Several techniques are available for CPR that increase its effectiveness:

• Rate of chest compressions
• Open-chest CPR
• Interposing abdominal compressions and CPR
• Cough CPR
• CPR in a prone position
• Precordial thump
• Percussion pacing

Rate of Chest Compressions

Research indicates that the optimal rate of compressions affects patient survival, ROSC, and physiological signs such as end-tidal CO₂ (ETCO₂). The research shows that a rate between 100 to 120 compressions per minute produces the best outcomes.⁶ Additionally, the depth of compressions is important. As the compression rate increases over 120 per minute, the depth progressively decreases so that 70% of compressions at a rate of 140 per minute are less than the goal depth.

The optimal compression rate is 100 to 120 compressions per minute.

Open-chest CPR is a technique in which the chest is opened via thoracotomy at the fifth intercostal space, and compressions are performed directly over the sternum. This technique improves the force generated by compressions, allowing improved perfusion of the coronary vessels and increased rates of ROSC. The technique has been used after trauma to minimize neurologic deficit and is particularly useful for

• Intraoperative cardiac arrest during chest or abdominal surgeries
• In the immediate post-operative period following cardiothoracic surgeries

Interposing Abdominal Compressions and CPR (IAC-CPR)

This technique requires three providers, with one person providing abdominal compressions (in addition to a provider compressing the chest). It is most commonly done by trained staff in the hospital setting and while the patient is intubated. The third provider compresses the abdomen between the xiphoid and umbilicus during chest recoil. The rate, rhythm, and depth are similar to those for chest compressions. Abdominal compressions help to improve venous return and lead to improved coronary vessel perfusion and systemic circulation. 

Cough CPR

This technique is reserved for alert patients following a cardiac arrest rhythm witnessed in a specialized setting such as a cardiac catheterization lab with the patient on continuous monitoring. The patient coughs at intervals between 1 and 3 seconds, which increases intrathoracic pressure and can cause blood pressure to increase beyond that produced by traditional CPR. Coughing also helps maintain consciousness while in arrhythmia. The coughs must be forceful enough to achieve adequate blood pressure. Consequently, if the patient is not able to do this, traditional CPR should not be delayed.  

CPR in a Prone Position

CPR can be done with the patient in a prone position, for example, if the patient is intubated and cannot be placed supine. 

Precordial Thump

The precordial thump is a specialized technique in which a strong, forceful, and very localized force to the sternum is provided to convert a ventricular arrhythmia. Research in OHCA has shown precordial thump to be ineffective in VF, VT, and PEA but possibly have some efficacy in converting asystole.⁷ It is important to note that this technique can lead to complications such as stroke, fracture of the sternum, and even additional arrhythmias. It should only be performed by very skilled providers when a patient has a ventricular arrhythmia causing cardiac arrest in a monitored medical setting and when a defibrillator is unavailable for use.

Percussion Pacing

Percussion pacing consists of regular and strong percussion of the chest using the fist for pacing the heart muscle. There is no good evidence that this therapy is effective during routine resuscitation efforts.