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Experts wary as CPR study questions need for mouth-to-mouth breathing

Thursday, May 25, 2000

By Anita Srikameswaran, Post-Gazette Staff Writer

Local experts are concerned about a new study from Seattle that suggests mouth-to-mouth breathing could be safely omitted from basic cardiopulmonary resuscitation, or CPR. The findings may only apply to very specific circumstances and are not evidence that mouth-to-mouth can be abandoned in all cases, they warned.

In the Seattle study, emergency dispatchers taught callers who had no CPR training to help a patient in cardiac arrest either by solely pushing rhythmically on the chest or performing the compressions along with mouth-to-mouth breathing, also called ventilation.

The researchers found that survival was similar for both groups of patients, according to findings published in today's New England Journal of Medicine.

Dispatchers were able to complete the compression-only instruction in 80 percent of the cases before paramedics arrived, but could do so only 60 percent of the time when the complex ventilation sequence had to be taught.

"Under these circumstances, it's a lot easier, quicker, simpler and, I think, more effective to give chest compressions alone," said investigator Dr. Leonard Cobb, an emeritus professor of the University of Washington. "I think there's a short period of time that you can probably get by without [ventilation]. I don't know how long that period of time is."

According to CPR pioneer Dr. Peter Safar, of the University of Pittsburgh's Safar Center for Resuscitation Research, the new study fails to prove that ventilation IS unnecessary, even for such specific circumstances. He is writing to the editors of the journal to express his concerns about the report.

"You cannot learn mouth-to-mouth from a [verbal] instruction," Safar said. "It has been known since our studies of the 1950s that acquisition of skills in mouth-to-mouth ventilation require mannequin practice. You can never teach this over the telephone."

That means that the researchers can't be certain that the callers performed ventilation properly, so in effect the patient received only chest compressions. Because they could not watch events unfold, the researchers can't verify that the callers who were asked to do mouth-to-mouth did so, or that the compression-only group didn't try to do ventilation.

Although the findings are intriguing, with such uncertainties, "drawing definitive conclusions would be premature," said Dr. Paul Paris, who heads Pitt's Center for Emergency Medicine.

Experts agree that there are many circumstances in which ventilation is essential for survival. In children, for example, a respiratory problem is usually the reason that the heart stops.

"In kids, the thing that most commonly saves lives is just doing ventilation," Paris said. "Knowing the skills of mouth-to-mouth is crucial for parents, day-care center [employees], and other people who are around kids."

A first crucial step is to make sure the patient doesn't have an obstructed airway, the A in the ABCs of resuscitation. This can be as simple as tilting the chin up or elevating the chest and shoulders.

"All some people need is to move the head back into a position where air can flow," Paris explained. "They just need you to put the airway into a position where there is no obstruction from the tongue and they'll start breathing on their own."

If they don't, the nostrils are squeezed shut and breaths of air are blown into the mouth.

Safar noted that trauma, near-drowning and slowed heart rates may all lead to cardiac arrest in adults and require ventilation for successful resuscitation. A lay person may not be able to identify the cause of the arrest, however, so a standardized procedure of breaths and chest compressions is the wiser course.

"It's sad that you have to give instruction over the telephone, which I doubt can teach you these skills," Safar said. "We should have the public at large made to acquire the skills of life-supporting first aid."

Paris said that in Seattle, CPR is initiated by bystanders in half of all cases of cardiac arrest, which is the best rate in the country. By contrast, paramedics in the Pittsburgh area find that only one out of four patients has been getting CPR from a bystander.

Some experts have suggested that people don't attempt resuscitation because they fear harming the patient or are squeamish about the intimate contact of mouth-to-mouth breathing. There have been no cases of transmission of the AIDS virus through ventilation, Paris said.

"And remember, most cardiac arrests occur in the home around people you know, neighbors and loved ones," he said. "Most people aren't going to be dissuaded from doing CPR on their mother or brother."

The greater problem is that people are not learning basic resuscitation or other first aid skills, such as the Heimlich maneuver. A few years ago, local paramedics rushed to a Christmas party where someone was choking. A hundred people were in attendance but no one acted, Paris said. The response team cleared the airway obstruction, but they were too late. The patient died.

The Seattle study does indicate that it is better to do chest compressions rather than nothing at all in cases of cardiac arrest.

"If nothing else, you could just do chest compression," said study author Cobb. "That would be a whole lot better than turning your back on the situation."

Even checking for a pulse and positioning the head to keep the airway open could help, Paris said. He added that Good Samaritan laws exist in Pennsylvania and other states to protect bystanders who come to the aid of others from liability.

The annual mass-training of CPR, Save-A-Life Saturday, will be held on Aug. 19 in the Strip District. Classes in both adult and pediatric CPR will be available, as well as instruction in the Heimlich maneuver and use of automated external defibrillators. For more information, phone (412) 578-3172.

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