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

The Breath of Life?

Thomas Rea MD MPH

University 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


Disclosures1

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 life1

The Breath of Life?

The Role of Rescue Breathing during CPR


Normal physiology

Normal Physiology


Cpr benefits

Preserve some measure of critical organ perfusion/oxygenation.

CPR Benefits


The debate

Optimal Balance of Oxygenation and Circulation

The Debate

Hands Only CPR

CC + Rescue Breathing


A rationale discourse

A Rationale Discourse


A rationale discourse1

Lay Person CPR

Professional CPR

A Rationale Discourse


A rationale discourse2

Lay Person CPR

Professional CPR

A Rationale Discourse

Distinct expectations and training

Different phase and type of arrest


Lay person cpr

Lay Person CPR


The breath of life

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


A case for hands only cpr1

#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


A case for hands only cpr2

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

A Case for Hands Only CPR


A case for hands only cpr3

#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


A case for hands only cpr4

#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


A case for hands only cpr5

#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%


A case for hands only cpr6

#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%


A case for hands only cpr7

#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

Ventricular Fibrillation

PEA / Asystole


A case for hands only cpr8

#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

45%

50%

40%

30%

Survival

15%

20%

10%

5%

VFPEAAsystole


A case for hands only cpr9

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

A Case for Hands Only CPR

Level 1 Evidence


A case for hands only cpr10

#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%


A case for hands only cpr11

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

Bipartisanship


Professional cpr

Professional CPR

CC + Rescue Breathing

Hands Only CPR


A case for hands only cpr12

#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


A case for hands only cpr13

#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


A case for hands only cpr14

#1.Sufficient Oxygen Reservoir at the Time of Collapse

A Case for Hands Only CPR

Oxygen Content

Time Interval from Collapse


A case for hands only cpr15

#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


A case for hands only cpr16

#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


A case for hands only cpr17

#3. Ventilations are difficult to perform and produce interruptions

A Case for Hands Only CPR

50% ….. produced < 30 compressions / minute


A case for hands only cpr18

#3. Ventilations are difficult to perform and produce interruptions

A Case for Hands Only CPR


A case for hands only cpr19

#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


A case for hands only cpr20

#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


A case for hands only cpr21

#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 cpr22

#4. The Importance of Etiology and Rhythm

A Case for Hands Only CPR

Ventricular Fibrillation

PEA / Asystole


A case for hands only cpr23

#4. The Importance of Etiology and Rhythm

75% of arrests

A Case for Hands Only CPR

25% of arrests

Ventricular Fibrillation

PEA / Asystole


A case for hands only cpr24

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

A Case for Hands Only CPR

Level 1 Evidence


A case for hands only cpr25

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

A Case for Hands Only CPR

(Empty Space)


A case for hands only cpr26

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


A case for hands only cpr27

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


The breath of life

Summary

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

A Great Debate


The breath of life

Summary


Normal physiology1

Requires

Normal Physiology


Disclosures2

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 life2

The Breath of Life?

Thomas Rea MD MPH

University of Washington

King County Emergency Medical Services


The great debate

The Great Debate


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