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San Francisco • Two of the three pillars of CPR opening a distressed person's airway and providing mouth-to-mouth breathing turn out to be not so essential when it comes to saving the life of someone in cardiac arrest.
Cardiopulmonary resuscitation should always begin with chest compressions to keep the blood circulating through the body, but nonmedical people need not bother with providing air passage clearance and mouth-to-mouth breathing at all, according to new guidelines being released Monday by the American Heart Association.
For the first time in decades the heart association is shaking up its "ABC" system for administering CPR, which until now involved opening the victim's airway first, then starting mouth-to-mouth breathing, and doing chest compressions last.
Several large studies in the past five years have found that skipping the first two steps and going straight to chest compressions yields better survival rates for people who suffer cardiac arrest. And by discouraging the average citizen from giving mouth-to-mouth emergency treatment, public health experts hope that more people will be willing to provide CPR to strangers.
"This is a major change. If we can just get people to start the compressions, then we can look at saving a lot more lives," said Dr. Gordon Fung, director of cardiac services at UCSF Medical Center and a board member of the San Francisco chapter of the American Heart Association. The heart association has taught CPR to the public using the "ABC" system since the 1960s. Sudden cardiac arrest is a common cause of death in the United States, and only about 6 percent of victims whose hearts stop outside of a hospital survive. But CPR may as much as double the chances of survival, studies have shown.
Two years ago, the heart association began encouraging untrained bystanders to forgo mouth-to-mouth and give chest compressions when someone collapses. Multiple studies had shown that any CPR was better than none at all, but lay people were reluctant to step in and help perhaps in large part because they didn't want to provide mouth-to-mouth breathing. "But the message is that you don't need to do mouth-to-mouth," said Dr. Ed Kersh, chief of cardiology at California Pacific Medical Center's St. Luke's campus. "The key is getting the circulation going again."
But because the vast majority of cases where a person collapses and stops breathing are due to cardiac arrest, public health experts say starting chest compressions should almost always be the priority.
In the most recent CPR study, which looked at 4,400 cardiac arrest patients and was published last week in the Journal of the American Heart Association, 13 percent of victims who got CPR using chest compressions alone survived and were eventually discharged from a hospital.
But only 7.8 percent of those who got traditional CPR with rescue breathing were discharged, which wasn't much better than the 5.2 percent of people who received no CPR at all and eventually left the hospital.
The thinking is that rescuers who use traditional CPR waste valuable time as much as half a minute adjusting the head to set up an airway and then providing a breath or two before starting chest compressions.
The body probably already has enough oxygen in it when a person collapses, meaning breathing usually isn't the immediate concern. What's important is getting the blood moving again and supplying vital organs with oxygen until help arrives in the form of a defibrillator, which can be used to get the heart beating on its own again.
"You're looking to push oxygenated blood to the brain and to the heart," said Dr. George Bulloch , chief of the Kaiser Permanente Redwood City emergency department. "There is enough oxygen intrinsically built in that you can concentrate on just circulating it. You're just trying to buy time until EMS can get there and supply a shock."
The new heart association guidelines also recommend more aggressive chest compressions, including faster and deeper pushes on the sternum. Rescuers should do chest compressions at a rate of 100 per minute, and push a good two inches down.
If the rescuer is trained in CPR, he or she may still give mouth-to-mouth assistance, at a rate of two breaths after 30 chest compressions.
One of the other advantages of recommending chest compressions only for most bystanders is that it's easy for a 911 operator to talk someone through the simpler form of CPR.
"If you call 911 and they say bend down and push, that's a quick trick," said Bulloch. "It will be eminently easier to teach."
The American Heart Association's new guidelines for cardiopulmonary resuscitation:
Before starting, shake the victim's shoulders and shout to see if he responds.
If the victim is not breathing, yell for someone to call 911. If you're alone, call 911.
Begin chest compressions. Push hard and fast on the center of the chest at a rate of at least 100 compressions a minute (which happens to be the beat of the 1977 Bee Gees disco hit "Stayin' Alive").
Push down on the chest at least two inches with each compression. Make sure you fully release the chest before beginning the next compression.
If you have not been trained in CPR, continue chest compressions until help arrives.
If you have been trained, after 30 chest compressions open an airway and begin mouth-to-mouth breathing. Give two breaths and then resume chest compressions. Continue sets of 30 chest compressions and two breaths until help arrives.