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Basic life support – Becoming more complex

      Sir,
      We read with interest the article of Adelborg et al.
      • Adelborg K.
      • Dalgas C.
      • Grove E.L.
      • et al.
      Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study.
      where lifeguards performed single rescuer cardiopulmonary resuscitation (CPR) in a simulated manikin scenario. Mouth-to-mouth ventilation resulted in reduced interruptions of chest compressions and a higher proportion of effective ventilations when compared to mouth-to-mask or bag-valve mask ventilation. The authors concluded that in this simulated single rescuer scenario CPR quality improved with mouth-to-mouth when compared to mouth-to-mask and bag-valve mask ventilation.
      We would like to highlight some further points regarding this study in particular, and basic life support in general. First, single rescuer CPR may not be the standard technique, and very likely it will be less effective than two rescuer CPR.
      • Sugerman N.T.
      • Edelson D.P.
      • Leary M.
      • et al.
      Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study.
      Thus, an additional study analyzing the afore-mentioned ventilation techniques in a two rescuer CPR scenario would be welcome. Second, lifeguards were only allowed to kneel on the side of the manikin. This position may have impaired efficiency of bag-valve-mask ventilation, which is routinely performed with the rescuer behind the patient.
      • Koster R.W.
      • Baubin M.A.
      • Bossaert L.L.
      • et al.
      European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators.
      Third, peak airway pressure and stomach inflation rate were not reported in this study.
      • Adelborg K.
      • Dalgas C.
      • Grove E.L.
      • et al.
      Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study.
      This would be highly interesting, as mouth-to-mouth ventilation in another study resulted in a higher peak airway pressure and stomach inflation rate.
      • Paal P.
      • Falk M.
      • Sumann G.
      • et al.
      Comparison of mouth-to-mouth, mouth-to-mask and mouth-to-face-shield ventilation by lay persons.
      Stomach inflation may not only result in regurgitation and pulmonary aspiration, but also negatively impact on haemodynamic and pulmonary function and even survival.
      • Paal P.
      • Neurauter A.
      • Loedl M.
      • et al.
      Effects of stomach inflation on haemodynamic and pulmonary function during cardiopulmonary resuscitation in pigs.
      Therefore, peak airway pressure and stomach inflation rate in our opinion are key parameters when interpreting this study;
      • Adelborg K.
      • Dalgas C.
      • Grove E.L.
      • et al.
      Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study.
      both parameters should be reported in future manikin ventilation studies. Fourth, while we agree with the authors that the inspired oxygen fraction may be increased during mouth-to-mouth ventilation employing a nasal catheter providing high flow oxygen, it is highly uncertain that the alveolar oxygen concentration will be similarly high as with bag-valve mask ventilation when employing a reservoir and high flow oxygen. Lastly, chest compression depth with ∼30 mm was very shallow in this study, which may be attributed to CPR performed on the beach instead of a poor rescuer performance. Unfortunately, the authors did not report on the characteristics of the beach surface. This, would be interesting, as chest compression quality significantly varies with the rigidity of the surface.
      • Tweed M.
      • Tweed C.
      • Perkins G.D.
      The effect of differing support surfaces on the efficacy of chest compressions using a resuscitation manikin model.
      For instance, when performed on a soft surface, chest compression depth tends to decrease. Thus, the shallow chest compression depth could be attributable to CPR performed on a soft beach surface, e.g. sand.
      Clearly, basic life support is becoming more complex than simply compressing the chest, and if applicable, defibrillating and ventilating a patient.

      Conflict of interest statement

      No author has any financial and personal relationships with other people or organisations that could inappropriately influence this work. This manuscript has been sponsored only by institutional means.

      References

        • Adelborg K.
        • Dalgas C.
        • Grove E.L.
        • et al.
        Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study.
        Resuscitation. 2011; 82: 618-622
        • Sugerman N.T.
        • Edelson D.P.
        • Leary M.
        • et al.
        Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study.
        Resuscitation. 2009; 80: 981-984
        • Koster R.W.
        • Baubin M.A.
        • Bossaert L.L.
        • et al.
        European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators.
        Resuscitation. 2010; 81: 1277-1292
        • Paal P.
        • Falk M.
        • Sumann G.
        • et al.
        Comparison of mouth-to-mouth, mouth-to-mask and mouth-to-face-shield ventilation by lay persons.
        Resuscitation. 2006; 70: 117-123
        • Paal P.
        • Neurauter A.
        • Loedl M.
        • et al.
        Effects of stomach inflation on haemodynamic and pulmonary function during cardiopulmonary resuscitation in pigs.
        Resuscitation. 2009; 80: 365-371
        • Tweed M.
        • Tweed C.
        • Perkins G.D.
        The effect of differing support surfaces on the efficacy of chest compressions using a resuscitation manikin model.
        Resuscitation. 2001; 51: 179-183