The Limitations of AHA Guidelines for CPR from Pioneer Resuscitation Researcher

By Gordon A. Ewy, MD, Professor of Medicine and Director, Sarver Heart Center at the University of Arizona College of Medicine.

Dr Ewy demonstration

The 2010 American Heart Association Guidelines again failed to endorse chest-compression-only CPR for all bystanders of witnessed primary cardiac arrest, and thus have become irrelevant. It is important for people to understand that Guidelines are just that, guidelines, not standards nor requirements. The Resuscitation Research Group at the University of Arizona Sarver Heart Center recently reported that when advocated and taught, chest-compression-only CPR significantly improves survival of patients with out-of-hospital cardiac arrest (JAMA Oct 6, 2020).  In fact, in the subset of patients with the greatest chance of survival—those with witnessed arrest and a heart rhythm that could be restored by a defibrillator shock—18 percent survived when bystanders provided “Guidelines” CPR and 34 percent survived when bystanders provided chest-compression-only CPR.
 
The fact that the Guidelines are decided upon and written months before they are published (therefore do not consider such recent evidence) is only one of the reasons that the process is seriously flawed.
 
Why do the 2010 Guidelines advocate that all emergency medical services dispatch centers instruct lay individuals in chest-compression-only CPR, and yet not advocate it for everyone? Why do the Guidelines state that, “Rescuers should avoid stopping chest compressions and avoid excess ventilations” and yet not advocate chest-compression-only CPR? The “Guidelines” have lost or are in danger of losing their credibility.
 
Since 1976, one of the rationales for the Guidelines advocating chest compressions plus ventilations for all patients with cardiac arrest is the concern that bystanders would not be able to tell the difference between primary and secondary cardiac arrest; that is secondary to drowning, drug overdose or respiratory failure. These patients, while they are the minority, need chest compressions plus assisted ventilation. Sarver Heart Center’s Resuscitation Research Group recommends that you also become trained to perform mouth-to-mouth assisted ventilation, especially if you have a swimming pool or live near a lake or the ocean—situations where you are likely to witness a drowning.
 
However, to set up the Guidelines to cover everyone by advocating suboptimal approaches for those who have the greatest chance of survival, is not logical. It is easy to distinguish a primary from a secondary cardiac arrest, but it must be taught, and chest-compression-only CPR must be advocated. Primary cardiac arrest is recognized by an unexpected witnessed (seen or heard) collapse in an individual who is not responsive. Patients with primary cardiac arrest often gasp (an abnormal snoring-like respiration) that provides adequate ventilation, but indicates a cardiac arrest. If chest-compression-only CPR is provided, the individual often continues to gasp, and in such patients assisted ventilations are not necessary for prolonged periods of time.
 
I’m deeply disappointed that the AHA continues to recommend 30 compressions to two breaths for lay persons who are trained in this method. Soon after the 2000 AHA Guidelines were published, it was found that lay individuals who were recently CPR certified interrupted each set of chest compressions an average of 16 seconds to deliver the so called “rescue breaths.” This prompted our experimental studies that showed that chest-compression-only CPR resulted in better survival than realistic chest compressions plus ventilations. The Arizona findings (JAMA Oct. 2010) have confirmed this in the community. Thus being certified will not improve the technique of bystander CPR for the majority of individuals with out-of-hospital primary cardiac arrest. Our estimate is that there are about 100 cardiac arrests for every drowning.
 
Changing the “ABCs” (Airway, Breathing, Compressions) algorithm to “CBA” will not improve survival, as stopping chest compressions to provide assisted ventilation results in inadequate blood flow to the brain.
 
So remember, Guidelines are just that, guidelines, not standards nor requirements.