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• Re:Effects of bed height on the performance of chest compressions- Clinical application of results
  Je Hyeok Oh
  Published on: 29 April 2016
• Effects of bed height on the performance of chest compressions- Clinical application of results
  PB Sherren
  Published on: 29 April 2016

• Published on: 29 April 2016

  Re:Effects of bed height on the performance of chest compressions- Clinical application of results

  • Je Hyeok Oh, Professor
  • Other Contributors:
    • Junho Cho

  We are incredibly glad to hear that Dr. Sherren has taken an interest in our research (1). I concur with his position on this matter. I believe that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac arrest patients will be solved through near future technologies such as extracorporeal membrane oxygenators. However, if we divide cardiac arrests broadly into in-hospital and out-of-hospital, or on-site arrests...

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  We are incredibly glad to hear that Dr. Sherren has taken an interest in our research (1). I concur with his position on this matter. I believe that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac arrest patients will be solved through near future technologies such as extracorporeal membrane oxygenators. However, if we divide cardiac arrests broadly into in-hospital and out-of-hospital, or on-site arrests, we must admit that, even in the future, on-site treatment will largely rely upon CPR administered by other persons who are on-hand. Therefore, it is necessary that resuscitation research on the often overlooked ergonomic aspects of CPR be revitalized and brought to greater focus. The starting point for an ergonomic approach to CRP research will have to begin with the effectiveness of chest compressions. Already, in the 2005 guidelines, the importance of chest compression was emphasized (2). Within such emphasis, our research group is especially interested in the influence the relative body positions of the patient in need of CPR and the rescuer have on the quality of CPR administered. Previous research in this area indicates that it is most effective to administer CPR from a kneeling position (CPRKP) on a patient who is on the floor (3). If this is true, there is a need to identify what factors cause CPR administered from a standing position (CPRSP) on a patient who lies on the bed to be less effective. Research such as this must look at the rescuer's changes in body positioning, as well as other factors, from an ergonomics perspective in order to be most effective. Under the assumption that making the conditions of performing CPRSP more similar to those of CPRKP would reduce the loss of effectiveness associated with CPRSP, our research team postulated the following hypotheses: 1) that if the bed on which the patient lies were to be lowered to the height of the rescuer's knees during CPRSP, the rescuer would be able to perform CPR in basically the same position as with CPRKP and 2) that rather than placing the patient on a mattress and then a backboard, removing the mattress altogether will improve the conditions of administering CPR. The current study that we are presenting is the first of several studies being conducted regarding these hypotheses. We feel that Dr. Sherren's suggestion of having the rescuer perform CPR while kneeling on the bed itself (CPRKOB) is also a valid hypothetical solution to solving the problem of loss of effectiveness associated with performing CPR on patients in beds. However, this too must undergo rigorous performance studies. While there are cases in which CPRKOB has been performed in clinical settings, most clinical beds are not very strong, and thus a level of instability is often a factor in such cases. This is especially true of smaller emergency-room gurneys. Indeed, it may be true that the simplest solution to preventing the loss of effectiveness in CPR performed on patients in beds is to remove the beds altogether. However, procedures such as endotracheal intubation and vascular access, as well as various monitors attached to a patient may make the act of removing a patient from a bed in order to perform CPR unrealistic; extensive performance studies would have to be performed in order to make any sort of a persuasive argument for such a procedure. As Dr. Sherren has pointed out, mannequin-based performance studies have not beed recognized as very important because they lack things as chest recoil and thoracic pump effects - therefore, making them less desirable than animal and clinical trials. However, considering that CPR is a procedure directly performed by persons, performance studies will give us the best evidence for the creation of guidelines for effective CPR. Again, we thank Dr. Sherren for his attention to our research and give him our regards.

  References

  1. PB Sherren. Effects of bed height on the performance of chest compressions - Clinical application of results. Emerg Med J 2010;eLetter

  2. International Liaison Committee on Resuscitation. International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 2. Adult basic life support. Resuscitation 2005;67:187-201.

  3. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different mattresses affect the quality of cardiopulmonary resuscitation? Intensive Care Med 2003;29:2330-5.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Effects of bed height on the performance of chest compressions- Clinical application of results

  • PB Sherren, Spr Anaesthesia/ICU

  Editor- I would like to start by congratulating Cho and colleagues (1) on undertaking a study that addresses an area of cardiopulmonary resuscitation (CPR) which potentially, could for such a simple intervention have such a dramatic impact on the quality of CPR delivered. There are surprisingly few papers published on this area, and the 2005 ILCOR guidelines (2) were based largely on expert opinion with little evidence...

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  Editor- I would like to start by congratulating Cho and colleagues (1) on undertaking a study that addresses an area of cardiopulmonary resuscitation (CPR) which potentially, could for such a simple intervention have such a dramatic impact on the quality of CPR delivered. There are surprisingly few papers published on this area, and the 2005 ILCOR guidelines (2) were based largely on expert opinion with little evidence base.

  The statistical relationship between a bed height at the knee level and the effectiveness of CPR is clear. The concern is the application of these results to the clinical setting. Having recently completed similar work within this area, I would suggest you would find it difficult to locate a hospital bed/trolley with mattress which is able to drop to the average person's knee level. So as a result, we may be continually subjecting patients to sub-optimal chest compressions, even if the beds are dropped to their lowest levels. Perkins et al suggested resuscitation carried out on the floor when compared to the bed is superior (3). Again, application of this not really possible on a daily basis and certainly not advocated by ILCOR guidelines.

  The solution may be to eliminate the human component to chest compression all together, by using one of the various automated devices available now. Initial studies were very encouraging and demonstrated not only their safety but also possible survival benefits (4,5). The slow uptake of these devices probably stems from not only their cost implication, but the results of the large randomised prospective ASPIRE trial (6), which demonstrated that the use of Autopulse was associated with a worse neurological outcome and a trend towards worse survival, when compared to manual CPR.

  So the answer in the mean time is a little bit more low-tech and a little bit more 'ER' esque; I would suggest we go back to kneeling on the bed when performing CPR. In this position the clinician can keep their arms straight and with the advantage of their upper body weight can perform effective chest compressions. It is always worth remembering, that in the real world good quality chest compressions are not simply dependent on the depth of chest compression. The vital role of chest recoil and the thoracic pump effect are not addressed with compression plates and manikin studies and form a key component of successful resuscitation.

  1. Cho J, Oh JH, Park YS, et al. Effect of bed height on the performance of chest compressions. Emer Med J 2009: 26; 807-810

  2. International Liaison Committee on Resuscitation. International Consensus on cardiopulmonary resuscitation and emergency cardiovascular science with treatment recommendations. Part 2. Adult basic life support. Resuscitation 2005; 67: 187-201

  3. Perkins GD, Smith CM, Augre C, et al. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med 2006;32:1632-5

  4. Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2005 Jan-Mar;9(1):61-7.

  5. Krep H, Mamier M, Breil M, Heister U, Fischer M, Hoeft A. Out-of- hospital cardiopulmonary resuscitation with the AutoPulse system: a prospective observational study with a new load-distributing band chest compression device. Resuscitation. 2007 Apr;73(1):86-95. Epub 2007 Jan 24.

  6. Hallstrom A, Rea TD, Sayre MR, et al: Manual chest compressions vs. use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest. JAMA 2006. 295(22):2620-2628.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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