"Topless" cardiopulmonary resuscitation? Should cardiopulmonary reanimation be performed without mouth-to-mouth reptilation?

A paper published in various US journals on Emergency Medicine in 1997 [9], has raised considerable concerns. The authors [9] question if it is justif ied to continue to recommend initial ventilation as part of basic CPR when performed by lay-bystanders. A few aspects need to be discussed and some qu estions have to be answered before any changes in the current recommendatio ns may even be considered: e.g. 1. How convincing does the available eviden ce support the following hypotheses: 1.1.Lay CPR without mouth-to-mouth-ven tilation provides better outcome after cardiac arrest than lay CPR with mou th-to-mouth-ventilation. 1.2. Endotracheal intubation may be detrimental in patients suffering from hemodynamic compromises, particularly from VF [46] .2. Is it scientifically and ethically acceptable to design and perform pro spective randomized controlled trials(RCTs) to evaluate the efficacy of tho se components of BCLS and ACLS which have in accordance with AHA-, ERC Guid lines and ILCOR Statements in the past been applied in millions of cardiac arrest victims and have obviously enabled the patients to lead a meaningsfu l life after survival; under conditions of the proposed study design patien ts of the study group would be left without the treatment option ventilatio n, th us diminishing their chances of survival. Ad 1:The arguments presented by the authors are hardly convincing. The auth ors themselves state elsewhere that reluctance to perform mouth-to-mouth-ve ntilation should not represent a major problem because most cardiac arrests of cardiac etiology occur at home and in the presence of a relative or fri end. Moreover, unreliable recommendations for mouth-to-mouth-ventilation(AH A) [4], lack of training, retention of skills and knowledge,and a deficit i n motivation include the main causes of the disappointingly low figures of bystander CPR worldwide. This situation cannot be improved simply by elimin ating a lifesaving component of CPR-ventilation. Instead, the proposal to a bandon the administration of unreasonably high ventilation volumens (800-12 00 ml/breath) from the present guidlines and to recommend volumes ranging f rom 400-500 ml/breath recently made by the ERC should be given serious cons ideration. Furthermore, equipment and training manikins need to be adapted to these more reasonable volumes. independently of the mechanisms of slow d ecreases in Sa02 after cardiac arrest (provided no compressions are perform ed) independently of gasping,ventilatory effects of standard compression or ACD-HCPR in the absence of mouth-to-mouth-ventilation, it is essential to realise that the patient's airways need to be maintained open at all times (this is unlike animal experiments where the airways are primarily kept ope n by the respective tissue structures):The minimum requirement of First Res ponder CPR is the guarantee that open airways are maintained. It may possib ly be discussed if the present sequence of ABC might be changed to CAB, a p ractice adopted in the Netherlands many yea rs ago, however, outcome trials an CAB have not been published to date. In addition, greater demands shoul d be made of training requirements in BLS, attendance of refresher courses should be required, and other groups of the population should be included i nto these programmes than only relatives or friends of patients at risk of a cardiac arrest. The programmes need to be made mandatory far greater Vari ety of groups and individuals to increase the efficacy and efficiency of by stander resuscitation. The hypotheses made by the above-mentioned authors a re neither scientifically nor ethically acceptable. Ad 2: Pepe's argument [46] regarding the efficacy of endotracheal intubatio n (ETI) in VF-patients has not been scientifically proven and lacks conclus ive evidence. ETI serves to protect the airways and lungs against aspiratio n of regurgitated material and to facilitate artificial ventilation includi ng PEEP, both under anaesthesia and resuscitation. The efficacy of ETI in t he OR has long been proven in RCTs. There is therefore no reason to believe that the protective capabilities of ETI are in any way different for anaes thesia or CPR. There is thus no need to require RCTs which would place one group of patients at a greater risk of mortality from aspiration (under con ditions which do not permit intubation) than any other group just because s omebody is interested in finding out if there is a higher mortality rate in one group of VF patients which is due to a greater percentage of patients dying from aspiration than from VF. Based on these considerations it follow s that the RCTs postulated by Becker e.a. are neither scientifically nor ec onomically or ethically justified apart from the fact that in the German sp eaking countries not a single ethics committee would agree to a study desig n similar to that described by Becker e.a.