The Demise of Rescue Breathing in CPR?

Mouth to Mouth
Mouth to mouth. (c) Stockbyte/Getty Images

Removing Mouth-to-Mouth from Adult CPR

Any change to CPR is bound to create controversy. A push by many in the industry to remove rescue breathing from adult CPR is the biggest cause celebre in emergency cardiac care.

CPR is one of the foundations of emergency medical care. It is required training for nearly all emergency medical service providers in the United States. CPR is widely taught to the lay public, and even required by many employers and organizations.

Some feel that CPR in its current form is not as effective as it could be for the population most likely to benefit from it. Mouth-to-mouth is seen as the culprit. To make CPR more effective, there is a push to eliminate rescue breathing from this staple of emergency medical care. I have my own opinion on removing mouth-to-mouth, but read on to see where both sides stand.

Latest Developments

A modified form of CPR, dubbed cardiocerebral resuscitation (CCR), was implemented in two counties in Wisconsin. This resuscitation technique eliminated rescue breathing.

According to an article published in April 2006 in the American Journal of Medicine, survival rates of out-of-hospital cardiac arrest victims improved with the new protocol.

A group of physicians in Tokyo published a study in The Lancet, a British medical journal, which examined how CPR was being performed by the lay public.

After comparing CPR with and without rescue breaths, they determined that CPR performed without rescue breathing was twice as successful for victims with the most chance of survival.

Dr. Gordon Ewy, director of the Sarver Heart Center at the University of Arizona, is a long-time advocate of withholding rescue breaths from victims of witnessed cardiac arrest. In the same issue of The Lancet, Dr. Ewy called for immediate changes in CPR guidelines.

On March 31, 2008, the American Heart Association changed its guidelines to include hands-only CPR, a new version using chest compressions only.

Hands-only CPR is intended for untrained rescuers and only for witnessed cardiac arrest.


CPR, or cardiopulmonary resuscitation, has been around in some form since the early 1960's. Teaching CPR to the lay public has always been a primary mission of the American Heart Association (AHA), as well as its biggest challenge.

One of CPR's problems has been its use of complicated algorithms. Most versions of CPR used ratios of chest compressions to ventilations (rescue breaths) that changed based on whether there was one rescuer or two. CPR steps that required lay rescuers to adequately assess victims were often to blame for a hesitancy to use this vital, life-saving procedure.

It was necessary for a rescuer to determine if the victim was breathing before delivering rescue breaths. Then the rescuer had to check for a pulse to determine if the victim's heart was beating or not. If not, the rescuer was instructed to give the victim 15 chest compressions, followed by two more rescue breaths. All of that has made CPR seem very complicated to those learning it for the first time.

Mouth-to-mouth resuscitation was the standard for reviving unresponsive victims of drowning or other medical problems long before modern CPR was developed.

When CPR as we know it today was created, mouth-to-mouth was an integral part of the process. Today, the elimination of mouth-to-mouth is seen by some as the answer to making CPR simpler to learn and follow.

In light of many studies showing the value of chest compressions, the American Heart Association Committee on Emergency Cardiac Care made changes to CPR guidelines in 2005. Among other changes, more compressions are now done between rescue breaths, and lay rescuers no longer check for pulses.

The changes were met with skepticism by some in emergency medical services. Airway and breathing had always been the foundation of emergency medical care, and CPR was emergency care in its most basic form.

These new changes meant airway and breathing were getting bumped off center stage by chest compressions. Even defibrillation, the sexy, power-tool answer to a stopped heart was getting a lesser role in order to give more focus to chest compressions.


Sudden cardiac arrest results in an instant stoppage of blood flow through the blood vessels. This stoppage of blood flow means that fresh, oxygenated blood is not transported to the brain, which will die within four minutes.

There is a significant amount of oxygen in the bloodstream capable of sustaining brain tissue for several minutes, even without breathing. Proponents of doing CPR without rescue breathing argue that continuous chest compressions get blood flowing better than chest compressions interrupted by rescue breaths, and that blood flow is the only way oxygen can reach vital organs such as the brain.

Proof that circulated blood holds enough oxygen to sustain life without taking a breath lies in examples of breath-holding. Freediver Tom Sietas of Germany holds the world record for holding his breath, lasting 8 minutes and 47 seconds. How could he do that unless his bloodstream was capable of sustaining his brain?

Opiate overdoses cause respiratory arrest - victims completely stop breathing while their hearts continue to pump blood. In my experience as a paramedic, I've seen many opiate overdose victims (usually victims of heroin overdose) respond well to the drug that reverses opiate intoxication and wake up without any brain damage - despite not breathing for several minutes.

Studies published in the American Journal of Medicine and The Lancet have indicated better survival rates for victims of cardiac arrest resuscitated by lay rescuers and EMS professionals using chest compressions only.

Dr. Gordon Ewy, director of the Sarver Heart Center at the University of Arizona, has said that training the public to perform CPR without rescue breathing is easier than training in traditional CPR. He has also published research that indicates the public is more likely to do CPR if mouth-to-mouth is not included.


Not all cardiac arrests are from a diseased heart. Sometimes, drowning or drug overdoses cause respiratory arrest that leads to cardiac arrest. In those cases, rescue breathing is an important part of resuscitation efforts.

Research is constantly being published on all manner of healthcare issues and treatments. Changing the guidelines is a process that takes all current research into account. If the guidelines changed regularly, or if there were no standards, public understanding of CPR would be diminished.

It's also very important to make sure everyone is taught the same standard in order to accurately measure the affect changes in CPR have on survival rates. The American Heart Association makes every effort to simplify CPR training while keeping it effective.

Where It Stands

Those who teach and research CPR have always been very passionate. Any changes in CPR have been met with resistance, especially when changes suggest deemphasizing airway and breathing from an emergency medical procedure.

The AHA has publicly stated no intention to change the guidelines immediately. Dr. Ewy, in a commentary published in The Lancet, called for a change in the CPR guidelines. He believes that compression-only CPR would be much easier for lay rescuers to perform.

Undoubtedly, more research is on the way for this prickly issue. CPR performed outside the hospital has not traditionally had a very good success rate. Any potential improvements should be examined.


Kellum, MJ, KW Kennedy and GA Ewy. "Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest." Am J Med. Apr 2006

Nagao, Ken, The SOS-KANTO Committee. "Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study." The Lancet. 17 Mar 2007

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