Sound Feedback of Metronome can Improve High Quality Cardio

Pulmonary Resuscitation

A Systematic Review

Senja Setiaka, Nursalam, Harmayetty

Faculty of Nursing Universitas Airlangga, Kampus C, Surabaya Indonesia

Keywords: Chest compression, Metronome, Cardio Pulmonary Resuscitation.

Abstract: Rhythm and depth of chest compression during cardiopulmonary resuscitation often doesn’t meet the

guidelines in achieving high quality CPR in simulation of manikin. The objective of this review was to

analyse the metronome effect in chest compression simulation. We searched international journals from the

following electronic databases; ProQuest, EBSCO, Springer Link, Sage, Science Direct, Google Scholar

start from 2012 to 2016 with keywords; metronome, compression, and CPR. Five RCT articles were

reviewed and analysed from 504 journals found. Metronome can improve chest compression correctly in

long time duration. Further research needed with larger sample size and randomized controlled trial design.

1 BACKGROUND

Cardiopulmonary Resuscitation (CPR) is a basic aid

to help save lives suffering from sudden cardiac

arrest. In recent years it has been proved that

patients suffering from sudden cardiac arrest depend

on the depth and compression rhythms that are

performed to save lives. The chest compression

rhythm should be 100-120 beats per minute because

it is very difficult to maintain the rhythm without

any feedback.

In recent years, an increase in quantitative

evidence has shown that cardiac survival of sudden

cardiac arrest depends on the quality of the depth

and rhythm of CPR performed. High quality CPR

improves survival. Improving the quality of CPR

can save lives. The optimal level for compression is

100-120 per minute, it feels quite heavy and difficult

to maintain without any guidance in the person who

performed chest compression. (American Heart

Association, 2015).

The American Heart Association’s (AHA)

recommendation measures 5-6cm depth for chest

compressions. From the research results obtained

when the chest compressed too slow, too fast, too

much, or too little, then the clinical negative effect

(Cave, 2010). Patients with sudden cardiac arrest in

the hospital should immediately have a heart attack

or external CPR with specific procedures and

applicable guidelines. In order for a good prognosis

should be given this CPR action with high CPR

quality.

The successful resuscitation of pre-hospital CPR

depends on many factors. The quality of chest

compressions or so-called High Quality Cardio

Pulmonary Resuscitation (HQCPR) has been

identified as a factor that affects survival after CPR

(Semeraro et al., 2011). The intended HQCPR is

CPR given its depth and proper rhythm, full chest

recoil chances remain to be done as well as minimal

interruption or interference and avoid excessive

ventilation (Cave, 2010). The delay between

watching a heart attack and CPR's performance in

emergency medical care suggests that CPR riders

increase the likelihood of unexpected rhythm and

survival after witnessing a heart attack outside the

home. According to existing guidelines, witnesses

can only provide cardiac compression (hands-only

CPR) (Buléon et al., 2013).

Patients' resuscitation (CPR) after a heart attack

has attracted the attention of scientists and doctors

for decades. The physiological underlying lifesaving

process when CPR (cardiopulmonary resuscitation)

remains only partially understood and often

controversial (Lurie, 2016). Quality analysis of CPR

by the National Institutes for Consortium Prehospital

Resuscitation shows that errors in general and

harmful CPR actions. Nearly mid-time until CPR is

stopped, emphasis is placed on rhythm and depth

Setiaka, S., Nursalam, . and Harmayetty, .

Sound Feedback of Metronome can Improve High Quality Cardio Pulmonary Resuscitation.

DOI: 10.5220/0008327304890494

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 489-494

ISBN: 978-989-758-336-0

489

beyond the recommended range of AHA (American

Heart Association) (Stiell 2012, Idris 2012, Idris

2015). The ILCOR Guide (International Liaison

Committee on Resuscitation) emphasizes the

importance of chest compression quality in

cardiopulmonary resuscitation (CPR). By 2016, the

incidence of Outdoor Medical Looting more than

350,000. Bystander managed to do CPR 46.1% and

was rescued as much as 12%. While in the same

year the In-Hospital incidence of Cardiac Arrest of

209,000 was saved 24.8% while the survival rate in

children was not recorded (American Heart

Association, 2015).

Real-time feedback devices have proven their

ability to improve the quality of cardiac compression

performed by trained rescue teams outside hospitals

and in hospitals due to heart attacks. (Park et al.,

2014). Metronome beats are the simplest and

cheapest feedback system. The use of audible

metronome to guide the level of chest compression

is one strategy to improve the effectiveness of chest

compression. Previous research on metronome

guidance during CPR has shown better adherence to

recommended chest compression rates In another

study reported better survival rates compared to the

historical control group when the metronome was

attached to the ambulance defibrillator (Fletcher D,

2008). Audio level level guidance significantly

improves chest compression rate and CO2 tidal

concentration during CPR (Kern, et al, 2010;

Milander et al, 1995). Successful resuscitation of

cardio-pulmonary pre-hospital (CPR) depends on

many factors. The quality of chest compressions has

been identified as a factor that affects survival after

CPR (Valenzuela, 2005).

Chest compression action becomes superficial

from the standard of half the time of action and its

rhythm is more than the standard rhythm. One

minute after the start of CPR in the manikin has

made tired of the masseuse so that effect on the

effectiveness of massage (Gutwirth, Williams, &

Boyle, 2009).

The purpose of this study was to compile a

review of the use of metronome in CPR as feedback

during actual exercise or resuscitation. What is the

effectiveness of using metronome in CPR action?

2 METHODS

This review was arranged in correlation with

American Heart Association Guidelines 2015

evidence evaluation process. Expert review of the

search technique egy and findings were listed by the

worksheet evaluation experts.

2.1 Eligibility Criteria

2.1.1 Participants

The cardiopulmonary provider should be a nurse as

a health care practitioner (HCP), defined as the

person whose primary role is the provision of health

services. Subjects can be manikins to overcome the

quality outcomes of CPR or human heart attack to

overcome both quality and survival outcomes of

CPR. Heart attacks can occur in hospitals or outside

hospitals.

2.1.2 Interventions

Several studies measured the quality of CPR using

monitors that detect chest wall motion and, at a

minimum, can measure the level or depth of cardiac

compression being considered for inclusion. Since

the main purpose of our review was to determine

whether the use of metronome feedback devices was

able to improve the performance and actual

outcomes of CPR and the outcome of heart attacks,

rather than teaching tools to improve skills

acquisition, it was decided that metronome feedback

devices should be used at the time of a heart attack

or simulation of arrest. The Manikin researches

investigating the feedback effects during exercise

alone, but not during simulation of resuscitation

trials, and human studies that provide delayed

feedback in the form of briefing or performance

evaluation are equally excluded. Studies that

investigate the use of unchanged timing and

metronome devices or provide feedback depending

on detected CPR quality are also excluded.

2.1.3 Comparison

Intervention (use of CPR in real time with

metronome feedback devices) compared to CPR

comparison groups performed without using the

device.

2.1.4 Results

The main outcome for human studies is the patient's

survival of hospital outlays with good neurological

outcomes. Secondary outcomes in human studies

include other patient survival data (ROSC, life

(spontaneous circulation) upon arrival to the

emergency department, survival to hospital

discharge). For human and manicured studies,

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

490

enhanced CPR markers are extracted: CC level, CC

depth, and proportion of time without CPR (fraction

without flow). We also collect data about the side

effects and user satisfaction of the device.

2.1.5 Types of Studies

Published original research articles on random and

non-randomized intervention studies, as well as

observational studies with comparator groups

included. Animal studies, case studies, reviews and

opinions are not included.

2.1.6 Search Strategy

Systematic literature searches using the terms and

strategy were conducted in electronic databases:

ProQuest, EBSCO, Spinger Link, Sage, Science

Direct, and Google Scholar start from 2012 to 2016.

The articles describe the effects of metronome on

the precise rhythm of the appropriate massage in the

inclusions. The article title reviewed by reviewers

and which articles are irrelevant will be removed.

Titles and abstracts with clearly unrelated content

removed. Excerpts marked as "included" or

"indefinite" by one of the reviewers are included in

the next level of review.

Abstracts that tend to be relevant in in-depth

reviews are then continued by reviewing existing

manuscripts. Disagreements at the full article stage

are resolved despite consensus with all reviewers.

The agreement between writers at each stage is

calculated using kappa statistics. A record is kept of

all excluded studies at the full text stage, along with

the reason.

2.2 Study Selection

In the study sought 504 journals. After deleting

duplicates, 349 titles are reviewed for relevance. Of

these 36 titles appears relevant to the research

questions that lead to a detailed review of the

abstract. Eight more articles are discarded in this

phase so 28 articles for full review. From review 5

the list is identified. The 5 articles are relevant to the

intended research objectives (figure 1).

3 RESULTS

According to the study reviewed by Kern results A

unique combination tock and voice prompting

metronome was effective at directing correct chest

compression and ventilation rates both before and

after intubation. It is mentioned that during CPR

with a bag/valve/mask the target compression rate of

90–110min−1 was achieved in 5/34 CPR sessions

(15%) for the control group and 34/34 sessions

(100%) for the metronome group (p<0.001).

Figure 1: Study Selection and Search Strategy.

An excessive ventilation rate was not observed in

either the metronome or control group during CPR

with a bag/valve/mask. During CPR with a

bag/endotracheal tube, the target of both a com-

pression rate of 90–110/min and a ventilation rate of

8–11/min was achieved in 3/34 CPR sessions (9%)

for the control group and 33/34 sessions (97%) for

the metronome group (p<0.001). Metronome use

with the secured airway scenario significantly

decreased the incidence of over-ventilation (11/34

EMT pairs vs. 0/34 EMT pairs; p<0.001) (Kern et

al., 2010).

Further research conducted by Hafner mentioned

that the control subjects had a higher mean

compression rate both immediately (121 [standard

deviation {SD} = 21] vs. 109 [SD = 15] cpm;

Presented as a poster presentation at the American

College of Emergency Physicians Scientific

Assembly and Research Forum, San Francisco, CA,

October 2011. Supported with a Graduate Medical

Education Grant from the University of Illinois

504 journals were

found in electronic

database

349 were taken as

suitable as the topic

taken

36 titles and abstract

that have been

filtered

Remove 8 articles

which is not in

fulltext

28 fulltext

articles

Remove 23

articles due to

the issue year.

5 articles RCT be

reviewed

Sound Feedback of Metronome can Improve High Quality Cardio Pulmonary Resuscitation

491

College of Medicine at Peoria. 95% confidence

interval [CI] of mean difference 4-19; p = 0.002) and

at follow-up (120 [SD = 20] vs. 111 [SD = 13] cpm;

95% CI of mean difference 2-16; p = 0.014).

Compression rates stratified to 100-120 cpm

demonstrated no difference between groups initially

(39% vs. 48%; p = 0.382), but more experimental

subjects main- tained these rates at follow-up (43%

vs. 74%; p = 0.003). Utilization of new music

metronomes during standard CPR training for the

layman improves the proportion of subjects who do

chest pacing properly during long-term follow-up,

even without the aid of music being played. The

introduction of the music metronome has no effect

on the depth of the chest compress or the true

percentage of emphasis on preliminary or follow-up

testing, although this size is low in both populations.

The music metronome also has no effect on

participants' willingness to perform CPR or their

perception of maintaining adequate levels of

compression. The use of music metronomes

represents an easy-to-teach and cost-effective

modality to help laypeople in steady chest

compressions (Hafner, Jou, Wang, Bleess, & Tham,

2015).

The Zimmerman study resulted in 155

participants performing 2 rounds of chest

compressions (74 with metronome at first and 81

with metronome during second cycle of CPR). There

was a significant increase in the average percentage

of compression given at adequate levels (90-100

pressure per minute) with the metronome compared

to 72% vs 50%; mean difference [MD] 22%; 95%

confidence interval [CI] , 15% to 29%). No

significant differences were noted in the average

percentage of compression at acceptable depth (38-

51 mm) (72% vs 70%, MD 2%, 95% CI, 22% to

6%). The metronome has a greater influence among

medical students (73% vs 55%, MD 18%, 95% CI,

8% to 28%) and the population of children and co-

workers (84% vs. 48%; MD 37%; 95% CI, 27% to

46%) but not among nursemaid children (46% vs

48%; MD 23%; 95% CI; 219% to 14%). The degree

of chest compressions during CPR can be optimized

with the use of metronome. These findings will help

medical professionals adhere to the American Heart

Association guidelines (Zimmerman et al., 2015).

The Tastan study reinforces and illustrates that

the first evaluation showed that the intervention

group participants had an average rate of 107.33 ±

7.29 ± chest compressive per minute, while the

control group level was 121.47 ± 12.91. A second

evaluation showed that chest compression rates for

the intervention and control groups were 106.24 ±

8.72 and 100.71 ± 9.54, respectively. The results of

this study indicate that a piece of music allows

students to remember the ideal rhythm for chest

compression. Conducting chest compression with

metronome music can be easily integrated into CPR

education because it does not require additional and

inexpensive technology (Tastan et al., 2017). There

are studies that explain incomplete chest stiffness

rates lower at compression rates of 100 and 120 min

-1 compared with at 160 min-1 (P = 0.001). The

amount of suppression that meets the criteria for

high-quality CPR at a rate of 120 min-1 is

significantly higher than that at 100 min-1 (p=0.016)

in which the highest amount of CPR compression is

highest at the 120-1 1 compression rate, and

incomplete incompatibility increment occurs with

increasing levels of compression (recoil) (Lee et al.,

2016)

4 DISCUSSION

This study has identified evidence that the use of

CPRs using metronome can provide appropriate

CPR skills. The use of the CPR metronomer system

during CPR performance in the manikin has

consistently improved the quality of CPR. Studies in

the early 1990s first identified an association

between the quality of CPR and patient outcomes,

with better quality CPR associated with improved

survival.

Depth and degree of chest compression,

interruptions in chest compressions (especially

before defibrillation) have an effect on patient

outcomes. The evidence in this review strongly

supports in showing that CPR with metronome

devices is associated with improved quality of CPR.

While it may be intuitive to assume that this will

lead to improvement in survival, this cannot be

assumed as the case. Indeed, none of the studies to

date have sufficient strength to show better patient

outcomes (return of spontaneous circulation,

neurological survival and so on) with CPR

metronomes.

For example in a pediatric simulation of the

manikin chest compression is performed with and

without metronome. It appears that the guide is a

metronome improves chest compression at an

adequate level but has no effect on depth. This

finding is consistent with several studies of adults

showing similar results. Research that focuses on

CPR only with chest compression without

ventilation, causing a shorter delay on chest

compression. Initiation of immediate chest

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

492

compression is of the utmost importance, as

emphasized by respiratory changes airway –

breathing - circulation is changed into circulation -

airway - breathing sequences proposed in

resuscitation guidelines 2010. This guideline is

supported by Kern et al, which shows it alone chest

compression early heart attacks provide a reasonable

reason for circulation, do not jeopardize survival,

and are associated with successful outcomes. In

addition, in an effort to minimize effect of helper

fatigue, CPR is done within 2 minutes for

compression. Furthermore, the importance of fatigue

aide is emphasized by Hong et al to substantially

reduce the quality of CPR as early as the third

minute of continuous chest compressions.

There are metronome-based studies that describe

an adequate increase in compression rates, but,

unlike certain studies, they show a negative impact

on the depth of chest compression. There is research

focusing on the feedback only - tariff of the

metronome because it is easily accessible as part of

the defibrillator engine on the code cart and

defibrillator in the resuscitation room. The real cause

of suboptimal depth of chest compression with

metronome guidance is unknown. However, it has

been hypothesized that a variety of factors may

contribute to superficial compression, including

multitasking, rescue rescuers, and rescuers of

disruption (concentrating on level management

rather than maximum effort).

The effect of greater compression depth is

related to increased coronary perfusion pressure,

success higher defibrillation, increased cardiac

output, and increased clinical outcomes. 5 cm

compression depth is more effective than 4 cm in

children and adults. The latest AHA guidelines

recommend a 5 cm compressive depth in children

and adults, in the hope of eliminating confusion

when depth ranges are provided. Overall CPR

quality is highly dependent on many factors, but is

largely important at the level and depth. Therefore,

the device is joined Feedback that is heard at both

levels and depth can improve the quality of CPR.

4.1 Limitation

The design and review methods used also have some

limitations. We review only English articles, and the

selection and extraction of data is not done

independently by two reviewers. However, in case

of doubt, the selection and extracted data are

discussed with other authors. We do not use standard

methods to assess the quality of each included study.

Meta-analysis is not possible because of the

heterogeneity of many studies.

5 CONCLUSIONS

The systematic identification of this CPR

intervention coupled with the metronome

simultaneously brings a good effect on the

compression rhythm performed. Because at the time

of doing CPR many confounding factors that make

the rhythm and accuracy in the acting process

becomes less precise. With the presence of a

metronome through a literature study undertaken

shows the level of significance of the metronome

effect. Therefore, the use of guided audio feedback

can be a good reference in cardiac arrest

management. So that the golden period can be

utilized optimally in the effort to save lives by the

nurse because the accuracy of CPR is done well.

The evidence suggests that the use of CPR with

metronome in clinical practice as part of the overall

strategy to improve the quality of CPR may be

beneficial. Further studies are needed to assess

whether the quality improvement of CPR generated

by these devices is translated into improvements in

patient focus results. The accuracy of CPR with a

metronome to measure the depth of compression

should be calibrated to account for the stiffness of

the supporting surface where CPR is being

performed.

REFERENCES

American Heart Association. (2015). Fokus Utama

Pembaruan Pedoman AHA 2015 untuk CPR dan ECC.

Circulation (Vol. 132). https://doi.org/10.1016/S0210-

5691(06)74511-9

Buléon, C., Parienti, J. J., Halbout, L., Arrot, X., De Facq

Régent, H., Chelarescu, D., … Hanouz, J. L. (2013).

Improvement in chest compression quality using a

feedback device (CPRmeter): A simulation

randomized crossover study. American Journal of

Emergency Medicine, 31(10), 1457–1461.

https://doi.org/10.1016/j.ajem.2013.07.029

Cave, D. M. (2010). Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care.

American Heart Association.

Chung, T. N., Kim, S. W., You, J. S., Cho, Y. S., Chung,

S. P., Park, I., & Kim, S. H. (2012). The specific effect

of metronome guidance on the quality of one-person

cardiopulmonary resuscitation and rescuer fatigue.

Journal of Emergency Medicine, 43(6), 1049–1054.

https://doi.org/10.1016/j.jemermed.2012.01.021

Sound Feedback of Metronome can Improve High Quality Cardio Pulmonary Resuscitation

493

Fletcher D, Galloway R, Chamberlain D, Pateman J,

Bryant G, N. R. (2008). Basics in advanced life

support: a role for download audit and metronomes.

Resuscitation, 78(2), 127–134.

Gutwirth, H., Williams, B., & Boyle, M. (2009). Rescuer

fatigue in cardiopulmonary resuscitation: a review of

the literature. Journal of Emergency Primary Health

Care, 7(4), NaN.

Hafner, J. W., Jou, A. C., Wang, H., Bleess, B. B., &

Tham, S. K. (2015). Death before disco: The

effectiveness of a musical metronome in layperson

cardiopulmonary resuscitation training. Journal of

Emergency Medicine, 48(1), 43–52.

https://doi.org/10.1016/j.jemermed.2014.07.048

Jäntti, H., Silfvast, T., Turpeinen, A., Kiviniemi, V., &

Uusaro, A. (2009). Influence of chest compression rate

guidance on the quality of cardiopulmonary

resuscitation performed on manikins. Resuscitation,

80(4), 453–457.

https://doi.org/10.1016/j.resuscitation.2009.01.001

Kern, K. B., Stickney, R. E., Gallison, L., & Smith, R. E.

(2010). Metronome improves compression and

ventilation rates during CPR on a manikin in a

randomized trial. Resuscitation, 81(2), 206–210.

https://doi.org/10.1016/j.resuscitation.2009.10.015

Lee, S. H., Ryu, J. H., Min, M. K., Kim, Y. I., Park, M. R.,

Yeom, S. R., … Park, S. W. (2016). Optimal chest

compression rate in cardiopulmonary resuscitation.

European Journal of Emergency Medicine, 23(4),

253–257.

https://doi.org/10.1097/MEJ.0000000000000249

Milander, M. M., Hiscok, P. S., Sanders, A. B., Kern, K.

B., Berg, R. A., & Ewy, G. A. (1995). Chest

Compression and Ventilation Rates during

Cardiopulmonary Resuscitation: The Effects of

Audible Tone Guidance. Academic Emergency

Medicine, 2(8), 708–713.

https://doi.org/10.1111/j.1553-2712.1995.tb03622.x

Park, C. S., Kang, I. G., Heo, S. J., Chae, Y. S., Kim, H. J.,

Park, S. S., … Jeong, W. J. (2014). A randomised,

cross over study using a mannequin model to evaluate

the effects on CPR quality of real-time audio-visual

feedback provided by a smartphone application. Hong

Kong Journal of Emergency Medicine, 21(3), 153–

160.

Semeraro, F., Taggi, F., Tammaro, G., Imbriaco, G.,

Marchetti, L., & Cerchiari, E. L. (2011). ICPR: A new

application of high-quality cardiopulmonary

resuscitation training. Resuscitation, 82(4), 436–441.

https://doi.org/10.1016/j.resuscitation.2010.11.023

Tastan, S., Ayhan, H., Unver, V., Cinar, F. I., Kose, G.,

Basak, T., … Iyigun, E. (2017). The effects of music

on the cardiac resuscitation education of nursing

students. International Emergency Nursing, 31, 30–35.

https://doi.org/10.1016/j.ienj.2016.06.007

Terence D. Valenzuela, Karl B. Kern, Lani L. Clark,

Robert A. Berg, Marc D. Berg, David D. Berg, Ronald

W. Hilwig, Charles W. Otto, Daniel Newburn, G. A.

E. (2005). Interruptions of chest compressions during

emergency medical systems resuscitation. Circulation,

112(9), 125965.

Zimmerman, E., Cohen, N., Maniaci, V., Pena, B.,

Lozano, J. M., & Linares, M. (2015). Use of a

Metronome in Cardiopulmonary Resuscitation: A

Simulation Study. Pediatrics, 136(5), 905–911.

https://doi.org/10.1542/peds.2015-1858

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

494