Letter by Lederer and Wiedermann Regarding Article, “Effectiveness of Bystander-Initiated Cardiac-Only Resuscitation for Patients With Out-of-Hospital Cardiac Arrest”
To the Editor:
It was with great interest that we read the study by Iwami et al1 on the effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. The authors reported that cardiac-only resuscitation without rescue breathing and conventional cardiopulmonary resuscitation (CPR) is similar in effectiveness for most adult out-of-hospital cardiac arrests of ≤15 minutes duration in areas with a low rate of bystander CPR. The authors presume that cardiac-only resuscitation is a much simpler technique that may increase the frequency of bystander CPR, thus improving survival following out-of-hospital cardiac arrest. Alas, the issue is not new.2 Furthermore, the willingness of individual bystanders to check for vital signs and initiate CPR depends on a variety of factors, of which distaste for rescue breathing is not the most important. Hence, to completely omit rescue breathing from bystander CPR does not necessarily increase willingness to resuscitate.3 We understand that bystanders may be reluctant to provide mouth-to-mouth rescue breathing in nonrelated patients. We furthermore agree that cardiac-only resuscitation without rescue breathing will involve fewer interruptions of chest compressions.4 However, simply abandoning ventilation during basic CPR will not inevitably improve the quality of chest compressions either. Odegaard et al5 reported that continuous chest compressions without ventilation gave significantly more chest compressions per minute but with decreased compression quality. The new international guidelines for resuscitation 2005 have already addressed this issue and reduced the ratio of rescue breaths to compressions in adults to 2:30. It would be worthwhile to investigate whether a ratio of 5:50 is even more efficient.
In order to improve quality and frequency of bystander CPR, we advocate encouraging bystander CPR in public awareness campaigns adapted for sociocultural background and recommend state-subsidized refresher courses offered by professional first-aid services. The decision to not perform rescue breathing should depend on the bystander on site and should definitely not be dictated by official resuscitation guidelines.
Iwami T, Kawamura T, Hiraide A, Berg RA, Hayashi Y, Nishiuchi T, Kajino K, Yonemoto N, Yukioka H, Sugimoto H, Kakuchi H, Sase K, Yokoyama H, Nonogi H. Effectiveness of Bystander-Initiated Cardiac-Only Resuscitation for Patients With Out-of-Hospital Cardiac Arrest. Circulation. 2007; 116: 2900–2907.
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. Resuscitation. 1997; 35: 189–201.