Title: Two-fingers method of chest compression in neonates- Is it appropriate?
For Award Paper category- S S Manchanda Award
Authors:

Shiv Sajan Saini, DM, Senior Research associate

Neeraj Gupta, MD, senior resident

Harvinder Kaur, PhD
Affiliation: Newborn Unit, Department of Pediatrics,
Postgraduate Institute of Medical Education and Research,
Chandigarh 160012, India
Following is the Contributions of the Authors:
Shiv Sajan Saini- Conceived the idea, planned the study, reviewed the analysis, revised the
manuscript critically for important intellectual content
Neeraj Gupta: Extracted, analyzed and summarized the data, wrote initial draft of the manuscript.
Harvinder Kaur: Anthropometrical measurements.
Financial disclosure: None
Conflict of interest: None
Word count of text: 2431
Corresponding author:
Dr Shiv Sajan Saini,
Department of Pediatrics,
PGIMER,
Chandigarh 160012,
India
Email: sajansaini@rediffmail.com
Tel: +91-9501112646
Fax: +91-172-2744401
Short title: 2-fingers technique of chest compression.
Abstract
Objectives
To find the proportion correct placements (POCP) achieved by ‘2-fingers’ and ‘thumbs’
techniques in neonates. Our secondary objectives were to compare these two techniques for
POCP in all neonates, and separately in full-term and preterm neonates. We also planned to
compare POCP in various subgroups of full-term and preterm neonates using 2-fingers and
thumb technique.
Methods
Design: Prospective observational study, over 3 months Setting: level III NICU. Subjects:
intramural singleton neonates (<7 days). Protocol: Distance between internipple line and sternoxiphoid junction in was compared with 2-Finger’s span and thumbs span of adult rescuers which
was recorded on a paper. The appropriate placement (defined by span of 2-fingers/thumbs
covering lower third of sternum and remained at/below the inter-nipple line and at/above the
sterno-xiphoid junction. The POCP was compared between 2 techniques, among term & preterm
neonates and various subgroups.
Results
A total of 1248 observations were made (23 term/16 preterm neonates and 32 rescuers). The
POCP among all study neonates was 8% vs 83% in 2-fingers and thumbs technique, (p<0.001).
In term vs preterm neonates, POCP was 13% vs 96% and 2% vs 65% in 2-fingers and thumbs
technique respectively, (p<0.001). POCP was 3% vs 10% and 85% vs 95% in term and preterm
SFD vs AFD neonates, respectively. POCP in preterm AFD vs SFD was 2% vs 0% using 2Fingers
and 70% vs
48% using thumbs
technique. POCP was
2%/1%/0% for
LBW/VLBW/ELBW neonates with 2-Fingers and 73%/62%/54% using thumbs technique.
Conclusion
There are high chances of incorrect placements using 2-Fingers technique. The correct
placements in Thumbs technique were obtained in 3/4th of LBW neonates, 2/3rd of all
preterm/VLBW neonates and ½ of SFD/ELBW neonates.
Introduction
Chest compressions or external-cardiac compressions is rhythmic compression of heart between
manubrium sterni and spine. It is performed during cardiopulmonary resuscitation if heart rate
remains below 60/minute despite 30 seconds of effective positive pressure ventilation. Fewer
than 1% of all live-born neonates require extensive resuscitation including chest compressions.1
American Heart Academy recommends 2-fingers technique and thumbs technique for
performing chest compressions during cardiopulmonary resuscitation in neonates.1 The
recommended site of chest compressions is—lower third of sternum, because centre of the heart
is positioned under lower third of the sternum.2-4 During chest compressions, we choose the
exact site of compression between imaginary line joining the two nipples and sterno-xiphoid
junction.1 The pressure over xiphoid process and abdomen should be avoided during chest
compressions, as it can cause laceration in liver.5,6 Due to fear of liver laceration by undue
pressure over abdomen while performing Hemlisch maneuver, European Resuscitation Council
doesn’t recommend abdominal thrusts in a choking infant.7 Clements et al8 have shown that by
using 3-fingers technique during cardiopulmonary resuscitation in infants and children, pressure
would be exerted on the xiphisternum or abdomen. Although widely practiced, the two
recommended techniques for neonatal cardiopulmonary resuscitation—2-fingers technique and
thumbs technique—have never been evaluated for the above-said concerns. It is possible that the
span covered by two fingers or thumbs of adult resuscitators might be more than the lower third
of sternum in neonates and could exert pressure over xiphisternum and abdominal viscera. This
concern is more in preterm neonates and particularly in extremely premature neonates. There is
no study in literature that has addressed this issue. Therefore, we planned this study to find out
the proportion of correct placements achieved with the two currently recommended techniques
of chest compression—2-fingers technique and thumbs technique—in neonates. In addition, we
planned to compare 2-fingers technique and thumbs technique for the proportion of ‘correct
placements’ in neonates. Our secondary objectives were to compare 2-fingers and 2-thumbs
techniques for the percentage of ‘correct placements’ separately for term and preterm infants.
We also intended to do subgroup analysis— among low birth weight, very low birth weight and
extremely low birth weight infants; among term appropriate for date and small for date infants;
and among preterm appropriate for date and small for date—for the proportion of ‘correct
placements’ using 2-fingers and thumbs techniques.
Methods
We conducted this prospective observational study over 3 months (June 2010- Aug2010) in the
neonatal unit of a tertiary care referral teaching hospital in northern India. This hospital serves
low to middle class population and gets referral from five neighboring states.
Study population
Full term and preterm intramural-singleton-neonates, less than seven days old, were enrolled
after obtaining written informed consent from one of the parents. Full term neonates were
defined as neonates with ≥37 weeks gestational age at birth. Preterm neonates were defined as
neonates with <37 weeks gestational age at birth. The neonates were randomly selected from the
cohort of intramural live-births over three months. Low birth weight (LBW), very low birth
weight (VLBW) and extremely low birth weight (ELBW) neonates were defined as neonates
with birth weight less than 2500 grams, 1500 grams and 1000 grams respectively. Appropriate
for date (AFD) neonates were defined as neonates with birth weight between 10th and 90th
centile for that gestational age. Small for date neonates (SFD) were defined as birth weight <10th
centile for that gestational age. The adult rescuers were also selected randomly from junior
residents, senior residents and nurses in Neonatal unit of our institute. Neonates with lethal
congenital malformations, thoracic wall deformities, and multiple gestations were excluded from
the study.
Parents of neonates, who had satisfied the above eligibility criteria, were explained and
information sheet providing the details of the study was provided to them. Enrollment was done
after obtaining written informed consent.
Study protocol
We recorded birth weight, crown heel length, occipito-frontal circumference, chest
circumference of enrolled neonates. Birth weight was recorded using electronic weighing scale
(precision 1 gram). Length of the neonate was measured by infantometer (precision 1 mm).
Occipito-frontal circumference and chest circumference was recorded by fibro-optic measuring
tape precision 1 mm). Length of their sternum was recorded from the sternal notch to the sternoxiphoid junction. The distance from imaginary line joining two nipples and lower end of
manubrium sterni was recorded. These recordings were done using Digimatic caliper (Mitutoyo
corporation, Japan; precision 0.1 mm). The adult rescuers were asked to place their 2-fingers or
thumbs on a plain paper using recommended methods.1 The span of 2-fingers was recorded by
marking the outer margin of contact of 2-fingers with the surface of paper. The thumbs-span was
recorded by outer margin of contact of thumbs with the paper. These recordings were also done
using Digimatic caliper (Mitutoyo Corporation, Japan).The distance between inter-nipple line
and sterno-xiphoid junction of each neonate was separately compared with 2-fingers span, and
thumbs-span of each individual adult rescuer. Each such one comparison was taken as one
observation. Hence total numbers of observations were equal to the product of number of
neonates with number of adult rescuers.
The ‘Correct placement’ was defined if the span of 2-fingers or thumbs covers the lower third of
the sternum and was restricted to—at or below the inter-nipple line and at or above the lower end
of sternum leaving the xiphoid process—the two anatomical landmarks. Span of fingers or
thumbs extending beyond any of the above anatomical landmarks was labeled as ‘incorrect
placement’. The proportion of correct placements was calculated among all neonates, and
separately among term and preterm neonates utilizing 2-fingers technique. Similarly, proportion
of correct placements was calculated among all neonates, and separately among term and
preterm neonates utilizing thumbs technique. The proportion of correct placements was
calculated for various subgroups—among LBW, VLBW, and ELBW neonates; among term
AFD and SFD neonates; and among preterm AFD and SFD neonates—separately for 2-fingers
technique and thumbs technique
Outcome variables
The primary outcome variable was the proportion of correct placements among all neonates with
2-fingers technique and thumbs technique. In addition we compared the two techniques—2fingers technique and thumbs technique—for proportions of correct placements among all
neonates. Our secondary outcome variable was comparison of proportion of correct placements
between 2-fingers and thumbs technique separately among term and preterm neonates. Our other
secondary outcome variables were proportions of correct placements among various
subgroups—among LBW, VLBW, and ELBW neonates; among term AFD and SFD neonates;
and among preterm AFD and SFD neonates—utilizing 2-fingers technique and thumbs
technique.
Statistical analysis and Sample size
Descriptive statistics was used to define the baseline variables. We used Chi-square tests with
Yates correction or Fisher-Exact test to compare the proportions of correct placements for
primary outcome and secondary outcomes. Analysis was done in SPSS version 17.
We did a pilot survey of 14 neonates (7 full-term and 7 preterm) and 14 adult rescuers (7 males
and 7 females to find the proportion of correct placements in two groups. A total of 196
observations were taken and proportion of correct placements was calculated for whole group.
The percentage of appropriate placements was 15%. We calculated the sample size to pick up a
proportion of 15% correct placements in neonates with a desired precision of 2% (1% on each
side), we needed 1224 observations.
Results
A total of 39 neonates and 32 adult rescuers were enrolled for the study. A total of 1248
observations were recorded. Out of all neonates, 23 were full-term and 16 were preterm
neonates. Among full-term neonates, 17 were AFD and 5 were SFD neonates, respectively.
Among preterm neonates, 13 and four neonates were AFD and SFD neonates respectively.
Among preterm neonates three were ELBW, six were VLBW, and eight were LBW neonates.
The average length of sternum among all neonates was5.2 ± 1.1 cm., The average length of
sternum among full-term and preterm neonates was 5.8 ± 0.9 cm and 4.3 ± 0 .6 cm, respectively.
The distance between internipple line and sterno-xiphoid junction among all neonates was 1.9 ±
0.7 cm. The distance between internipple line and sterno-xiphoid junction among full-term and
preterm neonates was 2.1 ±0.8 cm and 1.6 ± 0.4 cm, respectively. Average 2-finger span and 2thumb span of the adult rescuers was 2.5 ± 0.2 cm and 1.5 ± 0.2 cm respectively. Baseline
anthropometrical data of all neonates, term and preterm neonates has been presented in table 1.
A total of 1248 observations (39 neonates × 32 adult rescuers) were taken. Using 2-fingers
technique, the proportions of correct placements was 8%. Using thumbs technique the proportion
of correct placements was 83%.The difference of the proportion of correct placements among the
thumbs technique and 2-fingers was statistically significant, (p<0.001). We took 704
observations in term neonates. The proportion of correct placements were 13% and 96% in 2fingers and thumbs technique respectively, (p<0.001). Similarly, among 544 observations in
preterm neonates, proportion of correct placements was 2% and 65% in 2-fingers and thumbs
technique respectively, (p<0.001) (Table 2).
Among term neonates using 2-fingers technique, proportion of correct placements were 3% in
SFD neonates as compared to 10% in AFD neonates, p= 0.02; while using thumbs technique, the
proportion of correct placements was 85% and 95% respectively. Among preterm neonates using
2-Fingers technique, there was no correct placement among 128 observations in SFD group as
compared to 2% correct placements in AFD group. Among preterm neonates using thumbs
technique, proportion of correct placements was 48% for SFD neonates as compared to 70% in
AFD neonates, p=0.02. In various preterm subgroups using 2-Fingers technique, proportion of
correct placements was 2%, 1% and 0% for LBW, VLBW and ELBW neonates; while the using
thumbs technique proportion of correct placements was 73%, 62% and 54%, (p>0.02). (Table 3)
Discussion
In the current study proportion of correct placements were significantly less in 2-Fingers
technique as compared to thumbs technique. The difference was highly significant for all study
population as well as separately for full-term and preterm neonates, (p<0.001 for all
observations). Among various subgroups of full-term and preterm neonates using 2-Fingers
technique, proportion of correct placements was very poor (maximum correct placements <10%
among various subgroups). The worst results were obtained in preterm SFD and ELBW
neonates, where none of the placements was correct. With the use ofThumbs technique also, only
2/3rd of preterm neonates did not have appropriate placements. Similarly, proportion of correct
placements in preterm SFD and ELBW neonates was very low, where only 50% placements
were correct. Among VLBW and LBW neonates using thumbs technique, correct placements
could be achieved in <2/3rd and <3/4th observations, respectively.
We enrolled all strata of neonates including full-term, preterm, AFD, SFD, LBW, VLBW, and
ELBW neonates. Our study population had sternal lengths of 5.6 ± 0.6 cm for term neonates and
4.3 ± 0 .6 cm for preterm neonates (average gestational age 32.3 weeks for preterm neonates).
These values are shorter than the western figures of 6.4 cm (95% CI 5.4, 7.4) and 5.0 (95% CI
4.4, 5.8)9. The distance between the inter-nipple line and sterno-xiphoid junction in term
neonates was 1.9 cm (95%CI 1.3, 2.5) in our study, where as this was reported as 2.6 cm (95%CI
2,3.5) by Clements et al.8 They have taken measurements with a sliding caliper graduated in
millimeters. This difference in measurements could be due the difference in the geographical
population. The precision of the caliper could have contributed for this difference. There are no
reports of such measurements from India or other developing countries. Moreover the span of 2fingers and thumbs is also not available in literature. It is expected that these values would be
proportional due to the geographical variations.
There are no studies which have checked the proportion of correct placements using the
recommended methods of chest compressions in neonatal age group. Clements et al8 studied
whether 3-finger technique, for chest compression in infant cardiac arrest, can cause pressure on
the abdomen or xiphisternum. The adult rescuer’s 3-fingers position was recorded on paper
template simulating infant chest. The distance of the edge of the lower finger from the internipple line was significantly more than mean infant lower sternal length (4.4 cm (95% CI 0.9) vs
2.3 cm (95% CI 1.6). The authors showed that using the 3-Fingers method, pressure would be
exerted on the xiphisternum or abdomen in cases of cardiopulmonary resuscitation. In this study,
the method used was three fingers method in stead of two finger method which is recommended
by NRP for neonatal cardiac compressions. Out of total 30 observations only 7 were taken in
neonates and preterm neonates were excluded from the study. No other study, to the best of our
knowledge, has compared the 2-Fingers and thumbs techniques for correct placements in
neonatal age group.
Thumbs technique has previously been compared with the 2-Finger technique in animal models
of cardiac arrest and experimental designs for systolic and diastolic blood pressures, coronary
perfusion pressures.10-14 The thumbs technique has been found to generate more systolic and
mean blood pressures as compared to 2-Fingers technique10-12 although this finding is not
universal13. Other advantages of thumb over 2-finger technique include better control of depth of
compressions, less tiring, and suitable for individual with long finger nails.1
Our study is first of its kind, which have brought out the actual proportion of correctplacements
in such a commonly used procedure. The other strengths of the study are the high desired
precision selected so as to minimize the chances of error in such a delicate and lifesaving
procedure. The main drawback of the study is the external validity. Though the anthropometrical
measurements in our study are lesser than the western counterparts, they can be explained on the
basis of geographical differences, different genetic make-up, and more proportion of SFD
neonates in our population. Although the distance between internipple line and sterno-xiphoid
junction was larger in western studies,9 it is expected that the finger span and thumb span would
also be proportionately high due to the above said differences making proportion of correct
placements more or less the same. But our results may not be applicable to western population
till such data is available. We have taken neonates of <7 days of postnatal age and hence our
results may be applicable to the early neonatal period.
Conclusion
We conclude that there are high chances of inappropriate placements while using 2-Fingers
technique in cases of neonates undergoing chest compressions after birth in the early neonatal
period. Using thumbs technique too, the correct/ appropriate placements were obtained only in
3/4th of LBW neonates, 2/3rd of all preterm & VLBW neonates and ½ of SFD & ELBW
neonates.
Bibliography
1. American heart association. Part 13: Neonatal Resuscitation Guidelines Circulation
2005;112:IV-188- IV-195.
2. Phillips GWL, Zideman DA. Relation of the infant heart to sternum: its significance in
cardiopulmonary resuscitation. Lancet 1986;1:1024e5.
3. Orlowski JP. Optimum position for external cardiac compression in infants and young children.
Ann Emerg Med 1986;5:667e73.
4. Finholt DA, Kettick RG, Wagner HR, et al. The heart is under the lower one third of the
sternum. Am J Dis Child 1986; 140:646e9.
5. Thaler MM, Krause VW. Serious trauma in children after external cardiac massage. New Engl J
Med 1962;267:500.
6. Thaler MM, Stobie GHC. An improved technique of external cardiac compression in infants and
young children. New Engl J Med 1963;269:606–10.
7. European Resuscitation Council. Paediatric basic life support. Resuscitation 1998;37:97–100.
8. Clements F, McGowan J. Finger position for chest compressions in cardiac arrest in infants.
Resuscitation 2000;44:43e6.
9. Sivan Y, Merlob P, Reisner SH. Sternal length, Torso length, and internipple distance in
newborn infants. Pediatrics 1983;72:523-5.
10. Menegazzi JJ, Aubie TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression
during CPR in a swine infant model of cardiac arrest. Ann Emerg Med 1993;22:240-3.
11. Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized controlled trial of two finger chest
compression in a swine infant model of cardiac arrest. Prehosp Emerg Care 1997;1:65-7.
12. Dorfsman ML, Menegazzi JJ, Wadas RJ, Auble TE. Two-thumb vs two-finger chest
compression in an infant model of prolonged cardiopulmonary resuscitation. Acad Emerg Med
2000;7:1077-82.
13. Whitelaw CC, Slywka B, Goldsmith LJ. Comparison of a twofinger versus two-thumb method
for
chest
compressions
by healthcare
providers
in
an
infant
mechanical
model.
Resuscitation2000;43:213-6.
14. Udassia S, Udassia JP, Lamba MA, Theriaqueb DW, Shusterb JJ, Zaritskye AL et al. Twothumb technique is superior to two-finger technique during lone rescuer infant manikin CPR.
Resuscitation 2010;81:712–7.
Tables
Table1: Baseline variables of the study population.
Variable
All neonates (N=39)
Term (N=23)
Preterm (N=16)
Gestation
35.9 ± 3.8
38.5 ± 1.1
32.3 ± 3.2
Birth Weight
2242 ± 762
2788.5 ± 472.5
1534.8 ± 379.8
Length
45.2 ± 4.4
48.1 ± 2.1
41.4 ± 3.5
OFC
30.9 ± 3.1
32.8 ± 1.9
28.4 ± 2.4
Chest circumference
27.7 ± 3.8
30.4 ± 2.1
24.2 ± 2.3
Chest width
9.1 ± 1.3
9.9 ± 0.8
7.9 ± 0.8
Sternum length (B)
5.1 ± 0.9
5.6 ± 0.6
4.3 ± 0 .6
1.7 ± 0.4
1.9 ± 0.3
1.6 ± 0.4
0.36 ± 0.06
0.35 ± 0.07
0.36 ± 0.06
Distance between Nipple and
xiphisternum (A)
A/B ratio
OFC- Occipito-frontal circumference.
Table 2: Intergroup comparison of 2-Fingers and thumbs techniques.
Appropriate
2-Fingers Technique
thumbs Technique
p value
Overall
97/ 1248 (7.7%)
1032/ 1248 (82.7%)
<0.001*
Term
89/704 (12.64%)
678/704 (96.3%)
<0.001*
Preterm
8/ 544 (1.47%)
354/ 544 (65%)
<0.001*
Placements
Table 3: Within group comparison of 2-Fingers and thumbs techniques.
Appropriate placements
2-Fingers Technique
thumbs Technique
Term
89 (12.6%)
678
Preterm
vs Term
p<0.001*
(N-704)
Preterm
p<0.001*
(96.3%)
8 (1.5%)
354 (65.0%)
(N= 544)
Term
Preterm
AFD
54
(N=544)
(9.9%)
SFD
4
(N=128)
(3.1%)
AFD
8
(N=416)
(1.9%)
SFD
0
p= 0.02*
461 (84.8%)
p= 0.4
122 (95.3%)
p= 0.11
293 (70.4%)
p= 0.02*
61 (47.7%)
(N=128)
Preterm
LBW
6
(N=256)
(2.3%)
VLBW
4
(N=174)
(1.0%)
ELBW
0
(N=116)
p=0.1
186 (72.7%)
108 (62.1%)
62 (53.5%)
p= 0.09