REVIEW

CURRENT
OPINION High-quality cardiopulmonary resuscitation
Jerry P. Nolan

Purpose of review
The quality of cardiopulmonary resuscitation (CPR) impacts on outcome after cardiac arrest. This review will
explore the factors that contribute to high-quality CPR and the metrics that can be used to monitor
performance.
Recent findings
A recent consensus statement from North America defined five key components of high-quality CPR:
minimizing interruptions in chest compressions, providing compressions of adequate rate and depth,
avoiding leaning on the chest between compressions, and avoiding excessive ventilation. Studies have
shown that real-time feedback devices improve the quality of CPR and, in one before-and-after study,
outcome from out-of-hospital cardiac arrest.
Summary
There is evidence for increasing survival rates following out-of-hospital cardiac arrest and this is associated
with increasing rates of bystander CPR. The quality of CPR provided by healthcare professionals can be
improved with real-time feedback devices. The components of high-quality CPR and the metrics that can be
measured and fed back to healthcare professionals have been defined by expert consensus. In the future,
real-time feedback based on the physiological responses to CPR may prove more effective.
Keywords
bystander CPR, debriefing, feedback devices, high-quality cardiopulmonary resuscitation, mechanical CPR

INTRODUCTION (2) Monitoring and feedback

Survival from out-of-hospital cardiac arrest (OHCA)
is dependent on optimizing all links in the chain of
survival [1]. Early cardiopulmonary resuscitation
(CPR) forms the second link in the chain, and it is
now well recognized that the quality of the CPR
provided impacts significantly on the likelihood
of achieving return of spontaneous circulation
(ROSC). A recent consensus statement from the
American Heart Association (AHA) usefully sets
out the factors that contribute to the delivery of
&&
high-quality CPR (given below) [2 ]. This review
will discuss recent developments in the provision of
high-quality CPR.
Factors and metrics that contribute to high-
quality cardiopulmonary resuscitation (adapted
&&
from [2 ]):
(1) Metrics of CPR performance
(a) Minimize interruption – aim for chest com-
pression fraction above 80%
(b) Chest compression rate 100–120/min
(c) Compression depth at least 5 cm in adults
(d) Full chest recoil
(e) Avoid excessive ventilation (less than 12
breaths/min and minimal chest rise)
(a) Coronary perfusion pressure above 20
mmHg (if central venous and arterial
catheters in situ)
(b) Arterial diastolic pressure above 25 mmHg
(if arterial catheter in situ)
(c) End-tidal carbon dioxide value greater than
20 mmHg
(3) Team-level logistics
(a) Training nontechnical skills such as team
leadership
(b) Maximize chest compression fraction by
team training and choreography, mini-
mize time to place airway, avoid unneces-
sary pulse checks, minimize pre-shock
pauses
(c) Consider mechanical CPR for patient trans-
port
Royal United Hospital, Bath, UK
Correspondence to Jerry P. Nolan, Consultant in Anaesthesia and
Intensive Care Medicine, Royal United Hospital, Combe Park, Bath
BA1 3NG, UK. Tel: +44 1225 825056; e-mail: jerry.nolan@nhs.net
Curr Opin Crit Care 2014, 20:227–233
DOI:10.1097/MCC.0000000000000083

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 Cardiopulmonary resuscitation
KEY POINTS

There is evidence that survival rates after out-of-hospital
cardiac arrest are increasing and the increase in the
rate of bystander CPR is a major contributor.

The quality of CPR is associated with outcome.

A recent consensus statement from North America
defines five key components of high-quality CPR.

Metrics of CPR performance should be monitored and
used during debriefing.
(4) Continuous quality improvement for CPR
(a) Debriefing using checklists, data from
defibrillator downloads
(b) Frequent refresher training
(c) Regular system review, for example, cardiac
arrest committee meetings
ACTIVATING THE EMERGENCY MEDICAL
SERVICES
Early recognition of the cardiac arrest and activation
of the emergency medical services (EMS) is vitally
important because this enables high-quality CPR to
be started with minimal delay. A retrospective
analysis of the Victorian Ambulance Cardiac Arrest
Registry (VACAR) in Australia identified 2842 of
44 499 (6.4%) adult OHCA cases attended by the
EMS in which the first bystander call was not directed
to the EMS; calls to relatives, friends or neighbours
accounted for 60% of these [3]. Survival-to-hospital
discharge was significantly improved if bystanders
called the EMS first [odds ratio (OR) 1.64, 95% con-
fidence interval (CI) 1.13–2.36]. Public education
initiatives, possibly using mass media, should
encourage bystanders to first call the EMS in response
to medical emergencies.
DISPATCHING AND BYSTANDER
CARDIOPULMONARY RESUSCITATION
Recent studies have documented increasing survival
&&
rates following OHCA [4 ,5,6]. Several factors are
likely to have contributed to these outcomes, but an
increase in both the rate and quality of bystander
CPR and the quality of CPR provided by EMS person-
nel are likely to be major contributors.
Bystander CPR is considered to double survival
rates after OHCA; despite this bystander CPR rates
remain low in many parts of the world. An analysis
of the Danish Cardiac Arrest Registry has docu-
mented a doubling in the rate of bystander CPR
from 21.1% (95% CI 18.8–23.4%) in 2001 to
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44.9% (95% CI 42.6–47.1%) in 2010 (P < 0.001),
and this was associated with an increase in 30-day
survival from 3.5% (95% CI 2.5–4.5%) to 10.8%
(95% CI 9.4–12.2%; P <0.001) over the same period
&&
[4 ]. The improvement in survival is multifactorial,
but the increase in the rate of bystander CPR is
probably the most significant contributor. In this
study, the contribution of dispatcher-assisted CPR
(on establishing that cardiac arrest is likely, the
dispatcher instructs the bystander to provide CPR)
is unknown because these data were not available.
The introduction of a dispatcher-assisted CPR
program will increase bystander CPR rates and
survival. In Seoul, South Korea, the rate of bystander
CPR in 2009 was just 5.7%; this increased to 12.4%
after the implementation of a dispatcher-assisted
CPR program (P < 0.001) [7]. Survival-to-hospital
discharge rates increased from 7.1% in 2009 to
9.4% in 2011 (P ¼ 0.001; adjusted OR 1.33, 95%
CI 1.07–1.66). In 2012, the AHA published a Scien-
tific Statement on EMS dispatch CPR pre-arrival
instructions [8]. Recommendations included: callers
to the EMS should be systematically questioned to
determine whether the patient may have had a
cardiac arrest; if potential cardiac arrest is identified,
if CPR is not already ongoing, the dispatcher
should give instructions for the bystander to
provide compression-only CPR; and review of audio
dispatch recordings should enable metrics to be
integrated into a quality assurance program. The
second of these recommendations is supported by
a meta-analysis of three prospective randomized
trials of dispatcher-assisted compression-only CPR
versus dispatcher-assisted standard CPR (includ-
ing mouth-to-mouth ventilation) [9–11], which
showed a 22% increase in survival-to-hospital dis-
charge with dispatcher-assisted compression-only
bystander CPR (risk ratio 1.22, 95% CI 1.01–1.47,
number needed to treat 41) [12]. Data from two of
these studies indicate that long-term survival is
higher among those patients randomized to chest-
compression only dispatcher-assisted CPR [13].
Identification of cardiac arrest by dispatchers
is not always easy and there can be a significant
delay before chest compressions are given. Dispatch
recordings for 476 OHCAs occuring in King County,
Washington, in 2011 were reviewed to identify
factors that made it difficult for dispatchers to
identify cardiac arrest and prevented or delayed
&
the provision of dispatcher-assisted CPR [14 ]. Dis-
patchers were able to identify cardiac arrest in 80%
of reviewed cases and in 92% of cases in which they
were able to assess patient consciousness and breath-
ing; of the latter, dispatcher instructions resulted in
the delivery of chest compressions in 62% of the
cases. In this study, the median time to recognition
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June 2014

of cardiac arrest was 75 s and the time to the first
dispatcher-assisted chest compressions was 175 s.
Causes of non-recognition of cardiac arrest included
callers who were not with the patient, loss of phone
contact with the caller, callers who refused or could
not assess the patient, failure to recognize agonal
respiration, and conflicting information provided
by the caller. In a similar study from Scotland,
audio recordings were downloaded from 50 sus-
pected OHCAs and compared with stages of the
&
Medical Priority Dispatch System (MPDS) [15 ].
Confirming whether the patient was breathing
took the longest time [median 59 s, inter-quartile
range (IQR) 22–82 s].
HIGH-QUALITY CARDIOPULMONARY
RESUSCITATION
A recent consensus statement from North America
defined five key components of high-quality CPR:
minimizing interruptions in chest compressions,
providing compressions of adequate rate and depth,
avoiding leaning on the chest between com-
&&
pressions, and avoiding excessive ventilation [2 ].
Minimize interruptions
The chest compression fraction (CCF) is the pro-
portion of time that chest compressions are
delivered during a cardiac arrest. Interruptions in
chest compressions reduce blood flow and oxygen
delivery to the heart and brain, and reduce the
chance of achieving ROSC and neurologically
intact survival-to-hospital discharge. In a prospec-
tive observational study of 506 adult patients from
the North American Resuscitation Outcomes Con-
sortium (ROC) Cardiac Arrest Epistry, CCFs greater
than 60% were associated with ORs for survival-to-
hospital discharge three times higher than those
with CCFs less than 20% (OR 3.01, 95% CI 1.37–
6.58) [16]. The ROC Investigators have also docu-
mented a trend toward increased ROSC with higher
CCFs among OHCA patients with non-shockable
rhythms [17]. Expert consensus is that a CCF of
80% is achievable, and this was confirmed by the
results of the Circulation Improving Resuscitation
Care (CIRC) Trial [18], in which a CCF of approxi-
mately 80% was achieved in both the AutoPulse-
CPR and manual-CPR arms of the study. A CCF of
greater than 80% is now considered optimal during
&&
both in-hospital and out-of-hospital CPR [2 ].
Strategies to increase the CCF include minimiz-
ation of the pre-shock pause by continuing chest
compressions during defibrillator charging [19,20],
&&
use of real-time feedback [21,22 ] and use of supra-
glottic airway devices instead of tracheal tubes [23]
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High-quality cardiopulmonary resuscitation Nolan
and/or continuing chest compressions during air-
way insertion [24].
In a prospective, cluster-randomized trial, the
ROC investigators showed that monitor-defibrilla-
tors equipped to provide real-time audiovisual feed-
back improved the quality of CPR, but did not
influence ROSC or other clinical outcomes [21].
The CCF in the clusters with feedback was signifi-
cantly higher than in those without feedback, but
the difference was minimal (66 versus 64%, cluster-
adjusted difference 1.9, 95% CI 0.4–3.4). Following
the implementation of scenario-based training and
real-time audiovisual feedback, investigators from
Arizona documented an increase in survival-to-hos-
pital discharge from 8.7 to 13.9% (adjusted OR 2.72,
95% CI 1.15–6.41) among 484 all-rhythm OHCA
&&
patients [22 ]. The median CCF increased from 66.2
to 83.7% (difference 17.6%; 95% CI 15.0–20.1%)
and the median pre-shock pause decreased from
26.9 to 15.5 s (difference 11.4 s; 95% CI 15.7 to
7.2 s). This before-and-after study is subject to
hidden confounders, but the data suggest that
higher-quality CPR can improve outcome.
Chest compression rate
The 2010 International consensus on CPR and emer-
gency cardiovascular care science with treatment
recommendations (2010 CoSTR) recommended a
chest compression rate of at least 100/min, but
concluded that there was insufficient evidence to
recommend a specific upper limit for compression
rate [25]. The 2010 AHA guidelines also recom-
mended a rate of 100/min, without an upper limit
[26], but the European Resuscitation Council (ERC)
recommended an upper limit of 120/min [27]. The
ROC investigators analysed 5-min periods of data
downloaded from monitor-defibrillators in 3098
OHCAs and concluded that a compression rate of
125/min was associated with the maximum rate of
ROSC [28]. Compression rates above 125/min were
associated with a declining ROSC rate probably
because of the reduced compression depth that
&
occurs at these higher compression rates [28,29 ].
The recent AHA consensus statement on CPR qual-
ity recommends a compression rate of 100–120/min
&&
[2 ].
Compression depth
The 2010 CoSTR recommended a compression
depth of at least 5 cm, but concluded that there
was insufficient evidence for an upper limit for
compression depth [25]. The 2010 AHA guidelines
are consistent with this and did not recommend an
upper limit for compression depth [26]; however,
www.co-criticalcare.com 229
 Cardiopulmonary resuscitation
the ERC recommends that the compression depth
should not exceed 6 cm [27]. An analysis of 1029
adult OHCA patients in the ROC Epistry showed
that the median compression depth was less than
&
5 cm in 91.6% of patients [29 ]. There were strong
trends toward higher rates of ROSC and survival-to-
hospital discharge with increased depth. In a study
of 593 OHCAs in Arizona, mean compression depth
was significantly deeper in those surviving to hos-
pital discharge (53.6 mm; 95% CI 50.5–56.7) than in
&
non-survivors (48.8 mm; 95% CI 47.6–50.0) [30 ].
Each 5-mm increase in mean chest compression
depth significantly increased the odds of survival
(adjusted OR 1.29, 95% CI 1.00–1.65). An analysis of
the autopsy records of 170 patients who sustained
in-hospital cardiac arrest showed an association
between mean compression depth and frequency
in men (n ¼ 110), but not in women (n ¼ 60) [31].
The frequency of injuries in mean compression
depth categories less than 5, 5–6 and greater than
6 cm was 28, 27 and 49%, respectively (P ¼ 0.06).
These studies suggest that a compression depth of
5–6 cm in adults is probably optimal.
Full chest recoil
In a pig model of cardiac arrest, incomplete chest
wall recoil during the decompression phase of CPR
(‘leaning’) reduced venous return and decreased
mean arterial pressure, and coronary and cerebral
perfusion pressures [32]. An observational study of
108 in-hospital CPR episodes has shown that
leaning is common – it occurred in 12% of all
compressions [33]. In a study by the ROC investi-
gators, use of real-time feedback during out-of-hos-
pital CPR decreased the proportion of compressions
with incomplete release [15 versus 10%; adjusted
difference 3.4 (5.2 to 1.5)] [21]. Expert consen-
&&
sus is that leaning should be minimized [2 ].
Avoidance of hyperventilation
The low cardiac output generated during CPR means
that the required minute ventilation is considerably
less than normal. In animal models of cardiac arrest,
hyperventilation increases intra-thoracic pressure
and decreases coronary perfusion pressures (CPPs)
and survival rates [34]. Clinical studies have shown
that hyperventilation during CPR is common
[34,35]. The 2010 ERC guidelines recommend a
ventilatory rate of 10 breaths/min [36] and the
AHA guidelines 8–10 breaths/min [37], once an
advanced airway is placed. Use of real-time audio-
visual feedback can reduce mean ventilation rates
during CPR: among 484 OHCA patients studied in
Arizona, implementation of feedback was associated
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with a decrease of mean ventilation rate from 11.7
to 9.5/min (difference 2.2/min; 95% CI 3.9 to
0.5/min) [22 ].
&&
MONITORING AND FEEDBACK
Current audiovisual CPR feedback devices provide
information about the quality of CPR components
such as compression depth and rate, CCF and venti-
lation rate. Use of such devices improves quality of
CPR during training and in clinical practice [21,38],
but evidence that they improve survival in humans
&&
is confined to a before-and-after study [22 ].
CORONARY PERFUSION PRESSURE
Feedback based on measurements of the physiologi-
cal response to CPR may prove to be more effective
&
[39 ]. ROSC is dependent on achieving a CPP of at
least 15–20 mmHg [40], although animal data
suggest the CPP may need to be as high as 35–
40 mmHg [41]. In a recent pig study, haemody-
namic-directed resuscitation targeting a CPP greater
than 20 mmHg during ventricular fibrillation (VF)
cardiac arrest improved 45-min survival compared
with resuscitation targeted to a chest compression
&
depth of approximately either 3 or 5 cm [42 ]. In
clinical practice, the presence of arterial and central
venous catheters during cardiac arrest will enable
CPP to be measured, and under these circumstances
expert consensus is that a CPP greater than
&&
20 mmHg should be targeted [2 ]. Expert consensus
recommends targeting an arterial diastolic pressure
during CPR of greater than 25 mmHg if an arterial
catheter, but not a central venous catheter, is
&&
present [2 ].
END-TIDAL CARBON DIOXIDE
During CPR, end-tidal carbon dioxide (ETCO2)
values are dependent mainly on pulmonary blood
flow and therefore cardiac output. End-tidal CO2
values during CPR correlate with the likelihood of
ROSC: values below 1.33 kPa (10 mmHg) strongly
predict mortality, although they are not sufficiently
reliable as the sole predictors of outcome in indi-
&
vidual cases [43 ]. ETCO2 values can be used to guide
the quality of CPR, and one study has documented
the use of ETCO2 to direct the optimal hand pos-
ition for chest compressions, which probably varies
&
among patients [44 ]. An expert consensus panel
recommends titrating CPR performance in an
attempt to achieve ETCO2 values greater than
&&
20 mmHg [2 ]. Use of capnography is essential to
confirm the location within the airway of a tracheal
&
tube [45 ] and a sudden, sustained increase in
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Number 3
June 2014

ETCO2 values provides an early indication of ROSC
[46,47].
VENTRICULAR FIBRILLATION WAVEFORM
Other potential markers of the quality of CPR
include use of a pulse oximeter, which will display
a waveform if there is sufficient pulsatile blood flow
in the peripheries [48]; VF waveform analysis using
amplitude spectrum analysis (AMSA), for example,
&
[49]; and cerebral oximetry [50,51 ]. In a double-
blind, randomized study, OHCA patients were
treated with automated external defibrillators using
either a VF waveform analysis algorithm (that used a
threshold value to determine when defibrillation
was unlikely to achieve ROSC) or a standard
&&
shock-first protocol [52 ]. This enabled selective
use of a 2-min period of CPR before attempting
defibrillation. Of the 987 patients included in the
primary analysis, there was no difference in short
or long-term survival; however, those whose VF
scores increased and exceeded the predefined
threshold value after a period of CPR had higher
survival rates than those whose score did not
achieve the threshold value. Further research is
required to determine if VF waveform analysis will
be clinically useful as a guide to the quality of CPR.
Cerebral oximetry
Regional cerebral oxygen saturation (rSO2)
measured using near infrared spectroscopy (NIRS)
[53] is undergoing investigation as a potential
tool for the prediction of ROSC and for guiding
the quality of CPR. In a study of 50 in-hospital
and OHCA patients, mean rSO2 was significantly
higher in patients who achieved ROSC compared
with those who did not (47.2  10.7% versus
31.7  12.8%; P < 0.0001); no patients with a mean
&
rSO2 value below 30% achieved ROSC [51 ]. There
are conflicting reports about the potential of NIRS
for tracking the quality of CPR. In one case series of
nine in-hospital cardiac arrests, high-quality CPR
was not reflected in the recorded rSO2 values [54];
in contrast, the authors of another series of 15
patients conclude that rSO2 values do reflect the
quality of CPR. It is too early to know whether NIRS
will have clinical value during CPR and further
research is clearly required [55].
MECHANICAL CARDIOPULMONARY
RESUSCITATION
Manual CPR is tiring and the quality of chest
compressions deteriorates within 1–2 min [56,57].
Providing high-quality manual CPR during patient
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High-quality cardiopulmonary resuscitation Nolan
transport is extremely challenging. Mechanical
chest compression devices enable high-quality
CPR to be sustained for long periods and during
patient transport [58]. The two main devices in
clinical use are the AutoPulse (Zoll, Chelmsford,
Massachusetts, USA) load-distributing band and
the Lund University Cardiac Arrest System (LUCAS)
Chest Compression System (Physio-Control/Jolife
AB). These devices improve haemodynamic values
during human cardiac arrest [59], but whether they
improve survival is unclear. The CIRC trial [18]
recruited more than 4000 OHCA patients, but
showed no significant difference in survival-to-hos-
pital discharge between the AutoPulse-CPR and
manual-CPR arms of the study. In the LUCAS in
Cardiac Arrest (LINC) trial, 2589 OHCA patients
were randomized to either LUCAS-CPR combined
with defibrillation during ongoing compressions or
&&
to manual CPR [60 ]. After 4-h survival, the primary
endpoint was the same in both groups (23.6 and
23.7%). CCF data were available in only 10% of
patients and this showed a CCF of 0.78 in the
manual CPR group and 0.84 in the mechanical
CPR group. The results of a large cluster-randomized
trial comparing LUCAS-CPR with manual CPR [61]
will be presented later this year (Perkins, personal
communication). Pending the results of this latest
trial, the precise role of mechanical CPR has yet to be
determined and the recommendations to be made
by the International Liaison Committee on Resus-
citation (ILCOR) in 2015 are awaited with consider-
able interest [62]. In the mean time, the primary role
for mechanical devices is likely to be in select cases
to provide CPR during patient transport and to
facilitate percutaneous coronary intervention in
the cardiac catheterization laboratory [63].
NON-TECHNICAL SKILLS
Non-technical skills, such as situational awareness,
decision-making, effective communication, team
work and task management, play a significant role
&
in enabling high-quality CPR [39 ,64]. In a simu-
lation study, teams led by leaders with the best
leadership skills performed higher-quality CPR with
better technical performance, shorter pre-shock
pauses, higher CCF and shorter time to first shock
[64]. Post-cardiac arrest debriefing is another effec-
&
tive strategy for improving the quality of CPR [65 ].
A meta-analysis of two cardiac arrest studies docu-
mented an increased CCF (mean difference 6.80;
95% CI 4.19–9.40, P < 0.001) with debriefing
&
[66,67,68 ], and a meta-analysis of four cardiac
arrest studies documented increased rates of ROSC
(OR 1.46, 95% CI 1.01–2.13, P ¼ 0.05) with debrief-
ing, but there was no effect on survival-to-hospital
www.co-criticalcare.com 231
 Cardiopulmonary resuscitation
discharge (OR 0.80, 95% CI0.38–1.67, P ¼ 0.55)
&
[66,67,68 ,69,70]. Debriefing may include the use
of checklists, defibrillator data downloads, video
recordings and medical records. Hot debriefing is
undertaken immediately after the resuscitation and
is normally led by the resuscitation team leader. This
is probably the commonest form of debriefing, but is
not as effective cold debriefing, which takes places a
few days later and includes performance data from
defibrillator downloads and occasionally video
& 11. Svensson L, Bohm K, Castren M, et al. Compression-only CPR or standard
recordings [65 ].
CONCLUSION
There is evidence for increasing survival rates fol-
lowing OHCA and this is associated with increasing
rates of bystander CPR. An immediate alert to the
EMS should be followed by early bystander CPR,
which is dispatcher-assisted if the bystander is not
trained or unsure. The quality of CPR provided by
healthcare professionals influences outcome. A
recent consensus statement by the AHA defines
the components of high-quality CPR and the met-
rics that can be measured and fed back to healthcare
professionals. Real-time feedback devices improve
the quality of CPR, but in the future, feedback based
on the physiological responses to CPR may prove
more effective.
Acknowledgements
None.
Conflicts of interest
J.P.N. is editor-in-chief of the journal Resuscitation.
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30. Vadeboncoeur T, Stolz U, Panchal A, et al. Chest compression depth and
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Very useful editorial on several issues relating to CPR quality.
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A useful up-to-date review on the use of capnography to predict outcome during
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The first study that suggest that capnography can be used to guide the quality of
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A review that covers most of the current controversies in airway management
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One of several recent observational studies documenting the value of cerebral
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An important double-blind randomized study that used a VF waveform analysis
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One of the first large-scale randomized trials of a mechanical CPR device, in this
case LUCAS. Although it showed outcome benefit for LUCAS-CPR it remains an
important high-quality CPR study.
61. Perkins GD, Woollard M, Cooke MW, et al. Prehospital randomised assess-
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65. Couper K, Perkins GD. Debriefing after resuscitation. Curr Opin Crit Care
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