Cardiology

Physical activity and quality of cardiopulmonary resuscitation: A secondary analysis of the MANI-CPR trial

a b s t r a c t

Introduction: The association between the level of physical activity and quality of Cardio-pulmonary resuscitation performed by laypeople is unclear. The aim of this study was to evaluate the associations between physical activity level and laypeople performance during an eight-minute scenario of CPR.

Materials and methods: This study was a secondary analysis of the MANI-CPR Trial. The entire cohort of partici- pants was grouped based on the level of physical activity assessed using the International Physical Activity Ques- tionnaire (IPAQ) into a “low-moderate” level group and a “high” level group. Descriptive statistics were used for unadjusted analysis and multivariate logistic and Linear regression models were also performed.

Results: A total of 492 participants who reached the score of “Advanced CPR performer” at the 1-min final test monitored by Laerdal Resusci Anne QCPR were included in this analysis; 224 with a low-moderate level and 268 with a high level of physical activity. A statistically significant difference was found for the outcome of per- centage of compressions with adequate depth (low-moderate group: 87.8% [41.4%-99.3%], high group: 97% [63.2%-100%]; P = 0.003). No associations remained significant after controlling for biometric characteristics of the participants, compression protocols and sex.

Conclusion: Adequate quality CPR may not need high baseline level of physical activity to be performed by a lay rescuer.

(C) 2021

  1. Introduction

Out-of-hospital cardiac arrests is a global health issue with an incidence of 40.6 per 100,000 person-years in Europe and is witnessed by laypeople in 37-70% of the cases [1]. Cardio-pulmonary resuscitation (CPR) performed by bystanders before the arrival of a pro- fessional emergency team is associated with better survival rate and

Abbreviations: BLS, Basic life support; BMI, Body mass index; CPR, Cardiopulmonary resuscitation; IPAQ, International Physical Activity Questionnaire; OHCA, Out-of-hospital cardiac arrests.

* Corresponding author at: Department of Surgical, Oncological and Oral Science (Di. Chir.On.S.), University of Palermo, Italy.

E-mail address: [email protected] (A. Cortegiani).

neurological outcomes after out-of-hospital cardiac arrests [2,3]. For laypeople witnessing an OHCA, the decision to start CPR is strongly related to the ability to recognize the event, but is also probably affected by how much the bystander feels qualified for the task. For this reason, many basic life support (BLS) courses are offered worldwide to laypeople, with the aim of maximizing the number of bystanders able to provide help in such emergencies [4]. The most updated recom- mendation for lay rescuers is to prioritize chest compressions, eventu- ally performing them without interruptions, especially in the cases in which the bystander is not willing to perform mouth-to-mouth ventilation or is not trained in performing it [5-7]. This aspect has been stressed during COVID-19 period, as International Liaison Commit- tee on Resuscitation (ILCOR) and scientific societies issued specific guid- ance recommending laypeople to perform compression-only CPR,

https://doi.org/10.1016/j.ajem.2021.08.039

0735-6757/(C) 2021

withdrawing mouth-to-mouth ventilation, at least if the victim is a non- household member [8-10].

Factors associated with the Quality of CPR and its associated vari- ables have been widely investigated and it is well known that the CPR quality decreases rapidly, as early as 1-min, due to the physical effort needed to perform it [11]. In the MANI-CPR trial [12], it was hypothe- sized that intentional interruptions during the CPR could increase its quality when performed by laypeople, in comparison with the compression-only technique. The study tested this hypothesis on lay- people performing CPR on manikins during an 8-min scenario, which is the mean Time to intervention of Emergency Medical Services (EMS) on a Cardiac arrest scenario all over the world [13]. The study found that CPR protocols composed by 30 compressions and 2 s inter- ruptions (30c2s) or 50 compressions and 5 s interruptions (50c5s) were associated with a significantly higher percentage of compressions with correct depth, in comparison with the compression-only tech- nique. To date, the association between the level of physical activity and quality of CPR performed by laypeople is unclear. However, evi- dence suggests that biometric features of rescuers (e.g. gender, BMI) [14-16] may affect the quality of the performed CPR, both for laypeople and professional rescuers, and there are only few studies on very small populations which suggest that physical training may improve the qual- ity or the duration of CPR [17-19].

The aim of this study was to evaluate the associations between phys- ical activity level and laypeople performance during eight-minute sce- nario of CPR.

  1. Materials and methods

This study was a secondary analysis of the “Multicenter International Randomized Controlled Manikin Study on Different Protocols of Cardio- pulmonary Resuscitation for Laypeople (MANI-CPR Trial) [12]. The trial was prospectively registered in clinicaltrials.gov (NCT02632500) and was conducted in eight centers with experience in providing BLS courses, according to ILCOR 2015 recommendations. The study protocol and the main analysis have been published [12,20]. In the trial, laypeo- ple who attended a standard BLS/AED course according to ILCOR 2015 recommendations and reached the score of “Advanced CPR performer” at the 1-min final test monitored by Laerdal Resusci Anne QCPR [21,22], were invited to join the trial. Participants were randomized to one of the following 4 study techniques: 30c2s, 50c5s, 100 compressions and 10-s pause (100c10s), or compressions only in a 8-min scenario, on the Laerdal Resusci Anne QCPR manikin, connected to the QCPR software, without feedbacks or help from both the trainers or the software. For the purpose of the study, correct rate of compressions was defined as a rate comprised within 100 and 120 per minute, correct depth was de- fined as at least 5 cm, pauses were considered as 10-s pause up to 10.5 s and 11-s pause if 10.51 s or longer, “flow fraction” was defined as time where compressions were given.

After providing their consent, the participants answered to the Inter- national Physical Activity Questionnaire (IPAQ), aimed to assess the level of physical activity; height, weight, and body mass index (BMI) were also collected. The IPAQ is composed of seven open-ended ques- tions surveying the respondent’s physical activity during the preceding 7-day. The respondent was then scored as “high”, “moderate” or “low” level of physical activity according to the IPAQ scoring protocol [23]. For the purpose of this analysis, the entire cohort of participants was grouped on the basis of the level of physical activity assessed using the IPAQ into a “low-moderate” level group and a “high” level group. This subdivision allowed us to better evaluate the effect of a high level of physical activity, compared to more frequent and achievable levels of physical activity (low and moderate) as a unique comparison group. The primary outcome was the percentage of compressions with ad- equate depth (at least 5 cm) among the groups; secondary outcomes were percentage of compressions with correct rate, compression depth, percentage of correctly released compressions, percentage of

compressions with correct hand position, compression rate, flow frac- tion, duration of pauses, presence of pauses longer than ten seconds.

    1. Data management and analysis

Descriptive analysis was carried out using median and interquartile range (IQR) for the quantitative variables and percentages values for the qualitative ones. Normality distribution for quantitative variables was assessed by the Shapiro-Wilk Test. The association between endpoint variable (physical activity level) and explicative variables was investi- gated by Pearson ?2 test or the Fisher’s exact test for categorical data and non-parametric Wilcoxon rank-sum test for unpaired two- samples for continuous data.

Fractional logistic regression model was performed for the primary outcome, the percentage of compressions with adequate depth. Age, sex, BMI, CPR protocols (other than compressions only) and level of physical activity (high) were considered as independent variables. Sta- tistical significance was taken at the <0.05 level. All analyses were per- formed using STATA software v15.1 (StataCorp, College Station, USA).

  1. Results

A total of 492 participants, out of the 517 included in the original study, answered the IPAQ questionnaire, and were included in this anal- ysis. Of these, 224 had a low-moderate level of physical activity, and 268 had a high level of physical activity, according to IPAQ scoring. The base- line characteristics of the participants and the distribution across the trial protocols are presented in Table 1.

In our sample the high level of physical activity was significantly more common in male than female participants (76.5% vs. 23.5%, P < 0.001), and participants had a higher median height (176 cm vs 174 cm, P = 0.026).

    1. Unadjusted analysis

The results of all the evaluated outcomes are presented in Table 2, according to the level of physical activity. A statistically significant dif- ference was found for the outcome of percentage of compressions with adequate depth (low-moderate group: 87.8% [41.4%-99.3%], high group: 97% [63.2%-100%]; P = 0.003). No significant difference was observed in the percentage of correctly released compressions, ad- equate rate, total duration of pauses, number of pauses, duration of the longest pause, number of pauses longer than ten seconds, and flow frac- tion. We also found statistically significant differences between the two groups for the outcomes of compression depth in mm (low-moderate group: 53.5 [48-58], high group: 56 [51-60]; P = 0.001), compression rate (low-moderate group: 111.5 [105-118], high group: 114

Table 1 Baseline characteristics of the included participants, grouped based on the level of physical activity according to International Physical Activity Questionnaire and their distribution

across the randomized protocols.

Low-Intermediate

High

p.value

224 (45.5%)

268 (54.5%)

Sex, n(%)

Female

92 (41%)

63 (23.5%)

<0.0001

Male

132 (58.9%)

205 (76.5%)

Age, years

30 [24-42]

26 [23-39.5]

0.065

BMI, kg/m2

23.9 [21.7-26.7]

23.6 [21.6-25.6]

0.125

Height, cm

174 [167-180]

176 [170-180]

0.026

Weight, kg

72.5 [63.5-83.5]

73 [65-80]

0.939

Randomized protocol, n(%)

100c10s

47 (21%)

78 (29%)

0.193

30c2s

61 (27%)

64 (24%)

50c5s

53 (24%)

63 (23.5%)

Compression only

63 (28%)

63 (23.5%)

Data are reported as median [IQR] or numbers and percentages, as appropriate.

Table 2

Quality of CPR.

Low-moderate High p.value

compression depth) did not remain significant after controlling for bio- metric characteristics of the participants, compression protocols and sex. Furthermore, the observed differences related to the outcomes of compression depth and compression rate in the unadjusted analysis, were not clinically relevant (i.e. both groups remaining in the ranges of adequacy). These findings suggest that a high level of physical activity may not significantly improve the performance of lay rescuers that have recently attended a certified BLS course. However, this is in contrast with the results of a recent randomized trial, conducted on 50 active and first-year university students, randomized to perform CPR after a physical training period or no training period. The study showed that re- ceiving a four-week strength training program may improve the quality of CPR in a 10 min scenario of chest compressions and mouth-to-mouth ventilation on manikins [17]. Although these findings may suggest a specific physical training to be provided in addition to a standard BLS course, strong limitations affect the findings: the population analyzed consisted of young students, the physical training program was focused on the muscles involved in chest compressions, which is not a real-life

The table shows the outcomes measurements, describing the quality of CPR as performed by the two evaluated groups.

Total Compressions, n

Correctly Released

786

[722.5-852.5]

98 [88-100]

792.5

[734.5-855.5]

98 [88-100]

0.325

0.812

Compressions, %

Compression Depth, mm

53.5 [48-58]

56 [51-60]

0.001

Adequate Depth, %

87.8 [41.4-99.3]

97 [63.2-100]

0.003

Adequate Rate, %

81 [44.4-95.7]

79.5 [38.5-96]

0.945

Compression Mean Rate, n/min

111.5 [105-118]

114 [108-119]

0.017

correct hand position, %

100 [96-100]

100 [88.5-100]

0.023

Total duration of pauses, s

62 [30-80]

66 [36-83]

0.306

Pauses, n

12 [4-20]

9 [6-16]

0.734

Duration of the longest pause, s

Pauses longer than 10 s, n (%)

6 [3-11.5]

7 [3-12]

0.291

Absence

160 (71.4%)

183 (68.3%)

0.450

Presence

64 (28.6%)

85 (31.7%)

Flow fraction, %

87.1 [83.2-93.8]

86.3 [82.7-92.5]

0.306

Data are reported as median [IQR] or numbers and percentages, as appropriate.

[108-119]; P = 0.017) and percentage of correct hand position during CPR (low-moderate group: 100 [96-100], high group: 100 [88.5-100]; P = 0.023).

    1. Adjusted analyses

The variables age, sex, BMI, CPR protocols (other than compressions only) and level of physical activity (high) were considered in the ad- justed models. The detailed results of the adjusted analysis for the pri- mary outcome of adequate depth is provided in Table 3

No significant association was found between a high level of physical activity and adequate compression depth. Adequate compression depth was associated with male sex (OR 3.95 [2.85-5.46], P < 0.001), BMI (OR 1.11 [1.06-1.17], P < 0.001), and the protocols 30c2s (OR 2.13 [1.41-3.23], P < 0.001) and 50c5s (OR 2.08 [1.35-3.19], P = 0.001)

in comparison with compression-only.

  1. Discussion

To the best of our knowledge, this is the first study evaluating the as- sociations between lay rescuers’ level of physical activity and the quality of CPR, performed on manikins in a 8-min scenario without any audio- visual feedback.

Our main finding was that, in the unadjusted analysis, laypeople with a high level of physical activity performed CPR reaching a better quality, according to the evaluated outcomes. The association between a high level of physical activity and the primary outcome (adequate

Table 3

Fractional logistic regression for Adequate depth

OR (95%CI)

p.value

Sex (M vs F)

3.95 (2.85-5.46)

<0.001

Age, years

0.99 (0.98-1.01)

0.756

Bmi, kg/m2

1.11 (1.06-1.17)

<0.001

Protocols

Compression-only

1

100c10s

1.42 (0.93-2.15)

0.100

30c2s

2.13 (1.41-3.23)

<0.001

50c5s

2.08 (1.35-3.19)

0.001

Level of physical activity Low + Intermediate

1

High

1.24 (0.91-1.68)

0.168

The table shows the results of multivariate fractional logistic regression for the outcome of adequate depth.

situation and, moreover, no one could know when he/she may witness an OHCA. Thus, baseline level of physical activity should be considered more relevant for real life settings involving laypeople. Our findings may provide reassuring information for laypeople deciding to attend a CPR training course and should be probably conveyed as a key message: good quality CPR does not probably need a high baseline level of phys- ical activity to be well performed by a lay rescuer.

Adequate compression depth was independently associated with male sex (OR 3.95 [2.85-5.46], P < 0.001) and BMI (OR 1.11 [1.06-1.17], P < 0.001). This finding was in line with those by Lopez-Gonzalez et al., who performed a study on 63 students performing CPR for 20-min or until exhaustion on manikins. The study suggested that the heaviest people perform better than those who are underweight, in terms of adequate external chest compressions and ad- equate depth, independently of baseline muscle strength [14]. More- over, it is known that the quality of compressions-only CPR, performed by lay rescuers, decreases after the first minute [11], inde- pendently of the BMI or level of physical activity [24] and that rescuers may detect their own fatigue later than it occurs [25]. Additionally, even healthcare professionals with a high level of physical activity may reach the maximum fatigue after approximately 3-4 min of CPR [26]. Hasegawa et al. evaluated the performance of 18 nurses during a 5- min scenario of CPR on manikins, and concluded that individuals may rotate at 1-min intervals to maintain CPR quality over time, especially those with a low body weight [27]. Lucia et al. compared the perfor- mance of 14 sedentary healthcare professionals vs. 14 physically active laypeople on a 18-min CPR scenario [28]. They found that the overall performance was similar in both groups, but that duration of CPR was affected by the level of physical activity, i.e. fatigue led four participants from the sedentary group to stop CPR.

Considering these data, intentional interruptions and rotation of the rescuers have further relevance. Indeed, in our analysis, flow fraction was higher greater than 80%, which is the cutoff value for optimal out- come recommended by a recent consensus statement from the American Heart Association, both in “low-moderate” and “high” level groups.

CPR quality is also affected by Anthropometric variables. It is known that heavier people reach a better compression depth, but people who are heavier, taller, with a greater BMI and male are less likely to achieve a complete chest recoil [16]. The practical suggestions to be provided by instructors during a BLS course should probably be tailored on the phys- ical characteristics of the participants, i.e. that each participant should be invited to pay specific attention to the task he/she is at risk to fail, al- though the trainees’ attention should prioritize the performance feed- back they receive from the Feedback devices.

Some authors had issued suggestions towards people with a low body weight, e.g. improving their level of strength in arms [14] or join- ing a fitness program with muscle strength exercise [29]. Although

these indications seem in contrast with our findings, the different find- ings and conclusions may be explained by the large heterogeneity of populations (e.g. professional Healthcare workers or laypeople, an- thropometric characteristics), setting (e.g. duration of CPR scenario, compression protocols, availability of audiovisual feedbacks) and out- comes measurements.

Our analysis has limitations. Our study was performed on manikins, thus limiting the described evidence to real-life scenarios. Indeed, other tasks may be required of a rescuer (e.g. run to the scene [30], or wearing Personal protective equipment [31] in case of COVID-19 setting [32,33]), probably affecting the quality and the outcomes of CPR [34]. Moreover, the study group is a skewed, nonrandom sample represent- ing less than 25% of the total group of laypeople completing the training (i.e. people reaching >=75% in the parameters evaluated), thus limiting clinical significance and generalizability of the results. Indeed, we did not collect data on the level of physical activity from those participants who did not reach the ‘Advanced CPR performer’ threshold, since this was an inclusion criterion of the original trial. Thus, we could not com- pare the level of physical activity of this group of participants to those who reached it. External validity is also limited by the relatively young age of the participants, self-reported data on weight and height (i.e. we did not measure anthropometric features), the absence of any eval- uation of fatigue or physical strain and no objective exercise testing or evaluation of strength and endurance [35]. However, our study has strengths, such as the design (i.e. randomized trial), the absence of au- diovisual feedbacks provided during the performance, the duration of the scenario and the number of participants.

  1. Conclusions

No associations were found between a high level of physical activity and the quality of CPR performed by laypeople in a 8-min scenario of OHCA on manikins. A good quality CPR does not probably need a high baseline level of physical activity to be well performed by a lay rescuer. Future research should focus on the best compression protocol for lay- people, specifically considering intentional interruption and rotation timing, in populations as similar as possible to the general public.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Authors’ contribution

All the authors approved the final version of the manuscript and agreed to be personally accountable for all aspects of the work in ensur- ing that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Data sharing statement

The authors confirm that the data supporting the findings of this study are available from the corresponding author upon reasonable re- quest.

Declaration of interests”>Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influ- ence the work reported in this paper.

Acknowledgements

We wish to thank all the participants and all the volunteers and workers of the training centers involved in the study.

MANI-CPR collaborators list:

  • Pavia nel Cuore, Pavia, Italy: Martina Paglino, Chiara Barbati, Alessandro Agazzi, Marta Baggiani, Maria Concetta Bonomo, Gianni Bruno, Patrizia Castoldi, Eleonora Cerutti, Stefano Cornara, Amedeo Cutuli, Cinzia Dossena, Francesco Epis, Dario Fina, Alice Gabbrielli, Guido Giardini, Roberto Magnani, Luca Marzi, Francesca Mursia, Alberto Somaschini, Simone Somma, Francesco Tamborini, Alessandro Tavernari, Michela Tonani, Francesco Torresani, Davide Zacconi.
  • Department of Surgical, Oncological and Oral Science (Di.Chir.On. S.). Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy: Marinella Pugliesi, Pasquale Iozzo, Eugenia Maria Grutta, Francesca Montalto, Alessandra Moscarelli, Oriana Danile.
  • Robbio nel Cuore, Robbio, Italy: Daniele Bertaia, Alessandro Abate, Elia Arrigoni, Carola Bollato, Luca Calligari, Marila Cervio, Elisa Cusaro, Filomena Di Lauro, Cesare Ginju, Carola Isola, Luca Magarotto, Mauro Marzolla, Daniele Montagnini, Fabio Negrello, Roberto Sambinello.
  • Federazione Cantonale Ticinese Servizi Autoambulanze, Lugano, Switzerland: Christian Tami, Marco Verdi.
  • Emergency Training Center, Cugy, Switzerland: Daniel Lopez, Caro- line Tinguely.
  • Centro Studi e Formazione Gymnasium, Pordenone, Italy: Susi Boldarin, Claudio Deiuri, Luca Pontani, Roberto Bidinost.
  • Ecole Superieure d’Ambulancier et Soins d’Urgence Romande (ES- ASUR), Lausanne, Switzerland: Sandrine Denereaz, Yves Denereaz, Fabrice Follonier, Frederic Salamin, Marion Debono, Bruno Puveland, Audrey Von Buhren, Christian Vuille, Laurent Perriard, Dorothea Chuard, Damien Hennet, Cedric Frioud, Andrew Hobson.
  • Formamed Sarl, Cortaillod, Switzerland: Michael Terrapon, Carina Canelo, Matthieu Nonorgue.

References

  1. Kiguchi T, Okubo M, Nishiyama C, Maconochie I, Ong MEH, Kern KB, et al. Out-of- hospital cardiac arrest across the world: first report from the International Liaison Committee on Resuscitation . Resuscitation. 2020;152:39-49. https://doi. org/10.1016/j.resuscitation.2020.02.044.
  2. Hasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P, et al. early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015; 372:2307-15. https://doi.org/10.1056/nejmoa1405796.
  3. Yasunaga H, Horiguchi H, Tanabe S, Akahane M, Ogawa T, Koike S, et al. Collaborative effects of bystander-initiated cardiopulmonary resuscitation and prehospital ad- vanced cardiac life support by physicians on survival of out-of-hospital cardiac ar- rest: a nationwide population-based observational study. Crit Care. 2010;14. https://doi.org/10.1186/cc9319.
  4. Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, et al. Education, imple- mentation, and teams. Circulation. 2020;142:S222-83. https://doi.org/10.1161/CIR. 0000000000000896.
  5. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142:S366-468. https://doi.org/10.1161/CIR.0000000000000916.
  6. Olasveengen TM, Semeraro F, Ristagno G, Castren M, Handley A, Kuzovlev A, et al. European resuscitation council guidelines 2021: basic life support. Resuscitation. 2021;161:98-114. https://doi.org/10.1016/j.resuscitation.2021.02.009.
  7. Baldi E, Bertaia D, Savastano S. Mouth-to-mouth: an obstacle to cardio-pulmonary resuscitation for lay-rescuers. Resuscitation. 2014;85:e195-6. https://doi.org/10. 1016/j.resuscitation.2014.10.001.
  8. Nolan JP, Monsieurs KG, Bossaert L, Bottiger BW, Greif R, Lott C, et al. European re- suscitation council COVID-19 guidelines executive summary. Resuscitation. 2020: 1-11. https://doi.org/10.1016/j.resuscitation.2020.06.001.
  9. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines-resuscitation adult and pediatric task forces of the. Circulation. 2020:E933-43. https://doi.org/10.1161/CIRCULATIONAHA.120.047463.
  10. Baldi E, Contri E, Savastano S, Cortegiani A. The challenge of laypeople cardio- pulmonary resuscitation training during and after COVID-19 pandemic. Resuscita- tion. 2020. https://doi.org/10.1016/j.resuscitation.2020.04.040.
  11. Nishiyama C, Iwami T, Kawamura T, Ando M, Yonemoto N, Hiraide A, et al. Quality of chest compressions during continuous CPR; comparison between chest compression-only CPR and conventional CPR. Resuscitation. 2010;81:1152-5. https://doi.org/10.1016/j.resuscitation.2010.05.008.
  12. Baldi E, Contri E, Burkart R, Borrelli P, Ferraro OE, Paglino M, et al. A multicenter in- ternational randomized controlled manikin study on different protocols of

cardiopulmonary resuscitation for laypeople. Simul Healthc. 2021;16(4):239-45. https://doi.org/10.1097/sih.0000000000000505.

  1. Mauri R, Burkart R, Benvenuti C, Caputo ML, Moccetti T, Del Bufalo A, et al. Better management of out-of-hospital cardiac arrest increases survival erate and improves neurological outcome in the Swiss Canton Ticino. Europace. 2016;18:398-404. https://doi.org/10.1093/europace/euv218.
  2. Lopez-Gonzalez A, Sanchez-Lopez M, Garcia-Hermoso A, Lopez-Tendero J, Rabanales-Sotos J, Martinez-Vizcaino V. muscular fitness as a mediator of quality cardiopulmonary resuscitation. Am J Emerg Med. 2016;34:1845-9. https://doi.org/ 10.1016/j.ajem.2016.06.058.
  3. Ashton A, McCluskey A, Gwinnutt CL, Keenan AM. Effect of rescuer fatigue on perfor- mance of continuous external chest compressions over 3 min. Resuscitation. 2002; 55:151-5. https://doi.org/10.1016/S0300-9572(02)00168-5.
  4. Contri E, Cornara S, Somaschini A, Dossena C, Tonani M, Epis F, et al. Complete chest recoil during laypersons’ CPR: is it a matter of weight? Am J Emerg Med. 2017;35: 1266-8. https://doi.org/10.1016/j.ajem.2017.03.060.
  5. Abelairas-Gomez C, Barcala-Furelos R, Szarpak L, Garcia-Garcia O, Paz-Dominguez A, Lopez-Garcia S, et al. The effect of strength training on quality of prolonged basic car- diopulmonary resuscitation. Kardiol Pol. 2017;75:21-7. https://doi.org/10.5603/KP. a2016.0165.
  6. Ogata H, Fujimaru I, Kondo T. Degree of exercise intensity during Continuous chest compression in upper-body-trained individuals. J Physiol Anthropol. 2015;34. https://doi.org/10.1186/s40101-015-0079-x.
  7. Baubin M, Schirmer M, Nogler M, Semenitz B, Falk M, Kroesen G, et al. Rescuer’s work capacity and duration of cardiopulmonary resuscitation. Resuscitation. 1996; 33:135-9. https://doi.org/10.1016/S0300-9572(96)00998-7.
  8. Baldi E, Contri E, Burkart R, Borrelli P, Ferraro OE, Tonani M, et al. Protocol of a mul- ticenter international randomized controlled manikin study on different protocols of cardiopulmonary resuscitation for laypeople (MANI-CPR). BMJ Open. 2018;8:1-6. https://doi.org/10.1136/bmjopen-2017-019723.
  9. Cortegiani A, Russotto V, Montalto F, Iozzo P, Meschis R, Pugliesi M, et al. Use of a real-time training software (Laerdal QCPR(R)) compared to instructor-based feedback for high-quality chest compressions acquisition in secondary school students: a ran- domized trial. PLoS One. 2017;12. https://doi.org/10.1371/journal.pone.0169591.
  10. Baldi E, Cornara S, Contri E, Epis F, Fina D, Zelaschi B, et al. Real-time visual feedback during training improves laypersons’ CPR quality: a randomized controlled manikin study. Can J Emerg Med. 2017;19:480-7. https://doi.org/10.1017/cem.2016.410.
  11. IPAQ Research Group. IPAQ scoring protocol; 2005.
  12. Gianotto-oliveira R, Gianotto-oliveira IG, Gonzalez IMM, Quilici IAP, Andrade FP, Caio II, et al. Quality of continuous chest comperessions performed for one or two mi- nutes n.d.:190-5. doi:https://doi.org/10.6061/clinics/2015(03)07.
  13. Ochoa FJ, Ramalle-Gomara E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions. Resuscitation. 1998;37:149-52. https://doi.org/10. 1016/S0300-9572(98)00057-4.
  14. Nayak VR, Babu A, Unnikrishnan R, Babu AS, Krishna HM. Influence of physical activ- ity of the rescuer on chest compression duration and its effects on hemodynamics and fatigue levels of the rescuer: a simulation-based study. Indian J Crit Care Med. 2020;24:409-13. https://doi.org/10.5005/jp-journals-10071-23457.
  15. Hasegawa T, Daikoku R, Saito S, Saito Y. Relationship between weight of rescuer and quality of chest compression during cardiopulmonary resuscitation. J Physiol Anthropol. 2014;33:1-7. https://doi.org/10.1186/1880-6805-33-16.
  16. Lucia A, De Las Heras JF, Ferez M, Elvira JC, Canajal A, Alvarcz AJ, et al. The impor- tance of physical fitness in the performance of adequate cardiopulmonary resuscita- tion. Chest. 1999;115:158-64. https://doi.org/10.1378/chest.115.1.158.
  17. Ock SM, Kim YM, Chung JH, Kim SH. Influence of physical fitness on the performance of 5-minute continuous chest compression. Eur J Emerg Med. 2011;18:251-6. https://doi.org/10.1097/MEJ.0b013e328345340f.
  18. Arturo Abraldes J, Fernandes RJ, Rodriguez N, Sousa A. Is rescuer cardiopulmonary resuscitation jeopardised by previous fatiguing exercise? Int J Environ Res Public Health. 2020;17:1-11. https://doi.org/10.3390/ijerph17186668.
  19. Ippolito M, Ramanan M, Bellina D, Catalisano G, Iozzo P, Di Guardo A, et al. Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey. Ther Adv Infect Dis. 2021;8. https://doi.org/10.1177/2049936121998562.
  20. Martin-Rodriguez F. Metabolic fatigue in resuscitators using personal protection equipment against biological hazard. Investig Educ En Enferm. 2019;37. https:// doi.org/10.17533/udea.iee.v37n2e04.
  21. Moscarelli A, Iozzo P, Ippolito M, Catalisano G, Gregoretti C, Giarratano A, et al. Car- diopulmonary resuscitation in prone position: a scoping review. Am J Emerg Med. 2020;38:2416-24. https://doi.org/10.1016/j.ajem.2020.08.097.
  22. Ippolito M, Catalisano G, Marino C, Fuca R, Giarratano A, Baldi E, et al. Mortality after in-hospital cardiac arrest in patients with COVID-19: a systematic review and meta- analysis. Resuscitation. 2021. https://doi.org/10.1016/j.resuscitation.2021.04.025.
  23. Hansen D, Vranckx P, Broekmans T, Eijnde BO, Beckers W, Vandekerckhove P, et al. Physical fitness affects the quality of single operator Cardiocerebral resuscitation in healthcare professionals. Eur J Emerg Med. 2012;19:28-34. https://doi.org/10. 1097/MEJ.0b013e328347a2aa.

Leave a Reply

Your email address will not be published. Required fields are marked *