Mechanistic insights and technical advances in high-quality cardiopulmonary resuscitation_West China Medical Journal

Authors：

WANG Min ^1,2 , JIAN Mengyao ^1,3 , MA Wen ^1,3 , WU Yang ^1,3 ,  CAO Yu ^1,3

1. Department of Emergency Medicine and Institute of Disaster Medicine, Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
3. Disaster Medical Center, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

CAO Yu, Email: caoyu@wchscu.cn

Keywords：

Cardiac arrest; high-quality cardiopulmonary resuscitation; compression quality; ischemia-reperfusion

DOI：

10.7507/1002-0179.202506130

Video：

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Cardiac arrest (CA) represents a significant global public health challenge, severely endangering both individual lives and public safety. Over the past years, cardiopulmonary resuscitation (CPR) techniques have advanced significantly. In 2013, the American Heart Association proposed high-quality CPR (HQ-CPR) as a key component for enhancing survival and neurological prognosis in patients with CA. HQ-CPR extends beyond the fundamental skills of compression and ventilation by prioritizing key metrics such as compression rate and depth, full chest recoil, minimal interruptions, and early defibrillation, representing a pivotal shift of CPR toward evidence-based, standardized, and precision-oriented practices. Despite the widespread recognition and adoption of HQ-CPR in Western nations, China continues to encounter multiple barriers in CPR dissemination and quality assurance, including low public training rates, variable instructional quality, delayed emergency responses, and disparities in healthcare resource allocation. Accordingly, this article provides a comprehensive review of the essential components of HQ-CPR. By analyzing the key challenges in China’s current clinical implementation, this paper focuses on exploring the latest research on enhancing resuscitation efficacy in recent years, especially focusing on new strategies to minimizing myocardial ischemia and improving reperfusion efficiency, in order to provide information for clinical optimization and improving patient outcomes following CA.

Citation： WANG Min, JIAN Mengyao, MA Wen, WU Yang, CAO Yu. Mechanistic insights and technical advances in high-quality cardiopulmonary resuscitation. West China Medical Journal, 2025, 40(6): 1008-1015. doi: 10.7507/1002-0179.202506130 Copy

1.	Penketh J, Nolan JP. In-hospital cardiac arrest: the state of the art. Crit Care, 2022, 26(1): 376.
2.	Zheng J, Lv C, Zheng W, et al. Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry. Lancet Public Health, 2023, 8(12): e923-e932.
3.	Bartos JA, Grunau B, Carlson C, et al. Improved survival with extracorporeal cardiopulmonary resuscitation despite progressive metabolic derangement associated with prolonged resuscitation. Circulation, 2020, 141(11): 877-886.
4.	Perkins GD, Callaway CW, Haywood K, et al. Brain injury after cardiac arrest. Lancet, 2021, 398(10307): 1269-1278.
5.	Gräsner JT, Herlitz J, Tjelmeland IBM, et al. European resuscitation council guidelines 2021: epidemiology of cardiac arrest in Europe. Resuscitation, 2021, 161: 61-79.
6.	Schnaubelt S, Garg R, Atiq H, et al. Cardiopulmonary resuscitation in low-resource settings: a statement by the international liaison committee on resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC. Lancet Glob Health, 2023, 11(9): e1444-e1453.
7.	Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA, 2005, 293(3): 299-304.
8.	Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 2013, 128(4): 417-435.
9.	Panchal AR, Bartos JA, Cabañas JG, 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(16 suppl 2): S366-S468.
10.	Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation, 2022, 145(8): e153-e639.
11.	中国心脏骤停与心肺复苏报告编写组. 中国心脏骤停与心肺复苏报告(2022 年版)概要. 中国循环杂志, 2023, 38(10): 1005-1017.
12.	Li T, Essex K, Ebert D, et al. Resuscitation Quality Improvement^® (RQI^®) HeartCode Complete^® program improves chest compression rate in real world out-of hospital cardiac arrest patients. Resuscitation, 2023, 188: 109833.
13.	Morgan RW, Reeder RW, Bender D, et al. Associations between end-tidal carbon dioxide during pediatric cardiopulmonary resuscitation, cardiopulmonary resuscitation quality, and survival. Circulation, 2024, 149(5): 367-378.
14.	Kurz MC, Bobrow BJ, Buckingham J, et al. Telecommunicator cardiopulmonary resuscitation: a policy statement from the American Heart Association. Circulation, 2020, 141(12): e686-e700.
15.	Rott N, Scholz KH, Busch HJ, et al. Cardiac arrest center certification for out-of-hospital cardiac arrest patients successfully established in Germany. Resuscitation, 2020: 1-3.
16.	Silva LEV, Shi L, Gaudio HA, et al. Prediction of return of spontaneous circulation in a pediatric swine model of cardiac arrest using low-resolution multimodal physiological waveforms. IEEE J Biomed Health Inform, 2023, 27(10): 4719-4727.
17.	Jonsson M, Berglund E, Baldi E, et al. Dispatch of volunteer responders to out-of-hospital cardiac arrests. J Am Coll Cardiol, 2023, 82(3): 200-210.
18.	Gregers MCT, Andelius L, Kjoelbye JS, et al. Association between number of volunteer responders and interventions before ambulance arrival for cardiac arrest. J Am Coll Cardiol, 2023, 81(7): 668-680.
19.	Berglund E, Hollenberg J, Jonsson M, et al. Effect of smartphone dispatch of volunteer responders on automated external defibrillators and out-of-hospital cardiac arrests: the SAMBA randomized clinical trial. JAMA Cardiol, 2023, 8(1): 81-88.
20.	Chocron R, Loeb T, Lamhaut L, et al. Ambulance density and outcomes after out-of-hospital cardiac arrest. Circulation, 2019, 139(10): 1262-1271.
21.	Stieglis R, Zijlstra JA, Riedijk F, et al. Alert system-supported lay defibrillation and basic life-support for cardiac arrest at home. Eur Heart J, 2021, 43(15): 1465-1474.
22.	Katz D, Shah R, Kim E, et al. Utilization of a voice-based virtual reality advanced cardiac life support team leader refresher: prospective observational study. J Med Internet Res, 2020, 22(3): e17425.
23.	Nas J, Thannhauser J, Konijnenberg LSF, et al. Long-term effect of face-to-face vs virtual reality cardiopulmonary resuscitation (CPR) training on willingness to perform CPR, retention of knowledge, and dissemination of CPR awareness: a secondary analysis of a randomized clinical trial. JAMA Netw Open, 2022, 5(5): e2212964.
24.	Greif R, Bray JE, Djärv T, et al. 2024 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation, 2024, 150(24): e580-e687.
25.	刘洋, 张玮, 夏剑, 等. 复苏中心建设与管理急诊专家共识. 中国急救医学, 2024, 44(4): 277-283.
26.	Ma W, Liu E, Xiao L, et al. The development and accuracy assessment of a wearable cardiopulmonary resuscitation real-time audio-visual feedback device. Resuscitation, 2025, 211: 110602.
27.	Lakomek F, Lukas RP, Brinkrolf P, et al. Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: a prospective cohort study. PLoS One, 2020, 15(2): e0229431.
28.	Caputo ML, Monachino G, Cresta R, et al. Release velocity improvement with a new metronome guIding chest COmpressions: The RITMICO simulation study. Resusc Plus, 2025, 21: 100867.
29.	Koyama Y, Matsuyama T, Inoue Y. Association between haemodynamics during cardiopulmonary resuscitation and patient outcomes. Resuscitation, 2022: 295-302.
30.	Matsuyama T, Yasutake Y, Inaba D, et al. Novel mode of near-infrared spectroscopy as a continuous cerebral physiological monitoring device during cardiopulmonary resuscitation: four case reports. J Clin Med, 2022, 11(7): 2018.
31.	Zhao X, Wang S, Yuan W, et al. A new method to evaluate carotid blood flow by continuous Doppler monitoring during cardiopulmonary resuscitation in a porcine model of cardiac arrest. Resuscitation, 2024: 110092.
32.	Hwang M, Sridharan A, Freeman CW, et al. Contrast-enhanced ultrasound of brain perfusion in cardiopulmonary resuscitation. Ultrasound Q, 2022, 38(3): 257-261.
33.	Park S, Yoon H, Yeon Kang S, et al. Artificial intelligence-based evaluation of carotid artery compressibility via point-of-care ultrasound in determining the return of spontaneous circulation during cardiopulmonary resuscitation. Resuscitation, 2024, 202: 110302.
34.	Kim T, Suh GJ, Kim KS, et al. Development of artificial intelligence-driven biosignal-sensitive cardiopulmonary resuscitation robot. Resuscitation, 2024: 110354.
35.	Alremeithi R, Tran QK, Quintana MT, et al. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers. World J Emerg Med, 2024, 15(1): 3-9.
36.	Lendrum RA, Perkins Z, Marsden M, et al. Prehospital partial resuscitative endovascular balloon occlusion of the aorta for exsanguinating subdiaphragmatic hemorrhage. JAMA Surg, 2024, 159(9): 998-1007.
37.	Thrailkill MA, Gladin KH, Thorpe CR, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med, 2021, 29(1): 8.
38.	Sanguanwit P, Saksobhavivat N, Phattharapornjaroen P, et al. Appropriateness of recommended chest compression depths for cardiopulmonary resuscitation based on chest computed tomography parameters among Thai population: a multicenter retrospective study. Resusc Plus, 2024, 18: 100605.
39.	Goulding K, Marchetti R, Perera R, et al. Does the use of BariBoard^TM improve adequacy of chest compressions in morbid obesity? A pilot study using a simulation model. Aust Crit Care, 2022, 35(6): 688-695.
40.	Schwab K, Buhr RG, Grossetreuer AV, et al. Trends in endotracheal intubation during in-hospital cardiac arrests: 2001-2018. Crit Care Med, 2022, 50(1): 72-80.
41.	Robinson AE, Driver BE, Prekker ME, et al. First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department. Resuscitation, 2023, 186: 109726.
42.	姚鹏, 马雯, 王智渊, 等. 心肺复苏后脑损伤的研究进展. 中国科学: 生命科学, 2022, 52(11): 1715-1730.
43.	Idris AH, Aramendi Ecenarro E, Leroux B, et al. Bag-valve-mask ventilation and survival from out-of-hospital cardiac arrest: a multicenter study. Circulation, 2023, 148(23): 1847-1856.
44.	Hernández-Tejedor A, González Puebla V, Corral Torres E, et al. Ventilatory improvement with mechanical ventilator versus bag in non-traumatic out-of-hospital cardiac arrest: SYMEVECA study, phase 1. Resuscitation, 2023, 192: 109965.
45.	Prause G, Zoidl P, Eichinger M, et al. Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: a randomised controlled trial. Resuscitation, 2023: 109765.
46.	Wyckoff MH, Greif R, Morley PT, et al. 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation, 2022, 146(25): e483-e557.
47.	Queiroga AC, Dunne C, Manino LA, et al. Resuscitation of drowned persons during the COVID-19 pandemic: a consensus statement. JAMA Netw Open, 2022, 5(2): e2147078.
48.	Dezfulian C, McCallin TE, Bierens J, et al. 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2024, 150(23): e501-e516.

1. Penketh J, Nolan JP. In-hospital cardiac arrest: the state of the art. Crit Care, 2022, 26(1): 376.
2. Zheng J, Lv C, Zheng W, et al. Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry. Lancet Public Health, 2023, 8(12): e923-e932.
3. Bartos JA, Grunau B, Carlson C, et al. Improved survival with extracorporeal cardiopulmonary resuscitation despite progressive metabolic derangement associated with prolonged resuscitation. Circulation, 2020, 141(11): 877-886.
4. Perkins GD, Callaway CW, Haywood K, et al. Brain injury after cardiac arrest. Lancet, 2021, 398(10307): 1269-1278.
5. Gräsner JT, Herlitz J, Tjelmeland IBM, et al. European resuscitation council guidelines 2021: epidemiology of cardiac arrest in Europe. Resuscitation, 2021, 161: 61-79.
6. Schnaubelt S, Garg R, Atiq H, et al. Cardiopulmonary resuscitation in low-resource settings: a statement by the international liaison committee on resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC. Lancet Glob Health, 2023, 11(9): e1444-e1453.
7. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA, 2005, 293(3): 299-304.
8. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 2013, 128(4): 417-435.
9. Panchal AR, Bartos JA, Cabañas JG, 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(16 suppl 2): S366-S468.
10. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation, 2022, 145(8): e153-e639.
11. 中国心脏骤停与心肺复苏报告编写组. 中国心脏骤停与心肺复苏报告(2022 年版)概要. 中国循环杂志, 2023, 38(10): 1005-1017.
12. Li T, Essex K, Ebert D, et al. Resuscitation Quality Improvement^® (RQI^®) HeartCode Complete^® program improves chest compression rate in real world out-of hospital cardiac arrest patients. Resuscitation, 2023, 188: 109833.
13. Morgan RW, Reeder RW, Bender D, et al. Associations between end-tidal carbon dioxide during pediatric cardiopulmonary resuscitation, cardiopulmonary resuscitation quality, and survival. Circulation, 2024, 149(5): 367-378.
14. Kurz MC, Bobrow BJ, Buckingham J, et al. Telecommunicator cardiopulmonary resuscitation: a policy statement from the American Heart Association. Circulation, 2020, 141(12): e686-e700.
15. Rott N, Scholz KH, Busch HJ, et al. Cardiac arrest center certification for out-of-hospital cardiac arrest patients successfully established in Germany. Resuscitation, 2020: 1-3.
16. Silva LEV, Shi L, Gaudio HA, et al. Prediction of return of spontaneous circulation in a pediatric swine model of cardiac arrest using low-resolution multimodal physiological waveforms. IEEE J Biomed Health Inform, 2023, 27(10): 4719-4727.
17. Jonsson M, Berglund E, Baldi E, et al. Dispatch of volunteer responders to out-of-hospital cardiac arrests. J Am Coll Cardiol, 2023, 82(3): 200-210.
18. Gregers MCT, Andelius L, Kjoelbye JS, et al. Association between number of volunteer responders and interventions before ambulance arrival for cardiac arrest. J Am Coll Cardiol, 2023, 81(7): 668-680.
19. Berglund E, Hollenberg J, Jonsson M, et al. Effect of smartphone dispatch of volunteer responders on automated external defibrillators and out-of-hospital cardiac arrests: the SAMBA randomized clinical trial. JAMA Cardiol, 2023, 8(1): 81-88.
20. Chocron R, Loeb T, Lamhaut L, et al. Ambulance density and outcomes after out-of-hospital cardiac arrest. Circulation, 2019, 139(10): 1262-1271.
21. Stieglis R, Zijlstra JA, Riedijk F, et al. Alert system-supported lay defibrillation and basic life-support for cardiac arrest at home. Eur Heart J, 2021, 43(15): 1465-1474.
22. Katz D, Shah R, Kim E, et al. Utilization of a voice-based virtual reality advanced cardiac life support team leader refresher: prospective observational study. J Med Internet Res, 2020, 22(3): e17425.
23. Nas J, Thannhauser J, Konijnenberg LSF, et al. Long-term effect of face-to-face vs virtual reality cardiopulmonary resuscitation (CPR) training on willingness to perform CPR, retention of knowledge, and dissemination of CPR awareness: a secondary analysis of a randomized clinical trial. JAMA Netw Open, 2022, 5(5): e2212964.
24. Greif R, Bray JE, Djärv T, et al. 2024 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation, 2024, 150(24): e580-e687.
25. 刘洋, 张玮, 夏剑, 等. 复苏中心建设与管理急诊专家共识. 中国急救医学, 2024, 44(4): 277-283.
26. Ma W, Liu E, Xiao L, et al. The development and accuracy assessment of a wearable cardiopulmonary resuscitation real-time audio-visual feedback device. Resuscitation, 2025, 211: 110602.
27. Lakomek F, Lukas RP, Brinkrolf P, et al. Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: a prospective cohort study. PLoS One, 2020, 15(2): e0229431.
28. Caputo ML, Monachino G, Cresta R, et al. Release velocity improvement with a new metronome guIding chest COmpressions: The RITMICO simulation study. Resusc Plus, 2025, 21: 100867.
29. Koyama Y, Matsuyama T, Inoue Y. Association between haemodynamics during cardiopulmonary resuscitation and patient outcomes. Resuscitation, 2022: 295-302.
30. Matsuyama T, Yasutake Y, Inaba D, et al. Novel mode of near-infrared spectroscopy as a continuous cerebral physiological monitoring device during cardiopulmonary resuscitation: four case reports. J Clin Med, 2022, 11(7): 2018.
31. Zhao X, Wang S, Yuan W, et al. A new method to evaluate carotid blood flow by continuous Doppler monitoring during cardiopulmonary resuscitation in a porcine model of cardiac arrest. Resuscitation, 2024: 110092.
32. Hwang M, Sridharan A, Freeman CW, et al. Contrast-enhanced ultrasound of brain perfusion in cardiopulmonary resuscitation. Ultrasound Q, 2022, 38(3): 257-261.
33. Park S, Yoon H, Yeon Kang S, et al. Artificial intelligence-based evaluation of carotid artery compressibility via point-of-care ultrasound in determining the return of spontaneous circulation during cardiopulmonary resuscitation. Resuscitation, 2024, 202: 110302.
34. Kim T, Suh GJ, Kim KS, et al. Development of artificial intelligence-driven biosignal-sensitive cardiopulmonary resuscitation robot. Resuscitation, 2024: 110354.
35. Alremeithi R, Tran QK, Quintana MT, et al. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers. World J Emerg Med, 2024, 15(1): 3-9.
36. Lendrum RA, Perkins Z, Marsden M, et al. Prehospital partial resuscitative endovascular balloon occlusion of the aorta for exsanguinating subdiaphragmatic hemorrhage. JAMA Surg, 2024, 159(9): 998-1007.
37. Thrailkill MA, Gladin KH, Thorpe CR, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med, 2021, 29(1): 8.
38. Sanguanwit P, Saksobhavivat N, Phattharapornjaroen P, et al. Appropriateness of recommended chest compression depths for cardiopulmonary resuscitation based on chest computed tomography parameters among Thai population: a multicenter retrospective study. Resusc Plus, 2024, 18: 100605.
39. Goulding K, Marchetti R, Perera R, et al. Does the use of BariBoard^TM improve adequacy of chest compressions in morbid obesity? A pilot study using a simulation model. Aust Crit Care, 2022, 35(6): 688-695.
40. Schwab K, Buhr RG, Grossetreuer AV, et al. Trends in endotracheal intubation during in-hospital cardiac arrests: 2001-2018. Crit Care Med, 2022, 50(1): 72-80.
41. Robinson AE, Driver BE, Prekker ME, et al. First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department. Resuscitation, 2023, 186: 109726.
42. 姚鹏, 马雯, 王智渊, 等. 心肺复苏后脑损伤的研究进展. 中国科学: 生命科学, 2022, 52(11): 1715-1730.
43. Idris AH, Aramendi Ecenarro E, Leroux B, et al. Bag-valve-mask ventilation and survival from out-of-hospital cardiac arrest: a multicenter study. Circulation, 2023, 148(23): 1847-1856.
44. Hernández-Tejedor A, González Puebla V, Corral Torres E, et al. Ventilatory improvement with mechanical ventilator versus bag in non-traumatic out-of-hospital cardiac arrest: SYMEVECA study, phase 1. Resuscitation, 2023, 192: 109965.
45. Prause G, Zoidl P, Eichinger M, et al. Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: a randomised controlled trial. Resuscitation, 2023: 109765.
46. Wyckoff MH, Greif R, Morley PT, et al. 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation, 2022, 146(25): e483-e557.
47. Queiroga AC, Dunne C, Manino LA, et al. Resuscitation of drowned persons during the COVID-19 pandemic: a consensus statement. JAMA Netw Open, 2022, 5(2): e2147078.
48. Dezfulian C, McCallin TE, Bierens J, et al. 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2024, 150(23): e501-e516.

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