Is mouth-to-mouth ventilation effective in first responders? Comparing the effects between 30 : 2 algorithm versus hands-only. An exploratory pilot simulation study

Aim: Compare which resuscitation (for cardiac arrest scenario) has a higher quality when first responders with a duty of care are deprived of material: a standard resuscitation algorithm or a hands-only one when performed by first responders with training on mouth-to-mouth ventilation. Besides, a more specifics objectives were: to analyze the characteristics of these mouth-to-mouth ventilations and study the association between Body Mass Index and the different variables related to compressions.

Methods: We conducted a prospective quasi-experimental crossover study of consecutive standardized simulated cases with 41 volunteers attached to the Plan of Surveillance and Rescue in Beaches. Each participant performed 2 minutes of basic life support (CPRb). Afterward, each participant performed 2 minutes of CPR with hands-only (CPRho). The data collection was carried out with a CPR calibrated Mannequin.

Results: The mean depth was 48.1 ± 9.0 mm for CPRb, and 44.8 ± 9.7 mm for CPRho (t = 5.8, P < 0.001, 95% CI, 2.2 - 4.4), the rate was 123 ± 16.1 compressions/min for CPRb and 120 ± 17.9 for CPRho. The CPRho achieved a mean of 106 ± 42.5 complete compressions with full chest recoil, versus 57 ± 55.3 for CPRb (z = -2.6, P = 0.009). 20.7% of ventilation were hypoventilation and 42.7% were hyperventilation.

Conclusions: Mouth-to-mouth ventilations performed by first responders during simulated scenario not met European Resuscitation Council guideline based targets to ventilation, despite being performed by well-trained providers. When ventilations were not performed, the number of high-quality compressions increased in absolute values.

Cardiopulmonary resuscitation; Simulation; Chest compression; Basic life support; Hands-only

[1] 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: 2908-2912.

[2] Bobrow BJ, Spaite DW, Berg RA, Stolz U, Sanders AB, Kern KB, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. Journal of the American Medical Association. 2010; 304: 1447-1454.

[3] Kitamura T, Kiyohara K, Nishiyama C, Kiguchi T, Kobayashi D, Kawamura T, et al. Chest compression-only versus conventional cardiopulmonary resuscitation for bystander-witnessed out-of-hospital cardiac arrest of medical origin: a propensity score-matched cohort from 143,500 patients. Resuscitation. 2018; 126: 29-35.

[4] SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. The Lancet. 2007; 369: 920-926.

[5] Hüpfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. The Lancet. 2010; 376: 1552-1557.

[6] Olasveengen TM, de Caen AR, Mancini ME, Maconochie IK, Aickin R, Atkins DL, et al. 2017 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations summary. Circulation. 2017; 136: e424-e440.

[7] Spelten O, Warnecke T, Wetsch WA, Schier R, Böttiger BW, Hinkelbein J. Dispatcher-assisted compression-only cardiopulmonary resuscitation provides best quality cardiopulmonary resuscitation by laypersons: a randomised controlled single-blinded manikin trial. European Journal of Anaesthesiology. 2016; 33: 575-580.

[8] Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Berg RA, et al. Time-dependent effectiveness of chest compression-only and conventional cardiopulmonary resuscitation for out-of-hospital cardiac arrest of cardiac origin. Resuscitation. 2011; 82: 3-9.

[9] Svensson L, Bohm K, Castrèn M, Pettersson H, Engerström L, Herlitz J, et al. Compression-only CPR or standard CPR in out-of-hospital cardiac arrest. New England Journal of Medicine. 2010; 363: 434-442.

[10] Panchal AR, Bobrow BJ, Spaite DW, Berg RA, Stolz U, Vadeboncoeur TF, et al. Chest compression-only cardiopulmonary resuscitation per-formed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies. Resuscitation. 2013; 84: 435-439.

[11] Baldi E, Bertaia D, Savastano S. Mouth-to-mouth: an obstacle to cardio-pulmonary resuscitation for lay-rescuers. Resuscitation. 2014; 85: e195-e196.

[12] Nolan JP, Monsieurs KG, Bossaert L, Böttiger BW, Greif R, Lott C, et al. European resuscitation council COVID-19 guidelines executive summary. Resuscitation. 2020; 153: 45-55.

[13] Perkins GD, Olasveengen TM, Maconochie I, Soar J, Wyllie J, Greif R, et al. European resuscitation council guidelines for resuscitation: 2017 update. Resuscitation. 2018; 123: 43-50.

[14] Benoit JL, Vogele J, Hart KW, Lindsell CJ, McMullan JT. Passive ultra-brief video training improves performance of compression-only cardiopulmonary resuscitation. Resuscitation. 2017; 115: 116-119.

[15] Iwami T, Kitamura T, Kiyohara K, Kawamura T. Dissemination of chest compression-only cardiopulmonary resuscitation and survival after out-of-hospital cardiac arrest. Circulation. 2015; 132: 415-422.

[16] Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. Journal of the American Medical Association. 2013; 310: 1377-1384.

[17] Dumas F, Rea TD, Fahrenbruch C, Rosenqvist M, Faxén J, Svensson L, et al. Chest compression alone CPR is associated with better long-term survival compared to standard CPR. Resuscitation. 2012; 83: e41-e42.

[18] Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, et al. European resuscitation council guidelines for resuscitation 2015. Resuscitation. 2015; 95: 100-147.

[19] Neth MR, Benoit JL, Stolz U, McMullan J. Ventilation in simulated out-of-hospital cardiac arrest resuscitation rarely meets guidelines. Prehospital Emergency Care. 2020. (In press)

[20] Jaafar A, Abdulwahab M, Al-Hashemi E. Influence of rescuers’ gender and body mass index on cardiopulmonary resuscitation according to the American Heart Association 2010 resuscitation guidelines. International Scholarly Research Notices. 2015; 2015: 246398.

[21] Sayee N, McCluskey D. Factors influencing performance of cardiopul-monary resuscitation (CPR) by foundation year 1 hospital doctors. Ulster Medical Journal. 2012; 81: 14-18.

[22] López-González A, Sánchez-López M, Garcia-Hermoso A, López-Tendero J, Rabanales-Sotos J, Martínez-Vizcaíno V. Muscular fitness as a mediator of quality cardiopulmonary resuscitation. The American Journal of Emergency Medicine. 2016; 34: 1845-1849.

[23] Contri E, Cornara S, Somaschini A, Dossena C, Tonani M, Epis F, et al. Complete chest recoil during laypersons’ CPR: is it a matter of weight?American Journal of Emergency Medicine. 2017; 35: 1266-1268.

[24] Shin J, Hwang SY, Lee HJ, Park CJ, Kim YJ, Son YJ, et al. Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2014; 22: 59.

[25] Pujalte-Jesús MJ, Leal-Costa C, Ruzafa-Martínez M, Ramos-Morcillo AJ, Díaz Agea JL. Relief Alternatives during resuscitation: instructions to teach bystanders. A randomized control trial. International Journal of Environmental Research and Public Health. 2020; 17: 5495.

[26] Cheskes S, Schmicker RH, Verbeek PR, Salcido DD, Brown SP, Brooks S, et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation. 2014; 85: 336-342.

[27] Ashoor HM, Lillie E, Zarin W, Pham B, Khan PA, Nincic V, et al. Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: a systematic review. Resuscitation. 2017; 118: 112-125.

[28] Iserbyt P, Schouppe G, Charlier N. A multiple linear regression analysis of factors affecting the simulated Basic Life Support (BLS) performance with Automated External Defibrillator (AED) in Flemish lifeguards. Resuscitation. 2015; 89: 70-74.

[29] Pitts S, Kellermann AL. Hyperventilation during cardiac arrest. The Lancet. 2004; 364: 313-315.

[30] Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013; 128: 417-435.

[31] Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004; 109: 1960-1965.

[32] Park SO, Shin DH, Baek KJ, Hong DY, Kim EJ, Kim SC, et al. A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency department. Resuscitation. 2013; 84: 298-303.

[33] Chen KY, Ko YC, Hsieh MJ, Chiang WC, Ma MH. Interventions to improve the quality of bystander cardiopulmonary resuscitation: a systematic review. PLoS ONE. 2019; 14: e0211792.