1. Ventilation techniques used by lifeguards Bo Løfgren, MD, PhD Honorary Associate Professor in Resuscitation and Emergency Medicine Department of Internal Medicine and Clinical Research Unit Regional Hospital of Randers, Randers, Denmark & Research Center for Emergency Medicine Institute of Clinical Medicine Aarhus University Hospital, Aarhus, Denmark HLR2014 Conference Tylösand, Sweden | June 3-4 | Drowning

2. Conflict of interest None to disclose

3. Resuscitation in drowning Differs from primary cardiac arrest Ventilation is a priority Supplemental oxygen

4. Ventilation techniques Mouth-to-mouth ventilation (MMV) Mouth-to-pocket mask ventilation (MPV) Bag-mask ventilation (BMV) Supraglottic airway ventiation (SGA) Orotracheal intubation (OTT)

5. PICO: Which ventilation technique? Among adults and pediatric drowning victims (P), does delivery of ventilation with another specific ventilation technique (I), compared with mouth-to-mouth ventilation (C), change survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, hands-off time (O)? No clinical studies Outcome measure

6. Critical CPR skills for lifesavers The first and most important treatment of the drowning victim is provision of immediate mouth-to-mouth ventilation. (…) encourages that airway adjunct methods, such as mouth-to- mask, be taught to lifesavers and used as appropriate. (…) encourages the training and equipping of lifesavers with oxygen.

7. The use of oxygen by lifesavers (…) recommend a non-rebreathing mask with a fixed flow of 15 litres of oxygen per minute for spontaneously breathing victims and a transparent mask with oxygen inlet for patients in ventilatory arrest.

8. Which ventilation technique? Mouth-to-pocket mask ventilation (MPV) Bag-mask ventilation (BMV) Mouth-to-mouth ventilation (MMV) Allow supplementation of oxygen

10. Aim To compare different ventilation techniques on the quality of CPR

11. Primary outcome measure Interruptions in chest compressions

12. Methods Professional, surf lifeguards (> 18 years) Recruited from two Lifeguard Services Annual mandatory CPR re-training Oral and written consent obtained Performance not disclosed Questionnaire – demographics

13. Study design Randomized – single rescuer CPR – manikin MMV, MPV (PocketMask TM ), BMV (theBAG II TM ) Allowed to familiarize with the equipment 3 min. CPR 5 min. rest 3 min. CPR 5 min. rest 3 min. CPR 5 min. rest Data collected on the beach (laptop/video)

14. Results MMV-MPV-BMV n=12 BMV-MMV-MPV n=10 MPV-MMV-BMV n=9 MMV-BMV-MPV n=10 BMV-MPV-MMV n=9 MPV-BMV-MMV n=10 Eligible n=63 Included n=60 Randomized n=61 Declined to participate, n=2 Excluded due to nightfall, n=1 MMV: Mouth-to-mouth ventilation | MPV: Mouth-to-pocket mask ventilation | BMV: Bag-mask ventilation

15. Demographics Mean age  SD (years) 25.4  5.9 Sex (n, %) Female Male 20 (33%) 40 (67%) Certification year (mean  SD)2006  4.4 Years of experience (mean  SD)4.4  4.4 Health care professional (n, %)7 (13 %)

16. CPR quality 8.9  1.6 s10.7  3.0 s12.5  3.5 s ** † Data are mean  SD. *P<0.001 compared to MMV. †P<0.001 compared to MPV.

17. Chest compressions 112  13 min -1 110  13 min -1 112  14 min -1 32.1  8.9 mm31.7  8.7 mm31.5  9.0 mm

18. Another benefit from measuring … 32.1  8.9 mm31.7  8.7 mm31.5  9.0 mm Data are mean  SD. ERC 2005 ERC 2010

19. Ventilations *P<0.001 compared to MMV and MPV respectively 0.7  0.2 s 0.5  0.2 s * * 0.6  0.2 L0.6  0.3 s0.4  0.2 L *P<0.001 compared to MMV and MPV respectively

20. Effective ventilations MMVMPVBMV 91 % (n=515) 79 % (n = 518) 59 % (n=557) * p  0.001, MMV vs MPV, MMV vs BMV and MPV vs BMV * * *

21. Conclusion Mouth-to-mouth ventilation reduces interrup- tions in chest compressions and produces a higher number of effective ventilations when compared to mouth-to-mask and bag-mask ventilation during lifeguard CPR

22. Mouth-to-mouth by lifeguards? Reluctance Body fluids e.g. vomit, blood etc. Communicable disease

23. Ventilation technique Preferred ventilation technique Mouth-to-mouth ventilation Mouth-to-pocket mask ventilation Bag-mask ventilation 11 (18%) 42 (70%) 6 (10 %) No reply 1 (2%) Adelborg & Løfgren Resuscitation 2011;82:618-622

24. Barrier device Mouth-to-face-shield ventilation (MFV) Mouth-to-pocket mask ventilation (MPV)

25. Focused training in MPV 8.9  1.6 s10.7  3.0 s 7.8  1.3 s

27. Barrier device Mouth-to-face-shield ventilation (MFV) Mouth-to-pocket mask ventilation (MPV)

28. Aim To compare mouth-to-pocket mask and mouth-to-face shield ventilation on the quality of CPR

29. Study design 30 volunteer surf lifeguards (age 25 y; F 9/30) Oral and written consent obtained Formally trained in MPV and MFV Randomized – single rescuer CPR w MPV/MFV Data from manikin & video recordings Quality of CPR: interruptions in chest comp

30. CPR quality 8.6  1.7 s6.9  1.2 s * * p<0.0001

31. Ventilation

32. Chest compressions

33. Effective ventilations MFVMPVBMV 82 % (199/242) 100 % (239/240) 59 % (n=557) *p = 0.0002 **

34. Conclusion Mouth-to-face-shield ventilation increases interruptions in chest compressions reduces the proportion of effective ventilations and decreases delivered tidal volumes when compared with mouth-to-pocket mask ventilation.

35. General study limitations Manikin study No body fluids e.g. vomit, blood etc. Single rescuer scenario No physical exertion

36. Overall conclusion Mouth-to-mouth ventilation (MMV) Mouth-to-pocket mask ventilation (MPV)

37. Future directions More studies on ventilation techniques Multiple rescuers/team effort Supraglottic airway devices (SGA) Single rescuer over the head-CPR Clinical data needed

38. Acknowledgement John Mogensen, North Zealand Lifeguard Service Steve Martinussen, Copenhagen Lifeguard Service Carsten Jørgensen, Aalborg Lifeguard Service All the surf lifeguards participating in the studies Financial support Research Award from The Christenson-Ceson Family Foundation Aarhus University Hospital and Regional Hospital of Randers HLR2014 Conference Tylösand, Sweden | June 3-4 | Drowning

39. Further information - collaboration Bo Løfgren, MD, PhD bl@clin.au.dk