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Friday, October 22, 2010

Mouth to mouth not indicated for adult CPR

Way back in 1995 I learned that chest compressions during Basic Life Support (BLS) were all that was needed to get CO2 to exit the lungs and the 21% Fraction of Inspired oxygen that's in the air we breath to enter the lungs.

The constant banging on the chest causes the CO2 to sort of vibrate out of the body, and air to vibrate into the body. It works similar to high frequency ventilation. During normal living this wouldn't be comfortable, but in emergency situations it works.

Way back then we learned that chest compressions were all that was needed during CPR, and breaths were not indicated and even harmful.

Since then more and more evidence has come out confirming the idea that chest compressions alone are more beneficial to a patient who is in cardiopulmonary arrest than wasting your time putting your less than 21% Fraction of Inspired Oxygen (FiO2) that's in expired breaths into a person. 15% FiO2 is simply not that beneficial to the patient.

New evidence also supports that the negative recoil of the chest that you create during good chest compressions are enough to keep air flowing into the lungs, and CO2 out of the lungs. It's simply more evidence to support that mouth to mouth breathing is a waste of time.

Not only that , but mouth to mouth breathing is considered to be gross, and it's probably the #1 reason why some people don't do CPR. Plus trying to remember guidelines that recommend 2 breaths to 30 chest compressions for adults, and 1 breath to 15 compressions for two person CPR on children is way to confusing even for the well trained medical professional.

What is more important is that you keep the person's heart pumping. A person can stop breathing for minutes at a time, yet the heart never stops beating. So the best chance that person has is for you to keep the heart beating, preferably at 100 beats per minute.

The Red Cross has finally realized this by setting an initiative to teach people about hands only CPR by 2011 (article here). They now recommend hands only CPR outside the hospital setting.

I actually think this should say, "in the absence of advanced medical equipment." I say this because most hospitals don't have AMBU bags in every room, and there are times CPR must begin before one is available. In these cases, chest compressions should be given until such advanced medical equipment is available.

I don't think that just because we are "trained professionals" we should be expected to put our mouths over another person's mouth.

The American Heart Association (AHA) has updated its guidelines, although, in my opinion, they have yet to go far enough. As you can see by this post, the AHA has changed the sequence of doing CPR. While it previously recommended ABC (Airway-Breathing-Compressions) it now recommends CAB (Compressions-Airway-Breathing).

The new changes are recommended for all patients except for newborns. This is good, because for adults who suddenly become unresponsive, the heart is the cause, and this is why chest compressions are so important.

For babies who suddenly stop breathing the cause is more likely respiratory related, and in this instance breaths are important. So for newborn babies it's important to give breaths first, especially if the heart rate is less than 100. (In babies, the heart rate starts to go down when breathing is slowed down).

I like the Red Cross recommendation to do chest compressions only because it will get more people doing CPR, and makes the efforts more beneficial (although statistics of success are still minute). Yet the AHA still refuses to get rid of opening the Airway and giving Breaths. A true sign the old fogies making these guidelines are overly willing to hang on to old fallacies.

(Note: Breaths are still indicated if a respiratory problem is the cause of failure. A good example is near drownings).

So while our BLS instructor was spending loads of time making sure we were giving breaths correctly, I couldn't help but to think I was wasting my time. I even said so this time around. Yet she gave your typical, "I'm just teaching it as I was instructed." And I respect that: she is just doing as she's taught.

I have respect for that. Which is exactly the reason those old fogies at the AMH update their guidelines to get rid of un-oxygenated breaths during CPR in the absence of advanced medical equipment. It's simply pointless.

I was told during a recent Advanced Cardiac Life Support (ACLS) class a few years back taught by an AMH instructor that a board of 10 or so doctors sets and updates the guidelines every few years. And the last vote you had something like 8 of the 10 experts voting against giving breaths. Those two said something like, "Well, it only makes sense we should be giving breaths."

Sure it does. Yet the evidence shows these breaths are pointless and even detrimental. It's hard to keep your chest compression rhythm when you keep stopping to give breaths. Plus these recommendations that you give cycles of two breaths for each 30 compressions are too complicated. In real life it's impossible to do that. In real life we never do it like THEY recommended.

Way back in 2000 I had a patient whose heart stopped, and I did CPR with chest compressions only. My coworkers frowned at what I was doing, "Well, I'm not putting my mouth on that," I said, looking at the patient.

I simply pounded on the chest, and within a minute the CODE team had arrived with advanced medical equipment, an AMBU bag was used to give 100% oxygenated breaths, and the patient was shocked. Plus, believe it or not, the patient survived.

So it's time the AHA join the Red Cross by stopping the complicated recommendations in their guidelines that breaths should be given. It's time to go to chest compressions only when advanced medical equipment is not available.

1 comment:

TWF said...

Great post, thanks for getting the word out.

You're right, the more people we get trained for hands-only CPR, the more lives will be saved.