(Circulation. 1998;98:610-612.)
© 1998 American Heart Association, Inc.
Layperson CPR
Allan Braslow, PhD, MS
Braslow & Associates,
Rockville, Md
Robert T. Brennan, EdD, EdM, MA
Harvard University Graduate School of Education,
Department of Administration, Planning, and Social Policy,
Cambridge, Mass
To the Editor:
"A Reappraisal of Mouth-to-Mouth Ventilation During
Bystander-Initiated Cardiopulmonary
Resuscitation"1 argues that laypersons do not
perform CPR because of concerns about mouth-to-mouth resuscitation. On
the basis of this conclusion, the authors explore
physiological issues related to exclusion of
mouth-to-mouth as a component skill. With media coverage focusing on
the notions that mouth-to-mouth resuscitation poses significant risk of
infection and CPR without mouth-to-mouth breathing can be effective,
the Special Report's publication has done more harm than good to
efforts to train laypersons and encourage them to initiate CPR. We
believe the following facts about out-of-hospital cardiac arrest and
bystander action are more explanatory of the failure of bystander CPR
than the hypothesis offered in the Special Report:
1. CPR is not performed by bystanders because most
laypersons are not trained, and training is not targeted to those
likely to be present at the scene of a cardiac arrest.—At
least 74% of arrests occur in the home2
where the typical family bystander is 55 years
old.3 CPR trainees average 31, with a small
minority 55 or older. Fewer than 8% of participants take CPR training
because they live with someone at elevated risk of heart
attack.4 5
2. A layperson's decision to respond to an emergency
depends on a set of factors unlike those affecting medical
professionals.—According to the psychological research on
"helping behavior,"6 7 the decision to act
depends on acknowledging that the situation exists and having
confidence in one's abilities. An unaccustomed concern of
laypersons, such as disease transmission, will be but one, most
likely trivial, factor. One article8 cited in the
Special Report confirms that reluctance to perform mouth-to-mouth on
family members and friends is uncommon among laypersons. The only study
cited in which lay bystanders were interviewed9
reveals that they do not hesitate in helping the victim even in the
presence of disagreeable stimuli, nor do they advance concerns about
HIV.
3. Trained laypersons cannot competently perform
CPR.—Immediately after training, CPR trainees are not competent
in performing ventilations of sufficient volume and compressions of
sufficient depth.10 Because feelings of
competence are critical to the decision to take
action,6 7 lack of competence may be responsible
in part for low rates of initiation.
We urge that the American Heart Association (AHA) promulgate the
authors' recommendation that "current CPR guidelines for performing
mouth-to-mouth ventilation during CPR should not be changed" and
maintain that the risk of infection presented by mouth-to-mouth
ventilations is minimal. We further urge that (1) the argument that
laypersons do not initiate CPR because of fear of performing
mouth-to-mouth breaths be disavowed unless new studies reveal this to
be a significant contributory cause; (2) CPR training be targeted
at laypersons with high exposure to individuals with heart
disease; (3) CPR training programs produce, at the very least,
competent CPR performance immediately after training; (4) the
Emergency Cardiovascular Care Committee and training organizations
address laypersons and medical professionals as separate populations
requiring different curricula, teaching methods, and expert committees;
and (5) the AHA initiate and support research related to lay bystander
response.
References
1.
Becker LB, Berg RA, Pepe PE, Idris AH,
Aufderheide TP, Barnes TA, Stratton SJ, Chandra NC. A reappraisal of
mouth-to-mouth ventilation during bystander-initiated
cardiopulmonary resuscitation: a statement for healthcare
professionals from the Ventilation Working Group of the Basic Life
Support and Pediatric Life Support Subcommittees, American Heart
Association. Circulation. 1997;96:2102–2112.[Free Full Text]
2.
Lombardi G, Gallagher J, Gennis P. Outcome of
out-of-hospital cardiac arrest in New York City: the Pre-Hospital
Arrest Survival Evaluation (PHASE) study. JAMA. 1994;271:678–683.[Abstract/Free Full Text]
3.
Goldberg JJ, Gore JM, Love DG, Ockene JK, Dalen JE.
Layperson CPR: are we training the right people? Ann Emerg
Med. 1984;13:701–704.[Medline]
[Order article via Infotrieve]
4.
Brennan RT. Student, instructor, and course factors
predicting achievement in CPR training classes. Am J Emerg
Med. 1991;9:220–224.[Medline]
[Order article via Infotrieve]
5.
Pane GA, Salness KA. A survey of participants in a
mass CPR training course. Ann Emerg Med. 1987;16:1112–1116.[Medline]
[Order article via Infotrieve]
6.
Shotland RL, Heinold WD. Bystander response to
arterial bleeding: helping skills, the decision-making
process, and differentiating the helping response. J Pers Soc
Psychol. 1985;49:347–356.[Medline]
[Order article via Infotrieve]
7.
Mogielnicki RP, Stevenson KA, Willemain TR. Patient
and bystander response to medical emergencies. Med Care. 1975;13:753–762.[Medline]
[Order article via Infotrieve]
8.
Locke CJ, Berg RA, Sanders AB, Davis MF, Milander MM,
Kern KB, Ewy GA. Bystander cardiopulmonary resuscitation:
concerns about mouth-to-mouth contact. Arch Intern Med. 1995;155:938–943.[Abstract/Free Full Text]
9.
McCormack AP, Camon SK, Eisenberg MS. Disagreeable
physical characteristics affecting bystander CPR. Ann Emerg
Med. 1989;18:283–285.[Medline]
[Order article via Infotrieve]
10.
Braslow A, Brennan RT, Newman MM, Bircher NG,
Batcheller AM, Kaye W. CPR training without an instructor: development
and evaluation of a video self-instructional system for effective
performance of cardiopulmonary resuscitation.
Resuscitation. 1997;34:207–220.[Medline]
[Order article via Infotrieve]
Response
Lance B. Becker, MD (Chairman);
Robert A. Berg, MD;
Paul E. Pepe, MD, MPH;
Ahamed H. Idris, MD;
Thomas P. Aufderheide, MD;
Thomas A. Barnes, EdD, RRT;
Samuel J. Stratton, MD;
; Nisha C. Chandra, MD
Ventilation Working Group of the Basic Life Support and
Pediatric Life Support Subcommittees,
American Heart Association
We wish to thank Drs Braslow and Brennan for highlighting
the importance of educational research on the teaching of layperson
CPR. Although the issue of "why people don't perform CPR" was not
the focus of our recent article, we agree that these are important
issues. Drs Braslow and Brennan have made many critical contributions
to our understanding of how people learn CPR. They have been pioneers
in developing techniques for objective evaluation of CPR training
outcomes, peer-training methods, and video self-teaching methods. As
experts in the education of layperson CPR, their insights and
perspective are valuable.
We appreciate the opportunity to expand several points of the
article:
1. "Fear of AIDS" is not the primary reason people fail to
perform CPR, it is only one of the barriers to CPR performance.
We contend that the primary reason CPR is not performed is related to
training obstacles, not fear of infection. Failure to provide effective
CPR by the lay rescuer represents a real failure to save lives.
Additional resources must be targeted to improve lay bystander
response.
2. In our article, we discuss fear of disease transmission along
with several other issues (including pulmonary aspiration,
carbon dioxide, and time taken away from compression). These are
possible adverse side effects specific to mouth-to-mouth ventilation.
Few medical therapies are without side effects; CPR and mouth-to-mouth
ventilation are no exception. Our responsible reappraisal of CPR had to
include a consideration of these side effects. After careful review,
the Task Force concluded that "Current guidelines for performing
mouth-to-mouth ventilation during CPR should not be changed."
Suggestions that the article states otherwise misrepresent the
article.
3. We think bystanders considering mouth-to-mouth contact do
voice concerns about HIV. The available data support this statement.
Locke et al reported on 975 survey respondents, of whom 80% were
laypersons (see article referenced above). They concluded that
laypersons are reluctant to provide mouth-to-mouth ventilation and that
this layperson reluctance is a barrier to CPR provision even in
relatives and close friends. Moreover, we know from our training
network that concerns over disease transmission (and most specifically
HIV) continue to be an issue raised by participants taking CPR courses.
To answer these concerns, we first respond that most CPR will be
performed on family members and that the actual risk of disease
transmission is extremely low. However, for those who may delay or not
begin CPR because of persistent fears, we have a duty to at least
provide clear instructions to begin immediate chest compression. We
know that chest compression alone has been lifesaving for many. We know
that the lowest survival rate occurs when no efforts at resuscitation
are attempted.
4. Are research funds better spent on determining improved
methods to teach CPR to the public, or should we be concentrating on
further research into the physiology and improved mechanics of the
"pump and blow" techniques? There has been a scarcity of research
on the methodology of teaching CPR to the public. By contrast,
relatively more research has been published on the physiology of blood
flow and survival with CPR techniques. However, it seems to us
that both are still required. Although educational issues are
important, no one would advocate the teaching of an ineffective
technique simply because it was easy to teach, well retained, and easy
to perform. Likewise, no technique would be useful, even if it resulted
in near-perfect blood flow during CPR, if bystanders could never
acquire the skills to perform the task. Some balance is necessary. Our
position on funding is that the entire field of resuscitation and CPR
research has been underfunded relative to its importance for public
safety. It doesn't make sense to argue "over mere nickels" when we
need serious dollars to make headway and save more lives.
We look forward to continued contributions and perspectives on
CPR training and techniques, for this intervention is a major public
health issue that can directly impact the lives of many citizens.
