Mechanical versus manual cardiopulmonary resuscitation (CPR): an umbrella review of contemporary systematic reviews and more

Abstract

Background: High-quality cardiopulmonary resuscitation (CPR) can restore spontaneous circulation (ROSC) and neurological function and save lives. We conducted an umbrella review, including previously published systematic reviews (SRs), that compared mechanical and manual CPR; after that, we performed a new SR of the original studies that were not included after the last published SR to provide a panoramic view of the existing evidence on the effectiveness of CPR methods.

Methods: PubMed, EMBASE, and Medline were searched, including English in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) SRs, and comparing mechanical versus manual CPR. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and GRADE were used to assess the quality of included SRs/studies. We included both IHCA and OHCA, which compared mechanical and manual CPR. We analyzed at least one of the outcomes of interest, including ROSC, survival to hospital admission, survival to hospital discharge, 30-day survival, and survival to hospital discharge with good neurological function. Furthermore, subgroup analyses were performed for age, gender, initial rhythm, arrest location, and type of CPR devices.

Results: We identified 249 potentially relevant records, of which 238 were excluded. Eleven SRs were analyzed in the Umbrella review (January 2014-March 2022). Furthermore, for a new, additional SR, we identified eight eligible studies (not included in any prior SR) for an in-depth analysis between April 1, 2021, and February 15, 2024. The higher chances of using mechanical CPR for male patients were significantly observed in three studies. Two studies showed that younger patients received more mechanical treatment than older patients. However, studies did not comment on the outcomes based on the patient's gender or age. Most SRs and studies were of low to moderate quality. The pooled findings did not show the superiority of mechanical compared to manual CPR except in a few selected subgroups.

Conclusions: Given the significant heterogeneity and methodological limitations of the included studies and SRs, our findings do not provide definitive evidence to support the superiority of mechanical CPR over manual CPR. However, mechanical CPR can serve better where high-quality manual CPR cannot be performed in selected situations.

Keywords: CPR; Cardiac arrest; IHCA; Manual CPR; Mechanical CPR; OHCA; ROSC; Survival.

Fig. 1

PRISMA flow chart for a systematic review of systematic reviews (up to February 2024)

Fig. 2

Umbrella review Forest plot for ROSC

Fig. 3

Umbrella review for survival to hospital discharge

Fig. 4

PRISMA flow chart for the new systematic review (April 2021–February 2024)

Fig. 5

Odds ratio and 95% confidence intervals for the Outcomes of the studies included in the new systematic review: Restore spontaneous circulation (ROSC) (upper left panel) Survival to hospital discharge or 30 Days (upper right panel), Neurological recovery (lower panel)