Literature Review — Mechanical vs manual cardiac compressions Essay Example

LITЕRАTURЕ RЕVIЕW: МЕСHАNIСАL VS MАNUАL САRDIАС СОMРRЕSSIОNS

Location

Effect of Mechanical vs. Manual Cardiac Compressions on ROSC/positive outcome

Contents

1.0 Introduction

The importance of cardiac compressions has significantly multiplied over the decades due to the increased number of cardiac arrests globally. The occurrence of cardiac arrest is usually a result of failure of the heart to beat and subsequent failure of blood flowing throughout the organs of the body (Zeiler et al, 2015). The various conditions that trigger cardiac arrests include coronary heart disease which is the major cause of cardiac arrest (Ohlsson et al, 2017). Enlargement of the heart, also known as cardiomyopathy contributes to cardiac arrest as it weakens the heart. A third cause of cardiac arrest is Brugada syndrome where abnormal heart rhythms are caused due to a problem with the heart’s electrical system (Ohlsson et al, 2017). Marfan syndrome, a disorder of the genetic origin where the connective tissues in the body are stretched is an additional cause of cardiac arrest (Ohlsson et al, 2017). In Australia, cardiac arrests that take place out of the hospital contribute to a larger number of deaths from the condition (Stranely et al, 2015). Emergency aid on cardiac arrest is reliant on cardiac pulmonary resuscitation. The main objective of cardiac pulmonary resuscitation is to provide enough perfusion so that can life can be preserved before the required procedures are performed (Schober et al, 2016). The general principles of cardiac compressions include good quality compressions, minimal interruptions to the compressions, provision of oxygen to the lungs and avoidance of too much ventilation (Ong et al, 2012). Cardiac compressions have become increasingly difficult due to the safety and efficacy required in the process. Wibrandt et al (2015) furthermore attributes the success of chest compressions on the age of the patients, the time of the return of spontaneous circulation and the cardiac etiology of the patient.

The introduction of mechanical compression devices in the medical field has been in place over time to counter the limitations of manual compressions and improve positive outcome or more specifically the return of spontaneous circulation (Tang et al, 2015). Mechanical compression devices are therefore developed to ensure the provision of high quality chest compressions and avoid interruptions and tiredness that is associated with manual compressions (Brooks et al, 2014). One such device that is highly used in Australia is the LUCAS 2 device which performs active decompression in emergency cardiac care. Over time, studies have been published with conflicting views on the efficacy of mechanical chest compression over manual chest compression. Tang et al (2015) in their study of mechanical against manual compression, conclude that there is no improvement in the positive outcome while Fox et al (2013) emphasize that mechanical devices, particularly the LUCAS machine provide a dependent solution in the delivery of quality CPR.

Manual compression requires placing the heel of one hand on the lower part of the sternum while placing the other hand on top of the one on the sternum (Zhou et al, 2015). The compression required is usually one third the depth of the chest with a rate of approximately one hundred compressions per minute. In younger individuals such as infants, two fingers are used as opposed to the heel of one hand. In manual compression, the rate of fatigue is high thus medical personnel recommend rotation of personnel to avoid fatigue (Hyunjong et al, 2017). The aspect of rotation does not however cover the case of chest compressions needed in an environment where there is no substitute in case of fatigue. In manual compression, there is no adequate accuracy on the rate of the compressions, their efficacy and their safety. As such, mechanical compressions provide a better solution so far as cardiac pulmonary resuscitation is concerned.

The innovation of mechanical compression devices has been done to ensure the provision of chest compressions that are high quality (Brooks et al, 2014). The compression devices have equally been developed to reduce interruptions and fatigue that is related with the delivery of manual chest compressions (Couper et al, 2016). Studies by different authors such as Westfall et al (2013) and Couper et al (2016) show that mechanical chest compressions have a high probability of increasing cerebral blood flow, cardiac output and pressures affected by coronary perfusion thus improving the rate of survival compared to manual chest compressions (Brooks et al, 2014). In their study of the load distributing band device and the piston device, Westfall et al (2013) conclude that the aptitude of ROSC in these mechanical devices is higher than in the use of manual CPR. There are studies however that emphasize that there is no improvement in the outcome of the use of a mechanical chest compression device compared to manual CPR (Wyer, 2016). This review therefore seeks to evaluate the effect of manual compressions against that of mechanical compressions particularly the Lucas 2 chest compression system on positive/ROSC outcome.

2.0 Methodology

The review involved an electronic search over online databases including Cochrane, DynaMed, EBSCO and ProQuest. The search terms included; manual chest compression, manual CPR, mechanical chest compression or mechanical CPR, return to spontaneous circulation, manual vs. mechanical chest compressions, efficacy of manual chest compressions on positive outcome and effectiveness of mechanical chest compressions on ROSC. The objective of the search strategy was to identify all materials published on mechanical and manual compressions and the effectiveness of the trials. The relevance of the literature to current cardiac care practices was ensured through the use of peer reviewed journal articles and subsequent sources which were published after January 2012. The publications reviewed were in English and the choice of the literature was based on the evidence that included meta-analysis, randomized control trials, case reports and systematic reviews.

3.0 Background

The commonness and fatal nature of cardiac arrests has increased the need for emergency medical services, training of different individuals and the requirement of an innovative procedure that reduces the mortality and morbidity of cardiac arrests (Qingming et al, 2013). Survival rates of cardiac arrests vary from different settings; depending on whether the patient was in the hospital or out of it. Qingming et al (2013) suggests that most survivors of cardiac arrests are likely to have brain damage in different degrees. Cardiopulmonary resuscitation thus restores to varying degrees a crucial amount of blood flow that helps in the restoration of spontaneous circulation (Hartmann et al, 2015).

Traditionally, CPR is administered by a human rescuer through the delivery of manual chest compressions that are rhythmic. In the current decade however, there is the availability of mechanical compression devices that are suitable in the delivery of CPR (Westfall et al, 2013; Bonnes, 2016). The different devices have mechanisms that include pistons, pneumatic vests and load distributing bands (Li et al, 2016). One familiar attribute with all these machines is the force that is placed on the thoracic region at regular intervals. The load distributing band compression device includes a wide band that is attached to a short backboard that is put around the thorax of the patient. The mechanism of the band involves shortening and lengthening it mechanically and rhythmically around the patient’s thorax. The change that occurs in the band circumference provides the required compressions usually delivered in the traditional CPR. Westfall et al (2013) discuss the use of load distributing bands and piston devices and through their study purport that these devices provide a favourable outcome during emergency cardiac care. Piston devices use gas that is compressed to move a piston placed over the patient on the lower sternum (Rubertsson et al, 2014). A good number of the piston devices use an attachment in the form of a suction cup to enable dynamic compression and decompression CPR. The pneumatic vest almost works like a blood pressure cuff that is oversized and is placed on the circumference of the patient’s thorax. Compression of the chest is engineered by rapid introduction of air into the vest used. A majority of the newer mechanical chest compression devices for hospital use are portable, light and uncomplicated to use (Lyon et al, 2015).

Cortegiani et al, (2017) suggests that CPR done early guarantees higher chances of survival. The quality of the chest compressions administered also determines the chances of survival. Quality compressions are affected by; the depth of compressions, the continuity of the compressions and the rate of the compressions. The Australian resuscitation council guidelines for administration of CPR and CPR related issues emphasize these three factors in the provision of emergency cardiovascular care (Brooks et al, 2014). Based on several animal studies and at least one human study, there is a conflicting relationship between the interruptions of chest compression and short time survival (Brooks et al, 2014). The slightest pauses in the delivery of chest compressions for ventilation are significant in causing essential drop in the pressures needed for sufficient cerebral and coronary perfusion. Recent human observational studies purport that survival is potent at a rate of 125 compressions in a minute (Brooks et al, 2014). Increased depth of compression is equally related to spontaneous circulation in animals that have been studied.

From their research, Brooks et al (2014) suggest that the chest compressions which are performed by trained medical personnel do not meet the required standards of the rates of compression, the depth and the continuity. Fatigue among human rescuers has additionally been identified as a major contributor to the reduced quality of manual CPR. The quality of chest compressions tends to decrease as the time of the compressions stretches since the rescuer grows tired (Tanaka et al, 2017). The proposal of mechanical chest compression thus supersedes manual compression based on different studies as the devices do not tire and the rescuer is free to perform other imperative procedures to assist the patient.

LUCAS 2 Device

The LUCAS (Lund University Cardiac Arrest System) device is a mechanical cardiopulmonary resuscitation device that is used to improve coronary and cerebral perfusion pressures during cardiac arrests (Gyory et al, 2017). The device is either gas driven or electric driven and it is inclusive of a suction cup that is used for active decompression. The gas port in the LUCAS device provides compressed air and the system has an electric motor that has an engine cooling structure (Fox et al, 2013). Based on the use of LUCAS, the device has better results when compared to the use manual compressions (Gyory et al, 2017). The use of the LUCAS 2 device applies to patients with several suspected causes such as; cardiac arrest with intense hypothermia, massive PE going through rescue thrombolysis, toxicological causes of cardiac arrest during the initiation of specific therapy and cardiac arrest that happens in the cardiac catheter laboratory (Fox et al, 2013).

4.0 Discussion

4.1 Manual chest compressions

Manual chest compressions involve the use of a human rescuer delivering compressions on a patient using their hands (Zhou et al, 2015). The human rescuer needs to be professionally trained to deliver the compressions as required so that return of spontaneous circulation is achieved. The effectiveness of manual compressions is dependent on various factors most of which are attributed to the rescuer. The following section discusses several studies that have been carried out to determine how manual compressions are significant in the positive outcome, the factors affecting quality of manual compressions and supportive devices that are used to improve the delivery of manual compressions.

4.2 Effectiveness of manual chest compressions on the return of spontaneous circulation outcome (ROSC)

In their study of the manual and mechanical delivery of chest compressions in transport condition, Fox et al (2013) compare six sequences of the administration of CPR through manual means and through a mechanical device. During the manual CPR, the correct positioning of the hand over the sternum of the patients ranged from 85.3% to 100%. The depth of compression in manual CPR was significantly deeper, but the continuity of the performance was slightly affected. Of significant importance in this study was the quality of care accorded by the compressions in a moving vehicle. Emergency CPR out of the hospital is more often than not given while the patient is on transit. The safety and effectiveness of the procedure is thus affected especially when the chest compressions given are manual (Fox et al, 2013). The presence of external forces that affect the vehicle’s movement, limited space in the car or ambulance and safety concerns reduce the performance of manual chest compressions thus making them ineffective (Fox et al, 2013).

Kurowski et al (2015) studied the success of standard manual chest compressions against the use of CPR feedback devices and concluded that the use of a CPR feedback device is imperative in increasing the performance of manual chest compressions. In the delivery of standard manual chest compression, the study concluded that the human rescuer incorrectly positioned their hands over the mannequin’s thorax and experienced fatigue during the delivery of the chest compression. Fatigue is a recurring factor in the delivery of manual chest compressions aside from age of rescuer, gender and weight (Rad and Rad, 2017). Furthermore, the depth of the compression delivered was highly likely to cause injury to the ribcage of a patient (Kurowski, 2015). The use of a CPR feedback device on the other hand showed an improvement in the manual compressions thus a higher chance of positive outcome in the delivery of the manual CPR.

Hellevuo et al (2014) provides emphasis on the study above through suggesting that manual compressions are still significant especially when aided with the use of CPR feedback devices. Ruiz et al (2016) however emphasize that the accuracy of feedback devices need to be studied further to determine their effectiveness. The study purports that manual chest compression remains important as it is the pioneer form of compression that has guaranteed numerous positive outcomes before. Reliance upon mechanical devices cannot be fully done as in most instances the delivery of the compressions needs to be started manually prior to the initiation of the mechanical device (Hellevuo et al, 2014). In the case of delay, interruption or malfunctioning of mechanical compression devices, manual compression still provide the best emergency procedure.

Tang et al (2015) disputes the effectiveness of mechanical compression devices by mentioning the above limitations of delay and interruptions which significantly affect chances of survival. Tang et al (2015) therefore emphasizes that the return of spontaneous circulation happens faster in the administration of manual chest compressions and guarantees a higher percentage of survival on admission and long term after discharge.

Mechanical chest compressions

Mechanicalchest compressions are delivered through the use of devices, which have been developed to perform CPR and predominantly offset the limitations of manual chest compressions (Brooks et al, 2014). Studies that explain the effectiveness of the devices are outlined below showing the accomplishment of the devices in the presence of external factors as well as the outcome associated with these devices. The LUCAS device is specifically discussed to determine its efficacy as a mechanical device in return to spontaneous circulation.

4.3 Effectiveness of mechanical chest compressions on the return of spontaneous circulation outcome (ROSC)

The study by Fox et al (2013) suggests that mechanical delivery of CPR using the LUCAS device gives 99.96% reliable performance while an ambulance was in transit. The device does not experience fatigue compared to human rescuers.

In the study of the efficacy of LUCAS in pre hospital cardiac arrest cases Gyory et al (2017) purport that the quality of the CPR delivered through the LUCAS device meets the requirements of the Australian Resuscitation Council guidelines (Paradis, 2016). The LUCAS machine does not face fatigue like a human being and the quality of the compressions from the device are consistent. Additionally, the use of the device allows for medical personnel to perform other tasks such as medicine administration, IV access and airway management. In the event that the patient is in a moving vehicle, external factors such as centrifugal forces and limited space in the vehicle do not influence the quality of the compressions. The safety of the medical personnel attending to the patient is furthermore guaranteed thus ensuring that they monitor the patient well. The maintenance of adequate pressure needed to ensure perfusion is further maintained in the use of the device, thus ensuring the high possibility of survival in the patient.

The data from the study by Gyory suggests that the LUCAS device does not have delays in the defibrillation shocks as compared to manual chest compression. The study however found that the compression rate during manual CPR exceeded that recommended by the AHA which raises the question of the possibility of other human factors affecting delivery of manual CPR. The study additionally acknowledged that the effectiveness of the use of the LUCAS device was influenced by other factors such as; the correct usage of the device, the lack of knowledge in using the device, the preference of using manual CPR over mechanical devices and the potential mechanical problems that may affect the device.

Contrary to the study by Fox et al (2013) and Gyory et al (2017), Tang et al (2015) through a meta-analysis of randomized controlled trials suggest that the delivery of mechanical chest compressions does not improve survival in the long term. The study purports that on admission and discharge, the patients had worse survival rates compared to those who had undergone manual CPR. The study attributes the case of low survival during admission to the fact that there is a delay caused by interruptions when the device is being placed and initiated. Additionally, the deployment of the device affects the immediate response that would have been given through the instant delivery of manual compressions. The study by Tang et al, (2015) notes a 2.1 minute delay on the time mechanical CPR is initiated compared to manual compressions. From this study therefore, mechanical devices may fail to be significantly effective as return of spontaneous circulation is hugely reliant on timeliness and nil interruptions. The report further suggests that adverse clinical events such as bruising, pulmonary edema and rib fractures may occur based on the type of device used to administer the chest compressions.

5.0 Conclusion

This paper has discussed the delivery of manual chest compressions in comparison to mechanical chest compressions and the effectiveness of each for return of spontaneous circulation in the body. Chest compressions are primarily done to achieve return of spontaneous circulation in the body. Manual CPR has been in use for a long time but is associated with fatigue that affects the medical personnel delivering the care and the inconsistency of the compressions which reduces positive outcome and thus means lower chances of survival. Mechanical devices on the other hand do not fatigue and have continuity on the rate of compressions thus enabling positive outcome. Mechanical devices are suggested for chest compressions due to their innovation and designation to counter the limitations of manual chest compressions. From the literature reviewed, both types of compressions still remain imperative and are equally needed in the delivery of emergency cardiac care. Mechanical devices such as the LUCAS device however surpass the requirement of the AHA and will possibly maintain superiority over the manual compression in the medical field in the current era. There still remains a research gap on the factors that surround the use of both manual and mechanical chest compressions as these highly influence the ultimate delivery of quality chest compressions.

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APPENDIX 1: Summary of literature included in this review.

		Study design		Key findings
Brooks et al (2014)	To determine the success of mechanical chest compressions in comparison with manual chest compressions with regards to neurological survival in casualties of cardiac arrest	Randomized controlled trials	Analysis of six randomized controlled trials identified through database search	The administration of mechanical chest compressions in the event of cardiac arrest can either result in potential positive outcome or worsen the condition
Tang et al (2015)	To determine the effect of mechanical versus manual chest compressions on resuscitation outcomes in OHCA	Meta-analysis	Analysis of 5 randomized control trials identified through database search	Survival with positive outcome on the neurological system, ROSC, to hospital admission and discharge in the long term based on delivery of mechanical compressions is no better than in manual compressions
Li et al (2016)	To weigh the use of mechanical chest compression devices against manual chest compression during cardiac arrest with regards survival outcomes in the short term and functioning of the neurological system.	Systematic review and meta-analysis	Analysis of human prospective controlled studies of adult CA through systematic database search and analysis of 9 outside hospital; and 3 inside hospital studies	The achievement of ROSC with manual CPR is easier than with mechanical devices for chest compressions
Fox et al (2013)	To compare the performance of standard and technical manual CPR by an expert versus mechanical CPR (LUCAS) while on transit in an ambulance	Simulation study	Comparison of performance of two experienced human rescuers using an eight minute cardiac resuscitation situation with the performance of	The LUCAS CPR device provides a dependent option that can be used instead of manual CPR in an ambulance on transit during emergency evacuation
Gyory et al (2017)	To determine how efficient the LUCAS device is in Pre hospital Cardiac Arrest	Crossover mannequin study	Recording mannequin placed on a building’s second floor 5 miles from the medical centre and response of emergency medical personnel using manual and LUCAS CPR	The LUCAS device has an elevated rate of sufficient compressions and reduced total hands off time in comparison with manual CPR
Hartmann et al (2015)	To determine the maximal concentration of carbon dioxide value among casualties with (ROSC) as a first step toward establishing an accurate mark for treatment during resuscitation	Systematic review and meta-analysis	Analysis of 27 studies on maximal concentration of carbon dioxide value linked with ROSC during CPR identified through database search	The average maximal concentration of carbon dioxide value in partakers with ROSC purports that a suitable ETCO2 mark during CPR may be superior to the expected threshhold for making better compressions outcome suggested in present resuscitation principles
Hellevuo et al (2014)	To evaluate whether the value of CPR can be improved in the course of transportation by using audiovisual feedback that is real time	Non randomized, prospective mannequin study	Performance of standard CPR on a mannequin by 24 professionals in a moving ambulance with and without feedback devices	CPR value was excellent during transit in universal thus positive outcome. The feedback system thus improves CPR quality.
Ruiz et al (2016)	To assess the precision of three methodologies solely on the basis of the acceleration signal to enable feedback on the rate of compression and depth.	Simulation study	Analysis of three different principles of accelerometers using CPR scenarios by volunteers on mannequins	Precise response on the depth of chest compression and rate during CPR is possible using the chest acceleration signal as an entity.
Kurowski et al (2015)	To determine the success of standard manual chest compressions (SMCC) and CPR with the use of two CPR feedback devices: TrueCPR and PocketCPR	Randomized controlled trial	167 paramedics performing SMCC using TrueCPR and PocketCPR	During simulated CPR, TrueCPR device abundantly increased the effectiveness of chest compressions in comparison with SMCC and the use of PocketCPR smartphone application
Zhou et al (2015)	To determine how the up-down hand position switch affects the quality of ECC and the fatigue of resuscitators during	Randomized crossover manikin study	5th year and 6th year medical students performing 10 cycles o single adult CPR	The up-down hand position switch during CPR may elevate the external chest compression depth without changing the compression rate and exposure to air quality may cause the fatigue of new resuscitators but not experienced resuscitators.
Wibrandt et al (2015)	To determine rate of survival and neurological outcome at discharge for CA patients for a period of 90 days and assess the significance of the factors affecting mortality and neurological outcome, with emphasis on combination of initial pace and time to ROSC.	Retrospective cohort study	172 patients of cardiac arrest placed under care of the intensive care unit (ICU) in Odense University Hospital (OUH) over a three-year period	There is a powerful association between early pace and etiology. Combined and singly, these considerations are strong factors for a positive outcome
Bonnes et al (2016)	The effect of mechanical CPR versus manual CPR in the field on favourable outcomes after cardiac arrest happening out of hospital	Randomized controlled trials and meta-analysis	Analysis of 20 studies on survival to hospital admission, survival to discharge, and favorable neurologic outcome over a systematic search on online databases	There is no evidence of positive outcome in both the randomized or nonrandomized studies in mechanical CPR
Ogawa et al (2015)	To examine the effects LDB-CPR device on cerebral oxygen saturation.	Prospective study	34 patients with OHCA from December 2012 to December 2013	LDB-CPR considerably rose the rSO2 of cardiac arrest patients in teh course of resuscitation.
Straney et al (2015)	To categorize sample areas with high frequency of cardiac arrest happening out of hospital and low rates of bystander CPR in Victoria, Australia	Observational study	Information from the state of Victoria on cardiac arrest happening out of hospital	Significant area difference in cardiac arrest happening out of hospital and bystander CPR rates exists all over Victoria
SChober et al (2016)	To examine the changes in metabolism in the hippocampal region during cardiac arrest induced by ventricular defibrillation and traditional chest-compression CPR.	Experimental study	alterations in the cerebral metabolism during cardiac arrest in male rats	Metabolic changes in the course ischemia and resuscitation can be shown by cerebral microdialysis in the cardiac arrest induced by ventricular defibrillation CPR and ECLS rat model
Ong et al (2012)	To address the use of mechanical CPR devices in comparison with manual CPR in the event of cardiac arrests that happen out of hospital while on ambulance transit to improve positive outcomes	Systematic review	Analysis of 10 studies on the quality of CPR and ROSC, survival to hospital admission, survival to discharge and Categories of cerebral function identified through database search	Mechanical CPR devices do improve positive outcome, but may worsen the outcome of the neurological system
Wyer (2016)	To find out if CPR with a mechanical chest compression device improves positive outcome compared with manual CPR in out-of-hospital cardiac arrest	Randomized and non randomized controlled trials	Studies from 2000 to 2014 on cardiopulmonary resuscitation (CPR) over online databases	CPR with a mechanical chest compression device does not improve ROSC/positive outcome more than manual CPR.
Perkins et al (2015)	To examine whether the use of LUCAS-2 device during an emergency cardiac care response in emergency vehicles would improve survival from cardiac arrest happening out of hospital	Randomized controlled trials	Patients in 91 ambulance stations on manual and LUCAS CPR	No evidence of better performance within 30 day survival with LUCAS-2 device compared to manual compressions
Couper et al (2016)	To summarise proof in association to the custom use of mechanical chest compression devices during resuscitation from cardiac arrest within the hospital.	Systematic review and meta-analysis	Analysis of 9 studies that compared the effect of the use of a mechanical chest compression device with manual chest compressions in adults that sustained cardiac arrest within the hospital over online databases	Mechanical chest compression devices have a likelihood of improving patient outcome, when used at in hospital cardiac arrest. The worth of present evidence is nevertheless very low
Rubertsson et al, 2014	To establish whether administration of mechanical chest compressions with defibrillation during continuing compressions (mechanical CPR), compared with manual CPR, according to guidelines, would improve survival within four hours	Randomized controlled trials	Multicenter. Randomized clinical trial of 2589 patients with out-of-hospital cardiac arrest conducted between January 2008 and February 2013 in 4 Swedish, 1 British, and 1 Dutch ambulance services and their referral hospitals.	no noteworthy variation in 4-hour survival between patients treated with the mechanical CPR or those treated with manual CPR that is adherent to guidelines. The better majority of survivors in either groups had positive outcomes by a range of 6 months
Hyunjong et al (2017)	To study whether changing the cycle of the shift from two minutes to one would have a constructive outcome on the quality of chest compression in cardiopulmonary resuscitation (CPR) by two rescuers despite the strength of the rescuers.	Prospective, randomised, crossover study	39 medical students performing CPR from April 2012 to August 2012	The quality of compressions can be more easily sustained by decreasing the compression shift time from two minutes to one minute, despite the strength of the rescuer.
Cortegiani et al (2017)	To compare a typical instructor-based feedback for chest compressions assess to that of a real-time training software (Laerdal QCPR®) and assess their effectiveness in secondary school students	Randomized control	125 secondary students performing CPR from January to May 2016	From the study, the secondary school students learned more on the training for chest compressions based on the use of a real-time feedback software (Laerdal QCPR1) guided by an instructor is superior over instructor-based feedback and technical skill acquisition
Tanaka et al (2017)	To examine the achievement of chest compression quality by PH that is similar to that of using more usual Little Anne manikins for training laypersons	Randomized crossover study	42 Participants’ performing two 2-minute rounds of compressions; one round per CPR compression model being studied	The two models achieved satisfactory rates of chest compressions though the more aged participants had difficulty achieving adequate depth especially due to fatigue
Rad and Rad (2017)	To determine the factors that are important in CPR on the physical fatigue and resuscitation quality provision by Iranian nurses	Randomized cross-sectional study	194 participants performing CPR operations on a manikin	A number of factors such as the gender, weight, height, academic level, and the occupation place of the resuscitator are significantly associated with the onset time of physical fatigue experienced during CPR administration
Westfall et al (2013)	To evaluate the rates of ROSC from load-distributing band and piston-driven chest compression devices in comparison with manual compressions.	Meta-analysis	12 studies of human controlled investigations with confirmed cases of out of hospital over online databases	The aptitude to achieve return of spontaneous circulation with mechanical chest compression devices is significantly higher when compared with manual chest compressions. Load-distributing band CPR, is superior to manual cardiopulmonary resuscitation as the odds of positive outcome were over 1.6 times greater