The Breath of Life?

1. The Breath of Life? Thomas Rea MD MPH University of Washington King County Emergency Medical Services

2. I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities. Disclosures

3. 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

4. The Breath of Life? The Role of Rescue Breathing during CPR

5. Normal Physiology

6. Preserve some measure of critical organ perfusion/oxygenation. CPR Benefits

7. Optimal Balance of Oxygenation and Circulation The Debate Hands Only CPR CC + Rescue Breathing

8. A Rationale Discourse

9. Lay Person CPR Professional CPR A Rationale Discourse

10. Lay Person CPR Professional CPR A Rationale Discourse Distinct expectations and training Different phase and type of arrest

11. Lay Person CPR

12. A Case for Hands Only CPR

13. #1. Sufficient Oxygen Reservoir at the Time of Collapse A Case for Hands Only CPR

14. #1.Sufficient Oxygen Reservoir at the Time of Collapse A Case for Hands Only CPR Oxygen Content Time Interval from Collapse

15. #2. Hands Only CPR is easier to train and implement. A Case for Hands Only CPR

16. #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

17. #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

18. #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%

19. #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%

20. #4. The Importance of Etiology and Rhythm A Case for Hands Only CPR Ventricular Fibrillation PEA / Asystole

21. #4. The Importance of Etiology and Rhythm A Case for Hands Only CPR 45% 50% 40% 30% Survival 15% 20% 10% 5% VF PEA Asystole

22. #5. Evidence from Trials Comparing Hands Only vs CC + RB A Case for Hands Only CPR Level 1 Evidence

23. #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%

24. 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

25. Bipartisanship

26. Professional CPR CC + Rescue Breathing Hands Only CPR

27. #1.Sufficient Oxygen Reservoir at the Time of Collapse A Case for Hands Only CPR Oxygen Content Time Interval from Collapse

28. #1.Sufficient Oxygen Reservoir at the Time of Collapse A Case for Hands Only CPR Oxygen Content Time Interval from Collapse

29. #1.Sufficient Oxygen Reservoir at the Time of Collapse A Case for Hands Only CPR Oxygen Content Time Interval from Collapse

30. #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

31. #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

32. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR 50% ….. produced < 30 compressions / minute

33. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR

34. #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

35. #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

36. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR Asynchronous Ventilations Prior to Intubation

37. #4. The Importance of Etiology and Rhythm A Case for Hands Only CPR Ventricular Fibrillation PEA / Asystole

38. #4. The Importance of Etiology and Rhythm 75% of arrests A Case for Hands Only CPR 25% of arrests Ventricular Fibrillation PEA / Asystole

39. #5. Evidence from Trials Comparing Hands Only vs CC + RB A Case for Hands Only CPR Level 1 Evidence

40. #5. Evidence from Trials Comparing Hands Only vs CC + RB A Case for Hands Only CPR (Empty Space)

41. 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

42. 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

43. Summary Hands Only is an effective approach for layperson CPR

44. Summary Phase and patient differences Technical experts Changing epidemiology Lack of top-level comparative evidence

45. A Great Debate

48. Summary

49. Requires Normal Physiology

50. 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