CHICAGO — The American Heart Association's renewed emphasis on compression versus ventilation in its latest cardiopulmonary resuscitation guidelines folds children and adults into the same category when only one rescuer is present.
In the hands of a lone rescuer, regardless of whether it is a layperson or a health care provider, children of all ages (excluding newborns) should be treated using a 30:2 compression-ventilation ratio, said Dr. Robert Hickey, one of the authors of the guidelines, past chair of AHA's pediatric subcommittee, and chair of the Emergency Cardiovascular Care Committee of the AHA.
A ratio of 15:2 is advised if there are two trained (not lay) rescuers present. “In children, rescue breaths are more important partly because they largely have asphyxial arrest,” he said in an interview at a meeting sponsored by the American College of Emergency Physicians.
Another pediatric specification of the guidelines is that cuffed endotracheal tubes are as safe as uncuffed ones for infants (except newborns) and children in the hospital setting—as long as rescuers use the correct tube size and inflation pressure, and verify tube position, he said. In fact, cuffed tubes may even be preferable under certain circumstances, such as poor lung compliance, high airway resistance, and large glottic air leak, he said.
Dr. Hickey said the most important overall message in the new guidelines (Circulation 2005;112 [24 Suppl.]:IV1–203)—for both children and adults—is the renewed focus on cardiopulmonary resuscitation (CPR). “Not enough people get CPR, and not enough people who get CPR get good CPR,” said Dr. Hickey, professor of pediatrics at the University of Pittsburgh and attending physician in the division of pediatric emergency medicine at Children's Hospital of Pittsburgh.
The new guidelines stipulate that either one or two hands can be used for chest compressions in children. However, he said studies show that most efforts at CPR—even when given by health care professionals—are still inadequate, involving too few chest compressions, compressions that are too weak, too many ventilations, and too many interruptions.
There is strong evidence pointing to the importance of optimizing chest compressions, even at the expense of ventilation, he said. In fact, some studies suggest that excessive ventilation might actually be leading to life-threatening hyperventilation-induced hypotension. A recent paper suggested that unrecognized and inadvertent hyperventilation could be contributing to the currently dismal survival rates from cardiac arrest (Circulation 2004;109:1960–5).
“Even if you do it right, there is a loss of coronary perfusion pressure each time you stop to do a ventilation,” Dr. Hickey said. “This is what fuels arguments for chest compression only.”
Chest compressions should take priority even over defibrillation, he added. One study showed an improved survival rate of 22% in patients when defibrillation was delayed until after the initiation of chest compressions, compared with a 15% survival rate among patients whose chest compressions followed defibrillation (JAMA 2003;289:1389–95). The same study showed that among patients with more than a 5-minute delay in rescue response following cardiac arrest, immediate defibrillation resulted in only a 4% survival rate, compared with a 22% survival rate in those who had chest compressions before defibrillation.
Dr. Hickey added that high-dose epinephrine is not recommended in children, based on a study showing that it did not improve return of spontaneous circulation and resulted in worse 24-hour survival (New Engl. J. Med. 2004;350:1722–30).
In neonatal resuscitation cases, current recommendations no longer advise intrapartum oropharyngeal suctioning for infants born after meconium staining of amniotic fluid, he said. Endotracheal suctioning immediately after birth for infants who are not vigorous is now recommended, Dr. Hickey added.