Resuscitation 106 (2016) 102–107

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Mechanical chest compression devices are associated with poor

neurological survival in a statewide registry: A propensity score
analysis夽,夽夽
Scott T. Youngquist a,b,∗ , Patrick Ockerse a , Sydney Hartsell c , Chris Stratford a ,
Peter Taillac a,d
a
University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States
b
The Salt Lake City Fire Department, Salt Lake City, UT, United States
c
The University of North Carolina School of Medicine, Chapel Hill, NC, United States
d
The Utah Department of Health, Bureau of Emergency Medical Services, United States

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare functional survival (discharge cerebral performance category 1 or 2) among vic-
Received 25 January 2016 tims of out-of-hospital cardiac arrest (OHCA) who had resuscitations performed using mechanical chest
Received in revised form 10 June 2016 compression (mech-CC) devices vs. those using manual chest compressions (man-CC).
Accepted 27 June 2016
Methods: Observational cohort of 2600 cases of OHCA from a statewide, prospectively-collected cardiac
arrest registry (Utah Cardiac Arrest Registry to Enhance Survival). Comparison of functional survival
Keywords:
among those receiving mech-CC vs man-CC was performed using a mixed-effects Poisson model with
Cardiac Arrest
inverse probability weighted propensity scores to control for selection bias.
Chest Compressions
Mechanical Devices
Results: Overall, mech-CC was utilized in 405/2600 (16%) of the total arrests in Utah during this period.
371/405 (92%) were of the load-distributing band type (AutoPulse® ) and 22/405 (5%) were mechanical
piston devices (LUCASTM ), while 12/405 (3%) employed other devices. The relative risk (RR) for functional
survival comparing mech-CC to man-CC after propensity score adjustment was 0.41 (95% CI 0.24–0.70,
p = 0.001).
Conclusions: Mechanical chest compression device use was associated with lower rates of functional
survival in this propensity score analysis, controlling for Utstein variables and early return of spontaneous
circulation.
© 2016 Elsevier Ireland Ltd. All rights reserved.

Introduction interruptions.1,3–5 Manual chest compressions (man-CC) have been

Background
The performance of early and high-quality chest compressions
is a recognized predictor of out-of-hospital cardiac arrest (OHCA)
survival,1,2 with compression quality generally defined as of a
depth and rate consistent with published guidelines, the achieve-
ment of full chest recoil after each compression and minimal
夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.06.039.
夽夽 Presented, in part, as a poster presentation at the 2014 Resuscitation Science
Symposium of the American Heart Association, Chicago, IL, USA.
∗ Corresponding author at: North 1900 East, Room 1C26, Salt Lake City, UT 84132,
United States.
E-mail address: scott.youngquist@utah.edu (S.T. Youngquist).
frequently documented to fall short of these quality standards.6–10
In addition, providers are often unaware of increasing levels of
fatigue and attendant declines in compression performance.11 The
human factors and vulnerabilities of man-CC are exacerbated dur-
ing transport;6 thus OHCA patients that must be moved from the
field while pulseless are at particular risk for receiving poor quality,
interrupted chest compressions.
An estimated 400,000 adults in the US suffer OHCA annually.12,13
Survival rates, although improving in the past few years, still
average only 10% with substantial regional variation.12,14 Improve-
ments in chest compression quality and consistency, and thus the
effectiveness of CPR, could lead to improved survival with better
neurologic outcomes and a reduction in the resuscitation dispari-
ties observed between communities. Finding ways to achieve this
goal is a current research priority among several national and inter-
national medical societies.1,3,4,15

http://dx.doi.org/10.1016/j.resuscitation.2016.06.039
0300-9572/© 2016 Elsevier Ireland Ltd. All rights reserved.
 S.T. Youngquist et al. / Resuscitation 106 (2016) 102–107
Mechanical chest compression (mech-CC) devices have been
proposed as a solution to overcome the weaknesses inherent
in man-CC as the former consistently deliver high-quality CPR,
even during transport.6,16,17 Mechanical devices maintain higher
coronary perfusion pressures, myocardial blood flow, cerebral cir-
culation and end tidal carbon dioxide in animal models18–20 and in
limited human investigations.21,22 Limited human studies reported
increased rates of return of spontaneous circulation (ROSC),23
survival, and neurologic function.22 The most common mech-CC
devices used and studied are the LUCASTM piston-driven chest
compression system (Physio-Control, Inc., Redmond, WA) and the
AutoPulse® load-distributing band (Zoll Corp., Chelmsford, MA).
The former uses a compression piston over suction cup to depress
the sternum while the latter device utilizes a constricting band
mechanism to constrict the entire thorax.
Importance
It is natural to assume that a clinical benefit may be derived from
the deployment of these devices in the field, but the ultimate effect
of mech-CC when integrated into emergency medical services
(EMS) response systems is unclear. To date, four large randomized
trials have investigated mech-CC outcomes, with conflicting results
ranging from equivalence with man-CC24,25 to worse survival.26,27
Similar discordance exists in conclusions from reviews of observa-
tional and non-randomized studies.28,29 A 2015 Cochrane review
considers the evidence regarding the benefit or harm of mech-CC
inconclusive.30 Additionally, a recent meta-analysis of 5 random-
ized trials found no evidence of superiority of mech-CC over
man-CC for survival.31 Expert consensus in the resuscitation field
does not identify evidence of superiority of mech-CC, endorsing
instead man-CC as the standard of care, but generally leaving the
role of mech-CC as an undefined possibility in settings where high-
quality manual compressions are difficult to achieve and training
is appropriate.1,3,4
Goal of this investigation
The goal of this investigation is to determine the association,
if any, between mech-CC use and survival to hospital discharge
with favorable neurologic outcomes when compared to man-CC
as observed in a statewide cardiac arrest registry.
Methods
The Institutional Review Board at the University of Utah
approved of the reporting of this data.
Study design and setting
This is an observational cohort study of all cardiac arrests treated
by EMS in the state of Utah during the period of May 1, 2012 (when
the registry was initiated) through June 18, 2015. Details of the
Cardiac Arrest Registry to Enhance Survival (CARES) registry have
been published previously.32 In brief, CARES is a web-based cardiac
arrest data registry developed by the U.S. Centers for Disease Con-
trol and Emory University and is used by the state of Utah Bureau of
Emergency Medical Services and Preparedness to track outcomes
for victims of out-of-hospital cardiac arrest.
The State of Utah has a population of approximately 3 million
residents. The majority of the population (∼80%) is concentrated
along a long and narrow corridor known as the Wasatch Front.
Three different EMS response strategies are employed in this state:
An EMS agency using a tiered response with basic or advanced EMTs
follow by paramedics treated 58% of all cardiac arrest patients.
EMS agencies using crews that always contained at least one
103
paramedic treated 28% of patients, and the remaining 14% of car-
diac arrest patients were treated by crews that contained only basic
or advanced EMT certified members.
Methods and measurements
The Utah state CARES coordinator is a registered nurse (author
CS) who underwent 5 hrs of in-person training followed by a period
of remote proctoring prior to beginning unsupervised data entry.
All EMS agencies in the state of Utah upload patient care reports
electronically to the Utah State Bureau of EMS and Preparedness
database on a daily or weekly basis. Potential CARES eligible inci-
dents are identified via an algorithm developed by the Bureau for
this purpose using a combination of keywords searches, includ-
ing CPR, cardiac arrest, epinephrine, etc. A daily email is sent to
the CARES coordinator to inform him of potential OHCA incidents,
which are then hand reviewed for eligibility. Approximately 60%
of identified incidents are deemed eligible for CARES entry. The
data from these incidents are uploaded to CARES electronically
and manually reviewed for accuracy before submission. Missing
data for required fields is obtained by direct contact with the
local EMS agency. Patient outcomes, including neurologic status at
discharge, are acquired through direct contact with hospital coordi-
nators and via chart review. The CARES database software includes
error-checking procedures and an electronic data dictionary for
reference. While the CARES coordinator handles the majority of
incidents, historically approximately 10% of all entries have been
independently abstracted by a trained assistant as a check on accu-
racy and any disagreements resolved by consensus review. The
data coordinator and other data personnel were unaware of the
hypothesis of this study at the time of data entry.
Inclusion criteria
OHCA incidents are eligible for inclusion in the registry if the
victim received either automated external defibrillation (AED) by
a bystander or chest compressions by a prehospital provider.
Exclusion criteria
OHCA incidents are excluded from the registry if EMS cease or
withhold the resuscitation due to the presence of a standing do-
not-resuscitate order, or if the cause of the arrest is non-medical
in nature, such as those due to trauma, fire, drowning, or strangu-
lation. For the present study, we excluded from analysis pediatric
cases (age <18 years) since mechanical chest compression devices
are not currently sized for pediatric victims.
Outcomes
The outcome of interest in this analysis was survival to hospital
discharge with an acceptable functional neurologic status, defined
as a discharge cerebral performance category (CPC) score of 1 or 2.
Analysis
Data were exported into an Excel Spreadsheet (Excel for Mac,
Version 14.5.4, Microsoft Corp., Redmond, WA) and imported
directly into STATA/IC 14.0 for Mac (StataCorp, College Station, TX).
Summary measures of variables are reported as mean (±standard
deviation [SD]) or median (interquartile range [IQR]) as appro-
priate to the underlying distribution. The Wilcoxon rank-sum
(Mann–Whitney) test and Student’s t-test were performed to
compare continuous variables as appropriate to the underlying dis-
tribution. Chi-square and Fisher’s Exact Test were used to compare
binary variables.
104 S.T. Youngquist et al. / Resuscitation 106 (2016) 102–107
To estimate the effect of mech-CC on functional survival (rela-
tive risks [RR] with 95% confidence intervals [CI]) while controlling
for potential confounders we performed mixed-effects Poisson
regression with random effects for each EMS agency. The use of
a mixed effects model accounts for variability in the outcome
between and within EMS agencies. Variables were selected for
inclusion in the model based on a priori assumptions informed
by previous literature. The main exposure of interest was mech-
CC vs. man-CC with the following variables included to control
for confounding: age, gender, public vs. private location of arrest,
whether the arrest was witnessed by a bystander, whether EMS
witnessed, receipt of bystander CPR, delivery of a bystander AED
shock, whether the initial rhythm was shockable, and an indica-
tor variable for early return of spontaneous circulation (ROSC) –
since early ROSC would preclude the opportunity to use mechani-
cal CPR; early ROSC was defined as ROSC that occurred after either
a bystander AED shock, after EMS chest compressions only, or after
an EMS defibrillator shock. We also included binary variables to
indicate whether advanced life support medications were admin-
istered during the resuscitation and whether the patient received
an advanced airway in the field – all markers of a prolonged resus-
citation attempt.
We also used a propensity scores (PS) approach to control for
selection bias, since allocation to mech-CC was not randomized.
The PS estimates the probability of assignment to mech-CC condi-
tioned on observed covariates and is used to control statistically for
the likelihood of receiving mech-CC. To calculate the PS, a multivari-
able logistic regression model was constructed using confounder
variables (listed above) to predict the probability of assignment to
mech-CC, i.e., the PS. The probabilities obtained from this model,
or PS, were then converted to inverse probability weights, 1/PS, if
mech-CC was used, and to 1/(1 − PS) if mech-CC was not used, con-
sistent with the IPW approach. These inverse probabilities were
then entered as probability weights into a univariable mixed-
effects Poisson regression model for the outcome of functional
survival with mech-CC as the main predictor variable. Compared
to propensity score matching, IPW has the advantage of using all
Fig. 1. CONSORT style flow diagram of all cardiac arrests treated by EMS in the state of Utah during the period of May 1, 2012 (when the registry was initiated) through June
18, 2015.
observations in the analysis, whereas propensity score matching
drops observations for which a suitable match cannot be found.
Subgroup analysis
We performed several subgroup analyses on the results. In one,
we separately analyzed subgroups according to their presenting
initial rhythm: shockable, asystole, or pulseless electrical activ-
ity (PEA). In another, we compared outcomes in EMS-witnessed
arrests, since response time intervals and bystander interventions
are not a consideration in these victims. We also reran the analy-
sis after excluding all arrests that achieved early ROSC. Finally, we
reran the propensity score analysis including only AutoPulseTM CPR
cases, since this is the predominant device in use in Utah.
Results
Characteristics of study subjects
After exclusions, there were 2600 resuscitation attempts avail-
able for analysis (Fig. 1). Overall, mech-CC was utilized in 405/2600
(16%) of the total arrests in Utah during this period. Of the 66
EMS agencies in the State of Utah, 23 agencies (35%) reported
using mech-CC in at least 1 resuscitation attempt. The range in
the proportion of cases in which mech-CC was employed by those
agencies was between 1% and 100% of all resuscitations with a
median use of 39% (IQR 14–50%). The majority of mech-CC usage,
371/405 (92%), was of the load-distributing band type (AutoPulse® ,
Zoll Corp., Chelmsford, MA). Piston-compression devices (LUCASTM
Chest Compression System, Physio-Control Corp., Redmond, WA)
accounted for 22 (5%) uses, with a mechanical piston device
(Thumper Mechanical CPR Machine, Michigan Instruments, Grand
Rapids, MI) and “Other” devices making up the remaining 2 (0.5%)
and 10 (2.5%), respectively.
There were clinically important differences in baseline arrest
characteristics between patients receiving mech-CC and man-CC
(Table 1). Of note, mech-CC cases were less likely to present in a
 S.T. Youngquist et al. / Resuscitation 106 (2016) 102–107 105

Table 1
Comparison of Utstein variables between cardiac arrest victims receiving either manual or mechanical chest compressions (CC) by EMS.

Manual CC (N = 2195) Mechanical CC (N = 405) p value

Age (IQR) 63 (50–75) 61 (48–73) 0.08

Female gender 773 (35%) 151 (37%) 0.67
Initial rhythm
Shockable 597 (27%) 88 (22%) 0.022
Asystole 963 (44%) 225 (56%) <0.0001
PEA 335 (15%) 63 (16%) 0.88
Unknown non-shockable 299 (14%) 29 (7%) 0.0003
Public location 554 (25%) 71 (18%) 0.001
Bystander witnessed 851 (39%) 140 (35%) 0.25
EMS witnessed 215 (10%) 18 (4%) 0.001
Bystander CPR 765 (35%) 142 (35%) 0.99
Bystander AED shock 99 (5%) 12 (3%) 0.16
Advance life support medications administered 1890 (87%) 385 (95%) <0.0001
Advanced airway placed 1442 (66%) 319 (79%) <0.0001
Field return of spontaneous circulation 550 (25%) 81 (20%) 0.03
Hospital hypothermiaa 92/241 (38%) 9/15 (60%) 0.09
Coronary angiographyb 218/626 (35%) 28/87 (32%) 0.63
a
Among victims surviving to hospital admission who were intubated in the field, used as a gross indicator of neurologic status at admission since the ability to follow
commands upon hospital admission was not recorded in the dataset.
b
Among all victims surviving to hospital admission.

public location or be witnessed by EMS, less likely to present with
an initial shockable rhythm, more likely to present in asystole, and
were more likely to receive advanced life support (ALS) medica-
tions and have an advanced airway placed in the field. Mech-CC
cases were also less likely to achieve field return of spontaneous
circulation.
Main results
Unadjusted neurologically intact survival was 16/405 (4%)
among victims receiving mech-CC and 246/2195 (11%) among
those with man-CC (p < 0.0001). Survival among Utstein victims –
those with a witnessed arrest and an initial shockable rhythm –
was 8/45 (18%) vs. 117/322 (36%), respectively (p = 0.018).
In multivariable mixed-effects Poisson regression (Table 2), the
adjusted relative risk (aRR) for neurologically-intact survival com-
paring mech-CC to man-CC was 0.56 (95% CI 0.34–0.94, p = 0.03).
Using a propensity score approach, the RR was 0.41 (95% CI
0.24–0.70, p = 0.001).
Subgroup/sensitivity analysis
Results of subgroup/sensitivity analyses are given in Table 3.
Mech-CC was associated with statistically significant poor out-
comes for victims with an initial shockable rhythm and EMS
witnessed arrests. While outcomes were also poor when limiting
the analysis to AutoPulse devices, among the 22 LUCAS uses, there
were no survivors. After censoring patients with early field ROSC,
the estimated relative risk was revised upwards.
Discussion
Given the a priori potential benefits of mechancial chest com-
pressions, we had hypothesized that the use of mech-CC for OHCA
would be associated with improved or equivalent functional sur-
vival. Instead, however, we found that mech-CC was associated
with significantly worse neurological outcomes.
Two large randomized controlled trials (LINC and CIRC) showed
non-inferior outcomes between man-CC and mech-CC, but had
unusually high rates of high-quality manual chest compres-
sions (e.g. chest compression fractions of 78–84% and 75–79%
respectively).24,25 This was likely influenced by rigorous training
and oversight during the trials, resulting in a Hawthorne effect on
chest compression quality.33 Real-world measurements of com-
pression fractions have been significantly lower at 52–70%7,34,35
and a degradation in chest compression quality has been observed
due to fatigue or error in man-CC.36 The design of this study allows
appraisal of the performance of mech-CC devices in a wider clin-
ical setting, likely without the same degree of Hawthorne effect.
In these settings, these devices seem to significantly underperform
when compared to published clinical trials.
However, additional biases, including residual selection bias,
may exist in any observational investigation of this type. It is plau-
sible, for example, that longer resuscitations involving an initial

Table 2
Results of multilevel mixed-effects Poisson regression comparing the outcome of neurologically-intact survival to hospital discharge among cardiac arrest victims who
received mechanical vs. manual chest compressions (CC) by EMS while controlling for additional predictors of outcome.

Variable Adjusted relative risk (95% confidence interval) p value

Mechanical CC vs. manual CC 0.56 (0.34–0.94) 0.028

Age (years) 0.985 (0.98–0.99) <0.0001
Male gender 1.00 (0.76–1.34) 0.97
Public location 1.17 (0.87–1.57) 0.30
Bystander witnessed 1.55 (1.15–2.10) 0.005
EMS witnessed 1.34 (0.89–2.04) 0.16
Bystander CPR 0.97 (0.71–1.33) 0.86
Bystander AED shock 1.10 (0.74–1.62) 0.64
Shockable initial rhythm 3.51 (2.62–4.71) <0.0001
Advanced life support medications administered 1.12 (0.81–1.56) 0.50
Early return of spontaneous circulationa 4.84 (3.53–6.62) <0.0001
Advanced airway placed 0.61 (0.47–0.80) <0.0001
a
Defined as field ROSC occurring after either a bystander AED shock, EMS CPR only, or after an EMS defibrillator shock
106 S.T. Youngquist et al. / Resuscitation 106 (2016) 102–107
Table 3
Results of subgroup/sensitivity analyses comparing the outcome of neurologically intact survival to hospital discharge among cardiac arrest victims who received mechanical
vs. manual chest compressions (CC) by EMS among subgroups using a propensity score approach.
Relative risk
All cases 0.41
By initial rhythm
Shockable 0.47
Asystole 0.41
PEAa 0.24
EMS witnessed 0.18
Early field ROSCb excluded 0.53
AutoPulse only 0.51
a
Pulseless electrical activity.
b
Return of spontaneous circulation.
shockable rhythm were associated with use of mech-CC, as chest
compression providers became exhausted, or it is possible that they
were utilized early as an adjunct in settings with a small response
team, both of which may influence the measured association. Time
of deployment and response crew configuration was unavailable in
the dataset.
Aside from biases inherent to observational analysis, it is, nev-
ertheless, important to consider potential causal mechanisms that
might be responsible for the observed association, in order to
guide additional investigation. It should be noted that the load-
distributing band compression AutoPulse® device was used in 92%
of resuscitations in this analysis. Other studies have suggested
an unfavorable survival outcome with use of the AutoPulse® .27
While load-distributing band compression differs from conven-
tional chest compressions – in that it restricts expansion of the
thorax while compressing the sternum – it is unclear if or how this
might influence outcomes. Because of the significant differences in
the mechanism of compression, it may be difficult to generalize the
observed association to all compression devices; however, of the
22 cases where the LUCASTM system was utilized, there were no
survivors. The LUCASTM chest compression system was reportedly
ineffective in generating blood flow in a single human case report
in which transthoracic echocardiography was performed during
CPR,37 but it is unclear how often this occurs.
If not due to inherent limitations in the design and performance
of CPR devices, inadequate local oversight and quality assurance
with respect to device implementation may be responsible for the
observed worse outcomes. Device application, for example, may
lead to prolonged pauses in compressions. Shock frequency may
also decline as the cyclic rhythm of the resuscitation is altered by
mech-CC devices. As is the case with many prehospital interven-
tions such as rapid sequence intubation, insufficient training and
oversight can turn a potentially beneficial therapy into a health haz-
ard. We would have liked to have information on the nature and
frequency of such training and oversight, but this was unavailable.
Our study adds to the literature showing an association between
mech-CC and unfavorable neurologic outcomes.26,27 EMS medical
directors should be aware that the introduction of chest compres-
sion devices is unlikely, by itself, to result in improved outcomes
from OHCA and may paradoxically worsen outcomes. The imple-
mentation and use of these devices requires careful oversight to
optimize their use and further studies are needed to better charac-
terize their risk/benefit profile and how these devices can best be
implemented into prehospital systems of care.
Limitations
Given the non-randomized nature of this investigation, this
study is unable to demonstrate a causal effect between use of
mech-CC and functional survival from OHCA. It is unclear what
role residual confounding and misclassification may have played in
(95% confidence interval) p value
(0.24–0.70) 0.001
(0.25–0.86) 0.015
(0.11–1.57) 0.194
(0.02–2.26) 0.211
(0.08–0.40) <0.0001
(0.29–1.0) 0.05
(0.28–0.94) 0.028
our results, especially since traditional Utstein predictors account
for only 44% of between site variability in cardiac arrest survival.38
Time of device application may have been prolonged in many cases,
leading to increased ischemic burden and worse outcomes. This,
along with the duration of mech-CC use may be important missing
variables in this analysis.
Our cardiac arrest database did not include response intervals
for the majority of resuscitation attempts and were missing for
most rural agencies. Inasmuch as response intervals may be asso-
ciated with mech-CC use, this missing data would represent an
unmeasured confounder. Nevertheless, mech-CC was used largely
in urban settings (82% of cases) where response intervals are
expected to represent average intervals for urban municipal EMS
agencies. Despite the observed decrease in survival associated with
mech-CC use, Utstein survival was, overall, higher in the mostly
urban agencies that were mech-CC equipped (36% vs 26%, p = 0.09)
– although not statistically significant – a finding consistent with
an expected increased survival in urban settings where arrests are
more likely to be witnessed, response intervals are shorter, and
AEDs more ubiquitous. Additionally, when we separately analyzed
victims who were witnessed to arrest by EMS, the relative risk of
neurologically-intact survival was also lower in this setting, sug-
gesting an effect independent of response intervals.
Conclusions
This propensity score analysis found an association between
worse neurological outcomes and the use of mechanical chest com-
pression devices during resuscitation from out-of-hospital cardiac
arrest. Further study is needed to determine the best use of these
devices in the field.
Conflict of interest statement
The authors report no conflict of interest.
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