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Resuscitation
j o ur na l h o me pa g e:ww w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n
ILCOR
Summary
Statement
2017
International
Consensus
on
Cardiopulmonary
Resuscitation
and
Emergency
Cardiovascular
Care
Science
With
Treatment
Recommendations
Summary
夽
Theresa
M.
Olasveengen,
Allan
R.
de
Caen,
Mary
E.
Mancini,
Ian
K.
Maconochie,
Richard
Aickin,
Dianne
L.
Atkins,
Robert
A.
Berg,
Robert
M.
Bingham,
Steven
C.
Brooks,
Maaret
Castrén,
Sung
Phil
Chung,
Julie
Considine,
Thomaz
Bittencourt
Couto,
Raffo
Escalante,
Raúl
J.
Gazmuri,
Anne-Marie
Guerguerian,
Tetsuo
Hatanaka,
Rudolph
W.
Koster,
Peter
J.
Kudenchuk,
Eddy
Lang,
Swee
Han
Lim,
Bo
Løfgren,
Peter
A.
Meaney,
William
H.
Montgomery,
Peter
T.
Morley,
Laurie
J.
Morrison,
Kevin
J.
Nation,
Kee-Chong
Ng,
Vinay
M.
Nadkarni,
Chika
Nishiyama,
Gabrielle
Nuthall,
Gene
Yong-Kwang
Ong,
Gavin
D.
Perkins,
Amelia
G.
Reis,
Giuseppe
Ristagno,
Tetsuya
Sakamoto,
Michael
R.
Sayre,
Stephen
M.
Schexnayder,
Alfredo
F.
Sierra,
Eunice
M.
Singletary,
Naoki
Shimizu,
Michael
A.
Smyth,
David
Stanton,
Janice
A.
Tijssen,
Andrew
Travers,
Christian
Vaillancourt,
Patrick
Van
de
Voorde,
Mary
Fran
Hazinski,
Jerry
P.
Nolan,
On
behalf
of
the
ILCOR
Collaborators
a
r
t
i
c
l
e
i
n
f
o
Keywords:
AHAScientificStatements Cardiopulmonaryresuscitation Heartmassage
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b
s
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r
a
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t
TheInternationalLiaisonCommitteeonResuscitationhasinitiatedanear-continuousreviewof car-diopulmonaryresuscitationsciencethatreplacestheprevious5-yearcyclicbatch-and-queueapproach process.ThisisthefirstofanannualseriesofInternationalConsensusonCardiopulmonaryResuscitation andEmergencyCardiovascularCareScienceWithTreatmentRecommendationssummaryarticlesthat willincludethecardiopulmonaryresuscitationsciencereviewedbytheInternationalLiaisonCommittee onResuscitationinthepreviousyear.Thereviewthisyearincludes5basiclifesupportand1 paedi-atricConsensusesonCardiopulmonaryResuscitationandEmergencyCardiovascularCareScienceWith TreatmentRecommendations.Eachoftheseincludesasummaryofthescienceanditsqualitybasedon GradingofRecommendations,Assessment,Development,andEvaluationcriteriaandtreatment recom-mendations.InsightsintothedeliberationsoftheInternationalLiaisonCommitteeonResuscitationtask forcemembersareprovidedinValuesandPreferencessections.Finally,thetaskforcemembershave pri-oritisedandlistedthetop3knowledgegapsforeachpopulation,intervention,comparator,andoutcome question.
©2017EuropeanResuscitationCouncilandAmericanHeartAssociation,Inc.PublishedbyElsevier B.V.Allrightsreserved.
Untilrecently,theInternationalLiaisonCommitteeon Resusci-tation(ILCOR)cardiopulmonaryresuscitation(CPR)sciencereview process has been undertaken in 5-year cycles, the last being
夽 ThisarticlehasbeencopublishedinCirculation:CardiovascularQualityand Out-comes.
published in 2015.1,2 This batch-and-queue approach has the advantageofenabling a well-plannedand systematicupdateof guidelinesand training materials,butit couldpotentiallydelay theimplementationofneweffectivetreatments.In2016,ILCOR adoptedanewprocessthatwouldenableanear-continuousreview ofresuscitationsciencebyusingtaskforce–prioritisedpopulation, intervention, comparator,and outcome (PICO) questions. There willbe2distinct pathwaysfor evidenceevaluation.Knowledge
https://doi.org/10.1016/j.resuscitation.2017.10.021
synthesisunits(KSUs),organisationswithexpertiseinsearching scientificdatabasesandperformingsystematicreviewsand meta-analyses,willaddressPICOsthatarelargeandcomplicatedortopics forwhichseveralPICOscanbegroupedtogetherandaddressed throughsensitivityorsubgroupanalyses.Contractedsystematic reviewerswillundertakesimplesystematicreviewsinvolving typi-callysinglePICOquestions.Bothpathwaysinvolvecontentexperts, andcriticalstepsduringevidenceevaluationarediscussedwith relevanttaskforceswhenneeded.
TheGradingofRecommendations,Assessment,Development, andEvaluation(GRADE)processthatwasadoptedfortheILCOR “2015 International Consensus on Cardiopulmonary Resuscita-tionandEmergencyCardiovascularCareScienceWithTreatment Recommendations”(CoSTR)willalsobeusedforthecontinuous review of CPRscience.3 In theGRADE approach, thequality of evidencesupportinginterventioneffects(definedbythePICO ques-tion)israted as high,moderate, low, or verylow. Randomised controlledtrials(RCTs)startashigh-qualityevidence,and observa-tionalstudiesstartaslow-qualityevidence.Fivefactorsmaylead todowngradingofthequalityofevidence,and3factorsmayenable anupgradeofthequalityofevidence(Table).4–9Thequality assess-mentsforeachoutcomearesummarisedinGRADEevidenceprofile tables,whichalsoincludeasummaryoffindingsintheformofthe numbersofpatients,therelativerisk(RR),andanindicationofthe absoluterisk(describedastheriskdifference[RD]).
ThisisthefirstofaseriesofannualILCORCoSTRsummary arti-clesthatwillincludetheCPRsciencereviewedbyILCORinthe previousyear.Thereviewthisyearincludes5basiclifesupport (BLS)CoSTRsand1paediatricCoSTR.TheCoSTRswereproduced aftera systematic review bythe KSUat St. Michael’sHospital, Toronto,ON,Canada,incollaborationwithILCORcontentexperts andmembersoftheILCORBLSandPaediatricTaskForces.Allthe evidenceprofiletablesandmeta-analyseswereproducedbythe KSUandreviewedbyILCORBLSandPaediatricTaskForces.The CoSTRshavebeensubjectedtorigorousevaluation,peerreview, andpubliccomment.Weanticipatethatby2018,≈20PICO ques-tionswillbeaddressedperyear,andeachquestionwillgeneratea draftCoSTRthatwillbepublishedontheILCORwebsite.10Thedraft CoSTRspublishedonlinewillprovidethedatafortheannualCoSTR summaryarticlethatwillbepublishedeachyear.Thesummary articlediffersinseveralrespectsfromthedraftCoSTRspublished ontheILCORwebsite:Thelanguageusedtodescribethescience isnotrestrictedtostandardGRADEterminology,whichmakesit moreaccessibletoawideraudience;thevaluesandpreferences havebeenexpandedtoprovidegreaterinsightintotherationalefor treatmentrecommendations,particularlywhenhigh-quality evi-denceislacking;andthetop3knowledgegapsforeachtopichave beenprioritisedandrankedbythetaskforcemembers.
TableGRADEQualityAssessmentCriteria
StudyDesign Qualityof Evidence Lowerif Higherif Randomised trial High Moderate Riskofbias Inconsistency Largeeffect Doseresponse Observational study Low Verylow Indirectness Imprecision Publicationbias Allplausible confounding:would reduceademonstrated effectorwouldsuggest aspuriouseffectwhen resultsshownoeffect
TheCoSTRsarebasedonthedatasummarisedintheGRADE evidenceprofiletablesforeachofthekeyoutcomesforeachofthe clinicalscenarios.Thepertinentoutcomedataarelistedforeach statementasRR(with95%confidenceinterval[CI])andRD(with 95%CI).TheRDistheabsolutedifferencebetweentherisksand iscalculatedbysubtractingtheriskinthecontrolgroupfromthe
riskintheinterventiongroup.Thisabsoluteeffectenablesamore clinicallyusefulassessment ofthemagnitudeoftheeffectofan interventionandenablescalculationofthenumberneededtotreat (=1/RD).
CPRStrategies:Background
Oneoftheprimarymeasurestakentoimprovesurvivalafter car-diacarresthasbeenfocusedeffortstoimprovethequalityofCPR. Althoughtheimpactofhigh-qualitychestcompressionshasbeen studiedextensively,11–14theroleofventilationandoxygenationis lessclear.Effortstosimplifyresuscitationbydelayingventilation orbyprovidingpassiveoxygenationhavebeenimplementedfor bothlayandprofessionalrescuers.Thesestrategieshavebeen con-sistentlyassociatedwithincreasedbystanderCPRratesandfewer pausesinchestcompressions,buteffectsonsurvivalhavebeenless clear.15–18
Duringthedevelopmentofthe2015CoSTR,severalPICO ques-tionswerededicatedtoreviewingevidenceofcontinuouschest compressionstrategiesforbothlayand professionalrescuersin variouspopulations(adult,paediatric)andforvarioussettings(in hospital,out of hospital).19–22 Shortlyafter thesereviewswere completed,a 23711-patient RCTevaluating theeffectiveness of continuous chest compressionsin the emergency medical ser-vices(EMS)settingwaspublished.23Inparallel,developmentsof largenationalandregionalregistriesarecontinuallyprovidingnew insights into the epidemiology of cardiac arrest and bystander CPR.24Theseemergingpublicationsgeneratedanurgentneedto reviewallavailableevidenceoncontinuouscompressionstrategies toprovideupdatedevidenceevaluationsthatincludedthelatest scienceavailable.Thesystematicreviewandmeta-analysisofthis topicundertakenbySt.Michael’sHospitalKSUandILCORhasbeen publishedseparately.25
ThePopulation,Intervention,Comparator,Outcome,Study Designs,andTimeFrame
Thefollowing wasusedby St.Michael’s HospitalKSUwhen undertakingthesystematicreview:
• Population:Patientsofallages(eg,neonates,children,adults) withcardiacarrestfromanycauseandacrossallsettings(in hos-pitalandoutofhospital)wereincluded.Studiesthatincluded animalswerenoteligible.
• Intervention:AllmanualCPRmethods,including compression-onlyCPR,continuouscompressionCPR,andCPRwithdifferent compression-to-ventilation(CV)ratios,wereused. Compression-onlyCPRincludedcompressionswithnoventilations;continuous compressionCPRincludedcompressionswithasynchronous ven-tilationsorminimallyinterruptedcardiacresuscitation.Studies thatmentionedtheuseofamechanicaldeviceduringCPRwere consideredonly if the same device wasused acrossall rele-vantinterventionarmsand wouldthereforenotconfoundthe observedeffect.
• Comparators:Studieshad tocompare atleast2differentCPR methodsfromtheeligibleinterventions;studieswithouta com-paratorwereexcluded.
• Outcomes:The primaryoutcome wasfavourableneurological outcomes, measured by cerebral performance or a modified RankinScale.Secondaryoutcomesweresurvival,returnof spon-taneouscirculation,andqualityoflife.
• Study designs: RCTs and nonrandomised studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohortstudies)wereeligibleforinclusion.Studydesigns
with-outacomparatorgroup(eg,caseseries,cross-sectionalstudies), reviews,andpooledanalyseswereexcluded.
• Timeframe:PublishedstudiesinEnglishsearchedonJanuary15, 2016,wereincluded.
Dispatch-AssistedCompression-OnlyCPRComparedWith Dispatch-AssistedConventionalCPR(Adults):Consensuson Science
Dispatch-assistedcompression-onlyCPR wascompared with dispatch-assistedconventionalCPR(ratioof15compressionsto 2ventilations)in1RCTthatgeneratedlow-qualityevidencefor favourableneurologicalfunction.16 Thequality ofevidencewas downgradedforseriousimprecisionbecauseonly2ofthe3sites provided data onneurological outcome. In this study, instruc-tionstogivecontinuouschestcompressionshadnodemonstrable benefit for favourable neurological function (RR, 1.25 [95% CI, 0.94–1.66];RD,2.86percentagepoints[95%CI,−0.80to6.53]) com-paredwithinstructionstogivecompressionsandventilationsata ratioof15:2.
Dispatch-assisted compression-only CPR compared with dispatch-assistedconventionalCPR(ratioof15compressionsto 2ventilations) in 3RCTsprovided low-qualityevidenceforthe criticaloutcomeofsurvivaltohospitaldischarge.15–17Thequality ofevidenceforthesestudieswasdowngradedbecauseofserious riskofbias: All3studiesexcludedpatientsafterrandomisation andincludedaninterventionthatcouldnotbeblinded,andinat least1study,manyoutcomedataweremissing.17Inapreviously publishedmeta-analysis of thesestudies, there appeared tobe asmallbenefitinsurvivaltohospitaldischargeinfavourofthe groupinstructedtogivecontinuouschestcompressionscompared withthegroupinstructedtogivecompressionsandventilations ataratioof15:2(RR,1.22[95%CI,1.01–1.46];RD,2.4percentage points[95%CI,0.1–4.9];fixed-effectmodel;P=0.04).26This meta-analysisusedsurvivaltohospitaldischargeforall3studies,15–17 althoughtheSwensonstudywasmissing 55%oftheseoutcome data.Inameta-analysisusingarandom-effectmodeltocombine survivaltohospitaldischarge15,16and30-daysurvival17outcomes tocapturethemaximumamountofdata,survivalwasnolonger significantly different between the 2 groups. Continuous chest compressionshad anRR forsurvivalof1.20 (95%CI, 1.00–1.45; RD,1.88percentagepoints[95%CI,−0.05to3.82])comparedwith conventional15:2CPR.
TreatmentRecommendation
We recommend that dispatchers provide chest compression–only CPR instructions to callers for adults with suspected out-of-hospitalcardiacarrest (OHCA) (strong recom-mendation,low-qualityevidence).
ValuesandPreferences
In making these recommendations, we recognise that the evidenceinsupportoftheserecommendationscomesfrom ran-domisedtrialsofvariablequalityperformedatatimewhenthe ratioofchestcompressionstoventilationswas15:2,whichleads togreaterinterruptionstochestcompressionsthanthecurrently recommendedratioof30:2.However,thesignalfromeverytrial is consistently in favourof telephoneCPR protocols thatuse a compression-onlyCPR instructionset.Reviewing thetotalityof availableevidenceandconsideringcurrentcommonpractice, train-ing, and quality assuranceexperiences, theBLS Task Force has keptthestrong recommendationfor compression-only CPR for dispatch-assisted CPR despite low-quality evidence. In making theserecommendations,weplacedahighervalueontheinitiation
ofbystandercompressionsandalowervalueonpossibleharmsof delayedventilation.Thetaskforcerecognisesthattherearemany unansweredquestionswhenbalancingpossiblebenefitsandharms frombystanderventilation.Mostnotably,althoughsomecardiac arrestpathogeneses(eg,asphyxialcardiacarrest)mightbe depen-dentonearlyventilationtoincreasesurvival,bystanders’abilityto learnhowtoperformmouth-to-mouthventilationsoverthephone is notknown.Possible harmfuleffects ofincorrectly performed ventilations(gastricinflation)andfewercompressionsperformed beforeambulancearrivalbecauseofmorecomplexinstructionsand pausesforventilationwereweightedmoreheavilythanpotential benefitsfromearlyventilation.
Thisdocumentreferstodispatch-assistedCPR.Inadoptingthis terminology,weacknowledgethatthedispatchingofemergency medicalresourcesisalimiteddescriptionofthetasksperformedby multiprofessionalteamsworkinginemergencymedicaldispatch centres,andperhapsmoresuitableoptionsarebeingused world-wide.Theyincludetelecommunicators,ambulancecommunication officers,emergencymedicalcommunicators,andcallhandlers,as wellasothertermsmorecloselyrelatedtotheiractualtask descrip-tion.
KnowledgeGaps
Severalknowledgegapswereidentifiedinthereviewofthis topic.AmorecomprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3arethefollowing:
1Whatistheoptimalinstructionsequenceforcoachingcallersin dispatch-assistedCPR?
2Whataretheidentifyingkeywordsusedbycallersthatare asso-ciatedwithcardiacarrest?
3Whatistheimpactofdispatch-assistedCPRinstructionson car-diacarrestsfromnoncardiaccausessuchasdrowning,trauma, orasphyxiainadultandpaediatricpatients?
BystanderCompression-OnlyCPRComparedWith BystanderCPRUsingCompressionsandVentilations (Adults):ConsensusonScience
BystanderCPR usingchestcompressionsonlywascompared withbystanderCPRusingaCVratioof15:2or30:2in6cohort studies that generated very-low-quality evidence for the crit-ical outcome of favourable neurological function.24,27–31 In a meta-analysis of 2 studies, there was no significant difference in favourable neurological function in patients who received compression-onlyCPRcomparedwithpatientswhoreceivedCPR ataCVratioof15:2(RR,1.34[95%CI,0.82–2.20];RD,0.51 per-centagepoints[95%CI,−2.16to3.18]).27,29Thequalityofevidence wasdowngradedforseriousindirectnessandimprecisionbecause ofvaryingresultsacrossstudies,becausethecontrolgrouphad a different CV ratio from the intervention group, and because therewasvariablepostarrestcare.In ameta-analysisof3 stud-ies,therewasnosignificantdifferenceinfavourableneurological function in patientswho receivedcompression-only CPR com-paredwithpatientswhoreceivedcompressionsandventilations during a period when theCV ratiochanged from15:2 to30:2 (RR,1.12[95%CI,0.71–1.77];RD,0.28percentagepoints[95%CI, −2.33to2.89]).28,30,31Thequalityofevidencewasdowngraded forseriousindirectnessandimprecisionbecausethecontrolgroup had a differentCVratiofromtheintervention groupand there wasvariablepostarrestcare.Onestudyexaminedtheinfluenceof nationwidedisseminationofcompression-onlyCPR recommenda-tionsforlayrescuersandshowedthat,althoughbystanderCPR
ratesand nationwide survival improved, patientswhoreceived compression-onlyCPRhadlowersurvivalcomparedwithpatients whoreceivedchestcompressionsandventilationsataCVratioof 30:2(RR,0.72[95%CI,0.69–0.76];RD,−0.74percentagepoints[95% CI,−0.85to0.63]).24Thequalityofevidencewasdowngradedfor seriousindirectnessbecausethestudydidnotdirectlycompare compression-onlyCPRwithCPRwithchestcompressionsand ven-tilationsbutrathercomparedcompression-onlyandCPRwithchest compressionsandventilationswithnoCPR.Theevidencewasalso consideredindirectbecausemultipleaspectsofresuscitationwere likelytohavechangedovertimeinthisbefore-and-afterstudy.
BystanderCPRusingcompression-onlyCPRwascomparedwith bystanderCPRusingaCVratioof15:2or30:2in7cohortstudies thatgeneratedvery-low-qualityevidenceforthecriticaloutcome of survival.24,27,29,32–35 In a meta-analysis of 6 studies, there wasnosignificantdifferenceinsurvivalinpatientswhoreceived compression-onlyCPRcomparedwithpatientswhoreceivedCPR ataCVratioof15:2(RR,0.88[95%CI,0.74–1.04];RD,−0.83 per-centagepoints[95%CI,−1.85to0.19]).27,29,32–35 Thequalityof evidencewasdowngradedfor seriousrisk ofbias and indirect-ness.Riskofbiaswasrelatedtothecomparabilityofthecohorts becausethe majority did not adjust for potential confounders. Thestudieswerealsodowngradedforindirectnessbecausethey eitherwereinvestigatingCPRguidelinechangesordidnot explic-itlyreporttheCVratioamongincludedcases.In1study,patients receivingcompression-onlyCPRhadworsesurvivalcomparedwith patientswho receivedCPRat aCVratio of30:2(RR, 0.75[95% CI, 0.73–0.78]; RD, −1.42 percentage points [95% CI, −1.58 to −1.25]).24 Thequality of evidencewasdowngraded for serious indirectnessasdescribedearlier.Inameta-analysisof3 observa-tionalstudies,28,30,31therewasnosignificantdifferenceinsurvival when patientswho received compression-only CPR were com-paredwithpatientswhoreceivedCPRduringaperiodwhenthe CVratiochangedfrom15:2to30:2(RR,1.16[95%CI,0.64–2.09]; RD,1.27percentagepoints[95%CI,−3.70to6.23]).Thequalityof evidencewasdowngradedforseriousinconsistency,indirectness, andimprecisionasdescribedearlier.
TreatmentRecommendations
Wecontinuetorecommendthatbystandersperformchest com-pressionsforallpatientsincardiacarrest(goodpracticestatement). Inthe2015CoSTR,thiswascitedasastrongrecommendationbut basedonvery-low-qualityevidence.19,20
Wesuggestthatbystanderswhoaretrained,able,andwilling togiverescuebreathsandchestcompressionsdosoforalladult patientsincardiacarrest(weakrecommendation,very-low-quality evidence).
ValuesandPreferences
Inmakingtheserecommendations,thetaskforceplacedhigh valueonthe2010and 2015CoSTRs thatshowed thatrescuers should perform chest compressions for all patients in cardiac arrest.19,20,36,37Giventhatthe2017systematicreviewdidnotseek datacomparinganyCPRwithnoCPRandinkeepingwithGRADE recommendations,ourrecommendationforperformingchest com-pressionsforallpatientsincardiacarresthasbeencitedasagood practicestatement(seeAppendixes1and2).38Wealsoplacedhigh valueontheadvantagederivedfromthesimplicityof teaching orprovidinginstructionsforcompression-onlyCPR.This recom-mendationreflectsthevalueplacedonthedatathatindicateno apparentdownsideinpatientswithtruearrestwithsimilar sur-vivalratesfromadultcardiacarrestsofcardiacoriginbothwith andwithoutventilations.39,40Wealsoacknowledgedthe poten-tialadditionalbenefitsofCPRwithcompressionsandventilations
whendeliveredbytrainedlaypeople,particularlyinsettingswhere EMSresponseintervalsarelongorwhenthecauseofcardiacarrest isasphyxia.
KnowledgeGaps
Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3arelistedhere:
1.Theeffectofdelayedventilationversus30:2high-qualityCPR. 2.The impact of continuous chest compressions on outcomes
forcardiacarrestsfromnoncardiaccausessuchas drowning, trauma,orasphyxiainadultandpaediatricpatients.
3.Theabilityofbystanderstoperformcorrectmouth-to-mouth ventilations.
EMS-DeliveredCPR:ConsensusonScience
High-qualityCPRincludesminimalinterruptionstochest com-pressions.ThreedistincttechniquesareusedbyEMS todeliver continuouschestcompressionCPRduringOHCA:(1)continuous chestcompressionswithpositive-pressureventilation(PPV)ofthe lungswithabag-maskdevicetypicallyatarateof10breathsper minute,(2)continuouschestcompressionsandPPVofthelungs viaatrachealtubeorsupraglotticairway,and(3)continuouschest compressionswithpassiveoxygenationtypicallywithan oropha-ryngealairway and simpleoxygenmask (a strategy sometimes referredtoasminimallyinterruptedcardiacresuscitation). Stud-iesinvolvingthesetechniqueshavetypicallydelayedinsertionof anadvancedairwayuntilafterreturnofspontaneouscirculationor 3cyclesofCPR.
For thecritical outcome offavourable neurologicalfunction, weidentifiedhigh-qualityevidencefrom1RCT23and very-low-qualityevidencefrom2cohortstudies.18,41IntheRCT,patients whowererandomisedtoPPVdeliveredwithabag-maskdevice withoutpausingchestcompressionshadnodemonstrablebenefit forfavourableneurologicalfunction(RR,0.92[95%CI,0.84–1.00]; RD,−0.65percentagepoints[95%CI,−1.31to0.02])comparedwith patientsrandomisedtoconventionalCPRwithaCVratioof30:2.23 In1cohortstudy,patientswhoreceivedcontinuouschest compres-sionsandpassiveventilationfor3cycleshadimprovedfavourable neurologicalfunction(RR,2.58[95%CI,1.5–4.47];RD,24.11 per-centagepoints[95%CI,11.58–36.63])comparedwiththosewho receivedcompressionsandventilationsatatimewhentheCVratio changedfrom15:2to30:2.41Thequalityofevidencewas down-gradedforseriousriskofbiasandindirectness.Riskofbiasincluded moderateriskthatthecontinuouschestcompressioncohortwas notrepresentativeandhighriskthattherewereconfounding fac-tors between the cohorts for which there was no adjustment. Thestudywasconsideredindirectbecauseofitsbefore-and-after designincludingaperiodwithchangingguidelines.Intheother cohortstudy,18minimallyinterruptedcardiacresuscitation (ini-tialseriesof3 cyclesof200uninterruptedchest compressions, passiveventilation,before-and-afterrhythmanalysiswithshock ifappropriate)inpatientswithwitnessedshockablecardiacarrest hadnodemonstrablebenefitforfavourableneurologicalfunction (RR,0.81[95%CI,0.57–1.13];RD,−11.30percentagepoints[95% CI,−28.48to5.87])comparedwithconventionalCPR(mixtureof CVratiosof15:2and30:2).Thequalityofevidencewas down-gradedforseriousriskofbias,indirectness,andimprecision.Risk ofbiasincludedmoderateriskthatthecontinuouschest compres-sioncohortwasnotrepresentativeandunclearriskofinadequate follow-up.Thestudywasconsideredindirectbecauseofits
before-and-afterdesignincludingaperiodwithchangingguidelinesand imprecisebecausetheCIsforRDcrossedfromappreciableharm (0.75)toappreciablebenefit(1.25).
Forthecriticaloutcomeofsurvival,weidentifiedhigh-quality evidence from 1 RCT23 and very-low-quality evidence from 1 cohortstudy.18IntheRCT,therewasnosignificantdifferencein survivaltodischargeofpatientsrandomisedtocontinuouschest compressionscomparedwithpatientsrandomisedtoconventional CPRwithaCVratioof30:2(RR,0.92[95%CI,0.85–1.00];RD,−0.76 percentagepoints[95%CI,−1.51to0.02]).23Inthecohortstudy,18 patientswith witnessed shockablecardiac arrest who received minimallyinterruptedcardiacresuscitationhadimprovedsurvival (RR,2.37[95%CI,1.69–3.31];RD,5.24percentagepoints[95%CI, 2.88–7.60])comparedwithconventionalCPRusingamixtureof 30:2and15:2CVratios.Thequalityofevidencewasdowngraded forseriousindirectnessandimprecisionasdescribedearlier. TreatmentRecommendations
WerecommendthatEMSprovidersperformCPRwith30 com-pressionsto2ventilationsorcontinuouschestcompressionswith PPVdeliveredwithoutpausingchestcompressionsuntilatracheal tubeorsupraglotticdevicehasbeenplaced(strong recommenda-tion,high-qualityevidence).
WesuggestthatwhenEMSsystemshaveadoptedminimally interruptedcardiacresuscitation,thisstrategyisareasonable alter-nativetoconventionalCPRforwitnessedshockableOHCA(weak recommendation,very-low-qualityevidence).
ValuesandPreferences
Inmakingtheserecommendations,thetaskforcetookinto con-siderationthat althoughthere wasrelative homogeneityinthe bodyofevidencearoundEMScontinuouschestcompressionsand adjunctivetherapies(eg,bundlesofcareinthecommunitysuch asimprovedbystanderCPRstrategiesandhospitalsystemsofcare suchastransferstoresuscitationcentres),therewas heterogene-ityinthecontinuousCPRventilationstrategies(ie,passiveversus PPV strategies) and in the comparatorgroups. The recommen-dationsreflect high-qualityevidence forthesafety ofCPR with compressionsandventilations(CVratio,30:2)byEMSproviders whileacknowledgingthelackof datasupportingsuperior func-tionalorsurvivaloutcomes.Thetaskforcealsoplacedarelatively highvalueontheimportanceofprovidinghigh-qualitychest com-pressionsandsimplifyingresuscitationlogisticsforEMSsystems andnotedthesupportfortheclinicalbenefitofbundlesofcare involvingminimallyinterruptedcardiacresuscitation.Inmaking aweakrecommendationinsupportofsystemsthathave imple-mentedminimallyinterruptedcardiacresuscitation,thetaskforce alsoacknowledgesthelackofRCTsevaluatingpassiveoxygenation strategiessuchasthosedescribedinminimallyinterruptedcardiac resuscitation.
KnowledgeGaps
Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3follow:
1.Whatistheeffectofdelayedventilationversus30:2high-quality CPR?
2.Whichelementsofthebundledcare(compressions,ventilations, delayeddefibrillation)aremostimportant?
3.Howeffectiveis passiveoxygeninsufflation(applyinga flow ofoxygenviaafacemaskorasupraglotticairwaybutwithout PPV)?
In-HospitalCPR:ConsensusonScience
Only1cohortstudyevaluatingtheeffectofcontinuouschest compressionsinthein-hospital setting wasidentified.42In this study, PPV without interruption of chest compressions after trachealintubationwascomparedwithinterruptionofchest com-pressionsfor1ventilationaftereveryfifthchestcompression(a CVratioof5:1)amongpatientsadmittedtoahospitalemergency departmentafterOHCA.Chestcompressionsweredeliveredbya mechanicaldeviceknownastheThumperMechanicalCPRMachine (MichiganInstruments,GrandRapids,MI)inallpatients,adevice thatisnotcommonlyusedclinicallyandthatdelivereddifferent averagecompressionrates(70versus100perminute)betweenthe studyperiods.Thestudycomparedcontinuouschestcompressions andventilationsdeliveredafterevery10thcompression(without pausingcompressions)witha5:1CVratio(withpausesfor venti-lation)thatresultedinmorefrequentpausesincompressionsand higheroverallventilationratesthantheconventional30:2CVratio recommendedbythe2015CoSTR.19,20 Itwasconductedwitha before-and-afterdesignthat,althoughadjustedfordemographic and cardiac arrest characteristics,didnot account for potential temporal differencesinresuscitation efficienciesbetweenstudy periods.
Very-low-quality evidence was identified for the critical outcome of favourable neurological function.42 There was no differenceinfavourableneurologicaloutcomebetweenthe unin-terrupted10:1CPRandinterrupted5:1CPRcohorts(RR,1.18[95% CI,0.32–4.35];RD,0.29percentagepoints[95%CI,−2.05to2.64]). Thequalityofevidencewasdowngradedtoveryserious impreci-sionbecausetheCIsforRDcrossedfromappreciableharm(0.75) toappreciablebenefit(1.25).
Low-qualityevidencewasidentifiedforthecriticaloutcomeof survival.42Theuninterrupted10:1CPRcohorthadahighersurvival ratetohospitaldischargecomparedwiththeinterrupted5:1CPR cohort(RR,2.38[95%CI,1.22–4.65];RD,5.86percentagepoints [95%CI,1.19–10.53]).
TreatmentRecommendation
Whenever tracheal intubation or a supraglottic airway is achievedduringin-hospitalCPR,wesuggestthatproviders per-formcontinuouscompressionswithPPVdeliveredwithoutpausing chestcompressions(weakrecommendation,very-low-quality evi-dence).
ValuesandPreferences
Inmakingthisrecommendation,thetaskforcenotedthatthere is noprospectivestudyof in-hospitalCPR thatcompares deliv-eryofventilationsduringcontinuousmanualchestcompressions withventilationsdeliveredduringpausesinmanualchest com-pressions.Thetaskforceplacedvalueinthatdeliveringcontinuous chestcompressionsisacommonpracticeinmanysettingsafter trachealintubationorplacementofasupraglotticairway.Theonly studytohaveaddressedthisspecificquestioninanin-hospital set-tinghaslimitedapplicabilityinthatitwasperformedafterOHCA andinthecontextofmechanicalchestcompressions,alongwith otherlimitations.However,thefindingsofthisstudysupportthe treatmentrecommendation.
KnowledgeGaps
Severalknowledgegapswereidentifiedinthereviewofthis topic.AmorecomprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3areasfollows:
1.Noprospectivestudyofin-hospitalCPRcomparesdeliveryof ventilationsduringcontinuousmanualchestcompressionswith ventilationsdeliveredduringpausesinmanualchest compres-sions.
2.Whatistheeffectofdelayedventilationversus30:2high-quality CPR?
3.Whatistheoptimalmethodforensuringapatentairway? ChestCVRatio(Adults):ConsensusonScience
The30:2CVratiowascomparedwithadifferentCVratioin 2 observational cohort studies that generated very-low-quality evidence for the critical outcome of favourable neurological function.43,44Inameta-analysisofthesestudies,the30:2CVratio demonstratedbenefitforfavourableneurologicalfunction(RR,1.34 [95%CI,1.02–1.76];RD,1.72percentagepoints[95%CI,0.52–2.91]) compared with the CV ratio of 15:2. The quality of evidence wasdowngradedfor serious indirectnessbecausethesestudies werebefore-and-afterinvestigationsthatevaluatedthe bundle-of-careinterventionsimplementedafterthe“2005International ConsensusonCardiopulmonaryResuscitationandEmergency Car-diovascularCareScienceWithTreatmentRecommendations,”45,46 inwhichthechangeinCVratiowasjust1aspect.
Sevenobservationalcohortstudiesprovidedvery-low-quality evidenceforthecriticaloutcomeofsurvival.43,44,47–51The qual-ityofevidencewasdowngradedforseriousindirectnessbecause theCVratiowasnottheonlyaspectevaluatedinthesestudies.In ameta-analysisof6cohortstudies,thesurvivalratewashigher inthegroupof patientswhoreceived30:2CPRcomparedwith thegroupwhoreceived15:2CPR(RR,1.37[95%CI,1.19–1.59]; RD,2.48percentagepoints[95%CI,1.57–3.38]).43,44,47,49–51One retrospectivecohortshowedimprovedsurvivalwiththe50:2CV ratiocomparedwiththe15:2ratio(RR,1.96[95%CI,1.28–2.99]; RD,21.48percentagepoints[95%CI,6.90–36.06]).48Thequalityof evidencewasdowngradedforseriousriskofbiasandindirectness. Riskofbiasincludedhighriskthatthecohortswerenotcomparable onthebasisofdesignoranalysisandmoderateriskofinadequate follow-up.Thestudywasalsoconsideredindirectbecauseofits before-and-afterdesignpotentiallyevaluatingseveralchangesto practice.
TreatmentRecommendation
WesuggestaCVratioof30:2comparedwithanyotherCVratio inpatientswithcardiacarrest(weakrecommendation, very-low-qualityevidence).
ValuesandPreferences
Inmakingthisrecommendation,thetaskforceacknowledged thattherewouldlikelybesubstantialresourceimplications(eg, reprogramming,retraining)associated withachangein recom-mendation related to the CVratio. In theabsence of any data addressing the critical outcomes, the task force placed a high valueonmaintainingconsistencywiththe2005,2010,and2015 CoSTRs.19,20,36,37,45,46Wealsoplacedhighvalueonfindingsthat suggestthatabundleofcare(whichincludedaCVratioof30:2) resultedinmorelivesbeingsaved.
KnowledgeGaps
Severalknowledgegapswereidentifiedinthereviewofthis topic.Amore comprehensivelisthasbeenpostedontheILCOR website.10TheBLSTaskForcerankedtheknowledgegapsin prior-ityorder,andthetop3follow:
1.ThepossiblebenefitofhigherCVratios(morecompressionsper ventilations).
2.TheabilityofCPRproviderstodeliver2effectiveventilations duringtheshortpauseinchestcompressionsduringCPR. 3.Is there a ratio-dependent critical volume of air movement
requiredtomaintaineffectiveness?
BystanderCPRforPaediatricOHCA:ConsensusonScience Arecentsystematicreviewcomparedoutcomesassociatedwith bystander compression-only CPR with those of bystander CPR thatincludedchestcompressionsplusventilationfor paediatric OHCA.25Thereviewidentified2largeobservationalcohortstudies, bothusingdatafromJapan’snationwideAll-JapanUtsteinOHCA registry.52,53 This largemandatory registry includes all cardiac arrestsinpeopleofallagesinJapanandbothcardiacand non-cardiac(eg,trauma,hanging,drowning,drugoverdose,asphyxia, respiratorydiseases,cerebrovasculardiseases,malignanttumours) causesofarrest.Asof2017,itcontainsdatafrom>1millioncardiac arrests.
TheKitamuraetal52studyincludes5170eventsinchildren≤17 yearsofage,including2439eventsinwhichbystanderCPRwas performed,capturedfrom2005through2007.Atthetimeofthe study,resuscitationguidelinesinJapanweretransitioningfroma CVratioof15:2to30:2forpaediatricOHCA.TheGotoetal53study includes5056eventsinchildren18yearsofage,including2722 eventsinwhichbystanderCPRwasperformed,capturedfrom2008 through2010.Atthetimeofthestudy,paediatricCPRguidelinesin JapanrecommendedCPRthatincludedventilationwithaCVratio of30:2.Inaddition,nationalimplementationofadispatch-assisted CPRprogramwasoccurring.
Thequalityofevidencewasdowngradedtoverylowforthe critical outcome of favourable neurological function (Paediatric Cerebral PerformanceCategory [PCPC]1 or 2)at 1 month.52,53 Thequalityofevidenceforthesestudieswasdowngradedbecause ofseriousriskofbias(eg,potentialvariabilitybetween compari-songroups,single-country/healthcaresystemregistry,variability in protocolsamongfire/EMS departments),seriousindirectness (ie,the CVratioprovided was notspecifically described inthe publicationsandhad tobededucedfromthedescriptionofthe guidelinesandrecommendationsthatwerereportedtobeusedat thetimeofdatacollection),andseriousimprecision(wideCIs).In thefirststudy,inallchildren,survivalwithfavourable neurologi-calfunction(PCPC1or2)waslesslikelyamongchildrenreceiving chest compression–only CPR (RR, 0.46 [95% CI, 0.29–0.73]; RD, 3.02percentagepoints[95%CI,1.47–4.57]).52Afterfurther sub-groupanalysisbyage,patients1to17yearsofagewithbystander chestcompression–onlyCPRhadworseoutcomes(RR,0.46[95% CI,0.28–0.75];RD,4.34percentagepoints[95%CI,1.95–6.73]).In infants,outcomewasuniformlypoor,andtherewasno demon-strable difference in favourable neurological function whether bystandersprovidedchestcompression–onlyCPRorCPRwith ven-tilation(RR,0.39[95%CI,0.11–1.36];RD,1.31percentagepoints [95%CI,−0.17to2.80]).Thesecondstudydidnotreportresults divided by agesubgroups but identified fewer patients overall withfavourableneurologicalfunction(PCPC1or2)inthechest compression–onlyCPRgroupthaninthosereceivingCPRwitha CVratioof30:2,(RR,0.45[95%CI,0.31–0.66];RD,3.30
percent-agepoints[95%CI,1.71–4.88]).53Thesedatawerenotpublished intheoriginalarticlebutwereprovidedviae-mailfromthe cor-respondingauthorofthestudy(Y.Goto,MD,PhD,personale-mail communication,unpublisheddata,May2,2014).
Thequalityofevidencewasverylowforthecriticaloutcomeof survivalto1month.52,53Thequalityofevidenceforthesestudies wasdowngradedbecauseofseriousriskofbias,serious indirect-ness,andseriousimprecision(seereasonsfordowngradinggiven previously).IntheKitamuraetal52study,outcomeswereworsefor allchildrenwhoreceivedbystanderchestcompression–onlyCPR comparedwiththosewhoreceivedCPRwithventilation(RR,0.76 [95%CI,0.60–0.97];RD,2.98percentagepoints[95%CI,0.45–5.51]). Afterfurthersubgroupanalysisbyage,patients1to17yearsofage whoreceivedchestcompression–onlyCPRhad worseoutcomes (RR,0.70[95%CI,0.53–0.93];RD,4.74percentagepoints[95%CI, 1.17–8.31]).Ininfants,therewasnodemonstrabledifferencein sur-vivalto1month(RR,0.90[95%CI,0.56–1.45];RD,0.74percentage points[95%CI,−2.61to4.09]).IntheGotoetal53study,survivalwas worseamongchildrenwhoreceivedchestcompression–onlyCPR comparedwiththosewhoreceivedCPRwithventilation(RR,0.56 [95%CI,0.45–0.69];RD,7.04percentagepoints[95%CI,4.50–9.58]). Therewasnosubgroupanalysisfordifferentagesinthisstudy. TreatmentRecommendations
Wesuggestthat bystandersprovideCPRwithventilationfor infantsandchildren18yearsofagewithOHCA(weak recom-mendation,very-low-qualityevidence).
We continue to recommend that if bystanders cannot pro-viderescuebreathsaspartofCPRforinfantsandchildren18 yearsofagewithOHCA,theyshouldatleastprovidechest com-pressions(goodpracticestatement).Inthe2015CoSTR,thiswas citedasastrongrecommendationbutbasedonvery-low-quality evidence.21,22
AdditionalSciencePublishedSincetheSystematicReview WasCompleted
Afterthesystematicreviewwascompleted,2additional rel-evantobservationalstudies werepublished,54,55 and theyhave informedthetaskforcedecisioninitstreatmentrecommendation. Very-low-qualityevidencewasidentifiedforthecritical out-comeoffavourableneurologicalfunction(PCPC1or2)athospital discharge.54The GRADEquality forthis studywasdowngraded forseriousriskofbias(observationalstudywithpossible variabil-itybetweencomparisongroups)andseriousindirectness(specific CPRCVrationotlisted)from1cohortstudy.Thisstudyisfroma voluntaryAmericanOHCAregistryofnontraumaticcardiacarrest thatrepresentsacatchmentareaof>90millionpeoplein37states. Thisstudyincluded3900eventscapturedfrom2013through2015 andcomparedtheoutcomesofchildrenreceivingeitherbystander chestcompression–onlyCPRorbystanderCPRwithventilationfor the1411children forwhomdatawereavailableonthetypeof CPRprovided.DatafromFigure4ofthisstudyindicatethatthere wasnodifferenceinfavourableneurologicalfunctionwheninfants whoreceivedchestcompression–onlyCPRwerecompared with thosewhoreceivedCPRwithventilation(P=0.083),aswellasno differenceamongchildren(1–17yearsofage)whoreceivedchest compression–only CPRcompared withthose who receivedCPR withventilation(P=0.117).54
Very-low-qualityevidencehasbeenidentifiedforthecritical outcomeof favourableneurologicalfunction (PCPC1or 2)at1 month.55Thisstudywasanotherobservationalstudyfromthe all-Japanregistry.Thelevelofevidenceforthisstudywasdowngraded forseriousriskofbias(observationalstudywithpossible
variabil-itybetweencomparisongroups),seriousindirectness(specificCPR CVrationotlisted),andveryseriousimprecision(verywideCI). ThisJapanese OHCAregistry study(including traumaticcardiac arrest)reported2157eventsinchildren>1year(ie,noinfants) and18yearsofage,capturedfrom2011through2012,and com-paredtheoutcomesofchildrenreceivingeitherbystanderchest compression–onlyCPRorbystanderCPRwithventilationforthe 1150children forwhomdatawereavailableonthetypeofCPR provided. The studywas performedat a time when JapanCPR guidelinesrecommendeda CVratioof30:2,andan established nationaldispatch-assistedCPRprotocolexisted.Favourable neu-rologicalfunctionwasnodifferentamongchildrenwhoreceived chestcompression–onlyCPRandthosewhoreceivedCPRwith ven-tilation(adjustedoddsratio,1.52[95%CI,0.93–2.49]).
Very-low-quality evidence has been identified for the criti-cal outcome of survival to1 month.55 The quality of evidence for this cohort study was downgraded for serious risk of bias, seriousindirectness,andveryseriousimprecision(see explana-tionsgivenpreviously).Inthisstudy,1-monthsurvivalinchildren (age,1–18years) wasnodifferentwhethertheyreceivedchest compression–onlyCPRorCPRwithventilation(adjustedoddsratio, 1.38[95%CI,0.98–1.96]).
Very-low-qualityevidencehasbeenidentifiedforthecritical outcome ofsurvival tohospital discharge.54 Thequality of evi-denceforthiscohortstudywasdowngradedforseriousriskofbias (observationalstudywithpossiblevariabilitybetweencomparison groups).IninfantswithOHCA,survivaltohospitaldischargewas worseinthosereceivingchestcompression–onlyCPRcompared withthosereceivingCPRwithventilation(P=0.002).Conversely, forchildren≥1yearofage,therewasnodifferenceinsurvivalto hospitaldischargeinacomparisonofthosewhoreceivedbystander chestcompression–onlyCPRandthosewhoreceivedCPRwith ven-tilation(P=0.258).
ValuesandPreferences
BystanderCPRimprovessurvival, andCPR treatment recom-mendationsshouldstrivetoenhanceeaseofCPRimplementation andCPReffectiveness.Mostpaediatriccardiacarrestsareasphyxial inorigin,soeffectiveCPRislikelytorequireventilationinaddition tochestcompressions.Inmakingtheserecommendations,thetask forceplacedahighervalueontheimportanceofrescuebreathsas partofpaediatricCPRoverastrategythatdeemphasisesventilation tosimplifyCPRinstructionsandskills.The2(observational)articles publishedsincethecompletionofthesystematicreviewsuggest thatsurvivalandneurologicaloutcomemaynotdifferamong chil-dren(ie,≥1yearofage)whoreceivebystandercompression-only CPRorCPRwithventilation.54,55Thisconclusiondiffersfrom previ-ousevidencethatsuggestedthesuperiorityofCPRwithventilation forpaediatricpatientsofallageswithOHCA.21,22,56Availabledata arenowinconsistentandsomewhatcontradictoryforthe compar-isonofbystandercompression-onlyCPRandCPRwithventilation forinfant(1yearofage)OHCA.Thesediscrepanciesinfindings, especiallythosecomingfromthemorerecentpublications,helped informtaskforcedecisionswithrespecttothebystanderCPRwith ventilationversuscompression-onlyCPRtreatment recommenda-tionsand explaintherationale behindthetaskforce’s decision todowngradethestrengthofthetreatmentrecommendationto theweakerterminologyofsuggestsinsteadofthestrongerterm recommends.Thisrelativeclinicalequipoiseshouldstimulatethe developmentofprospectiveclinicaltrialstodefinitivelydetermine theoptimalbystanderCPRtechniqueforinfants(1yearofage) andchildren(≥1yearofage).
Despitetheavailabilityofonlyvery-low-qualityevidence (ana-lysed as part of the 2015 ILCOR evidence evaluation process), thetaskforceunanimouslyagreedtoreiterate the2015strong
treatment recommendation for providing any CPR (including compression-onlyCPR)overnoCPRforpaediatricOHCAbecause thepotentialbenefitoutweighsanypotentialharm.Giventhatthe systematicreviewdidnotseekdatacomparinganyCPRwithnoCPR andinkeepingwithGRADErecommendations,our recommenda-tionhasbeencitedasagoodpracticestatement(seeAppendixes1 and2).38
KnowledgeGaps
Inorderofpriority,thetopknowledgegapsforthistopicareas follows:
1.Morehigh-qualitystudiesareneededtocompare compression-onlyCPRandCPRwithventilationforinfantsandchildrenwith OHCA.
2.Data areneeded fromother resuscitationregistries that will enablecomparisonoftheroleofventilationwithCPRbecause thisvariesworldwide,largelyonthebasisofdifferencesinlocal resuscitationcouncilguidelines.Thisshouldalsoinclude sub-groupanalysisofdifferentpatientages(eg,infancy,1–8years, >8years)andcausesofcardiacarrest.
3.Cantelephonedispatcherscoachbystanderstoprovideeffective rescuebreaths/CPRwithventilationforinfantsandchildren? Acknowledgements
The authors thank the ILCOR Collaborators for their contri-butionstothis document:KarlB.Kern,MD, FAHA;KoenraadG. Monsieurs,MD,PhD,FERC,FAHA; RobertW.Neumar,MD, PhD, FAHA;CliftonW.Callaway,MD,PhD;andTzong-LuenWang,MD, PhD.
Appendix1.
GlossaryofTermsUsedinThisSummary
Advancedairway Trachealtubeorsupraglotticairway
Compression-onlyCPR Chestcompressionswithoutactiveventilation(eg, mouth-to-mouthventilation,bag-mask ventilation,orventilationviaanadvancedairway) CPRwithventilation ChestcompressionswithPPV;thisincludesa
varietyofchestCVratiosandcontinuouschest compressionswithventilationsdeliveredwithout pausingchestcompressions.
Continuouschest compressionCPR
Chestcompressionsdeliveredwithoutpausingfor ventilation.PPVmay(oftenat10breathsper minute)ormaynotbeprovided.Maintenanceof airwaypatencymayenablepassiveventilation.
Dispatch-assistedCPR AbystanderprovidesCPRundertelephone instructionbyanEMSdispatcher,mostoften compression-onlyCPR.Alternativeterminologyfor thesedispatchersincludestelecommunicators, ambulancecommunicationofficers,emergency medicalcommunicators,andcallhandlers. Appendix2.
GRADETerminology
Riskofbias Studylimitationsinrandomisedtrialsincludelack ofallocationconcealment,lackofblinding, incompleteaccountingofpatientsandoutcome events,selectiveoutcomereportingbias,and stoppingearlyforbenefit.Studylimitationsin observationalstudiesincludefailuretoapply appropriateeligibilitycriteria,flawed
measurementofexposureandoutcome,failureto adequatelycontrolconfounding,andincomplete follow-up.
Inconsistency Criteriaforinconsistencyinresultsincludethe following:pointestimatesvarywidelyacross studies;CIsshowminimalornooverlap;statistical testforheterogeneityshowsalowPvalue;andthe I2islarge(ameasureofvariationinpointestimates
resultingfromamong-studydifferences). Indirectness Sourcesofindirectnessincludedifferencesin
population(eg,OHCAinsteadofin-hospitalcardiac arrest,adultsinsteadofchildren),differencesin theintervention(eg,differentCVratios), differencesinoutcome,andindirectcomparison. Imprecision Loweventratesorsmallsamplesizeswill
generallyresultinwideCIsandtherefore imprecision.
Publicationbias Severalsourcesofpublicationbiasinclude tendencynottopublishnegativestudiesand influenceofindustry-sponsoredstudies.An asymmetricalfunnelplotincreasessuspicionof publicationbias.
Goodpractice statements
Guidelinepanelsoftenconsideritnecessaryto issueguidanceonspecifictopicsthatdonotlend themselvestoaformalreviewofresearch evidence.Thereasonmightbethatresearchinto thetopicisunlikelytobelocatedorwouldbe consideredunethicalorinfeasible.Criteriafor issuinganongradedgoodpracticestatement includethefollowing:overwhelmingcertainty thatthebenefitsoftherecommendedguidance willoutweighharmsandaspecificrationaleis provided;thestatementsshouldbeclearand actionabletoaspecifictargetpopulation;the guidanceisdeemednecessaryandmightbe overlookedbysomeprovidersifnotspecifically communicated;andtherecommendationsshould bereadilyimplementablebythespecifictarget audiencetowhichtheguidanceisdirected.
T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214 209 Disclosures
WritingGroupDisclosures
WritingGroup
Member
Employment ResearchGrant OtherResearch
Support
Speakers’ Bureau/Honoraria
ExpertWitness Ownership
Interest Consultant/Advisory Board Other TheresaM. Olasveengen OsloUniversity Hospital(Norway) LaerdalFoundation (unrestrictedresearch grant)*;South-Eastern RegionalHealth Authority(unrestricted researchgrant)†
None None None None None None
RichardAickin StarshipChildren’s
Hospital(NewZealand)
None None None None None None None
DianneL.Atkins UniversityofIowa None None None None None None None
RobertA.Berg Children’sHospitalof
Philadelphia
None None None None None None None
RobertM.Bingham GreatOrmondStreet
HospitalNHS
FoundationTrust
(UnitedKingdom)
None None None None None None None
StevenC.Brooks Queen’sUniversity
(Canada)
HeartandStroke
FoundationofCanada
(researchoperating
granttostudyamobile
deviceapplication
designedtoincrease
bystanderresuscitation
forOHCA)†
None None None None None None
MaaretCastrén HelsinkiUniversity
Hospital(Finland)
None None SMACCBerlin*;
EMS2017*
None None None None
SungPhilChung YonseiUniversity
CollegeofMedicine
(RepublicofKorea)
None None None None None None None
JulieConsidine DeakinUniversity
(Australia)
None None None None None None None
Thomaz Bittencourt Couto
HospitalIsraelita
AlbertEinstein(HIAE),
SãoPaulo,Brazil;
department:Centrode
Simulac¸ãoRealística
(CSR)ANDUnidadede
ProntoAtendimento
(UPA);Institutoda
Crianc¸adoHospitaldas
ClínicasdaFaculdade
deMedicinada
UniversidadedeSão
Paulo(ICr-HCFMUSP),
SãoPaulo,Brazil;
department:Pronto
Socorro
None None None None None None None
AllanR.deCaen UniversityofAlberta,
StolleryChildren’s
Hospital(Canada)
None None None None None None None
RaffoEscalante Inter-AmericanHeart
Foundation(Peru)
T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214
RaúlJ.Gazmuri RosalindFranklin
UniversityofMedicine andScience DePaul-Rosalind FranklinUniversity CollaborativePilot ResearchGrant
Program(basicscience
research:study mechanismsbywhich cyclophilin-D modulates transcriptionof mitochondrialgenes)†; DepartmentofDefense USArmyMedical
ResearchandMaterial
Command
(translationalresearch:
sustainedV1Areceptor
activationfor prolonged haemodynamic supportand neurologicalprotection afternoncompressible haemorrhageand traumaticbrain
injury)†;ZollMedical
Corp(translational
research:AMSAto
guideshockdeliveryin
aswinemodelof
ventricularfibrillation
andclosedchest
resuscitation)†;James
R.&HelenD.Russell
InstituteforResearch&
Innovation:Small
ResearchGrants
Program(basicscience
research:preventionof
oxidativeinjurytothe
neonatalheart)*
None None None None None None
Anne-Marie Guerguerian
TheHospitalforSick
Children(Canada)
None None None None None None None
TetsuoHatanaka KyotoPrefectural
UniversityofMedicine
(Japan)
None None None None None None None
MaryFranHazinski VanderbiltUniversity None None None None None AmericanHeart
AssociationECC†
None
RudolphW.Koster AcademicMedical
Center(the
Netherlands)
PhysioControl
(fundingfordata
management, researchers,
equipment)†
None None None None PhysioControl* None
PeterJ.Kudenchuk Universityof
WashingtonMedical
Center
T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214 211 (Canada)
SweeHanLim SingaporeGeneral
Hospital(Singapore)
None None None None None None None
BoLøfgren AarhusUniversity
Hospital(Denmark)
None None None None None None EuropeanResuscitation
Council,International
BLS/AEDCourse
Committee*
IanK.Maconochie St.Mary’sHospital
(UnitedKingdom)
None None None None None None None
MaryE.Mancini UniversityofTexasat
Arlington
None None None None None PhysioControl* None
PeterA.Meaney Children’sHospitalof
Philadelphia
None None None 2017,Defensewitness,
ICUcareofgraftvshost
disease*
None None None
WilliamH.
Montgomery
StraubClinicand
Hospital
None None None None None AmericanHeart
Association†
None
PeterT.Morley Universityof
Melbourne(Australia)
None None None None None None None
LaurieJ.Morrison St.Michael’sHospital
(Canada)
CanadianInstitutefor
HealthResearch
(operatinggrantfor5
yearswithoutsalary
support)†;Heartand
StrokeFoundationof
Canada(operating
grantfor5years
withoutsalary
support)†
None None None None None None
VinayM.Nadkarni Children’sHospitalof
Philadelphia
None None None None None None None
KevinJ.Nation NewZealand
ResuscitationCouncil
(NewZealand)
None None None None None None None
Kee-ChongNg KKHospital
(Singapore)
None None None None None None None
ChikaNishiyama KyotoUniversity
(Japan)
None None None None None None None
JerryP.Nolan RoyalUnitedHospital,
Bath(UnitedKingdom)
UKNationalInstituteof
HealthResearch(NIHR
researchgrantsfor
AIRWAYS-2and
PARAMEDIC-2
studies)*
None None Medicolegalreports
relatingto
resuscitation†
None None None
GabrielleNuthall StarshipChildren’s
Hospital(NewZealand)
None None None None None None None
GeneYong-Kwang
Ong
KKWomen’sand
Children’sHospital
(Singapore)
None None None None None None None
GavinD.Perkins WarwickMedical
SchoolandHeartof
EnglandNHS
FoundationTrust
(UnitedKingdom)
None None None None None None None
AmeliaG.Reis Inter-AmericanHeart
Foundation(Brazil)
None None None None None None None
GiuseppeRistagno ItalianResuscitation
Council-Scientific
Committee(Italy)
T.M. Olasveengen et al. / Resuscitation 121 (2017) 201–214
TetsuyaSakamoto TeikyoUniversity
(Japan)
None None None None None None None
MichaelR.Sayre Universityof
Washington
None None None None None None Physio-ControlInc.
(FundsEMSMedicine
Fellowshipat
Universityof
Washington.Ihave
travelreimbursement
fromthosefunds.)*
StephenM.
Schexnayder
Universityof
Arkansas/Arkansas
Children’sHospital
None None None None None AmericanHeart
Association(course
developmentand
scientificediting
consultant)†
None
NaokiShimizu TokyoMetropolitan
Children’sCenter
(Japan)
None None None None None None None
AlfredoF.Sierra Inter-AmericanHeart
Foundation(Mexico)
None None None None None None None
EuniceM.
Singletary
UniversityofVirginia None None None None None AmericanRedCross
(chair,FirstAid
Subcouncilofthe
ScientificAdvisory
Council)*
None
MichaelA.Smyth UniversityofWarwick
(UnitedKingdom)
None None None None None None None
DavidStanton ResuscitationCouncil
ofSouthernAfrica
(SouthAfrica)
None None None None None None Netcare911(head,
ClinicalLeadership)†
JaniceA.Tijssen LondonHealthServices
Center(Canada)
HeartandStroke
FoundationofCanada
grantinaid(grant
recipientforresearch)*
None None None None None None
AndrewTravers EmergencyHealth
Services,NovaScotia
(Canada)
None None None None None None None
Christian Vaillancourt UniversityofOttawa, OttawaHospital ResearchInstitute (Canada)
CIHR(Grantforc-spine
ruleimplementation)†;
CIHRandHSFC
(CanROCSteering
CommitteeChair)†
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PatrickVande
Voorde
ReviewerDisclosures
Reviewer Employment Research
Grant OtherResearch Support Speakers’Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ AdvisoryBoard Other
MioaraD.Manole UniversityofPittsburgh None None None None None None None
ArthurB.Sanders ArizonaHealthSciences Center
None None None None None None None
DemetrisYannopoulos UniversityofMinnesota None None None None None None None
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