Optimal Chest Compression Rate and Compression to Ventilation Ratio in Delivery Room Resuscitation: Evidence from Newborn Piglets and Neonatal Manikins

Abstract

Cardiopulmonary resuscitation (CPR) duration until return of spontaneous circulation (ROSC) influences survival and neurologic outcomes after delivery room (DR) CPR. High quality chest compressions (CC) improve cerebral and myocardial perfusion. Improved myocardial perfusion increases the likelihood of a faster ROSC. Thus, optimizing CC quality may improve outcomes both by preserving cerebral blood flow during CPR and by reducing the recovery time. CC quality is determined by rate, CC to ventilation (C:V) ratio, and applied force, which are influenced by the CC provider. Thus, provider performance should be taken into account. Neonatal resuscitation guidelines recommend a 3:1 C:V ratio. CCs should be delivered at a rate of 90/min synchronized with ventilations at a rate of 30/min to achieve a total of 120 events/min. Despite a lack of scientific evidence supporting this, the investigation of alternative CC interventions in human neonates is ethically challenging. Also, the infrequent occurrence of extensive CPR measures in the DR make randomized controlled trials difficult to perform. Thus, many biomechanical aspects of CC have been investigated in animal and manikin models. Despite mathematical and physiological rationales that higher rates and uninterrupted CC improve CPR hemodynamics, studies indicate that provider fatigue is more pronounced when CC are performed continuously compared to when a pause is inserted after every third CC as currently recommended. A higher rate (e.g., 120/min) is also more fatiguing, which affects CC quality. In post-transitional piglets with asphyxia-induced cardiac arrest, there was no benefit of performing continuous CC at a rate of 90/min. Not only rate but duty cycle, i.e., the duration of CC/total cycle time, is a known determinant of CC effectiveness. However, duty cycle cannot be controlled with manual CC. Mechanical/automated CC in neonatal CPR has not been explored, and feedback systems are under-investigated in this population. Evidence indicates that providers perform CC at rates both higher and lower than recommended. Video recording of DR CRP has been increasingly applied and observational studies of what is actually done in relation to outcomes could be useful. Different CC rates and ratios should also be investigated under controlled experimental conditions in animals during perinatal transition.

Comparison of two infant chest compression techniques during simulated newborn cardiopulmonary resuscitation performed by a single rescuer: A randomized, crossover multicenter trial

“…American Heart Association recommends five components of high-quality pediatric cardiopulmonary resuscitation: ensuring CCs of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in CCs, and avoiding excessive ventilation [3,26]. The suboptimal quality of CCs with TFT was emphasized by several studies indicating that the only main advantage of TFT as compared with TTHT was optimal full chest relaxation [27].…”

Comparison of Different Compression to Ventilation Ratios (2: 1, 3: 1, and 4: 1) during Cardiopulmonary Resuscitation in a Porcine Model of Neonatal Asphyxia

“…Along with high-quality CC, providing ventilation is important during neonatal CPR [19, 26]. Manikin studies reported higher ventilation rates during 3: 1 C:V compared to higher C:V ratios [27, 28].…”

Which position should we take during newborn resuscitation? A prospective, randomised, multicentre simulation trial

“…As indicated in numerous studies involving both children and adults, maintaining adequate CC frequency can be problematic because medical staff tend to perform CCs with too high a rate [18][19][20]. Moreover, the optimal frequency of CCs in both children and adults is not specified [21][22][23]. Li et al [24] showed that even though it was possible for neonatal staff to perform continuous CCs at rates of 90 and 120 × min -1 , a significant decay in CC pressure occurred after 96 s and 72 s, respectively.…”