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CPR Not as Effective as Chest Compressions Alone
patiwat writes "A Japanese study detailed in the New York Times has found that people suffering from cardiac arrest were more likely to recover without brain damage if rescuers focused on chest compressions rather than on rescue breaths. Some experts advised dropping the mouth-to-mouth part of CPR altogether. Interrupting chest compression to perform mouth-to-mouth ventilation might do more harm than good if blood flow to the heart was not properly re-established, a researcher from Tokyo's Surugadai Nihon University Hospital said. According to the article, 'More than 300,000 Americans die from cardiac arrest each year. Roughly 9 out of 10 cardiac arrest victims die before they get to a hospital — partly because they do not get CPR.'"
This year the Red Cross changed their standard from 2 rescue breaths every 15 compressions to 2 rescue breaths every 30 compressions (or that is what my yearly training reflected). They also removed abdominal thrusts for unconscious choking victims and basically made the care the same as for a heart attack (minus the AED). I had thought they were dumbing the program down (in the case of choking)so the average person who takes first aid/CPR wouldn't have too many things to remember. Now I see that rescue breaths are generally without merit. I wonder if my training next year will reflect this particular study.
The mouth-to-mouth ventilation part was always the tricky bit. To be effective you had to blow a large volume of air into the patient with a frequency that made you dizzy and tired quickly. But you also had to be careful not to blow too hard and get air into the stomach which would then blow out all the food out. Often members of the public were reluctant to engage in CPR because of the ventilation part (because of hygiene and sensitivity consideration) and many victims didn't get any CPR because of this. In many countries, including here in Finland, the directives for teaching non-professionals CPR have been changed years ago to teach only the compression part. But I see no reason here why the ventilation part would make CPR less effective when done properly and by professionals. Perhaps this study just shows the lack of skill in doing it properly. After all, what's the point of circulation, if there's no oxygen going in?
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So if the person is still breathing but their heart has stopped, rescue breaths provide no benefit. DUH!
It's not that much of a 'duh'. The idea originally behind CPR is that you manually perform the action of the heart through the chest compressions, and that the chest compressions don't do much good without some fresh O2 in there. As such, one could ask what good CPR is without the breathing part?
The research basically just shows that circulating the remaining O2 in the blood and stimulating the heart muscle is much more valuable than stopping occasionally to ensure the air is fresh, but that's not a determination you could make with no education, experience, or actually performing the research.
If you're going to call 'duh', you're asserting thay you know more about medicine than the medical professionals who created it and have practiced it all these years. I don't think that's the case, and as is usually the case, the facts are more complicated than it seems to laypeople.
After each 1 minute of pumping someone's chest, i like to teabag the victim for about 30 seconds.
As emphasized by someone in the article, which I read when they published it (and I'm also a swim instructor, lifeguard, and first responder) it's VERY important to note that using only compressions is best and useful in the event of a dryland cardiac event. If someone has just been pulled from the water for instance and is not drowning, you need to give them AIR. Rehashing from the article: most people suffering from heart problems and fibrilliation have plenty of oxygen in their blood and it will remain that way for about 8 minutes. They are not generally in danger of losing oxygenated blood flow to their brain and dying that way. Thus, the exec that collapses in the stairmaster you can probably do just fine with giving compressions: and if you're the ONLY one there who can do that, you had probably better do that. Having actually given CPR for more than 2 minutes, it can literally cause you to pass out if you're the only one there: you have to combine forceful compressions (of breaking THROUGH the ribcage to the heart to get it going) with breathing into a person...and then there are people who might know CPR but, as the article points out, are afraid of catching something. In summary: don't forget to breath into the victim if they aren't breathing. Especially if they were drowning.
Could this be the end of being able to trick hot teenage lifeguards into making out with you?
Just to be pedantic, as a paramedic, I watched a few people who were breathing while in cardiac arrest. It's not common, but it can happen. The thing is, they won't breathe for long while in cardiac arrest. One guy in a witnessed arrest for 5 minutes, no pulse, not breathing, v-fib on the monitor, grabbed me and screamed "NO!" when I tried to defibrillate him. I almost shocked both of us. After I got his hands pried off my collar, I sparked him and got him back into a decent rhythm. When he woke up a couple hours later, he didn't know why he screamed "NO!" I've always wondered what was going on in his mind.... The ability to move blood decreases dramatically with time when blood isn't flowing. This result may indicate that stopping compressions for anything short of a return of cardiac activity isn't worth it. In the field and in the hospital, it's not uncommon for the person doing chest compressions to stop occasionally to perform an intervention. This result may change how CPR is done by the medical professionals as well. On the other hand, if rescue breathing is being done poorly in the field, perhaps it's complications like air in the stomach that results in vomiting and thus aspiration pneumonia that's causing the problem. More work will definitely need to be done on this question.
This sig seemed like a good idea at the time....
I teach CPR instructors for the layperson as well as for professionals. Yes, I do work in emergency medicine. Here is my take on the findings and from my experience.
First responders (people first on the scene, not medical professionals) historically tend to do a very poor job of ventilating a patient. Often times this renders the rescue breathing almost useless. This has been known about and debated for many years. The "something is better than nothing" attitude as prevailed through the years, even though the majority of the time "nothing" is exactly what the patient gets in terms of oxygen. They often also tend to perform very poor quality CPR compressions (not deep enough, not fast enough).
You are breathing 21% oxygen now. When you exhale into an individual, they are not receiving 21% for part of it was used by the rescuer. The patient is only receiving 16% oxygen. This is a drastic reduction, but it is far better than nothing.
When any patient is determined to not be breathing, there are 3 things a rescuer must remember:
ABC
Airway
It the airway is not clear and straight, no oxygen can get into the lungs.
Breathing
If a person is not breathing, you MUST breath for them or their heart will stop due to lack of oxygen.
Circulation
If a pulse is not detected, you must do proper CPR to circulate oxygenated blood.
These must be maintained in the order ABC. Maintaining circulation when there is no breathing or oxygen is bad.
CPR buys time until properly trained medical personnel arrive. It will not get the heart starting to beat again. You are simply trying to circulate oxygenated blood since the body is not capable of doing that on its own. When there is no pulse in the early stage of a heart attack you see, generally the heart is in an abnormal, but regular rhythm most of the time, but not always. It is basically beating so fast that it cannot circulate blood, and the rhythm at some point becomes very irregular. Defibrillation and cardiac drugs are needed for the heart to return to a normal rhythm. If there is electrical activity still in the heart there is a significantly greater chance of resuscitation. When the heart is in asystole, there is no electrical signal and it is game over. Circulating oxygen is key to survival.
It is also a known fact that most people who take a CPR class forget more than half of what they were taught the day before. As more time elapses, even more is forgotten. If I were having a heart attack, I would prefer that someone tried to give me rescue breaths, even though there is a chance they will do it wrong. It is better to have oxygenated blood circulated than deoxygenated blood. This is just my opinion.
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As a physician who deals with in-hospital cardiac arrests on a regular basis, and whom has RTFA, there are couple important points. First, this study really only looked at bystander-provided CPR. The paramedics/other trained professionals who arrived still intubated and ventilated these patients - as this is standard of care. The authors of the study say that the likely explanation for their finding is likely that bystanders interrupted chest compressions to give rescue breaths. So, we may need to change the training for the lay public regarding CPR, but professional responders will still need to give ventilations, and once an airway is secured simultaneous compression and ventilation can be given. If you don't breath - you don't live. Second, while this is likely one of the better studies that can be done on a topic like this, it was not randomized, it was not controlled, nor was it even comprehensive/population-based. There are multiple types of errors that can creep in and cause erroneous results in these types of studies. Finally, we need to keep results in perspective. While any improvement is important - and should be pursued - the overall statistics they report for outcomes are still pretty dismal. The overall survival rate for out of hospital arrest was 8-9%, and the number of people with only moderate/mild disability afterward (ie able to walk, talk, etc) was ~6% if you only got chest compressions, ~4% if you got compressions and rescue breaths. So, even with the "chest compressions only" strategy, the absolute difference is relatively small.