Elsevier

Resuscitation

Volume 82, Issue 5, May 2011, Pages 618-622
Resuscitation

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Mouth-to-mouth ventilation is superior to mouth-to-pocket mask and bag-valve-mask ventilation during lifeguard CPR: A randomized study

https://doi.org/10.1016/j.resuscitation.2011.01.009Get rights and content

Abstract

Aim

The quality of cardiopulmonary resuscitation (CPR) is a crucial determinant of outcome following cardiac arrest. Interruptions in chest compressions are detrimental. We aimed to compare the effect of mouth-to-mouth ventilation (MMV), mouth-to-pocket mask ventilation (MPV) and bag-valve-mask ventilation (BMV) on the quality of CPR.

Materials and methods

Surf lifeguards in active service were included in the study. Each surf lifeguard was randomized to perform three sessions of single-rescuer CPR using each of the three ventilation techniques (MMV, MPV and BMV) separated by 5 min of rest. Data were obtained from a resuscitation manikin and video recordings.

Results

A total of 60 surf lifeguards were included (67% male, 33% female, mean age 25 years). Interruptions in chest compressions were significantly reduced by MMV (8.9 ± 1.6 s) when compared to MPV (10.7 ± 3.0 s, P < 0.001) and BMV (12.5 ± 3.5 s, P < 0.001). Significantly more effective ventilations (visible chest rise) were delivered using MMV (91%) when compared to MPV (79%, P < 0.001) and BMV (59%, P < 0.001). The inspiratory time was longer during MMV (0.7 ± 0.2 s) and MPV (0.7 ± 0.2 s, P < 0.001 for both) compared to BMV (0.5 ± 0.2 s). Tidal volumes were significantly lower using BMV (0.4 ± 0.2 L) compared to MMV (0.6 ± 0.2 L, P < 0.001) and MPV (0.6 ± 0.3 L, P < 0.001), whereas no differences were observed when comparing MMV and MPV.

Conclusion

MMV reduces interruptions in chest compressions and produces a higher proportion of effective ventilations during lifeguard CPR. This suggests that CPR quality is improved using MMV compared to MPV and BMV.

Introduction

Administration of ventilations plays an important role in cardiopulmonary resuscitation (CPR), especially in asphyxial cardiac arrests.1 The European Resuscitation Council recommends a ventilation duration of one second to achieve chest rise and effective ventilation. Likewise, reduction of interruptions in chest compressions (no-flow time) is crucial for maintaining coronary and cerebral perfusion.2, 3 Consequently, survival increases and neurological injuries following cardiac arrest can be reduced.4, 5, 6 Previous studies have compared the ability of different ventilation techniques to deliver the recommended tidal volume7 and inspiratory rates.8 Except from over-ventilation resulting in gastric inflation and potential secondary lung injury, these variables are of unknown clinical importance.9 No previous studies have compared the effect of ventilation techniques on no-flow time. Lay rescuers are recommended to use mouth-to-mouth ventilation (MMV),2 while healthcare professionals provide bag-valve-mask ventilation (BMV) during CPR.10 Mouth-to-pocket mask ventilation (MPV) is an effective alternative.2 In the resuscitation of a drowning victim, lifeguards are recommended to use MPV.11 However, this recommendation is not evidence-based. The objective of this study was to compare the effect of MMV, MPV and BMV on CPR quality among surf lifeguards.

Section snippets

Participant recruitment and ethics

Eligible participants were professional, paid surf lifeguards in active service (seasonal: May–August) aged 18 or above. Participants were recruited from two Danish lifeguard organisations. All surf lifeguards complete annual mandatory CPR re-training before commencing active service. Demographic data on age, sex, certification year, surf lifeguard experience, occupation and preferred ventilation technique were collected (Table 1).

Study participation was voluntary and oral and written consent

Results

A total of 63 surf lifeguards were invited to participate in the study of which two declined to participate. Of the 61 randomized individuals, one was excluded due to nightfall, as it was impossible to complete video recordings. Demographic information is shown in Table 1 (mean age: 25.4 years, male: 67% and female: 33%).

Results from single-rescuer scenarios are shown in Fig. 2. Overall, no-flow time significantly differed between the three groups (MMV: 8.9 ± 1.6 s, MPV: 10.7 ± 3.0 s and BMV: 12.5 ± 3.5

Discussion

In this randomized study, we found that MMV significantly reduces interruptions in CPR and produces a higher proportion of effective ventilations compared to MPV and BMV. When MPV and BMV were used, there was a mean delay in starting compressions of 1.8 s and 3.6 s in each cycle compared to MMV (MMV 8.9 s, MPV 10.7 s and BMV 12.5 s). In Denmark, surf lifeguards often work on beaches far from EMS. Assuming 20 min of lifeguard CPR before arrival of the EMS at the beach and a compression–ventilation

Conclusion

This study is the first to demonstrate that MMV is superior to MPV and BMV during simulated single-rescuer CPR, as it reduces the no-flow time and results in more effective ventilations. Our results suggest that compared to MPV and BMV, CPR quality is improved using MMV.

Conflict of interest

None of the authors have conflicts of interest to declare.

Acknowledgements

We sincerely thank Chief lifeguard of the North Zealand Surf Lifeguard Service, John Mogensen and Chief of the Surf Lifeguard Service at Amager Beach Park and Svanemølle Beach, Steve Martinussen for excellent collaboration. We are greatly indebted to all the surf lifeguards who volunteered to participate in the study.

Funding: The study was supported by the Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.01.009.

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