1. The Breath of Life? Thomas Rea MD MPH University of Washington King County Emergency Medical Services

2. Disclosures I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities.

3. Disclosures I receive support from the NIH, the Laerdal Foundation, and the Medtronic Foundation as part of programmatic and research activities. There is much to learn.

4. The Breath of Life? The Role of Rescue Breathing during CPR

5. Normal Physiology

6. CPR Benefits Preserve some measure of critical organ perfusion/oxygenation.

7. The Debate Optimal Balance of Oxygenation and Circulation Hands Only CPR CC + Rescue Breathing

8. A Rationale Discourse

9. Lay Person CPR Professional CPR

10. A Rationale Discourse Lay Person CPR Professional CPR Distinct expectations and training Different phase and type of arrest

11. Lay Person CPR

12. A Case for Hands Only CPR

13. #1. Sufficient Oxygen Reservoir at the Time of Collapse

14. A Case for Hands Only CPR #1.Sufficient Oxygen Reservoir at the Time of Collapse Oxygen Content Time Interval from Collapse

15. A Case for Hands Only CPR #2. Hands Only CPR is easier to train and implement.

16. A Case for Hands Only CPR 2005 2006 2007 2008 2009 50% 30% 40% 20% 10% 33% 40% 28% 32% 36% Bystander CPR #2. Hands Only CPR is easier to train and implement.

17. #3. Ventilations are difficult to perform and produce interruptions Rigorous often repeated CPR training of laypersons A Case for Hands Only CPR Public Access Defibrillation Trial

18. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR During the time bystanders were prompted to provide CPR, what proportion of time was actually spent performing chest compressions? A.75% B.67% C.50% D.25%

19. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR During the time bystanders were prompted to provide CPR, what proportion of time was actually spent performing chest compressions? A.75% B.67% C.50%.. resulted < 30 compressions / minute D.25%

20. A Case for Hands Only CPR Ventricular Fibrillation #4. The Importance of Etiology and Rhythm PEA / Asystole

21. A Case for Hands Only CPR Survival VFPEAAsystole 50% 30% 40% 20% 10% 15% 5% 45% #4. The Importance of Etiology and Rhythm

22. #5. Evidence from Trials Comparing Hands Only vs CC + RB A Case for Hands Only CPR Level 1 Evidence

23. A Case for Hands Only CPR HO CPRCC + RB Seattle 14% 10% TANGO 9% 7% DART 14% 11% Survival #5. Evidence from Trials Comparing Hands Only vs CC + RB

24. Hands Only CPR CC + Rescue Breathing 1. Reservoir of oxygenated blood 2. Hands only is easier to train and implement 3.Ventilations are challenging to perform 4.Hands only favors VF resuscitation 5.Evidence from Human Trials A Case for Hands Only CPR Optimal Balance of Oxygenation and Circulation

25. Bipartisanship

26. Professional CPR Hands Only CPR CC + Rescue Breathing

27. A Case for Hands Only CPR Oxygen Content Time Interval from Collapse #1.Sufficient Oxygen Reservoir at the Time of Collapse

28. A Case for Hands Only CPR Oxygen Content Time Interval from Collapse #1.Sufficient Oxygen Reservoir at the Time of Collapse

29. A Case for Hands Only CPR Oxygen Content Time Interval from Collapse #1.Sufficient Oxygen Reservoir at the Time of Collapse

30. A Case for Hands Only CPR 2005 2006 2007 2008 2009 50% 30% 40% 20% 10% 33% 40% 28% 32% 36% Bystander CPR #2. Hands Only CPR is easier to train and implement.

31. A Case for Hands Only CPR Professional CPR 2005 2006 2007 2008 2009 100% 50% #2. Hands Only CPR is easier to train and implement.

32. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR 50% ….. produced < 30 compressions / minute

33. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR

34. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR Interruptions for Rescue Breathing 30:2 Compression to Ventilation Ratio

35. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR Interruptions for Rescue Breathing 30:2 Compression to Ventilation Ratio

36. #3. Ventilations are difficult to perform and produce interruptions A Case for Hands Only CPR Asynchronous Ventilations Prior to Intubation

37. A Case for Hands Only CPR Ventricular Fibrillation #4. The Importance of Etiology and Rhythm PEA / Asystole

38. A Case for Hands Only CPR Ventricular Fibrillation #4. The Importance of Etiology and Rhythm PEA / Asystole 25% of arrests 75% of arrests

39. A Case for Hands Only CPR Level 1 Evidence #5. Evidence from Trials Comparing Hands Only vs CC + RB

40. A Case for Hands Only CPR (Empty Space) #5. Evidence from Trials Comparing Hands Only vs CC + RB

41. Hands Only CPR CC + Rescue Breathing 1.Reservoir of oxygenated blood 2.Hands Only is easier to train and implement 3.Ventilations are challenging to perform 4.Hands only favors VF resuscitation 5.Evidence from Human Trials A Case for Hands Only CPR Optimal Balance of Oxygenation and Circulation

42. Hands Only CPR CC + Rescue Breathing 1.Reservoir of oxygenated blood 2.Hands Only is easier to train and implement 3.Ventilations are challenging to perform 4.Hands only favors VF resuscitation 5.Evidence from Human Trials A Case for Hands Only CPR Optimal Balance of Oxygenation and Circulation

43. Hands Only is an effective approach for layperson CPR Summary

44. Phase and patient differences Technical experts Changing epidemiology Lack of top-level comparative evidence

45. A Great Debate

48. Summary

49. Normal Physiology Requires

50. Disclosures Curveball Beholden to the evidence RCT Bipartisanship Bystander CPR Are there persons who might benefit from ventilation? Optimize oxygenation delivery to critical tissues. Ventilations are too difficult to perform and produce interruptions in compression / circulation There is enough oxygenated blood in the reservoir so that the best strategy is to circulate. Only those with a cardiac as opposed to a respiratory cause can survive The weight of the evidence supports hands only CPR

51. The Breath of Life? Thomas Rea MD MPH University of Washington King County Emergency Medical Services

52. The Great Debate