PONE-D-19-19476

Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study

PLOS ONE

Dear Dr Kim,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Lars-Peter Kamolz, M.D., Ph.D., M.Sc.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: After reviewing the PONE-D-19-19476 manuscript entitled “Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study” some suggestions and clarifications were raised as follows:

The aim of the study was to assess a new technique/device against 4 different techniques on a simulation manikin. In general, the manuscript is well written with minor spelling or grammar mistakes.

After checking the literature, and to my knowledge, this is the only manuscript that evaluated the use of a devise to assist the rescuers in performing CPR. This is a vital area of research since improving CPR in pediatric would rescue many lives.

Please find below some of the suggestions that would improve the quality of the manuscript.

Major suggestions or questions:

1. Why did it take the investigators a long time after the simulation (Oct and Nov 2016) to prepare the manuscript and submit it for publications? Many papers were published during this period on new finger location and numbers since then. (1-5) one of the new techniques has many publications showing its superiority to TFT.

2. The authors used a random cross over method to test the different techniques. Also they mentioned that some of the techniques caused fatigue more than the others. Did the authors check the effect of starting with a harder technique on the performance of participants in the other techniques?

3. Did the authors check the difference in the performance of the participants depending on their levels (doctors, residents and students)?

4. How were the CD, the compression rate, finger position, and the recoil recorded and evaluated? Does the manikin record them?

5. Does the manikin record other parameters like simulated SBP, DBP, mean arterial pressure, and pulse pressure?

6. Did the author account for the primary/dominant hand of the participant? In the text they mentioned that all the participants used their right hand fingers for the compressions. How many participants were left handed? How was the performance of these participants in comparison with the right handed ones?

7. The authors should provide further description or details about the used device in the PAT technique.

a. Is it patented?

b. Is it commercially available? What company invented it?

c. Is there any other device in the market or experimental to compare this device to it?

8. Depending on the author responses to question 7, the conflict of interest of the group would be more clear to the reviewers and the journal.

Minor

1. Spelling mistakes (line 2 Paediatric and line 4, pediatric).

2. On line 145, remove one of “That” after TFT.

3. The description of the dimensions of the circular piece (line 39) must report either the diameter or the radius and not 2 dimensions since it is circle shape. Please modify.

4. Authors must improve the appearance of Table 1. It is hard to get the results as it is now.

5. The orientation of the manikin and the fingers position in figure 1 (PT1 and PT2) is not clear. I suggest a better orientation like the other images.

6. I suggest that the authors move some of the graphs presented in the supplementary sections to the main manuscript body to enrich the article.

7. The numbering of the figures in the supporting information file should start with 1, and the authors should assign a special character to reflect the location of the figure in the supplement file. The authors should check the guidelines of PLoS one for this issue.

1. Ladny J, Smereka J, Rodriguez-Nunez A, Leung S, Ruetzler K, Szarpak L. Is there any alternative to standard chest compression techniques in infants? A randomized manikin trial of the new “2-thumb-fist” option. 2018. e9386 p.

2. Smereka J, Bielski K, Ladny J, Ruetzler K, Szarpak L. Evaluation of a newly developed infant chest compression technique A randomized crossover manikin trial 2017. e5915 p.

3. Smereka J, Szarpak L, Ladny J, Rodriguez-Nunez A, Ruetzler K. A Novel Method of Newborn Chest Compression: A Randomized Crossover Simulation Study 2018. 159 p.

4. Smereka J, Szarpak L, Rodriguez-Nunez A, Ladny J, Leung S, Ruetzler K. A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study 2017. 1420-5 p.

5. Smereka J, Szarpak L, Smereka A, Leung S, Ruetzler K. 2017. Evaluation of new two-thumb chest compression technique for infant CPR performed by novice physicians. A randomized, crossover, manikin trial 604-9 p.

Reviewer #2: Dear authors,

Thank you for the opportunity to review the manuscript "Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study".

A very interesting study concerning an important medical field that I have read with great interest.

I wish you all the best for publication.

Kind regards

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Reviewer #1: Yes: Moustafa Al Hariri

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-19-19476R1

Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study

PLOS ONE

Dear Dr Kim,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Dec 15 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Lars-Peter Kamolz, M.D., Ph.D., M.Sc.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: Dear authors,

I got to review your manuscript "Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study", in which you show the superiority of a newly developed technique over the currently recommended ones. While in general, I think your manuscript is of great value and has gained a lot of value by the first revision, I would like to add a few minor points:

1.) Consider adding another figure about the currently recommended techniques (lines 8ff.) for the purpose of presentation.

2.) I would appreciate a little more context about your motivation, on WHY you performed this research. You mention, that you wanted to "overcome the insufficient CD of the TFT and alleviate discomfort", however, please elaborate a little bit more, especially considering the fact THAT and why other techniques seem to be insufficient.

3.)In line 51, you should mention that the 5-point Likert scale questionnaire was performed after EVERY one of the techniques. As it is written now, it appears that it was performed just ones at the very end (In line 118 you mention it correctly).

4.) In the measured outcomes section you write about all the outcomes, however, it remains unclear how "correct" is defined. in Data Collection you write about the correct finger position, but how correct (or adequate) compression rate, correct chest recoil and correct CD are defined, remains unclear. Please clarify.

5.) I would be very interested, whether the sequence yielded different results for the different techniques (e.g. has the TFT1 technique yielded better results when performed first...?) I am wondering, because I can imagine, that when performing five different techniques, the motivation reduces over time. Furthermore, it would be also very interesting how the "correctness" of each technique changed over the duration of the performance - can any statement concerning the recommended length before a change of rescucitator be given? How significant is the fatigueness during the performance?

6.) Please add a sentence to the limitations section that this experiment should also be repeated with a group of experienced doctors/health care practitioners (like paediatricians or emergency doctors) to evaluate the effectiveness in a group of other relevance.

Thank you.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: a prospective simulation study

PONE-D-19-19476R2

Dear Dr. Kim,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Lars-Peter Kamolz, M.D., Ph.D., M.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No