3.2 Return of spontaneous circulation
As shown in Figure 2, 6 studies with a total of 8501 subjects, compared the success rates of return of spontaneous circulation (ROSC) between the LUCAS group and the Manual group. The success rate of ROSC in the LUCAS group and the Manual group was similar, and the difference was not statistically significant (33.3% vs 33.0%, P = .98, OR = 1; 95% CI: [0.89, 1.13]).
3.3 Survival to hospital admission
As shown in Figure 3, 8430 cases were enrolled, including 3425 cases in the LUCAS group and 5005 cases in the Manual group. There was no significant difference in survival to hospital admission between the 2 groups (22.7% vs 24.3%, P = .32; OR = 0.86; 95% CI: [0.65, 1.15]).
3.4 Survival to hospital discharge
As shown in Figure 4, 3959 cases were enrolled in 4 papers, including 1773 cases in the LUCAS group and 2186 cases in the Manual group. There was no significant difference in survival to hospital discharge between the 2 groups (8.6% vs 10.7%, P = .50; OR = 0.92; 95% CI: [0.73, 1.17]).
3.5 Survival to 30 days
As shown in Figure 5, 7954 cases were enrolled in 3 papers, including 2952 cases in LUCAS group and 4108 cases in Manual group. There was no significant difference between the 2 groups (7.5% vs 8.5%, P = .50; OR = 0.92; 95%CI: [0.73, 1.17]).
3.6 Quality evaluation and publication bias
In this study, each paper was scored using the Review Manager 5.3 bias analysis tool. Because of the need to rescue patients, double-blind design was impossible. As shown in Supplemental Digital Content (Suppl 1, http://links.lww.com/MD/D308), each study had a low blind score, but had high scores in other indicators, and the sample size of the study was large, so this meta-analysis had relatively high quality. Moreover, the results of univariable meta-regression analysis were shown in Supplemental Digital Content (Suppl 2, http://links.lww.com/MD/D308). The differences for sample size (P = .612), research type (P = .756), publication year (P= .774), and race (P = .536) did not significantly explain the heterogeneity. Also, the results of the funnel plot were shown in Figure 6. The included papers are distributed on both sides of the mid-line and the figure is relatively symmetrical. It are located at the tip of the funnel, indicating that this systematic review had high quality and small publication bias.
4.1 Summary of study findings
This meta-analysis of 4 randomized controlled trials and 2 nonrandomized controlled trials evaluated the success rate and prognosis between LUCAS and manual CPR. It found that there was no meaningful difference between the experimental group and control group in ROSC, survival to hospital admission, survival to hospital discharge and survival to 30 days.
Some studies have shown that there is a direct relationship between the quality of chest compression and short-term survival. The American Heart Association guidelines and emergency cardiovascular care emphasize the high quality of CPR. However, manual chest compression will be affected by fatigue, especially after 2 to 3 minutes of CPR.[11,25] It is difficult to maintain high-quality CPR. The replacement personnel will lead to CPR interruption, which will lead to a decline in CPR quality and affect prognosis of patients with CA.[26–28] The use of mechanical chest compression can avoid these problems, thereby maintaining high-quality CPR, and even international guidelines published in 2010 that these devices can be seen as part of an overall strategy to improve the quality of CPR.
LUCAS is a chest compression device that provides automatic chest compression and decompression CPR according to the principle of pneumatic. By improving the point pressing and the pressing head and adopting the suction disc press head, the chest can be pulled up while pressing it at the same time. It makes the thorax to fully rebound, causing a large negative pressure in the chest to promote blood return. Previous studies have shown that there is a controversy that whether LUCAS will bring better benefits to patients with CA. Existing experimental studies about LUCAS are controversial, but the results of relevant meta-analysis are generally consistent. A meta-analysis by Gates et al in 2015 did not show that an advantage to the use of mechanical chest compression devices for ROSC, survival to discharge from hospital or 30 days and survival with good neurological outcome. A study by Li et al in 2016 showed that there was no significant difference in admission survival rate, discharge survival rate and CPC score between manual compression and mechanical compression, and that manual compression was superior to mechanical compression in ROSC. And in this meta-analysis, we found that LUCAS has no advantage over manual CPR. The results is consistent with the above research in ROSC, survival to hospital admission, survival to hospital discharge, and survival to 30 days. Compared with the above 2 meta-analysis, this study included more studies and included more subjects; in addition, this study only discussed the results with LUCAS, without other mechanical CPR, which reduce the bias from other machines. Therefore, this meta-analysis is more reliable.
We had the following assumption for this situation: first, LUCAS lacks the simplicity and timeliness of manual chest compression. As mentioned above, the delay of chest compression and interruption of chest compression will lead to a decrease in CPR quality. When a CA patient is encountered, manual chest compression can begin immediately, while LUCAS will delay the time of CPR due to the assembly by professional. Second, the depth of chest compression with the LUCAS is 4 to 5 cm, which is less than 5 cm as defined by the guideline. It will lead to invalid CPR. Giraud et al performed a study of the effectiveness of LUCAS in 2015 which showed that it was ineffective with the LUCAS by transesophageal echocardiography. Therefore, the application of LUCAS is limited due to these shortcomings. Some studies even showed that manual CPR is better than LUCAS.[30,32]
Compared with the previous study, this paper, a meta-analysis of 6 studies, including more subjects, is a large sample survey. In addition, the studied indicators in this paper include not only the success rate after CPR, but also the short-term outcome indicators such as ROSC, survival to hospital admission, survival to hospital discharge and survival to 30 days of patients. It ensure this meta-analysis higher credibility. And the subjects in this meta-analysis come from various country, therefore, the results of this study have a wide range of applicability. Hence, this study may help to choose the ways of CPR. Manual CPR is still good for emergencies; in the case of prolonged compression, LUCAS may be a better alternation than manual PCR.
There were also some limitations in this meta-analysis. This article contains a prospective observational study and a descriptive, nonrandomized controlled trial, which may cause some bias due to the heterogeneity of research; second, all included studies failed to do blind method due to the need to rescue patients. Third, the included studies lacked data which can evaluate quality indicators in the process of CPR (such as end-tidal carbon dioxide, degree of blood oxygen saturation, etc), cerebral performance category, and neurological recovery, and so on. Therefore, these data were not analyzed. But a study by Rubertsson 2014 in suggested that there was no significant difference between manual CPR and Mechanical chest compression with LUCAS in 4-hour survival. Finally, all subjects were adults in this study, and age stratification was not analyzed, as a result, the results of this study only apply to adults.
4.4 Future directions
Manual CPR and LUCAS have their own advantage and defect respectively, but the study found no significant difference in clinical outcomes of patients. It showed that the LUCAS is a practical tool, with a similar clinical outcome to manual CPR. Therefore, more research is needed to confirm this in the future. Moreover, it was not studied that whether the way combined manual CPR with LUCAS can improve the clinical outcome of CA patients. Future research can analysis it and explore the situation of using LUCAS.
In this systematic review, combined with a meta-analysis of related data, it is found that there is no significant difference between manual chest compression and LUCAS in improving clinical outcomes in patients with out-of-hospital CA. More large-scale studies are needed in the future.
Conceptualization: Mao Liu.
Investigation: Zhuang Shuai, Kai Tang, Jiankang Zheng.
Methodology: Mao Liu, Zhuang Shuai, Jiao Ai, Hui Liu.
Project administration: Mao Liu, Zhan Lv.
Resources: Zhuang Shuai, Kai Tang, Jiankang Zheng.
Software: Mao Liu, Zhuang Shuai, Jiao Ai, Hui Liu, Junqi Gou.
Supervision: Mao Liu, Hui Liu, Zhan Lv.
Validation: Mao Liu, Zhan Lv.
Writing – original draft: Mao Liu, Zhuang Shuai.
Mao Liu orcid: 0000-0001-5622-5178.
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cardiac arrest; cardiopulmonary resuscitation; LUCAS
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