High Quality CPR - Infant Chest Compression

High-Quality CPR

Sudden cardiac arrest is not a rare event. According to American Heart Association (AHA) figures, every year more than 326,000 out-of-hospital cardiac arrests occur in the United States. Since the introduction of automated external defibrillators (AED) the chance of survival has improved. Unfortunately, the rate of survival is still as low as 10%, despite advances in resuscitation science. One reason for this low figure for out-of-hospital cardiac arrests is a bystander CPR rate of 45.7% in adults and 61.4% in children ( AHA, Heart Disease and Stroke Statistics - 2018 Update ).

Currently, the AHA and the American Red Cross conduct public education and training campaigns to improve bystander CPR rates and close existing gaps in CPR education by targeting middle and high schools. Cardiac defibrillation represents an important part of CPR but chest compression and the quality of chest compression are considered even more important, especially in situations where the cardia arrest was not witnessed by the rescuer. Immediate commencement of chest compressions is life-saving. High quality CPR must to be applied until the AED is ready to analyze the rhythm.

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This blog article describes components of High-Quality CPR and novel techniques of infant resuscitation which have the potential to improve the outcome of victims of sudden cardiac arrest.

Components of High-Quality CPR (AHA)

The 2015 Guidelines of the American Heart Association for cardiopulmonary resuscitation (CPR) emphasize the importance of high-quality CPR. The guidelines present a table of all relevant components for providers of basic life support (BLS).

The AHA states that there is research available that demonstrates improved survival from cardiac arrest when the following performance targets are applied:

 Adults / AdolescentsChildren
(1 year to puberty)
(less than 1 year, excluding newborns)

Chest Compression


At least 2 inches (5 cm)
but not more than 2.4 inches (6 cm).

At least 1/3 anteroposterior diameter of chest - about 2 inches (5 cm)

At least 1/3 anteroposterior diameter of chest About 1 1/2 inches (4 cm)


100 - 120 compressions per minute

Chest Recoil

Allow full recoil of chest after each compression;
do not lean on the chest after each compression

Minimize interruptions in chest compressions

Limit interruptions in chest compressions to less than 10 seconds

Avoid excessive ventilation

Even though, some patients may require high pressures to achieve visible chest expansions,
it is important not to apply too many breaths or too large a volume.

Excessive ventilation can potentially be harmful by

  • increasing intrathoracic pressure
  • decreasing venous return to the heart
  • thereby diminishing cardiac output and survival
  • causing gastric inflation which my result in regurgitation and aspiration

BLS Dos and Don'ts of Adult High-Quality CPR

Hand Position for Chest Compression in Adults

Adult CPR - Hand Position

According to the AHA, the rescuer should place the heel of one hand on the center of the patient's chest which is the lower half of the breastbone (sternum). The heel of the other hand is placed on top of the lower hand so that the hands are overlapped and parallel.

Chest Compression in Infants and Newborns

Depending on the number of rescuers, the AHA recommends in pediatric BLS either the two-finger technique or the two thumb-encircling hands technique.

Chest Compression in Infants

Infant CPR 2 or more rescuer - two thumb-encircling hands
infant-2-finger CPR 1 rescuer - two-finger technique

Novel method of infant chest compression

Most recently, the American Journal of Emergency Medicine published an article ahead of print about "Novel method of infant chest compression. Does the arrangement of the thumbs matter?" (Ruetzler K, et al, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.030 ).

The authors performed a cross-over randomized manikin study in a group of 36 paramedics. The resuscitation was performed in accordance with the current pediatric basic life support resuscitation guidelines (15:2 chest compression to ventilation rate with the recommended 100-120 chest compressions per minute). The researchers simulated a single-rescuer 2-min cardiopulmonary resuscitation with the use of a Laerdal ALS Baby trainer manikin. The study group was divided into 2 groups. The subjects were randomly assigned to either place two thumbs in a 45° angle to the chest or place the two thumbs in a 90° angle.

Two thumbs technique (TTT)

infant cpr 45 dgree diagram with thumbs in 45° angle
Infant CPR 90 Degree with thumbs in 90° angle

The study protocol comprised evaluation of the chest compression depth, chest compression rate, percentage of compressions with correct depth, percentage of chest compressions with the recommended rate, and percentage of complete chest relaxation. The preliminary results were discussed in conjunction with a previous article published by the same authors (Smereka et al. 2017. Evaluation of new two-thumb chest compression technique for infant CPR performed by novice physicians. A randomized, crossover, manikin trial. Am J Emerg Med. 2017 Apr;35(4):604-609 ). The results suggested that the 90° angle of the thumbs helped to optimize chest compression.

Further research is required to find the best mode of chest compression in infants. The AHA recommendations for pediatric BLS to either use the two-finger technique for 1 rescuer or the two thumb-encircling hands technique for 2 or more rescuers are currently the standard.

Author: Dr Christoph Camphausen, Pediatric Cardiologist and Pediatric Intensivist
Sep 10, 2018