Dallas 2015 TFQO: Myra Wyckoff #COI EVREV 1: Myra Wyckoff #COI EVREV 2: Lindsay Mildenhall #107 Taskforce: NRP NRP: 605 Two thumb verses two finger

Dallas 2015 COI Disclosure (specific to this systematic review) EVREV 1 COI# Commercial/industry Nil Potential intellectual conflicts Nil EVREV 2 COI #107 Commercial/industry Nil Potential intellectual conflicts Nil

Dallas CoSTR Chest compressions in the newborn should be delivered by the 2 thumb–encircling hands method as the preferred option. Compressions should be centered over the lower third of the sternum and should compress the chest one third the anterior- posterior diameter. Any chest compressions should be performed in combination with adequate inflation breaths.

Dallas 2015 C2015 PICO Population:Neonates receiving cardiac compressions Intervention:Does the use of a Two thumb technique Comparison:As opposed to a Two finger technique Outcomes: 9-Critical decrease time to ROSC 9-Criticalimprove neurological outcomes 9-Criticalincrease survival rates 8-Criticalimprove perfusion/gas exchange 6-Importantdecreased compressor fatigue

Dallas 2015 Inclusion/Exclusion & Articles Found Inclusions Neonatal / Infants / Animal / Manikins RCT, Observational Exclusions: Adult, V-Fib, Abstracts, Editorials Number of Articles initially identified80 Finally Included in Evidence Profile tables RCTs13 non-RCTs15 Excluded52

Dallas Proposed Treatment Recommendations We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option (weak recommendation, very low quality of evidence). Compressions should be delivered over the lower 1/3 of sternum.

Dallas 2015 Risk of Bias in studies RCT bias assessment StudyYearDesign Total Patients Population Industry Funding Allocation: Generation Allocation: Concealment Blinding: Participants Blinding: Assessors Outcome: Complete Outcome: Selective Other Bias Menegazzi 1993RCT5 BLSPigletsNilLow High Low Houri 1997RCT11 BLSPigletsNilLowUnclearHigh Low Dorfsman 2000RCT21 ERManikinsNilLowHighLowHighLow Whitelaw 2000RCT209 BLSManikinsNilHigh Low Udassi (PCC) 2009RCT32 BLSManikinsNilUnclear LowHighLow Udassi (R) 2009RCT 64 BLS ManikinsNilLow Unclear Udassi S 2010RCT34 BLSManikinsNilLow Christman 2011RCT25 NRPManikinsNilUnclear LowHighLow Fakhraddin 2011RCT60 PALSManikinsNilUnclear LowHighLow High Huynh 2012RCT20 NRPManikinsNilUnclear LowHighLow Martin (ADCH) 2013RCT22 APLSManikinsNilUnclear Low Martin p RCT40 EPLSManikinsNilUnclear LowHighLow Unclear Martin p RCT69 APLSManikinsNilLowUnclearLowUnclearLow

Dallas 2015 Risk of Bias in studies Non-RCT bias asssesment StudyYearDesignTotal PatientsPopulationIndustry Funding Eligibility Criteria Exposure/Outcome Confounding Follow up Moya 1962 Non-RCT 5NeonatesNilHigh Thaler 1963 Non-RCT MixedHumansNilHigh Todres 1975 Non-RCT 1NeonatesNilHigh Orlowski 1985 Non-RCT MixedHumansNilHigh Phillips 1986 Non-RCT 55HumansNilHigh David 1988 Non-RCT 2NeonatesNilHigh Clements 2000 Non-RCT 30HumansNilHigh You 2009 Non-RCT 75HumansNilHigh S H Lee 2011 Non-RCT 84 HumansNilHigh Saini 2012 Non-RCT 39 NeonatesNilLow High Lim 2013 Non-RCT 48 BLS ManikinNilLow High Dellimore 2013 Non-RCT 1 ManikinNilHigh K H Lee 2013 Non-RCT 63 HumansNilHigh Franke 2014 Non-RCT 80 HumansNilHigh Park 2014 Non-RCT 40 BLSManikinNilLow High

Dallas 2015 Key data from key studies Reference: Case Hx: David, 1988; Moya, 1962; Thaler, 1963; Todres, 1975 P: Neonates receiving chest compressions I:TT C:TF O: David 1988, 552 Todres 1975, 781

Dallas 2015 Key data from key studies Reference: Menegazzi 1993; Houri 1997 P: Piglets receiving chest compressions I:TT C:TF O: Houri 1997, 65 Menegazzi 1993, 240

Dallas 2015 Evidence profile table(s) Population: Neonates needing cardiac compressions Intervention: Two thumb Comparison: Two finger Outcome: Decrease time to ROSC Decrease time to ROSC No data CRITICAL-9 OutcomeNo of studies Author Year 1 st page Study Design Risk of bias Inconsist- ency Indirect- ness ImprecisionOther (including publication bias) Quality of evidence for outcome Importance Population: Neonates needing cardiac compressions Intervention: Two thumb Comparison: Two finger Outcome: Improve neurologic outcomes OutcomeNo of studies Author Year 1 st page Study Design Risk of bias Inconsist- ency Indirect- ness ImprecisionOther (including publication bias) Quality of evidence for outcome Importance Improve neurologic outcomes No data CRITICAL-9

Dallas 2015 Evidence profile table(s) Population: Neonates needing cardiac compressions Intervention: Two thumb Comparison: Two finger Outcome: Increase survival rates OutcomeNo of studies Author Year 1 st page Study Design Risk of bias Inconsist- ency Indirect- ness ImprecisionOther (including publication bias) Quality of evidence for outcome Importance Increase survival rates No data CRITICAL-9

Dallas 2015 Evidence profile table(s) Population: Neonates needing cardiac compressions Intervention: Two thumb Comparison: Two finger Outcome: Improved perfusion and gas exchange during CPR OutcomeNo of studies Author Year 1 st page Study Design Risk of bias Inconsist- ency Indirect- ness ImprecisionOther (including publication bias) Quality of evidence for outcome Importance Improved perfusion and gas exchange during CPR 15 Studies Christman, 2010, 99 Dorfsman, 2000, 1077 Houri, 1993, 65 Martin, 2013, 576 Martin, 2013, 666 Martin, 2013, 1125 Menegazzi, 1993, 240 Udassi, 2010, 712 Whitelaw, 2000, 213 David, 1988, 552 Moya, 1962, 798 Thaler, 1963, 606 Todres, 1975, 781 Dellimore, 2013, 350 Park, 2014, 1659 RCT Non- RCT SeriousNot Serious Serious (manikins or swine model) Human case reports Manikins SeriousNot Serious Very Low CRITICAL-8

Dallas 2015 Evidence profile table(s) Population: Neonates needing cardiac compressions Intervention: Two thumb Comparison: Two finger Outcome: Decrease Compressor fatigue OutcomeNo of studies Author Year 1 st page Study Design Risk of bias Inconsist- ency Indirect- ness ImprecisionOther (including publication bias) Quality of evidence for outcome Importance Decreased Compresso r fatigue 4 Studies Dorfsman, 2000, 1077 Huynh, 2012, 658 Udassi, 2009, 328 Udassi, 2010,712 RCT SeriousNot Serious Serious (manikins only) SeriousNot Serious Very Low IMPORTANT -6

Dallas 2015 Proposed Consensus on Science statements ​ For the critical outcome of Time to ROSC, we found no data. For the critical outcome of Survival Rates, we found no data For the critical outcome of Neurologic Injury, we found no data.

Dallas 2015 Proposed Consensus on Science statements ​ For the critical outcome of “improved perfusion and gas exchange during CPR” we identified low quality evidence from 9 RCT’s (7 manikin and 2 piglet down graded for indirectness and imprecision) and 6 Non-RCT’s (4 human and 2 manikin down graded for indirectness, imprecision and high risk of bias) Summary: Higher BP (force) generation identified with the two thumb method verses the two finger.

Dallas 2015 Proposed Consensus on Science statements For the important outcome of “compressor fatigue” we identified low quality evidence from 4 RCT’s using manikins (downgraded for indirectness and imprecision): 2 identifying less fatigue with the two thumb technique and 2 finding no difference.

Dallas 2015 Proposed Consensus on Science statements New Compression Methods: Fakhraddin, 2011, 15: New method (Thumb and index finger-TIF) compared with TT and TF on manikins. Udassi, 2009, 1158: Manikin study using adhesive glove compared with standard CPR in 4 groups including infant group. Summary: No evidence that the new thumb and index finger technique is superior to two thumb method. Adhesive glove enhanced active decompression but did not reduce fatigue.

Dallas 2015 Proposed Consensus on Science statements Best Location on the Sternum: 8 non-RCT’s Infants: Phillips, 1986; Orlowski, 1986; Clements, 2000; Saini, 2012; supporting chest compressions best performed over lower third of the sternum plus further support for TT over TF Infant CT scan / manikin measurements: You, 2009; Lee, 2011; Lim, 2012; Lee, 2013; LV mostly under lower third of sternum. TT and superimposed thumbs method less likely to compress other structures Summary: Lower one third of sternum remains the best location to compress the newborn heart. Superimposed thumbs maybe the better technique.

Dallas Draft Treatment Recommendations We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option (weak recommendation, very low quality of evidence). Compressions should be delivered over the lower 1/3 of sternum.

Dallas 2015 Knowledge Gaps No studies of any kind available regarding the most critical outcomes No data from good transitional models Very limited human neonatal data

Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date Essential slide (one slide only). Estimated time <30 sec