Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Abstract

Introduction: Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA). Methods: We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting. Results: A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance. Conclusion: Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

Comparison between Prehospital Mechanical Cardiopulmonary Resuscitation (CPR) Devices and Manual CPR for Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis

“…In our TSA ( Figure 2 B and Figure 3 B), after accumulating recent cohort studies, we found that the cumulative Z-curve finally crossed into the O’Brien-Fleming boundaries and showed the true-positive effects of mechanical CPR. This overturns the conclusion of no benefit for short-term survival outcomes in the use of mechanical CPR in the recent SRMA [ 8 , 45 ]. For the outcomes of ROSC and survival to hospital admission, the requirement of adequate sample size for statistical power was not met.…”

“…To date, 10 systematic reviews have been published to compare the effects of manual CPR and mechanical CPR on cardiac arrest [ 8 , 9 , 10 , 11 , 12 , 45 , 46 , 47 , 48 , 49 ]. Among them, five systematic reviews focused on OHCA [ 8 , 10 , 11 , 45 , 48 ], four systematic reviews, including one Cochrane review, enrolled both OHCA and IHCA [ 9 , 12 , 46 , 49 ], and one review involved in IHCA [ 47 ].…”

“…To date, 10 systematic reviews have been published to compare the effects of manual CPR and mechanical CPR on cardiac arrest [ 8 , 9 , 10 , 11 , 12 , 45 , 46 , 47 , 48 , 49 ]. Among them, five systematic reviews focused on OHCA [ 8 , 10 , 11 , 45 , 48 ], four systematic reviews, including one Cochrane review, enrolled both OHCA and IHCA [ 9 , 12 , 46 , 49 ], and one review involved in IHCA [ 47 ]. Among the five systematic reviews involving pure OHCA, only one systematic review (in 2011) focused on the prehospital use of mechanical CPR, suggesting that there was insufficient evidence to support mechanical CPR device use in OHCA in prehospital settings [ 48 ].…”

“…Theoretically, the application of mechanical CPR in prehospital settings should improve CPR quality. This difference compared to manual CPR is not reflected in the survival outcome of OHCA [ 8 , 45 ]. Since 2019, several observational studies have evaluated the resuscitative effects of mechanical and manual CPR on OHCA in prehospital settings [ 17 , 18 , 39 , 44 ].…”

Traumatic Injuries Following Mechanical versus Manual Chest Compression

“…In a 2021 meta-analysis examining the effectiveness of mechanical chest compression devices, 20 15 studies (n=18,474) were analyzed: 6 randomized controlled trials, 2 cluster randomized controlled trials, 5 retrospective case-control studies, and 2 phased prospective cohort studies. The pooled estimate summary effect did not indicate a significant difference in achieving ROSC between mechanical and manual compression (Mantel-Haenszel OR 1.16, 95% CI 0.97–1.39; p=0.11, I2=0.83).…”