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The highest quality and effectiveness of Cardiopulmonary Resuscitation (CPR) will be difficult to achieve if ventilatory assistance is provided using a Bag-Valve Mask (BVM) device and combined with compression by a single rescue. This study aims to compare the different qualities of CPR between the over-the-head (OTH) position and the lateral position performed by a single rescue with a BVM device.
Method
This study was a comparative study, comparing the quality of CPR produced by lateral position and OTH position on mannequins. This study involved 100 respondents divided into two groups, namely 50 respondents had lateral position and 50 had OTH position. CPR quality assessment was guided by five CPR quality indicators referring to the American Heart Association (AHA). The statistical test used was Mann-Whitney.
Results
Statistical tests show CPR using the OTH position had higher quality than the lateral position (p = 0.004). Based on five CPR quality indicators, two indicators had a significant difference between the OTH and lateral positions, namely speed (p = 0.026), and interruption (p = 0.008). Meanwhile, the other three indicators did not have significant differences, namely depth (p = 0.427), hand placement (p = 1.000), and complete chest recoil (p = 1.185).
Conclusion
The OTH position was more effective and had better quality when CPR used a single rescue with a BVM device compared to the lateral position.
The European Resuscitation Council (ERC) in 2015 set the position in performing CPR. They set the standard position when compression is on the patient's lateral and ventilation is above the patient's head, which is then called the lateral position.
This position will be easy to do if CPR is performed by two rescues, producing effective and quality CPR. On the other hand, it will be very difficult to do when ventilation assistance uses a Bag-Valve Mask (BVM) and is combined with chest compressions performed by a single rescue. This condition can occur in a hospital when a rescue has to start CPR, but another rescue personnel has not arrived, or when someone qualified to perform CPR finds a patient who has SCA and requires an immediate start to CPR.
Over-the-head cardiopulmonary resuscitation improves efficacy in basic life support performed by professional medical personnel with a single rescuer: a simulation study.
The lateral position in CPR recommended by the ERC (2015) is considered less comfortable and effective. It will produce less quality of CPR if done by a rescue. This is because when the compression of the patient's lateral side finishes, a rescue will continue to ventilate using a BVM device in the upper position of the patient's head, making many interruptions to make changes in the position.
Meanwhile, American Heart Association (AHA) guidelines stated that one of the main factors determining the quality and success of CPR is to minimize interruptions (<10 s).
Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
In addition, minimizing interruptions has a direct influence on reducing hemodynamic disorders, limiting the occurrence of complications, and increasing the effectiveness of CPR.
ERC (2015) recommends that chest compressions generally be performed from the lateral position of the patient. Compression performed from the upper of the patient's head can only be used when CPR is performed in a narrow or limited room.
Compression and ventilation carried out from the upper of the patient's head or the over-the-Head (OTH) position can be an alternative to CPR with a single rescue.
Therefore, this study aims to compare different qualities of CPR between over-the-head (OTH) position and the lateral position performed by a single rescue with a BVM device.
2. Methodology
This study was a comparative study that compares the quality of CPR produced by the OTH and lateral positions performed by a single rescue with a BVM device. The respondents in this study were nurses who worked at Stella Maris Makassar hospital and were selected using purposive sampling, choosing respondents based on certain criteria.
The respondents in this study were nurses who had attended Basic Cardiac Life Support (BCLS) training and were willing to become respondents by filling out an informed consent form. The total respondents who met the criteria was 100 nurses.
Before the study, the researcher explained to the respondents about the research procedure. Then, the respondents were asked to perform CPR for at least 2 min on the CPR mannequin-type Resusci Anne® SkillReporter. This type of mannequin was chosen because it has a monitor that can display several CPR quality indicators, such as speed and depth of compression. Respondents were divided into two groups, in which 50 respondents had CPR with the lateral positions (Fig. 1) and 50 respondents had the OTH positions (Fig. 2). The lateral position, which is compressed, is carried out next to the patient and ventilation is carried out above the patient's head. In contrast, the OTH position, compressed and ventilation, is carried out above the patient's head. During CPR, the observer assessed the quality of CPR performed by the respondent. The observer in this study was a nurse who had worked in the emergency department for ten years with an education background of the Master of Nursing, specializing in an emergency. In addition, the observer was an instructor of Basic Trauma and Cardiac Life Support (BTCLS) training. Based on these experiences and educational background, it is considered worthy of being an observer in this study.
Fig. 1The Lateral Position (Compression is carried out in the patient's laterals, while ventilation is carried out above the patient's head), Own material.
The role of the observer is to observe the quality of CPR performed by the respondent and document it on the observation form. CPR quality assessment uses five CPR quality indicators referring to AHA (2015) as can be seen in Table 1.
Table 1CPR quality indicators (AHA, 2015).
No
Indicators
Assessment Standards
1
Depth of chest compressions
If the indicator light on the mannequin is green, then the depth is 50–60 mm
2
Compression speed
100–120x/min
3
Hand placement
Placed in the center of the sternum
4
Interruptions
Total interruption or pause time during CPR (<10 s)
5
Complete chest recoil
Not applying pressure (compression) before the occurrence of full chest wall development each time compression
Participants were given a score of 1 on each indicator done correctly and a score of 0 on an indicator done incorrectly. The total score obtained by respondents was 5. If the score obtained by the respondent is 5, then the CPR is considered high quality, while if the score obtained by the respondent is < 5, then the CPR is considered unqualified. The statistical test used in this study was the Mann-Whitney statistical test with a value of α = 0.05.
3. Results
Table 2 shows that most of the respondents were women (86%) with an age range of 31–40 years (37%). In addition, most respondents worked in the inpatient room (72%), and the length of the work was 1–5 years (55%). In addition, Table 2 shows that most respondents have a BMI in the normal weight category (73%).
Table 3 shows that the two indicators have significant differences. The first indicator is speed (p = 0.026, ɑ = 0.05), meaning that the OTH position group produces a better speed of performing CPR (100–120x/min) by a single rescue with a BVM device compared to the lateral position group. The second indicator that has a difference is the interruption (p = 0.008, ɑ = 0.05), meaning that the OTH position group produces a more minimal interruption during CPR (<10 s) by a single rescue with a BVM device compared to the lateral position group. Meanwhile, the other three indicators do not have a significant difference between the OTH position and the lateral position; those indicators are depth indicator (p = 0.427, ɑ = 0.05), hand placement (p = 1.000, ɑ = 0.05), and complete chest recoil (p = 1.185, ɑ = 0.05).
Table 3Collective summary of OTH and lateral position CPR results based on CPR quality indicators.
Table 4 shows a difference in quality produced between the OTH and lateral positions where most OTH position groups produced quality CPR (84%) compared to lateral position (58%).
Table 4Difference in quality of CPR between OTH and lateral positions (n = 100).
Table 5 shows the Mann-Whitney statistical test, resulting p-value of 0.004 (ɑ = 0.05), which means that there is a significant difference in CPR quality between the OTH and the lateral positions by a single rescue with a BVM device. In addition, the mean rank value of the OTH position is higher (57.00) compared to the lateral position mean rank (44.00), which means that the higher mean rank value is the highest quality.
Table 5Analysis of differences in CPR quality of OTH and lateral positions (n = 100).
The study results show that there was a different qualities of CPR between over-the-head (OTH) position and the lateral position performed by a single rescue with a BVM device as shown in 42 respondents (84%) of the OTH group who succeeded in performing high-quality CPR compared to the lateral position of only 29 respondents (58%) with a p-value = 0.004 (p < 0.05). The OTH position is more effective and quality because the position of the rescue is above the patient's head, allowing the administration of compression and ventilation; thus, it is considered more comfortable. The results of this study are in line with the research of Ćwiertnia (2019), Feorentina (2020), and Nasiri (2014). They found that CPR position by a single rescue with a BVM device is more recommended to use OTH position because it is considered more qualified than lateral position or conventional position.
Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
The study results show that two indicators had significant differences.
First, the compression speed indicator showed the average speed generated by the OTH position group was 100–120 x/min (96%), compared to the lateral position group (78%) with a p-value = 0.026 (p < 0.05). Thus, the OTH position group was more qualified in speed indicators because it did not require power when moving the position from compression to ventilation, and the compression rate was not affected by other factors such as arm length and body weight. On the other hand, the lateral position group was easier to complain of physical fatigue because it required energy to transfer the position from compression next to the patient to the ventilation above the patient's head, resulting the speed did not reach the standard of 100–120x/min. Furthermore, 22 respondents produced a compression speed of <100x/min. A speed of less than <100x/min will decrease heart capacity and increase the patient's mortality.
Two-thumb encircling technique over the head of patients in the setting of lone rescuer infant CPR occurred during ambulance transfer: a crossover simulation study.
Second, interruptions were made by the OTH group <10 s (98%), compared to the lateral position group where there were only 78% of respondents who interrupted <10 s, while there were still 22 respondents who interrupted for >10 s (p-value = 0.008, p < 0.05). The OTH position group produced more minimal interruptions because when compression and ventilation are carried out simultaneously above the patient's head, it does not take much time to perform both movements simultaneously. On the contrary, when compression was done next to the patient and ventilation using a BVM device was carried out above the patient's head, it took interrupted time (>10 s) to change the movement and shift the position. Minimizing interruptions must be done during CPR, including during ventilation, because interruptions that take too long will reduce blood flow to the brain and decrease patient survival.
In addition, minimizing interruptions can maximize the chest compression fraction circulated by the blood to meet the oxygenation needs of the body's tissues.
Furthermore, the study results show that three CPR quality indicators did not have significant differences between the OTH position and the lateral position. The first indicator is the depth of compression. Based on the recommendations of the ERC (2015), the correct compression depth is 50–60 mm8. Compression depth in this study refers to the indicator lights on the CPR mannequin with precise, too deep, and shallow depths. If the indicator light on the mannequin is green, the compression depth is precise; if the indicator light on the mannequin is red, the compression depth is too deep (>60 mm). Meanwhile, if the indicator light on the mannequin is yellow, the compression depth is too shallow (<50 mm). This study showed no significant difference in terms of compression depth indicators in the OTH or lateral position groups. The compression depth (50–60 mm) produced by the OTH position group was 86%, while in the lateral group, it was 80% (p = 0.427, p > 0.05). This is in line with the study of Ćwiertnia et al. (2019), indicating no significant difference in the compression depth between the OTH position and the lateral position.
In addition, Masic et al. (2010) state that CPR is performed by a single rescuer using BVM, the OTH position can significantly perform CPR with a more precise depth than the lateral position, especially in narrow spaces.
Comparison of the over-the-head, lateral and alternating positions during cardiopulmonary resuscitation performed by a single rescuer with a bag-valve-mask device.
Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American heart association.
The second indicator is hand placement. Recommendations in the ERC (2015) are to perform compression right in the center of the patient's sternum and be carried out to identify the location of the hand placement. However, this study shows no significant difference in hand placement indicators between the OTH and lateral position groups. Both groups produced correct hand placement, with 88% of respondents (p = 1,000, p > 0.05).
The third indicator is complete chest recoil. ERC guidelines (2015) recommend performing compression in the event of a return of the chest wall. The study results show that the OTH group performed a compression after a chest wall recoil was 94% and the lateral position was 86% (p = 1.185, p > 0.05), meaning that it did not show a significant difference in the complete chest recoil indicators both OTH and lateral position group. Even though there was a slight difference in the percentage of complete chest recoil, this amount was insignificant, and the statistical test results showed no significant difference. This is in contrast to Ćwiertnia et al. (2019), which stated that the OTH position provides more opportunities for complete chest recoil compared to the lateral position. This may be due to different methods and tools for measuring complete chest recoil. This study measured complete chest recoil based on direct observation by observer, while Ćwiertnia et al. (2019) measured complete chest recoil using mannequins reported in a computerized manner.
This study did not identify differences in compression and ventilation ratios. Based on the AHA guidelines (2015), the compression and ventilation ratio is 30:2. In contrast, Ćwiertnia et al. (2019) stated that there was no significant difference in the ratio of compression and ventilation between the OTH position and the lateral position.
Even though more respondents correctly performed compression and ventilation ratios in the lateral position, it was not significant and not caused by the CPR position, instead due to a calculation error. Therefore, it is advisable to calculate compression and ventilation ratios using an Impedance Threshold Device (ITD) rather than manually to reduce compression and ventilation ratio calculation errors.
This study recommends that if CPR is performed by a single rescue with a BVM device, it will be more effective to do it with the OTH position than the lateral position. Several advantages are obtained when done with the OTH position, such as producing better speed and interruptions than the lateral position. However, this study does not adequately recommend replacing the lateral position with the OTH when performing CPR, especially if it is performed by two rescues. CPR position is performed only when CPR is performed by a single rescue or under special conditions, such as CPR performed in a narrow room or performed in a pre-hospital. Therefore, it is recommended that the lateral position remains the main choice in performing CPR but can include the choice of the OTH position under special conditions.
5. Conclusion
The OTH position was more effective and had better quality if the CPR is performed by a single rescue with a BVM device compared to the lateral position. The OTH position was better in speed indicators and minimal interruptions. Therefore, this study recommends that if CPR is performed by a single rescue with a BVM device, it is better to choose the OTH position to apply.
Source of funding
This research received a grant from Ministry of Education, Culture, Research, and Technology Republic of Indonesia in 2022 with the number 0267/E5/AK.04/2022.
Author's contributions
WW, AS, AA, and AB conceptualized, designed, analyzed, literature searched and drafted the study. JLS, YGM, and MMP contributed to the conceptualization, edited, formatted, and prepared the final manuscript draft. SA additionally analyzed data with intellectual content and literature search. All authors substantially contributed with equal efforts until approval of the final article and acknowledge that all those entitled to authorship are listed as authors until publication.
Declaration of competing interest
We declare no potential conflicts of interest with respect to the study, authorship, and/or publication of this article.
Acknowledgments
The researcher would like to thank the Ministry of Education, Culture, Research, and Technology Republic of Indonesia for providing funds to implement this research. Researchers also thank to Sekolah Tinggi Ilmu Kesehatan Stella Maris Makassar for facilitating the implementation of this research.
References
Donoghue A.J.
Myers S.
Kerrey B.
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Analysis of CPR quality by individual providers in the pediatric emergency department.
Over-the-head cardiopulmonary resuscitation improves efficacy in basic life support performed by professional medical personnel with a single rescuer: a simulation study.
Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
Two-thumb encircling technique over the head of patients in the setting of lone rescuer infant CPR occurred during ambulance transfer: a crossover simulation study.
Comparison of the over-the-head, lateral and alternating positions during cardiopulmonary resuscitation performed by a single rescuer with a bag-valve-mask device.
Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American heart association.
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