The breath of life
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The Breath of Life?. Thomas Rea MD MPH University of Washington King County Emergency Medical Services. I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities. Disclosures.

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The Breath of Life?

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The Breath of Life?

Thomas Rea MD MPH

University of Washington

King County Emergency Medical Services


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.

Disclosures


The Breath of Life?

The Role of Rescue Breathing during CPR


Normal Physiology


Preserve some measure of critical organ perfusion/oxygenation.

CPR Benefits


Optimal Balance of Oxygenation and Circulation

The Debate

Hands Only CPR

CC + Rescue Breathing


A Rationale Discourse


Lay Person CPR

Professional CPR

A Rationale Discourse


Lay Person CPR

Professional CPR

A Rationale Discourse

Distinct expectations and training

Different phase and type of arrest


Lay Person 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 Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


#2. Hands Only CPR is easier to train and implement.

A Case for Hands Only CPR


#2. Hands Only CPR is easier to train and implement.

A Case for Hands Only CPR

50%

40%

40%

36%

33%

32%

Bystander CPR

30%

28%

20%

10%

2005 2006 2007 2008 2009


#3. Ventilations are difficult to perform and produce interruptions

A Case for Hands Only CPR

Public Access Defibrillation Trial

Rigorous often repeated CPR training of laypersons


#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?

75%

67%

50%

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?

75%

67%

50% .. resulted< 30 compressions / minute

25%


#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

Ventricular Fibrillation

PEA / Asystole


#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

45%

50%

40%

30%

Survival

15%

20%

10%

5%

VFPEAAsystole


#5. Evidence from Trials Comparing Hands Only vs CC + RB

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

Survival

HO CPRCC + RB

Seattle 14% 10%

TANGO 9% 7%

DART 14% 11%


Optimal Balance of Oxygenation and Circulation

1. Reservoir of oxygenated blood

2. Hands only is easier to train and implement

Ventilations are challenging to perform

Hands only favors VF resuscitation

Evidence from Human Trials

A Case for Hands Only CPR

CC + Rescue Breathing

Hands Only CPR


Bipartisanship


Professional CPR

CC + Rescue Breathing

Hands Only CPR


#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


#2. Hands Only CPR is easier to train and implement.

A Case for Hands Only CPR

50%

40%

40%

36%

33%

32%

Bystander CPR

30%

28%

20%

10%

2005 2006 2007 2008 2009


#2. Hands Only CPR is easier to train and implement.

A Case for Hands Only CPR

100%

Professional CPR

50%

2005 2006 2007 2008 2009


#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


#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

Ventricular Fibrillation

PEA / Asystole


#4. The Importance of Etiology and Rhythm

75% of arrests

A Case for Hands Only CPR

25% of arrests

Ventricular Fibrillation

PEA / Asystole


#5. Evidence from Trials Comparing Hands Only vs CC + RB

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)


Optimal Balance of Oxygenation and Circulation

  • Reservoir of oxygenated blood

  • Hands Only is easier to train and implement

  • Ventilations are challenging to perform

  • Hands only favors VF resuscitation

  • Evidence from Human Trials

A Case for Hands Only CPR

CC + Rescue Breathing

Hands Only CPR


Optimal Balance of Oxygenation and Circulation

  • Reservoir of oxygenated blood

  • Hands Only is easier to train and implement

  • Ventilations are challenging to perform

  • Hands only favors VF resuscitation

  • Evidence from Human Trials

A Case for Hands Only CPR

Hands Only CPR

CC + Rescue Breathing


Summary

Hands Only is an effective approach for layperson CPR


Summary

Phase and patient differences

Technical experts

Changing epidemiology

Lack of top-level comparative evidence


A Great Debate


Summary


Requires

Normal Physiology


Curveball

Beholden to the evidence RCT

Bipartisanship

Bystander CPR

Are there persons who might benefit from ventilation?

Optimize oxygenation delivery to critical tissues.

Ventilations are too difficult to perform and produce interruptions in compression / circulation

There 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 survive

The weight of the evidence supports hands only CPR

Disclosures


The Breath of Life?

Thomas Rea MD MPH

University of Washington

King County Emergency Medical Services


The Great Debate


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