Letter by Rottenberg Regarding Article, “Conventional Versus Compression-Only Versus No Bystander Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest”
Authors: Eric M. Rottenberg
Journal: Circulation (2017)

Fukuda et al 1 published an observational study comparing conventional versus compression-only versus no bystander cardiopulmonary resuscitation (CPR) for pediatric out-of-hospital cardiac arrest.They presented clinical implications of their study which, based on newly published and existing evidence, elicit comments.They suggested that both conventional and compression-only bystander CPR may be lifesaving in children.However, Naim et al 2 found that, although both conventional CPR and compression-only CPR were associated with better outcomes than no bystander CPR for children aged 1 to 18 years, in infants, only conventional bystander CPR was associated with improved neurologically favorable survival in comparison with no bystander CPR.Therefore, because chest compression-only bystander CPR is not a viable lifesaving option for the resuscitation of infants, abdominal compressions-only bystander CPR 3,4 is likely necessary.Chest compression CPR is a known contraindication in patients with left ventricular assist devices who experience a cardiac arrest because of the risk of dislodging the inflow cannula, which may directly underlie the compression point of the sternum.Rather than not providing any external or internal cardiac massage, abdominal-only CPR can be provided while the surgeon rapidly deploys extracorporeal membrane oxygenation.Rottenberg et al 4 found that, despite an asystolic arrest during resternotomy for a left ventricular assist device exchange, abdominal compressions-only CPR performed at only an 80/min rate while the surgeon performed a femoral bypass to cannulate the groin for extracorporeal membrane oxygenation support, which took 15 minutes, provided a mean coronary perfusion pressure of 15 mm Hg, which is the minimal pressure considered necessary for successful resuscitation with return of spontaneous circulation.However, abdominal CPR has never been studied in an infant animal model of cardiac arrest; therefore, future studies are needed to determine the proper compression technique and rate and depth of compression such that the optimal compromise between adequate compression-induced ventilation and adequate circulation is achieved and whether return of spontaneous circulation with favorable neurological outcome can be achieved.However, once the airway of the pediatric patient develops adult-like characteristics, head rotation, 5 which is a hands-free method (once the head is rotated) of potentially maintaining an open airway during the provision of chest or abdominal compressions-only CPR that has yet to be developed for CPR purposes, is necessary to allow effective gasping and compression-induced ventilation.The effectiveness of head rotation is demonstrated during drug-induced sleep endoscopy in patients with obstructive sleep apnea in the supine position, where rotation both significantly reduced complete and increased partial anteroposterior upper airway collapse at the level of the velum (or soft palate), tongue base, and epiglottis, despite dose-dependent attenuations of upper airway muscle activity, which increases collapsibility.Although, according the current CPR guidelines, even in infants, head tilt Letter by Rottenberg Regarding Article, "Conventional Versus Compression-Only Versus No Bystander Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest"