Continuous CCs with asynchronized ventilation comprised a series of three cycles of continuous CCs without ventilation pauses followed by rhythm analysis until the ROSC or completion of three cycles of CPR, whichever occurred first. In this cluster-randomized trial, including 114 EMS agencies, 23,711 adult patients with non-traumatic OHCAs were assigned for primary analysis either to an intervention group (continuous CCs with asynchronous ventilation, n=12,653) or a control group (30:2 interrupted CCs with synchronous ventilation, n=11,058). The committee also made recommendations regarding steps to be implemented to increase the rates.
Committee members periodically reviewed data and assessed whether prescribed targets for performance were met for measures such as enrollment rate, treatment-adherence rate, and key elements of concurrent care. A notable difference between this ROC report and earlier trials was the application of the CPR-process monitoring.
HIGH QUALITY CPR PAUSES IN COMPRESSION TRIAL
In the December 3, 2015, issue of NEJM, the resuscitation outcomes consortium (ROC) in the US reported a trial comparing continuous and interrupted CCs during CPR performed by emergency medical service (EMS) personnel ( 14). A prospective cohort study showed that increased CCF among non-VF OHCA patients was associated with a trend toward an increased likelihood of ROSC ( 13). Many observational studies have reported that higher survival rates are often associated with a higher, and not lower, CC fraction (CCF) in patients with cardiac arrest and a shockable initial rhythm ( 9- 12). For advanced life support, CCs at a rate of 100 per minute, with ventilations at a rate of 10 per minute without pauses, were applauded for patients who had been fitted with an advanced airway. Moreover, the time taken to rescue breathing (inspiration) was reduced from 2 to 1 sec. Furthermore, to reduce the interruption of CCs by rhythm analysis with an automated external defibrillator (AED), defibrillation was delivered only once after a 2-min interval of rhythm analysis (known as the “1-shock strategy”). A change in the compression to ventilation ratios from 15:2 to 30:2 and the initiation of CCs immediately after defibrillation were also introduced. In the revised CPR guidelines of 2005 ( 7, 8) in Europe, the US, etc., the interruption of CCs was minimized to further improve the quality of CPR. It has been reported that a desirable level of pressure is obtained only after CCs are continued for a longer period, and the level decreases rapidly after CCs are discontinued ( 6). Coronary perfusion pressure is an important indicator pertaining to the ROSC ( 4, 5). Since the publishing of the CPR guidelines 2000, increasing attention has been dedicated to the proportion of time spent performing or interrupting CCs. These guidelines also recommended chest compression (CC) at a rate of 100 compressions per minute with a complete release of pressure after each CC to achieve optimal forward blood flow. The CPR guidelines 2000 ( 3) recommended the use of ventilation for OHCA victims with a small tidal volume and low inspiratory pressure to avoid gastric inflation. High-quality cardiopulmonary resuscitation (CPR), which can supply blood to critical organs such as the heart, lungs, and brain, with an optimal level of perfusion pressure, is known to be essential for the return of spontaneous circulation (ROSC) and a good outcome in case of out-of-hospital arrests (OHCAs) ( 1, 2). Professor and Chair, Department of Emergency Medical Science, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
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