Unresponsive and abnormal breathing (adolescent and adult)
1. Open their airway: Gently tilt their head back until the mouth falls open and lift the person’s chin
(You may need to turn the person onto their back to do this.)
2. Check for breathing: Keeping the airway open, look, listen and feel for normal breathing for up to ten seconds. Look for chest or abdominal movement; listen for breath sounds; feel for air on your cheek. Professional responders may also do a pulse check at this time.
First aid steps
If the person’s breathing is abnormal or they are not breathing:
1. Immediately ask bystanders to access emergency medical services (EMS), or if you are alone access EMS yourself. If using a phone, activate the speaker function.
2. Begin chest compressions without delay; push down on the centre of the person’s chest at a fast and regular rate (100–120 compressions per minute).
3. Continue to give chest compressions unless otherwise instructed to pause (either by an automated defibrillator or professional responder). Pause compressions if the person shows signs of recovery, such as coughing, opening their eyes, speaking or moving purposefully and breathing normally.
Local adaptation
• If transporting the person from a remote area to medical care, continuous CPR on a firm surface must be provided during transit.
NOTE
Identify that the person is an adolescent or an adult. If they are a child, follow the approach for Unresponsive and abnormal breathing (baby or child).
NOTE
• If one is available, ask a bystander to bring an automated external defibrillator as soon as possible.
Follow the voice prompts, interrupting chest compressions as little as possible. (See Unresponsive and abnormal breathing when a defibrillator is available.)
• If able and willing, combine chest compressions and rescue breaths at a ratio of 30:2 (30
compressions and two breaths). Rescue breaths can benefit people who are unresponsive because they were unable to breathe. Conditions include drowning, Choking, strangulation, opioid overdose or babies and children. Rescue breaths may also be beneficial if there is likely to be a delay in defibrillation.
• If more than one first aid provider is present, alternate giving chest compressions every one to two minutes to prevent getting tired. Ensure that there is no interruption in compressions as the next person takes over.
• If a person has drowned or has hypothermia, there is a chance they may respond to CPR even if defibrillation is not possible.
Access help
• When speaking to EMS, very clearly explain that the unresponsive person is not breathing normally;
this will prompt EMS to prioritise your case appropriately.
• Ask bystanders for help accessing EMS and providing CPR, as well as bringing and using an automated external defibrillator.
• An unresponsive person who is not breathing is unlikely to achieve spontaneous circulation from CPR alone. Their heart needs an electric shock from a defibrillator. It is vital that EMS arrive, and a defibrillator is used.
• The survival of the person depends upon immediate and effective CPR; when accessing help, keep any interruptions to chest compressions minimal.
Self-recovery
• Even if the first aid provider has performed CPR and defibrillation and the person is now responsive and breathing normally, you must continue close monitoring until EMS arrives as the person may stop breathing again.
Education considerations
Supporting learners to have the confidence and willingness to attempt CPR on a person who is unresponsive and breathing abnormally is a priority for first aid educators. Remember that the opportunity to provide CPR is generally very low - some learners might never have to perform it. However, if such a situation does arise, learners need to be prepared for feelings of doubt, uncertainty and lack of confidence. Therefore, CPR education should always take these feelings into account, and support the learner to overcome them.
Context considerations
• Refer to and follow the guidance of regional resuscitation councils or other national protocols and tailor education accordingly.
• Consult local regulators to consider differences in regulation and liability protection for first aid providers.
• Where EMS is available, learners should be encouraged to start compression-only CPR rather than hesitate as they consider the possibility of rescue breaths.
• In some countries, specifically those with a high rate of tuberculosis, rescue breaths may be discouraged. Teach first aid providers chest compression-only CPR (or bag-valve-mask resuscitation if they are professional responders). Also, see Pandemic.
• In contexts where there isn’t any EMS or access to onward care, prepare learners for the likely death of the person who is unresponsive and has abnormal breathing. This should include telling them what to do according to local regulations and requirements for registering a death.
Learner considerations
• Prioritise training community members most likely to encounter cardiac arrest emergencies in CPR.
Members include but are not limited to medics, police officers, firefighters and lifeguards. Also, consider that these groups, given their status and role in the community, might make effective educators for the general public (Tweed and Wilson, 1977). Despite advances in resuscitation science and standardised life-support methods, the overall survival rate of out-of-hospital cardiac arrests remains at less than 10% (Bobrow et al., 2010; Kazaure et al., 2013).
• Build on the motivation that people with family members who are at high risk of cardiac arrest due to illness might have to learn first aid (See Motivation to learn; Huang et al., 2016).
• Adapt educational tools (e.g. manikins and defibrillators), locations (e.g., waterfront scenarios for
lifeguards) and methods to make them accessible and appropriate for learners’ needs and abilities.
(Papalexopoulou et al., 2014; Sopka et al., 2013).
• Consider that age and size of learners. The depth of compressions that can be achieved correlates with physical factors such as increasing weight and height. Children between 10 and 13 may be able to deliver effective chest compressions (Plant, 2013).
• Remind learners that they are most likely to witness the collapse of a person who they know (such as a member of their household), rather than a stranger because in general, we spend more time with people we know.
• Some studies noted that bystanders have concerns about disease exposure and transmission through standard CPR, which has caused a significant decrease in their willingness to provide it to both strangers and family members. Compression-only CPR is the preferred method (Cheng-Yu et al., 2016; Jelinek et al., 2001; Lam et al., 2007; Pei-Chuan Huang et al., 2019).
• Consider the gender makeup of a group of learners. There is limited evidence to demonstrate that female-only learner groups are beneficial to female learners, but there is evidence to support that males are more likely to learn in mixed groups (Sopka et al., 2013).
Facilitation tips
• Emphasise that survival relies upon:
> immediate recognition that someone is unresponsive and breathing abnormally
> early access to help and EMS
> early high-quality CPR (compression-only or standard CPR)
> early defibrillation with an automated external defibrillator.
• Emphasise the importance of the first aid provider, other bystanders and EMS working together to provide quick and effective care.
• Help learners understand the desired outcomes of CPR – to pump blood around the body (chest compressions) and get oxygen into the lungs (rescue breaths). This keeps the vital organs like the brain alive until defibrillation can take place.
• Define proper compression rate and depth and highlight that the unresponsive person will have the best chance of recovery if chest compressions are of good quality.
• Emphasise that the person should be lying flat on a firm surface if possible.
• Emphasise that starting CPR early has a significant impact on the likelihood of achieving the return of spontaneous circulation for some people experiencing cardiac arrest. However, overall, the likelihood of return of spontaneous circulation remains low.
• Ensure learners understand the fundamental components of standard CPR before being taught compression-only CPR (Lam et al., 2007).
These considerations are specific to emergency medical dispatchers.
• Emergency medical dispatchers play a critical role by promptly recognising cardiac arrest, providing CPR instructions by phone and dispatching EMS with a defibrillator. Consider as part of the education for this role:
> The use of scripted protocols as a helpful way to confirm when a person is in cardiac arrest.
> Additional training around the recognition of agonal breathing.
> How to provide CPR instructions for an adult.
> How to provide instructions for both rescue breaths and compressions if the person is a baby or child.
• Dispatchers who communicate using video-assisted emergency calls may need more training for this tool to be effective and widespread within CPR education (Bolle et al., 2009). Bang et al. (2000) suggest that dispatchers with further training (e.g. technical and emotional) are more effective.
Facilitation tools
• If instructing learners on how to perform chest compressions and rescue breaths, refer to the resource Facilitating CPR skills (adolescent and adult). See also Pandemic.
• Massive multiplayer virtual worlds allow learners to play a role and experience “real-life” scenarios and environments in which to practise their CPR skills. If implementing this tool, ensure facilitators understand how to use it and that the technology is not too complex (Creutzfeldt et al., 2013). (See Gamification, and Online learning for adults.)
• If video-assisted dispatcher support is provided in your country, explain how this might work so that learners are prepared to use it, if available. Use role-play to help learners to understand what happens when they call an emergency number. (Bolle et al., 2009; 2011).
• In settings without manikins, used car tyres could be used to practise CPR compressions. Dig the tyre about two-thirds of the way into the ground to simulate a chest, which will recoil when pushed on.
• For learners who train regularly and are knowledgeable in CPR, extend skills training to include performing CPR in different settings and situations (e.g., in noisy or distracting environments, with anxious relatives present, in crowds or small spaces with restricted access). Such training exercises stimulate team-based approaches and lateral thinking.
• Use film clips or demonstrations to improve learners’ recognition of abnormal breathing including agonal breathing and someone who is not breathing.
Learning connections
• In contexts where a defibrillator is likely to be available, pair this topic with Unresponsive and abnormal breathing when a defibrillator is available.
• Ensure learners also understand how to maintain an open airway if someone is Unresponsive and breathing normally.
• The most common condition to result in a person becoming unresponsive with abnormal breathing is a heart attack (see Chest pain).
• Situations that may influence whether rescue breaths could be beneficial include Opioid overdose, drowning or Remote.
• Consider different learning methods, such as the use of Feedback devices, Peer learning, or video learning with a manikin.
• Consider other topics such as Acute grief and Traumatic event if appropriate to the learners.
Scientific foundation
Prompt recognition of cardiac arrest
In 2010, the International Liaison Committee on Resuscitation (ILCOR) conducted an evidence summary on the recognition of cardiac arrest (Koster et al., 2010). In this context, recognition of cardiac arrest includes checking the pulse and recognising agonal breathing.
To date, there are no studies that assess the accuracy of checking the pulse to detect cardiac arrest.
Additionally, first aid providers have difficulty mastering the pulse check and remembering how to perform it.
There is often a high frequency of agonal gasps after cardiac arrest, but several studies showed that first aid providers and EMS dispatchers often do not recognise them. There are many terms used to describe abnormal breathing, confusing first aid providers and dispatchers alike. Sometimes these terms are limited due to cultural influences and translation limitations, even in the same country. Teaching people to identify agonal breathing using a video clip improved the accuracy of recognising cardiac arrest.
Evidence shows that with EMS dispatchers, failure to recognise cardiac arrest may be associated with a
Chest compression-only CPR versus standard CPR
Many studies were conducted to evaluate chest compression-only CPR versus standard CPR with or without dispatcher instruction. We used two systematic reviews, one from ILCOR (Olasveengen et al., 2017) and one from Cochrane (Zhan et al., 2017) and the adult basic life support, 2020 international consensus on CPR from ILCOR (Olasveengen, 2020).
Compression-only CPR versus standard CPR
For the critical outcome of survival with favourable neurological function, a meta-analysis of two cohort studies showed no significant difference between people who received compression-only CPR compared to people who received CPR with a compression-to-rescue-breath ratio of 15:2. Further, a different meta- analysis of three studies, this time using CPR with a compression-to-rescue-breath rate of 30:2, also showed no significant difference in the outcome.
For the critical outcome of survival only, a meta-analysis of six studies did not demonstrate significant differences in people who received compression-only CPR compared to those who received standard CPR with a compression-to-rescue-breath ratio of 15:2. One study showed that people who received compression- only CPR had a worse survival rate than those who received CPR with a compression-to-rescue-breath ratio of 30:2. In another meta-analysis of three observational studies, there was no significant difference between people who received either type of CPR (compression-only or standard with a rate of 30:2).
For the important outcome of return of spontaneous circulation, a meta-analysis of three cohort studies showed no benefit to using the 15:2 ratio compared to using a different ratio.
The Cochrane systematic review compared chest-compression-only-CPR versus standard CPR on non- asphyxial out-of-hospital cardiac arrest. The meta-analysis found high-quality evidence that continuous chest compression CPR without rescue breathing improved people’s survival to hospital discharge compared to interrupted chest compressions with pauses for rescue breathing (ratio 15:2).
Compression-only CPR versus standard CPR (adults) - dispatcher-assisted
Low-quality evidence from a randomised controlled trial demonstrated no benefit to favourable neurological function when dispatchers provided instructions for continuous chest compressions compared to instructions for compressions and rescue breaths at a ratio of 15:2. Conversely, three randomised controlled trials also compared the two types of dispatcher-assisted CPR and found that compression-only CPR resulted in a small benefit to peoples’ survival to hospital discharge.
In the nationwide recommendation of compression-only CPR for first aid providers in Japan, results associated dispatcher-assisted compression-only CPR with improved bystander CPR rates. However, the outcome for people receiving CPR was better when bystanders performed standard CPR rather than compression-only.
First aid provider fatigue in chest-compression-only CPR
A comparison of first aid provider fatigue in chest compression between first aid providers who perform compression-only CPR versus standard CPR has been the subject of scoping review for the 2020 ILCOR recommendation. Fifteen manikin studies evaluating fatigue and its effects on CPR quality in volunteers performing continuous compressions and 30:2 or 15:2 CPR. They suggest that continuous compressions are effective in the first two minutes with regard to depth and frequency, and there are indications that short periods of rest (pauses in compression) reduce first aid provider fatigue and increase CPR quality.
Chest compression quality Hand position during compression
The recommendations for hand position during compressions, based on only low- or very-low-certainty evidence in 2015 was reviewed in 2020. No studies reporting favourable neurological outcome, survival, or return of spontaneous circulation. Only two observational studies that reported physiological endpoints are found. One study with a few people who received prolonged resuscitation from nontraumatic cardiac arrest observed improved peak arterial pressure and ETCO2 during compression systole when compressions were performed over the lower third of the sternum compared with the centre of the chest. The other physiological endpoints did not differ in this study and the second one, in 30 adults with cardiac arrest, observed no difference in ETCO2 values resulting from changes in hand placement.
Chest compression rate
The scientific foundation for chest compression rate includes an evidence summary completed by ILCOR (Perkins et al., 2015) and a scoping review by ILCOR (Considine et al., 2019) which served as the basis for the adult basic life support, 2020 International Consensus on CPR from ILCOR (Olasveengen, 2020, S41).
There was an inconsistent association between chest compression rate and survival with a favourable neurological outcome. The results varied depending on the study population (adult versus child), study size and whether any adjustments were made for potential confounders.
One study reported that when it adjusted for confounders, including compression depth and fraction, survival to hospital discharge was lower when compression rates were 80–99 and 120–139/min, compared to 100–119/
min. No other studies reported specific compression rates benefitting the survival to hospital discharge outcome.
There were no significant differences reported between various chest compression rates on one-month survival, one-day survival, or hospital admission while alive. Of the eight studies that examined spontaneous circulation return, one study said that, compared to a reference chest compression rate of 100–120/min, 121–140/min was associated with an increased return of spontaneous circulation. Another study associated higher mean chest compression rates with an increased likelihood of spontaneous circulation return. None of the three studies that reported on blood pressure showed a significant effect between chest compression rate and either systolic or diastolic blood pressure.
Chest compression depth
The scientific foundation for chest compression depth includes an evidence summary completed by ILCOR (Travers et al., 2015 S51) and a scoping review by the Basic Life Support ILCOR task force (Considine et al., 2019). This served as the basis for the adult basic life support, 2020 International Consensus on CPR from ILCOR (Olasveengen, 2020, S41). Four observational studies suggest that the return of spontaneous circulation with a compression depth of more than 5 cm in adults is more likely than all other compression depths. Another study suggested that deeper chest compressions were associated with a greater likelihood of successful defibrillation.
For survival to hospital admission, one study showed that increased chest compression depth was associated with increased odds of admission to a hospital alive, while another study showed no association between different mean chest compression depths and survival to hospital admission.
Three studies compared different chest compression depths with survival and a favourable neurological outcome. None of the chest compression depths significantly increased or decreased survival or favourable neurological outcomes. However, one observational study suggests that a compression depth in adults of more than 5 cm increased survival and good neurological outcomes, compared to all other compression depths during standard CPR.
For survival, three studies reported statistically significant relationships between one-day survival and chest compression depth in adults. For each 5 mm increase in chest compression depth, one-day survival increased. One study that looked at survival to the emergency department showed that mean chest compression depths of 5–6 cm had the highest survival to emergency department rates in adults.
One study reported that survival to hospital discharge decreased when chest compression depth was less than 38 mm, compared to more than 51mm and adjusting for confounders. Two adult studies reported that for each 5 mm increase in chest compression depth, survival to hospital discharge increased.
At least one study detailed injury frequency and showed that increased chest compression depths were associated with higher injury rates. The mean chest compression depth of people with injuries was 56 mm versus 52 mm in people with no injuries.
Chest wall recoil
The scientific foundation for chest wall recoil includes an evidence summary completed by ILCOR (Perkins et al., 2015) and a scoping review by ILCOR (Considine et al., 2019). This served as the basis for the adult basic life support, 2020 international consensus on CPR from ILCOR (Olasveengen, 2020, S41). The first two outcomes examined were favourable neurological outcomes and survival to hospital discharge. Two studies had conflicting results, while another study reported that - once adjusted for confounders – there was no difference in survival to hospital discharge associated with different chest compression release speed. One study reported the return of spontaneous circulation and showed no statistically significant improvement associated with a 10 mm per second increase in chest compression release speed. Only animal studies have found reduced coronary perfusion pressure with incomplete chest recoil.
Check for circulation during basic life-support
There is no evidence to justify doing further research and changing the 2015 treatment recommendation.
Outside the advanced life-saving environment, there is insufficient data about the value of a pulse check while performing CPR.
Firm surface for CPR
For this topic, we use the adult Basic Life Support, 2020 International Consensus on CPR from ILCOR (Olasveengen, 2020, S41). Variation in backboard use and the practice of moving a person from the bed to the floor to improve the quality of CPR are reported. The identified science has been grouped by mattress type, floor compared with bed and backboard. Four manikin randomised controlled trials did not identify a difference in chest compression depth between mattress types. Two manikin meta-analyses found no effect on chest compression depth and neither two manikin trials identified a difference in chest compression depth between groups. At least, six manikin randomised controlled trials found that the effect of chest compression is improved when they are used on the backboard and one randomised controlled trial did not find a better effect. It’s important to indicate that we have no clinical studies reporting on the critical outcomes of survival and favourable neurological outcome or important outcome of chest compression quality.
Harm caused by CPR to a person who is not in cardiac arrest
This topic’s scientific foundation includes an evidence summary from a systematic review, the Consensus of Science, and a Basic Life Support ILCOR task force treatment recommendation from Svavarsdottir et al. (2019).
Many first aid providers are concerned that they will harm a person who is not in cardiac arrest or cause severe complications by giving chest compressions. This belief makes them reluctant to start CPR. The systematic review included four observational studies that looked at 762 people who were not in cardiac arrest but still received CPR by first aid providers outside the hospital. Pooled data of three of these studies found an incidence of muscle damage of 0.3%, bone fracture (rib and clavicle) of 1.7%, pain in the area of chest compression of 8.7% and no visceral injury. The fourth study reported no injury.