria. As
such, animal studies
and all other studies
that met the inclusion
criteria were included.
Differe
nce
(95%
CI)
Relative
effect
(RR)
(95% CI)
The two animal studies
used a swine model of
cardiac arrest to assess
the effect of incomplete
recoil/residual leaning
on haemodynamic
measurements during
CPR. One used an
Criteria
Judgement
s
○ No
○ Probably
Are the
desirable
anticipate
d effects
large?
no
● Uncertain
○ Probably
yes
○ Yes
○ Varies
○ No
○ Probably
Are the
undesirabl
e
anticipate
d effects
small?
Survival
with
Favorable
neurological
/functional
outcome
-
-
not
estima
ble
not
estimable
Survival
only at
discharge
-
-
not
estima
ble
not
estimable
Return of
spontaneous
circulation
-
-
not
estima
ble
not
estimable
The mean
coronary
perfusion
pressure
in the
control
group was
The mean
coronary
perfusion
pressure in
the
intervention
group was
not
estima
ble
not
estimable
N/A
N/A
The mean
cardiac
output/
Cardiac
index in
the
control
group was
The mean
cardiac
output/
Cardiac
index in the
intervention
group was
no
○ Uncertain
● Probably
yes
Coronary
perfusion
pressure
○ Yes
○ Varies
Cardiac
output/
Cardiac
index
Are the
desirable
effects
large
relative to
undesirabl
e effects?
○ No
○ Probably
no
● Uncertain
○ Probably
Additional
considerations
Research evidence
N/A
N/A
automated
compression/decompres
sion device and only
allowed 75%
decompression to
assess incomplete
recoil. The other placed
weights on the chest
wall to replicate leaning.
The human study
applied sternal wall
pressure to paediatric
heart transplant
patients with
spontaneous circulation
undergoing cardiac
catheterisation. Using
these models of
incomplete
recoil/residual leaning,
the investigators
measured
haemodynamics.
None of the included
studies measured
survival with favourable
neurological/ functional
outcome, survival only
at discharge, or return
of spontaneous
circulation.
not
estima
ble
not
estimable
Cardiac output/ index
was an outcome in two
studies (one human,
one animal).(Glatz,
2013, 1674, Zuercher,
2010, 1141) Coronary
perfusion pressure was
an outcome in all three
studies.(Glatz, 2013,
1674, Zuercher, 2010,
1141, Yannopoulos,
2005, 363)
yes
○ Yes
○ Varies
Of the three studies
including coronary
perfusion pressure, all
three found that
incomplete
recoil/residual leaning
was associated with
decreased coronary
perfusion pressure. Of
the two studies that
included cardiac index,
the animal study by
Zuercher reported a
Criteria
Judgement
s
Research evidence
Additional
considerations
reduction in cardiac
index with residual lean.
In contrast, the
paediatric study by
Glatz found that
residual leaning forces
had no observed effect
on cardiac index/
output.
Study heterogeneity
precluded pooling of
results for all outcomes.
Evidence certainty for
both coronary perfusion
pressure and cardiac
output/index outcomes
was judged to be very
low.
Minimising chest wall leaning can be achieved with no
additional resources through provider education. Additional
focus on chest wall recoil should not add to current training
costs.
○ No
○ Probably
no
Are the
resources
required
small?
○ Uncertain
○ Probably
yes
● Yes
○ Varies
Resource
use
Chest wall recoil at cardiac arrests can be measured using
defibrillators with additional attachments. These devices can
be used to provide real-time feedback on
performance.(Hostler, 2011, Abella, 2007, 54, Bobrow, 2013,
47) The purchase of such devices does require additional
investment, but their use is recommended by bodies such as
the American Heart Association.(Meaney, 2013, 417,
Morrison, 2013, 1538) There may be additional training costs
associated with the use of these devices.
Several communities have improved chest wall recoil and
other CPR metrics through the use of interventions such as
specialised training and real-time feedback.(Bobrow, 2013,
47, Hostler, 2011) In some studies, this improvement in CPR
metrics has been associated with improvements in patient
outcomes.
Is the
increment
al cost
small
relative to
the net
○ No
○ Probably
no
○ Uncertain
The purchase of additional equipment may demand additional
resources to upgrade defibrillators. Whilst organisations do
not already have this equipment, upgrades should be
considered as part of an organisational focus on improving
CPR quality.
The purchase of
additional equipment
cannot be
recommended to aid
chest wall recoil alone,
but the purchase of
such equipment may be
Criteria
benefits?
Judgement
s
○ Probably
yes
● Yes
○ Varies
○ Increased
○ Probably
Equity
What
would be
the impact
on health
inequities?
Acceptabi
lity
Feasibility
Optimising chest wall recoil is unlikely to have an effect on
health inequities, but it may help improve health for all.
● Uncertain
○ Probably
reduced
○ Reduced
○ Varies
Key stakeholders recognise the importance of improving CPR
quality to help improve outcomes following cardiac arrest.
no
○ Uncertain
○ Probably
yes
Last year, the American Heart Association released
statements that highlight the importance of improving CPR
quality, and make recommendations for interventions to
achieve this.(Meaney, 2013, 417, Morrison, 2013, 1538)
● Yes
○ Varies
○ No
○ Probably
Is the
option
feasible to
implement
?
Where such equipment is already in place, no additional
resources are required to use such equipment to optimise
chest wall recoil.
increased
○ No
○ Probably
Is the
option
acceptable
to key
stakeholde
rs?
Research evidence
Improvements in chest wall recoil have been reported in
previous studies.
no
○ Uncertain
○ Probably
yes
● Yes
○ Varies
The minimising of chest wall leaning is feasible, particularly in
organisations that already monitor CPR quality metrics.
Additional
considerations
recommended as part of
an overall organisational
strategy to improve CPR
quality.
Recommendation
Should maximizing chest wall recoil vs. ignoring chest wall recoil be used in adults and
children who are in cardiac arrest in any setting?
Balance of
consequences
Undesirable
consequences clearly
outweighdesirable
consequences in most
settings
Undesirable
consequences
probably outweigh
desirable
consequences in
most settings
The balance
between desirable
and undesirable
consequences is
closely balanced or
uncertain
Desirable
consequences
probably outweigh
undesirable
consequences in
most settings
Desirable
consequences
clearly outweigh
undesirable
consequences in
most settings
○
○
○
●
○
Type of
recommendation
Recommendation
We recommend against
offering this option
We suggest not
offering this option
We suggest offering
this option
We recommend offering
this option
○
○
●
○
We suggest that chest wall leaning should be avoided as opposed to ignoring chest wall recoil in adults
and children who are in cardiac arrest in any setting.
For the critical outcomes of Return of Spontaneous Circulation, Survival at Hospital Discharge and
Survival with Favorable Neurologic/Functional Outcome we found no evidence to inform the question.
For the important outcome of Coronary Perfusion Pressure (CPP) we found three observational studies
(two animal and one human non-cardiac arrest model) representing very low quality evidence, following
downgrading for serious risk of bias and very serious indirectness.(Glatz, 2013, 1674, Yannopoulos,
2005, 363, Zuercher, 2010, 1141) All three studies reported reduced coronary perfusion with incomplete
recoil. Glatz et al analysed two levels of leaning (10% and 20%) and noted a dose response, with
increased levels of leaning force associated with reduced coronary perfusion pressure.(Glatz, 2013, 1674)
Similarly Zuercher et al analysed both 10% and 20% leaning, but the reduction in CPP only became
significant at the 20% level.(Zuercher, 2010, 1141)
Justification
For the important outcome of cardiac output/cardiac index we found two observational studies (one
animal and one human non-cardiac arrest model) also representing very low quality evidence
downgraded for serious risk of bias and very serious indirectness.(Glatz, 2013, 1674, Zuercher, 2010,
1141) The animal study by Zuercher et al reported a reduction in cardiac index when 10% and 20%
leaning forces were applied.(Zuercher, 2010, 1141) In contrast, Glatz et al found that leaning forces had
no effect on cardiac index/ output.(Glatz, 2013, 1674)
Chest compression (CC) quality, defined by rate, depth, fraction, and recoil, is thought to impact cardiac
arrest outcomes and may contribute to variability in cardiac arrest survival. In 2010, both the European
Resuscitation Council (ERC) and the American Heart Association (AHA) recommended complete chest
wall recoil as a component of high-quality CPR. While optimal CC rate, depth and fraction have been
associated with improved outcomes from cardiac arrest there is a paucity of data describing the release
phase of CCs. (Vadeboncoeur, 2014, 182, Vaillancourt, 2011, 1501, Stiell, 2012, 1192, Idris, 2012,
3004, Christenson, 2009, 1241, Cheskes, 2011, 58) The available evidence has not changed significantly
since the publication of the 2010 guidelines. Specifically, there remain no human studies evaluating
ROSC, survival to hospital discharge, or neurologically intact survival with or without complete chest wall
recoil during CPR.
The recommendation that chest wall leaning should be avoided is based on two studies of cardiac arrest
in swine, and a human study of paediatric heart transplant patients with spontaneous circulation
undergoing cardiac catheterisation. These studies implicate complete chest wall recoil/no leaning as an
important factor in maximizing blood flow during CPR. Animal studies demonstrate reductions in coronary
perfusion pressure, cardiac index and other haemodynamic measures, such as myocardial blood flow,
with only small amounts of incomplete chest recoil/residual leaning.(Yannopoulos, 2005, 363, Zuercher,
2010, 1141) Glatz et al also demonstrated that residual leaning force was associated with reduced
coronary perfusion pressure in anesthetised children during cardiac catheterisation.(Glatz, 2013, 1674)
The importance of these haemodynamic measures is demonstrated by data showing an association
between coronary perfusion pressure and return of spontaneous circulation.(Paradis, 1990, 1106)
Studies continue to demonstrate that incomplete chest wall recoil persists in clinical practice.(Fried,
2011, 1019, Sutton, 2009, 494, Niles, 2009, 553) It has been shown that with dedicated efforts, the
release phase of chest compressions can be improved.(Bobrow, 2013, 47) It is important to note that
while animal data supports complete recoil improving haemodynamics, chest wall recoil is just one
parameter of high quality CPR and it likely does not work in isolation. The same interventions that have
been shown to improve chest wall recoil are also associated with improvements in other CPR metrics.
Subgroup
considerations
Complete chest wall recoil has already been implemented as it was recommended in the 2010 ILCOR
statement, and international resuscitation guidelines.
Implementation
considerations
It remains uncertain whether chest wall recoil has improved since 2010, and whether or not it has had an
effect on patient outcomes.
There is no evidence of benefit associated with ignoring chest wall recoil.
Monitoring and
evaluation
Research
possibilities
Organisations that already utilize certain CPR measurement and feedback technologies can readily
monitor and evaluate chest wall recoil.
Organisations without these technologies will have difficulty monitoring chest wall recoil.
The use of technology to measure chest wall recoil now provides the opportunity to assess the impact of
chest wall recoil on clinical outcomes.
Attempts should be made to clarify the role that chest wall recoil plays in conjunction with other
compression variables, namely rate and depth.
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