Q I have heard that ventilations are no longer important in resuscitation – is this true?
A The American Heart Association (AHA) has recently published a statement on compression-only CPR aimed at increasing the rate of bystander CPR and therefore long-term survival following out-of-hospital cardiac arrest (Sayre et al, 2008). The Resuscitation Council (UK) has endorsed this statement (RCUK, 2008), reiterating its previously published guidance stating ‘if you are not able, or are unwilling, to give rescue breaths, give chest compressions only’.
Out of hospital cardiac arrests
In most cases, ventricular tachycardia or ventricular fibrillation (eminently treatable) will be the initial arrhythmia. Effective bystander basic life support (BLS) increases the chance of survival, buying time while awaiting the arrival of the defibrillator.
Importance of BLS
Effective BLS is therefore important. In fact, it is one of only two interventions that have been shown unequivocally to improve long-term survival following a cardiac arrest, the other being early defibrillation (RCUK, 2006). It involves maintaining an open airway and supporting breathing and circulation without the use of equipment other than a protective shield (Handley et al, 2005).
A key component of BLS is the delivery of effective ventilations. Although chest compressions are now given priority over ventilations during the initial resuscitation sequence (Handley et al, 2005), effective ventilations are still required and are, indeed, paramount in a prolonged arrest if cerebral function is to be maintained and the chance of survival is to be optimised (Jevon, 2006).
Mouth to mouth ventilation and infection
Mouth-to-mouth ventilation is unpleasant to perform and there have been isolated reports of it resulting in transmission of infection following mouth-to-mouth ventilation (Handley et al, 2005). None of these have involved HIV or hepatitis B. However, as blood remains the single most important source of the transmission of HIV and hepatitis B virus, there is a theoretical risk of their transmission during mouth-to-mouth ventilation in cases of facial trauma, or if there are breaks in the skin around the lips or soft tissues of the oral cavity mucosa (Jevon, 2006).
Sometimes CPR is not started by bystanders – including off-duty healthcare professionals – because they are reluctant to perform mouth-to-mouth ventilation.
During the first few minutes following a non-asphyxial (where the primary cause of cardiac arrest is anoxia) cardiac arrest, chest compression-only CPR may be as effective as combined ventilation and compression (Kern et al, 2002). If the patient’s airway is open, occasional gasps and passive chest recoil may allow some gas exchange (Berg et al, 1997).
In adults, the outcome of chest compression-only CPR is far better than the outcome of no CPR (Becker et al, 1997). This led to the above AHA and Resuscitation Council UK statements.
CPR in healthcare settings
In healthcare settings, to minimise the risk of cross-infection during CPR, all nurses should have immediate access to ventilatory equipment, for example a pocket mask and self-inflating bag, in their working environment, which will avoid the need for a nurse to perform mouth-to-mouth ventilation.
Nurses working in the community should have immediate access to a pocket mask or mouth-to-mouth barrier device, in case one of their patients has a cardiac arrest.
Ventilations remain an important part of CPR.
In healthcare settings, they should always be performed. Ventilatory equipment should be at hand to avoid the need to perform mouth-to-mouth ventilation.
In bystander CPR, ‘if you are not able, or are unwilling, to give rescue breaths, give chest compressions only’ (Resuscitation Council UK, 2006).
Phil Jevon, PGCE, BSc, RGN, is resuscitation officer/clinical skills lead, Manor Hospital, Walsall
Becker L et al (1997) A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association. Resuscitation; 35: 189–201.
Berg R et al (1997) Assisted ventilation during ‘bystander’ CPR in a swine acute myocardial infarction model does not improve outcome. Circulation; 96: 4364–4371.
Handley A et al (2005) European Resuscitation Council Guidelines for Resuscitation 2005: Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation; 67S1, S7–S23.
Jevon P (2006) Mouth-to-mouth ventilation. Nursing Times; 102: 37, 30–31.
Kern K et al (2002) Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation; 105: 645–649.
Resuscitation Council (UK) (2008) Statement on Compression-Only Cardiopulmonary Resuscitation. London: Resuscitation Council (UK).
Resuscitation Council (UK) (2006) Resuscitation for the Citizen. London: RCUK.
Sayre M et al (2008) Hands-only (compression-only) CPR: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. A science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation; online publication 31 March 2008.