Breathe-and-Push/Push-Hard-Push-Fast

"I understood why they took out the mouth-to-mouth breathing part by lay people, mainly because it delays initiation of chest compression."
"When you push the chest down, you're exhaling; when you let the chest recoil, air goes in. But that's only if the airway is unobstructed. [The head-tilt, chin-lift may help buy more time] that the patient desperately needs."
"It's basically pulling the chin upwards and backwards. As you do that, the head will tilt to some extent as well. We do that on a daily basis as anesthesiologists."
Dr. Anthony Ho, department of anesthesiology and perioperative medicine, Queen's University, Kingston General Hospital, Kingston, Ontario

A man opens the airway on a mannequin while learning CPR. (Photo by Justin Sullivan/Getty Images)

"We always advocate airway manoeuvres and all the other bits and pieces of the chain of survival. But never at the expense of poor chest compressions."
"So asking an average person who is at home -- commonly alone -- who has witnessed the arrest of collapse of their spouse, husband or family member to now do two things without sacrificing CPR quality is really pushing it. [If the same person can't do both] what do you want me to do? Hold the airway open or do chest compressions? There's only one of me here."
"It's missing a little bit of the focus on, where do untrained bystanders respond to a cardiac arrest? Most of those, 95 percent, are in a person's home, not in a public location where there may be multiple responders."
"What we're talking about is, in the moment, for people who have never had any (CPR) training, we want you to keep it simple: Push hard, push fast."
Dr. Andrew Travers, International Liaison Committee on Resuscitation (ILCOR) 

Over 20,000 Canadians will experience an out-of-hospital heart attack (cardiac arrest) each and every year. With no one around to administer CPR and defibrillation, fewer than five percent of people experiencing that emergency health collapse will survive their experience. When there are others around, in a public arena, or just in a home setting, there are those who will respond in a desperate effort to keep the person experiencing that heart-failing situation alive.

It is a daunting experience, both for the person who is suffering the attack, through for them, possibly at that point not entirely aware of how their heart is critically failing them, full awareness would be faint if at all present, while it is the onlooker who is horrified and galvanized into action. That is, an attempt to usefully restore breathing function and normalize as much as possible the heart response. Even those who have undergone basic emergency CPR training in reaction to such events, will be fearful of the outcome.

Those who have a more dim awareness of the procedure requiring the traditional two-step approach of breathing into the person's mouth, then pumping the chest and repeating those two steps interminably until expert help will have arrived, will find the physical let alone mental requirement to pace themselves, be fully aware of the person in distress, and muster somehow the determination to forge on, hoping for help, have a far more difficult experience.

In 2010, the International Liaison Committee on Resuscitation -- and Dr. Travers is one of the expert co-authors of the most recent CPR guidelines, as well as co-chair of the basic life support task force for the International Liaison Committee on Resuscitation (ILCOR) -- issued new North American guidelines recommending that bystanders with no training in CPR methodology bypass the mouth-to-mouth "rescue breathing" in the presence of an adult collapse, focusing instead in performing rapid chest compressions.

Recently, Dr. Anthony Ho of Queen's University and some of his colleagues argued in this week's edition of the Canadian Medical Association Journal, that skipping mouth-to-mouth may be inimical to the rescue attempt. "Rescue breathing" is represented by two manoeuvres; one, tilting the head and chin back, and two, blowing into the mouth. The first step has its own benefits, helping to keep the airway open, allowing passive air entrance.

Dr. Ho's conclusion was that the "wholesale elimination" of mouth-to-mouth ventilation advised in the new adult CPR protocol for the use of untrained lay people "may be misguided". This contradicts other experts who found in their studies that stopping to blow into someone's mouth detracts time away from the chest compressions that maintain blood flow to the heart and brain. Additionally many people feel an unwillingness to perform CPR in the fear of contracting an infection through mouth-to-mouth.

Eliminating the head-tilt, chin-lift "was like throwing out the baby with the bath water", as far as Dr. Ho is concerned. The manoeuvre aids in the maintenance of airway "patency" (openness), and as such can still be viable in delivering air into the chest. A simple procedure, easier to learn and to perform in a crisis that traditional mouth-to-mouth with its two-step approach.

A review of three randomized controlled trials demonstrating chest-compression-only CPR to be associated with an improved chance of survival compared with conventional mouth-to-mouth CPR, supported by three randomized controlled trials, (14% versus 12%), led to the decision to eliminate rescue breathing from the CPR protocol. "It's a small but significant improvement. But it's still only 14%", cautioned Dr. Ho.

"There is much room for improvement, and perhaps we can affect that improvement by making certain that airway patency is maintained." For children and infants, however, the most recent CPR guidelines include rescue breathing. When children experience cardiac arrest it is not the result of a heart problem, but a respiratory problem, and there lies the difference. The attack may have resulted from an asthmatic attack or allergy reaction.

— 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.

— Push down on the chest at least 2 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, then resume chest compressions. Continue sets of 30 chest compressions and two breaths until help arrives.