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The Breath of Life?
Thomas Rea MD MPHUniversity of Washington
King County Emergency Medical Services
Disclosures
I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities.
Disclosures
I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities.
There is much to learn.
The Breath of Life?
The Role of Rescue Breathing during CPR
Normal Physiology
CPR Benefits
Preserve some measure of critical organ perfusion/oxygenation.
The Debate
Optimal Balance of Oxygenation and Circulation
Hands Only CPR CC + Rescue Breathing
A Rationale Discourse
A Rationale Discourse
Lay Person CPR Professional CPR
A Rationale Discourse
Lay Person CPR Professional CPR
Distinct expectations and trainingDifferent phase and type of arrest
Lay Person CPR
A Case for Hands Only CPR
A Case for Hands Only CPR
#1. Sufficient Oxygen Reservoir at the Time of Collapse
A Case for Hands Only CPR
#1.Sufficient Oxygen Reservoir at the Time of CollapseO
xyge
n Co
nten
t
Time Interval from Collapse
A Case for Hands Only CPR
#2. Hands Only CPR is easier to train and implement.
A Case for Hands Only CPR
2005 2006 2007 2008 2009
50%
30%
40%
20%
10%
33%40%
28% 32%36%
Byst
ande
r CP
R
#2. Hands Only CPR is easier to train and implement.
#3. Ventilations are difficult to perform and produce interruptions
Rigorous often repeated CPR training of laypersons
A Case for Hands Only CPR
Public Access Defibrillation Trial
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
During the time bystanders were prompted to provide CPR, what proportion of time was actually spent performing chest compressions?A. 75%B. 67%C. 50%D. 25%
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
During the time bystanders were prompted to provide CPR, what proportion of time was actually spent performing chest compressions?A. 75%B. 67%
C. 50% .. resulted < 30 compressions / minuteD. 25%
A Case for Hands Only CPR
Ventricular Fibrillation
#4. The Importance of Etiology and Rhythm
PEA / Asystole
A Case for Hands Only CPRSu
rviv
al
VF PEA Asystole
50%
30%
40%
20%
10%
15%
5%
45%
#4. The Importance of Etiology and Rhythm
#5. Evidence from Trials Comparing Hands Only vs CC + RB
A Case for Hands Only CPR
Level 1 Evidence
A Case for Hands Only CPR
HO CPR CC + RBSeattle 14% 10%TANGO 9% 7%DART 14% 11%
Survival
#5. Evidence from Trials Comparing Hands Only vs CC + RB
Hands Only CPR
CC + Rescue Breathing
1. Reservoir of oxygenated blood2. Hands only is easier to train and implement3. Ventilations are challenging to perform4. Hands only favors VF resuscitation5. Evidence from Human Trials
A Case for Hands Only CPR
Optimal Balance of Oxygenation and Circulation
Bipartisanship
Professional CPR
Hands Only CPR CC + Rescue Breathing
A Case for Hands Only CPRO
xyge
n Co
nten
t
Time Interval from Collapse
#1.Sufficient Oxygen Reservoir at the Time of Collapse
A Case for Hands Only CPRO
xyge
n Co
nten
t
Time Interval from Collapse
#1.Sufficient Oxygen Reservoir at the Time of Collapse
A Case for Hands Only CPRO
xyge
n Co
nten
t
Time Interval from Collapse
#1.Sufficient Oxygen Reservoir at the Time of Collapse
A Case for Hands Only CPR
2005 2006 2007 2008 2009
50%
30%
40%
20%
10%
33%40%
28% 32%36%
Byst
ande
r CP
R
#2. Hands Only CPR is easier to train and implement.
A Case for Hands Only CPRPr
ofes
sion
al C
PR
2005 2006 2007 2008 2009
100%
50%
#2. Hands Only CPR is easier to train and implement.
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
50% ….. produced < 30 compressions / minute
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
Interruptions for Rescue Breathing
30:2 Compression to Ventilation Ratio
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
Interruptions for Rescue Breathing
30:2 Compression to Ventilation Ratio
#3. Ventilations are difficult to perform and produce interruptions
A Case for Hands Only CPR
Asynchronous Ventilations Prior to Intubation
A Case for Hands Only CPR
Ventricular Fibrillation
#4. The Importance of Etiology and Rhythm
PEA / Asystole
A Case for Hands Only CPR
Ventricular Fibrillation
#4. The Importance of Etiology and Rhythm
PEA / Asystole
25% of arrests
75% of arrests
A Case for Hands Only CPR
Level 1 Evidence
#5. Evidence from Trials Comparing Hands Only vs CC + RB
A Case for Hands Only CPR
(Empty Space)
#5. Evidence from Trials Comparing Hands Only vs CC + RB
Hands Only CPR CC + Rescue Breathing
1. Reservoir of oxygenated blood2. Hands Only is easier to train and implement3. Ventilations are challenging to perform4. Hands only favors VF resuscitation5. Evidence from Human Trials
A Case for Hands Only CPR
Optimal Balance of Oxygenation and Circulation
Hands Only CPRCC + Rescue Breathing
1. Reservoir of oxygenated blood2. Hands Only is easier to train and implement3. Ventilations are challenging to perform4. Hands only favors VF resuscitation5. Evidence from Human Trials
A Case for Hands Only CPR
Optimal Balance of Oxygenation and Circulation
Hands Only is an effective approach for layperson CPR
Summary
Summary
Phase and patient differences
Technical experts
Changing epidemiology
Lack of top-level comparative evidence
A Great Debate
Summary
Normal Physiology
Requires
Disclosures
CurveballBeholden to the evidence RCTBipartisanshipBystander CPRAre there persons who might benefit from ventilation?
Optimize oxygenation delivery to critical tissues. Ventilations are too difficult to perform and produce interruptions in compression / circulationThere is enough oxygenated blood in the reservoir so that the best strategy is to circulate.Only those with a cardiac as opposed to a respiratory cause can surviveThe weight of the evidence supports hands only CPR
The Breath of Life?
Thomas Rea MD MPHUniversity of Washington
King County Emergency Medical Services
The Great Debate
