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Over-the-Head Cardiopulmonary Resuscitation Improves Efficacy in Basic Life Support Performed by Professional Medical Personnel with a Single Rescuer: A Simulation Study

Hüpfl, Michael, MD*†; Duma, Andreas, MD*†; Uray, Thomas, MD; Maier, Christina; Fiegl, Nikolaus; Bogner, Norbert; Nagele, Peter, MD*‡

Section Editor(s): Takala, Jukka

doi: 10.1213/01.ANE.0000154305.70984.6B
Critical Care And Trauma: Research Report

Two-rescuer cardiopulmonary resuscitation (CPR) is considered the best method for professional basic life support (BLS). However, in many prehospital cardiac arrest situations, one rescuer has to begin CPR alone while the other performs additional tasks. In theory, over-the-head CPR is a suitable alternative in this situation, with the added benefit of allowing the single rescuer to use a self-inflating bag for ventilation. In this trial, we compared standard single-rescuer CPR with over-the-head CPR in manikins. We planned this study using a crossover study design where each participant administered both CPR techniques in a randomized order. Ventilation and chest compression data were collected with analysis software during a 2-min CPR test for each technique. Sixty-seven emergency medical technician students participated in this trial. Over-the-head CPR allowed for superior ventilation compared to standard CPR (number of correct ventilations: 330 of 760 versus 279 of 779; P = 0.002). The quality of delivered chest compressions did not differ between the two groups (correct chest compressions: 4293 of 6304 versus 4313 of 6395; P = 0.44). In conclusion, our study has shown that over-the-head CPR may be an effective alternative BLS technique when a single professional rescuer has to perform CPR, likely offering superior ventilation and comparable chest compression quality compared with standard BLS.

IMPLICATIONS: In this manikin study, a new basic life support technique designed for a single professional rescuer, over-the-head cardiopulmonary resuscitation (CPR), provided superior ventilation and was more effective than standard one-rescuer basic life support. Although two-rescuer CPR is considered optimal, the new technique could have advantages in situations where one professional rescuer has to start CPR alone.

*Department of Anesthesia and General Intensive Care, Medical University; †St. John's Ambulance, Vienna, Austria; and ‡Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri

Accepted for publication December 9, 2004.

Address correspondence and reprint requests to Peter Nagele, MD, Department of Anesthesia and General Intensive Care, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. Address e-mail to

The Consensus Guidelines for basic life support (BLS) state that ideally, two-rescuer cardiopulmonary resuscitation (CPR) should be performed by health care professionals treating cardiac arrest (1). This allows the rescuer positioned at the head of the patient to use a self-inflating bag for ventilation instead of giving mouth-to-mouth ventilations, with the added benefits that supplemental oxygen can be administered and the fatigue of the rescuer can be reduced (2). However, the Guidelines also state that the priority is to get an automated external defibrillator and to summon help in order to make the delay at which advanced life support (ALS) is begun as short as possible (3). These conflicting recommendations lead to the situation where one professional rescuer has to leave the patient and the other has to begin BLS alone. In this situation, the single rescuer would have to administer standard BLS, including mouth-to-mouth ventilation, because the use of a self-inflating bag from the side of the patient is nearly impossible, and a change of positions (head to side) is too time consuming. These circumstances would not allow the single professional rescuer to administer supplemental oxygen and would increase his chances of contamination from mouth-to-mouth ventilation (4).

To improve this unsatisfactory situation, several emergency medical systems in the United Kingdom, Germany, Switzerland, Australia, and Austria have integrated an alternative technique, over-the-head CPR, which allows a single professional rescuer to use a self-inflating bag for ventilation and administer chest compressions without changing position during CPR. Three recent small simulation trials have evaluated this method (5–7) but did not show a consistent difference between standard CPR and over-the-head CPR; this might be due, in part, to the small sample size of approximately 20 participants in 2 of the trials (5,6) and to the different criteria for selection of participants. The goal of this study was to test the hypothesis that over-the-head CPR provides a better overall quality of BLS for professional single rescuers compared with standard BLS.

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Emergency medical technicians (EMTs) from the St. John's Ambulance Service, Vienna, Austria, volunteered to participate in the study. There was no selection of volunteering participants. All volunteers had received formal training in standard BLS as EMT students and were required to participate in BLS training once a year for re-certification. Over-the-head CPR was practiced on a regular basis during these BLS trainings, and each study participant was familiar with this technique. BLS was taught according to the current European Resuscitation Council guidelines for BLS (1). The level of clinical experience in real cardiac arrest situations varied greatly among the participating EMTs.

In this study, standard CPR was compared with over-the-head CPR. During standard CPR, the EMT performed regular single-rescuer CPR according to published guidelines (1), with mouth-to-mouth ventilation and chest compressions performed while kneeling at the side of the manikin. No self-inflating bag was used for ventilations.

Over-the-head CPR was performed while kneeling, with the head of the manikin between the rescuer's knees/thighs (Fig. 1). Ventilations and chest compressions were administered from this position without changing to the side of the manikin. Ventilation was administered with a self-inflating bag (Ambu® bag; Ambu A/S, Ballerup, Denmark) and a mask size #3, according to the published guidelines for ventilation during BLS (1). Target ventilation volume was 400–800 mL. This range was chosen because the manikin simulates a lightweight adult, and thus, the correct tidal volume (10 mL/kg of body weight) would be between 400 and 800 mL. After giving two ventilations, the rescuer started to administer chest compressions. The rescuer first identified the correct hand position in the center of the lower part of the sternum in the same way as in the standard technique. He then positioned his shoulders over the chest of the manikin, with elbows locked in position and arms straightened so that the applied force was perpendicular to the surface (Fig. 2). Fingers were extended and kept off the chest. After each compression, the hands were kept in contact with the victim's sternum to maintain proper hand position. Chest compressions were performed at a rate of approximately 100 per minute, with an audio timing prompt helping the rescuer to maintain the frequency. The study participant was instructed to evenly split the timing for one chest compression between compression and decompression. The ratio of ventilations to chest compressions was aimed accordingly at 2:15.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Study participants were informed about the general aim of the study but were blinded to the outcome assessments and the specific hypothesis stated. They were instructed to administer CPR with optimum performance. Each participant performed both CPR techniques in a successive order that was randomly assigned. Both techniques were performed for 2 min. Before the actual evaluation, both techniques were practiced for 1–2 min, with a resting period of 4 min between 2 sets.

The manikin (Resusci® Anne, Laerdal Medical, Stavanger, Norway) was connected to a computer running an analysis software (Laerdal PC SkillReporting® software, version 1.0.0). Data were recorded during a 2-min period of the BLS test. The printout of the test period was further manually analyzed by a blinded person to assess the quality of every chest compression and ventilation (a representative printout is shown in Fig. 3). The software measures the quality of the BLS performance (ventilation and chest compressions) and classifies these variables as correct or incorrect, according to the published International Liaison Committee on Resuscitation guidelines (1). The following variables were recorded for each individual ventilation or chest compression: correct ratio of ventilations-to-compressions (2:15); ventilation: correct tidal volume (400–800 mL), correct duration of inflation (1–2 s), and correct inspiratory flow rate (<500 mL/s); and chest compressions: correct depth (38–51 mm), correct rate per min (80–120/min), correct hand position (automatically recorded by device, specified according to published guidelines) (1), and correct release (complete release of pressure during chest compressions). Data were not released to the participants.

Figure 3.

Figure 3.

Because of the crossover design of this study, normally distributed continuous variables were analyzed with the two-tailed paired t-test. Dichotomous variables from 2 × 2 contingency tables (e.g., correct/incorrect) were analyzed with either the χ2-test (including Yates correction for continuity, where appropriate) or the two-tailed Fisher's exact test. A value of P < 0.05 was considered statistically significant.

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Over-the-head CPR was compared with the standard protocol for professional BLS (2) in a manikin simulation study. Sixty-seven EMTs participated in this trial; 62 data sets were complete, and 5 were partially incomplete because of recording problems. The demographic characteristics of the participants were the following: of 67 participants, 53 were men and 14 women; the median age was 29 yr old (range, 18–55 yr); the average height was 180 cm (range, 154–200 cm); and the average weight was 72 kg (range, 50–150 kg).

Over-the-head CPR was superior to standard CPR in the quality of ventilation (Table 1); there were significantly more adequate and correct inflations in the over-the-head CPR group, which was almost exclusively caused by more frequent correctly applied tidal volume and not-too-rapid insufflations. Although not statistically significant, the time required to apply 2 ventilations (one cycle) was on average 0.5 s shorter for the over-the-head CPR group.

Table 1

Table 1

The quality of chest compressions did not differ between the two study groups; neither rate, mechanical performance, nor correct 2:15 ratio were different (Table 2). Most of the chest compressions classified as incorrect were caused by too shallow of compression depth and not the wrong hand positioning.

Table 2

Table 2

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Our simulation study found that over-the-head CPR with bag/mask ventilation is as effective as standard CPR with respect to hemodynamic support but provides superior ventilation. Not only is over-the-head CPR superior in delivering adequate and effective ventilation, but it also provides additional advantages over standard CPR with mouth-to-mouth ventilation.

First, the use of a self-inflating bag enables the rescuer to administer a larger inspiratory oxygen concentration (16% for mouth-to-mouth, as compared to up to 100% for bag-valve masks with demand valve, an example of which is the Life Support Products Demand Valve; Allied Healthcare Products Inc, St. Louis, MO), which allows a reduction of the tidal volume administered, from 700–1000 mL to 500 mL (8). The reduction of tidal volume reduces the risk of stomach inflation (9) and thereby the risk of regurgitation, aspiration, and pneumonia. Second, avoiding mouth-to-mouth ventilation dramatically reduces the risk of contamination from the victim (4), a risk that is the major reason health care workers are reluctant to administer mouth-to-mouth ventilation (10,11). Although the risk of transmission of an infectious disease (human immunodeficiency virus, tuberculosis, etc.) seems to be small, most health care professionals would not give mouth-to-mouth ventilations to an unknown victim (10). Third, using a self-inflating bag instead of giving mouth-to-mouth ventilations is, although never tested, likely to reduce the fatigue of the rescuer, which could, in turn, improve the overall performance of CPR. Although a possible option, we did not test pocket mask ventilation instead of mouth-to-mouth ventilation because the use of pocket masks is not common in most Austrian emergency medical service (EMS) systems.

It could be argued that there must be other options for a single professional rescuer other than regular BLS or over-the-head CPR. Using a self-inflating bag-valve mask from the side of the patient is theoretically possible but is, in our opinion, very ineffective and barely controllable. A second option, changing positions during CPR from the head of the patient to the side, is also possible, but we know from clinical experience that this is impractical and time consuming.

However, there is a third option that has received much attention in recent years: administering continuous chest compressions without ventilating the patient. This method is not recommended in the current BLS guidelines but seems like a suitable alternative, as many health care professionals are very reluctant to give mouth-to-mouth ventilations (10). Furthermore, studies in humans (12) and swine (13,14) have shown no benefit of ventilation during BLS, but an increase in survival in the chest-compression-only technique (15). The authors explain their findings with superior myocardial perfusion during uninterrupted chest compressions compared with standard BLS, spontaneous gasping during CPR, and a larger initial oxygen delivery during the first minutes of CPR.

However, other studies show that ventilation is an indispensable part of successful CPR (8,16,17), in particular, when the airway is obstructed. Moreover, chest-compression-only CPR has been advocated mostly in witnessed cardiac arrests and situations in which the interval to initiation of CPR is short because oxygen tension levels are still high in the cardiac arrest victim. This situation does not represent the usual circumstances when professional health care providers, such as paramedics or prehospital emergency physicians, arrive at the scene. Most of the time, several minutes have passed and the arterial oxygen content of the patient has decreased to low levels, thereby requiring delivery of oxygen via ventilation (18,19). A recent multicenter CPR trial with more than 1000 patients from several German, Austrian, and Swiss EMS reported an average duration of untreated cardiac arrest of approximately 8 minutes (20) compared to 3.1 minutes in the Seattle metropolitan area (12).

For a single professional rescuer, ventilation could be accomplished using the new over-the-head CPR technique, because it allows the rescuer to ventilate a patient with a self-inflating bag from the head of the patient without the need to change positions during CPR and without having to give mouth-to-mouth ventilations, as recommended in the current guidelines for BLS (1). In particular, this might be even more the case in situations with prolonged CPR.

Three other studies have evaluated at the quality of over-the-head CPR (5–7). The first compared over-the-head CPR with standard two-rescuer CPR in an ALS scenario and found that the quality of ventilations and chest compressions did not differ between the two techniques and that the time until administration of the first defibrillation was significantly shorter in the over-the-head CPR group (7). However, because only one rescuer delivered CPR in the over-the-head group compared to two rescuers in the standard CPR group, the number of delivered chest compressions was significantly less in the over-the-head group, which led the authors to conclude that over-the-head CPR is not a suitable alternative for professional two-rescuer CPR (7). The setting of our study was a professional single-rescuer scenario, and therefore, the results of the two trials are complementary rather than comparable.

The two other studies, both small simulation studies in manikins, compared over-the-head CPR with standard CPR in a single-rescuer BLS scenario (5,6). In contrast to our study, which focuses on professional rescuers with experience in bag-valve mask ventilation, in both other trials, the participants had no previous experience with over-the-head CPR and used a pocket mask for ventilation (no bag-valve mask). Handley and Handley (6) focused on trained laypersons performing CPR in a confined space and found that there was no difference between the two methods except for more frequent wrong hand position in the over-the-head CPR group. Importantly, the quality of ventilation was not assessed in this trial. Perkins et al. (5) also found no major difference in quality between over-the-head CPR and standard CPR with the exception that hand positioning during chest compressions was better in the over-the-head group. Both studies conclude that over-the-head CPR might be a suitable alternative technique. However, both studies failed to exploit one of the greatest advantages that over-the-head CPR might offer: the use of a self-inflating bag instead of reliance on the rescuer's own breath to ventilate the patient.

The findings of our study strongly support the notion that the use of a self-inflating bag for ventilation during over-the-head CPR allows the single rescuer to deliver better ventilation than with a pocket mask or mouth-to-mouth ventilation. One possible explanation for the different findings of our study is that in our trial, all participants had previous theoretical and practical experience with over-the-head CPR.

Despite clear results, our study has several limitations. First, this study was performed in manikins, not patients. Although the technique of over-the-head CPR has been used in real patients, there are no published reports on efficacy and outcome. Therefore, the first step was to test this method under well-described circumstances of a CPR simulation comparing BLS performed according to published guidelines and over-the-head CPR. Second, the overall quality of ventilations and chest compressions was poorer than expected, but this might reflect the average performance of professional rescuers in CPR simulation studies, as one study suggests (21). Third, this study obviously compares two different ventilation methods, which is, in theory, a limitation of this study but does, in fact, represent clinical practice and is one of the major reasons this study was performed. In our study, we compared the two techniques during a two-minute CPR cycle, an interval that might be too short compared with real-life cardiac arrest situations. Thus, differences between the two CPR methods that are caused by increasing fatigue during prolonged CPR might be much larger than our study could show.

In conclusion, this study has shown that over-the head CPR may be an efficient alternative to the BLS technique for health care professionals when a single rescuer has to perform CPR. It offers superior ventilation compared with standard BLS but cannot be recommended for laypersons unfamiliar with bag-mask ventilation.

The authors would like to thank Doris Wundsam for her support of this study, Boris Steiner for his help in data analysis, and all members of the study center and participating EMTs from St. John's Ambulance, Vienna, Austria. Furthermore, we are indebted to Professor Volker Wenzel, University of Innsbruck, Austria, for his support in improving the quality of the manuscript.

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