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Woman giving cardiopulmonary resuscitation (CPR) to a man at public park.

CPR Minus Mouth-to-Mouth

By Eric Van De Graaff, MD August 09, 2010 Posted in: Heart Health

The New England Journal of Medicine just published a study casting doubt on the utility of rescue breathing—commonly known as mouth-to-mouth resuscitation—in cardiopulmonary resuscitation (CPR). Residents in the state of Washington participated in a large trial in which emergency dispatchers recommended either chest compressions accompanied by rescue breathing or chest compressions alone as they gave instructions to bystanders in the cases of 1941 people who suffered out-of-hospital cardiac arrest. The success (or, more accurately, lack of success, since only 1 in 8 patients survived to hospital discharge) of the victims was followed and tabulated. Persons receiving the full “standard” CPR that included mouth-to-mouth did no better (in fact, a little worse) than those who received only chest compressions. The verdict of the study is that the use of rescue breathing by bystanders is of no benefit.

This report comes on the heels of other studies that produced similar results. A paper published in 2006 evaluated a similar system of “CPR minus mouth-to-mouth” and showed that focusing on the “cardio” part of CPR and eliminating the “pulmonary” portion proved to be a vast improvement. Another study from Japan, published in The Lancet in 2007, demonstrated improved success of resuscitation if it were limited to chest compressions only.

The findings of these studies are actually not too surprising when you take into context the mechanism of cardiac arrest. In most cases of witnessed collapse in adults the culprit is a malignant ventricular arrhythmia such as ventricular tachycardia or fibrillation. In these instances the heart begins to beat so rapidly that it’s unable to effectively pump blood to the body and simply quivers in the chest as the patient loses consciousness and the brain becomes starved for oxygen. The only effective therapy is the delivery of an expeditious electrical shock to the chest by a quick-witted bystander or emergency medical team. The shock effectively “resets” the electrical status of all the cells in the heart, allowing the sinus node (the small island of tissue that serves as the usual pacing center of the heart) to regain control of the organ. The whole purpose of chest compressions is to forcibly and artificially provide a limited amount of circulation to the heart and brain until somebody shows up with a defibrillator—in doing CPR you’re simply buying a few minutes of time until EMS can get to the patient. Adding mouth-to-mouth resuscitation does nothing more than distract you from pumping on the chest.

Worse, the prospect of placing your mouth over the mouth of a collapsed stranger can also deter you from jumping in as a volunteer in the first place. I’ve never personally been in this situation, but my wife has. Shortly after we were first married and the Air Force banished me to a dusty border town in Texas to serve 2 years as an internist, my wife (an ICU and ER nurse) took an extra job with a home health agency to help pay the bills. On her very first day she walked into the home of an elderly female only to see the patient clutch her chest and collapse. My wife called 911 and rushed to begin CPR only to find the patient’s mouth covered in a cocktail of half-chewed breakfast burrito, free-floating dentures, and vomit. Dutifully, my saint of a wife plunged in with chest compressions and the “kiss of life.” Needless to say my next birthday present for her was a CPR pocket mask that she could keep in her car (widely available at a reasonable price) and a promise that I’d someday find a job that pays more than minimum wage.

The concept of bystander CPR has been around for about 50 years now and was made popular by numerous books and training videos after researchers stumbled upon the concept of “closed chest massage” (previously, hospitalized victims of cardiac arrest were eviscerated by resident surgeons attempting open heart massage—the only type of resuscitation known at the time). The addition of rescue breathing was based on the theory that artificial ventilation was a necessary adjunct to the resuscitation effort, a supposition that was never clinically vetted. Over the years it has been canonized by generations of Basic Life Support instructors and is now embedded into our culture much like the Heimlich maneuver, “starving a cold and feeding a fever” (or is it the other way around?), and the mantra to not run with scissors.

Soon that will all come to an end. Just two years ago the American Heart Association released a consensus statement calling for an end to mandatory mouth-to-mouth resuscitation in adult arrest victims unless they succumb to drowning or drug overdose (children, by the way, are far more likely to suffer from respiratory compromise and should always be treated with both chest compression and rescue breathing). It’s likely that the International Liaison Committee on Resuscitation will soon revise their guidelines to reflect these recommendations.

The real tragedy in this whole turn of events has nothing to do with 50 years of futile mouth-to-mouth by thousands of well-meaning strangers who stoically pinched the nose of downed victims and dove in for an intimate but ultimately fruitless exercise in lip-to-lip bonding. No, the real victim here is Hollywood. For as long as I can remember, CPR (along with amnesia, that other equally abused medical condition) has been a favorite tripe of screenwriters looking to exploit the dramatic or comedic effect of two strangers intertwined in an intimate struggle for life.

Just take a moment and think about all the times CPR has played a central role in movies you’ve seen. The leading lady has suffered some sort of traumatic injury to the chest (gunshot, drowning, stabbing) and the hero comes to the rescue with a gallant display of lifesaving resuscitation, chest pounding, and lots of dramatic proclamations: “live, damn you!” or “don’t you dare die on me!” The all-time greatest CPR scene (or worst, depending on your perspective) is found in the deep-sea sci-fi flick “The Abyss,” where the female lead drowns at the bottom of the ocean and is pulled—blue, lifeless, nearly barnacled—into the undersea research complex by Ed Harris, her heroic counterpart. Standard resuscitation ensues with a mix of ineffective chest compressions, electrical shocks and worried, teary faces. After several minutes the team admits defeat and terminates their efforts. That’s when Ed Harris’ character flies into a life-saving frenzy, swearing and cursing and slapping her rigor mortis body back to health as he jettisons the oxygen mask in favor of the more intimate mouth-to-mouth. As with all Hollywood drowning victims she dutifully spits out a little water and is ready for her next scene.

Where would the movies be without the comedic device of rescue breathing? Think back to “The Sandlot,” the 1993 coming-of-age film where the tweener runt of the group fakes a drowning in the community pool to score a little lip action with the voluptuous life guard. Or consider the movie “Superman” (the first with Christopher Reeve) where the evil mastermind Lex Luther distracts an army battalion by enticing their commander (played by Larry Hagman) to gleefully perform mouth-to-mouth on the well-endowed Miss Teschmacher:

Sergeant Hayley: She's having trouble breathing sir. What do you think?
Major: Well, I suggest a vigorous chest massage, and if that doesn't work, uh, mouth-to-mouth.
Sergeant Hayley: [enthusiastically] Yes, sir! [bends to the task]
Major: [the Major pulls him to his feet] Sergeant, I won't have one of my men doing anything I wouldn't be prepared to do myself.
Sergeant Hayley: [disappointed] Yeah, but, sir!
Major: Get an ambulance. All right, men. Gather around. About face!

If and when rescue breathing becomes a thing of the past, where does that leave all the screenwriters in need of a sure-fire gag? I suppose they still have the rest of CPR to draw from. After all, there’s still plenty of drama in chest compressions and defibrillation (that alone was the central plot line of the 1990 movie “Flatliners”).

Not that Hollywood’s depiction of CPR is in any way helpful, mind you. It’s likely that the public’s overly optimistic belief in the success of cardiac resuscitation stems from being inundated with movies and TV episodes where seemingly dead victims spring back to life after a few chest compressions. A few years ago the New England Journal of Medicine published a study comparing the success of CPR in the real world to the fictionalized version on TV. Not surprisingly, victims of cardiac arrest on shows like “ER” faired much better than we see in the community (75% of fictional patients enjoyed immediate recovery, while the actual rate meaningful survival is typically well below 30%). The authors of the study maintain this discrepancy is harmful and leads to unrealistic expectations:

“In a subtle way, the misrepresentation of CPR on television shows undermines trust in data and fosters trust in miracles. . . . We should clarify misperceptions, provide actual data on outcomes, and address specifically the differences between CPR as seen on television and CPR as it is experienced by real patients.”

This newest article that casts doubt on the utility of mouth-to-mouth is a breath of fresh air into a subject that is steeped in history, misinformation, and pop culture. Hopefully there will soon be new guidelines that reflect this information and improve the application of CPR in the community. At that point the only group to suffer from this will be the Hollywood screenwriters; but, to paraphrase Humphrey Bogart, we’ll always have amnesia.

Eric Van De Graaff, MD
Eric Van De Graaff, MD

Eric Van De Graaff, MD is a Heart & Vascular Specialist at CHI Health Clinic.

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