CC+SI or 3:1 C:V Ratio During Neonatal CPR in the Delivery Room: A Systematic Review and Meta-Analysis

Background Current neonatal resuscitation guidelines recommend a 3:1 chest compression/ventilation (C:V) ratio, but this approach has been associated with high morbidity and mortality. Researchers are exploring an alternative method

known as continuous chest compression superimposed with high distending pressure or sustained inflation (CC + SI).

Objective The goal of this study was to compare CC + SI with the standard 3:1 C:V during neonatal cardiopulmonary resuscitation (CPR) to determine if it offers any benefits.

Methods A comprehensive literature search was conducted using MEDLINE (via PubMed), Google Scholar, EMBASE, and ClinicalTrials.gov through June 2024. The analysis included randomized controlled trials comparing CC + SI with 3:1 C:V during neonatal CPR in the delivery room. The risk of bias was assessed using the Covidence collaboration tool, and a meta-analysis was performed using a fixed-effects model.

Key Outcomes

• Primary Outcome: In-hospital mortality

• Secondary Outcomes: Time to return of spontaneous circulation (ROSC), incidence of air leaks, and intraventricular hemorrhages

Results Two studies met the inclusion criteria. The pooled data indicated no significant difference in infant mortality between CC + SI and 3:1 C:V during neonatal CPR (RR 0.64, 95% CI 0.21–1.7, p = 0.33, I2 = 63%). The use of CC + SI could potentially result in 182 fewer deaths per 1000 infants (ranging from 351 fewer to 311 more). However, a significant reduction in time to ROSC was observed with CC + SI compared to 3:1 C:V (mean difference of 115 seconds, ranging from 184.75 to 45.36 seconds, p = 0.001, I2 = 26%). The incidence of air leaks and and intraventricular hemorrhages were similar between groups.

Conclusion While in-hospital mortality and air leak rates did not differ between the two approaches, CC + SI was associated with a significantly shorter time to ROSC. These findings suggest that a large-scale clinical trial is warranted to determine if CC + SI could improve neonatal resuscitation outcomes.

Further research will help determine whether CC + SI should become the new standard in neonatal CPR, potentially improving survival rates and reducing long-term complications.

Mortality

Time to Return of Sponateous Circulation