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* Statement on compression-only
      cardiopulmonary resuscitation
 
      April 2008

 
 
The American Heart Association (AHA) has published a statement entitled ‘Hands-only (compression-only) CPR: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest’.1   The primary objective of this statement is to increase the rate of bystander CPR and therefore long-term survival after out-of-hospital cardiac arrest. The central message is consistent with the existing Resuscitation Council (UK) basic life support (BLS) guidelines which include the statement: 'If you are not able, or are unwilling, to give rescue breaths, give chest compressions only'. Having considered carefully all the available evidence, there is no indication to change the existing guidelines for BLS but, like the AHA and the European Resuscitation Council (ERC), the Resuscitation Council (UK) strongly supports any initiative to increase the rate of bystander CPR after out-of-hospital cardiac arrest.

The Resuscitation Council (UK) endorses the statement on BLS that has been issued by the ERC (www.erc.edu) in response to the AHA document. The opening paragraph of the ERC statement reinforces the actions to be taken by those who witness an out-of-hospital cardiac arrest:
 
 
 Bystanders who have been trained in Basic Life Support (BLS) and who witness a sudden collapse in an adult should immediately initiate rescue actions by providing 30 chest compressions of adequate force and depth at a rate of 100 per minute followed by two mouth-to-mouth ventilations. The rescuer(s) should ensure that ventilations cause minimum interruption of chest compressions. At the same time, other bystanders should alert the Emergency Medical Services. This sequence of chest compressions and ventilations should be continued until professional help arrives. For lay rescuers who have not been trained in BLS, or who are not willing or unable to give mouth-to-mouth ventilations, an acceptable alternative is to give uninterrupted chest compressions at a rate of 100/minute. For those rescuers without BLS training and who receive telephone instructions for BLS, the preferred instruction is to give uninterrupted chest compressions until professional help arrives.

Children should be treated exactly as indicated by the existing paediatric basic life support guidelines.

The evidence for and against the use of compression-only CPR instead of conventional CPR is being fully evaluated in preparation for the 2010 Consensus Conference on CPR Science. The evidence available to date is insufficient to warrant a change in guidelines before 2010. The factors that have been taken into consideration when making this decision are summarised in the table below.
 
In favour of compression-only 
CPR 		Against compression-only CPR 
 
Many animal cardiac arrest studies have shown no survival benefit with the addition of ventilation.2-7 In these studies, animals’ airways are generally patent, which may enable chest compressions alone to generate some ventilation. Pigs continue frequent gasping during good quality CPR and this provides significant ventilation.8   Unconscious humans in the supine position will generally have an obstructed airway (unless the airway is supported) and prolonged gasping is less common (7.1% in a recent study9).   A study using an animal model incorporating an obstructed airway demonstrated rapid and profound hypoxaemia with compression-only CPR.10
 
Several surveys of both laypeople and healthcare professionals have documented a reluctance to perform mouth-to-mouth ventilation, partly because of fears of infection, but also because it is aesthetically unpleasant.11-14   This fear may prevent bystanders making any attempt at CPR. One study indicates that laypeople trained in BLS do not perform bystander CPR mainly because of panic; when interviewed after actual cardiac arrests, only 4 out of 279 (1.4%) CPR trained bystanders who failed to do CPR indicated that this was because they objected to doing mouth-to-mouth ventilation.15
 
In comparison with conventional CPR, compression-only CPR is easier to teach and learn.16 Potentially, far more people could be trained in the compression-only technique, which should lead to an increase in the rate of bystander CPR. If laypeople are trained in compression-only CPR they will not be capable of providing mouth-to-mouth ventilation in those cases in which it is clearly essential, e.g. if cardiac arrest is caused by drowning.
 
The AHA statement indicates that the recommendation for compression-only CPR does not apply to unwitnessed cardiac arrest, cardiac arrest in children or cardiac arrest presumed to be of non-cardiac origin. This implies that laypeople must be able to differentiate cardiac from non-cardiac arrest (unproven) and would need to be trained in conventional CPR as well as compression-only CPR.
 
In a study of dispatch-assisted (telephone) CPR, full instructions were more likely to be delivered completely when the ventilation component was omitted, and survival was (non-significantly) higher in the compression-only group.17 A controlled trial involving 4400 bystanders, randomised to provide either dispatch-assisted conventional or compression-only CPR, will finish recruiting this year (personal communication Prof. Maaret Castren). The results of this trial may help to determine whether compression-only CPR should be adopted more widely.
 
At least five observational studies have shown similar survival rates when bystanders deliver compression-only CPR rather than conventional CPR.9,18-21   In all of these studies, any CPR (rather than none) was associated with a higher survival rate compared with no CPR. These observational studies were undertaken before implementation of the 2005 BLS guidelines, which included a compression-ventilation ratio of 30:2 instead of 15:2. It is feasible that the outcome after conventional CPR using a 30:2 ratio is much better.
 
Any benefit of compression-only CPR over conventional CPR has usually been seen only when EMS response times are short (< 4 minutes).9   Most EMS response times are significantly longer than this, and ventilation becomes increasingly important as the duration of cardiac arrest increases.20
 
A change to compression-only CPR may benefit particularly those patients in cardiac arrest from a cardiac cause: approximately 65% - 80% of out-of-hospital, EMS-treated cardiac arrests are of primary cardiac aetiology.9,22
  		Victims of asphyxial cardiac arrest will need early ventilation if they are to have any chance of surviving. This includes children and drowning victims.
 
 
References:

  1. Sayre MR, Berg RA, Cave DM, Page R, Potts J, White RD.   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. published online Mar 31 2008; DOI: 10.1161/CIRCULATIONAHA.107.189380.
  2. Berg RA, Kern KB, Hilwig RW, Berg MD, Sanders AB, Otto CW, Ewy GA. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation.   Circulation. 1997;95(6):1635-1641.
  3. Berg RA, Kern KB, Hilwig RW, Ewy GA.   Assisted ventilation during 'bystander' CPR in a swine acute myocardial infarction model does not improve outcome.   Circulation. 1997;96(12):4364-4371
  4. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA.   Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario.   Circulation. 2002;105(5):645-649.
  5. Berg RA, Kern KB, Sanders AB, Otto CW, Hilwig RW, Ewy GA.   Bystander cardiopulmonary resuscitation. Is ventilation necessary?   Circulation. 1993;88(pt 1)(4):1907-1915.
  6. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter ME, Ewy GA.   Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest.   Circulation. 2001;104(20):2465-2470.
  7. Ewy GA.   Cardiocerebral resuscitation: the new cardiopulmonary resuscitation.   Circulation. 2005;111(16):2134-2142.
  8. Steen PA.   Does active rescuer ventilation have a place during basic cardiopulmonary resuscitation?   Circulation. 2007;116(22):2514-2516.
  9. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study.   Lancet. 2007;369(9565):920-926.
  10. Dorph E, Wik L, Stromme TA, Eriksen M, Steen PA.   Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio 2:30 versus chest compressions only CPR in pigs.   Resuscitation. 2004;60(3):309-318.
  11. Taniguchi T, Omi W, Inaba H.   Attitudes toward the performance of bystander cardiopulmonary resuscitation in Japan.   Resuscitation. 2007;75(1):82-87.
  12. Ornato JP, Hallagan LF, McMahan SB, Peeples EH, Rostafinski AG.   Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic.   Ann Emerg Med. 1990;19(2):151-156.
  13. Hew P, Brenner B, Kaufman J.   Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. J Emerg Med. 1997;15(3):279-284.
  14. Brenner BE, Kauffman J.   Reluctance of internists and medical nurses to perform mouth-to-mouth resuscitation.   Arch Intern Med. 1993;153(15):1763-1769.
  15. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S.   CPR training and CPR performance: do CPR-trained bystanders perform CPR?   Acad Emerg Med. 2006;13(6):596-601.
  16. Heidenreich JW, Sanders AB, Higdon TA, Kern KB, Berg RA, Ewy GA.   Uninterrupted chest compression CPR is easier to perform and remember than standard CPR.   Resuscitation. 2004;63(2):123-130.
  17. Hallstrom A, Cobb L, Johnson E, Copass M.   Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.   N Engl J Med. 2000;342(21):1546-1553.
  18. Waalewijn RA, Tijssen JG, Koster RW.   Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST).   Resuscitation. 2001;50(3):273-279.
  19. Van Hoeyweghen RJ, Bossaert LL, Mullie A, Calle P, Martens P, Buylaert WA, Delooz H.   Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group.   Resuscitation. 1993;26(1):47-52.
  20. Iwami T, Kawamura T, Hiraide A, Berg RA, Hayashi Y, Nishiuchi T, Kajino K, Yonemoto N, Yukioka H, Sugimoto H, Kakuchi H, Sase K, Yokoyama H, Nonogi H.   Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.   Circulation. 2007;116(25):2900-2907.
  21. Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L.   Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation.   Circulation. 2007;116(25):2908-2912.
  22. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM.   Presentation, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology.   Heart. 2003;89(8):839-842.
 
 
 
 
 
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