CPR may not be the best option

ON THE ALERT: You could very well save someone if you are willing to pump chests - even if you are averse to giving mouth-to-mouth.


WHEN a person has a heart attack, you should perform CPR. Correct? Well, maybe not.

In 2005, University of Arizona Sarver Heart Centre cardiologists published research that showed how, if someone were to collapse unexpectedly, he or she should not be given mouth-to-mouth cardio-pulmonary resuscitation (CPR). Just focus on pumping his or her chest instead.

Their report was published in Circulation, Journal of the American Heart Association (AGA). Last month, the University of Arizona's chief of cardiology, Dr Gordon Ewy, updated their account in another article in the Cleveland Clinic Journal of Medicine.

He noted that both the AHA and the International Liaison Committee on Resuscitation had revised their CPR guidelines in 2005 without adopting the Arizona innovation wholesale and the 'dismal...survival rates for victims of out-of-hospital cardiac arrest...have remained essentially unchanged for decades'.

The reason for the Arizona doctors' finding: It takes time for chest compressions to build up pressure in the arteries to move blood forward and keep the flow going. Whenever you stop chest compressions to, say, assist the victim's breathing, the brain will suffer because blood flow to the brain is reduced.

In standard CPR, rescuers pump the chest only half the time, with the other half spent on mouth-to-mouth. However, the reason to administer CPR is to save the brain. As the brain is the organ most sensitive to a lack of oxygen, anything that saves it will save other organs as well.

To highlight the aim of saving the brain, the originators of the continuous-chest-compression-only method christened it cardio-cerebral resuscitation (CCR). While only 15 per cent of victims survive with intact brain function using traditional CPR, the Arizona studies recorded a threefold rise in survival with the new method.

In Singapore, cardiac arrest is the most important cause of death, after cancer. But according to a local study, bystanders administered CPR in only 37 per cent of cases if they actually saw the person collapsing. If people entered the scene without witnessing the collapse, CPR was initiated in just 1.7 per cent of cases.

Clearly, Singaporeans are averse to doing mouth-to-mouth, so many will just call 995 and wait for help to arrive, by which time it could be too late for the victim. If more people knew about CCR, the situation may improve.

Why has CPR prevailed until now? The main reason might be that CPR was actually designed for not one but two conditions - when the heart stops out of the blue (cardiac arrest) and when the heart stops some time after a person stops breathing (respiratory arrest). While the former does not need mouth-to-mouth assistance, the latter does.

Because doctors assumed that laypersons would not be able to tell the difference between the two, CPR became the default practice. But people probably can tell the difference: You stop breathing during an asthmatic attack, a drug overdose or when you choke or drown. In such situations, CPR is the way to go.

If you see someone unexpectedly keeling over clutching his chest, it is very likely that his heart has just arrested. In this case, CCR is better. And since cardiac arrests are much more common than respiratory arrests, by default CCR may have a better chance of success than CPR.

When the heart stops beating out of the blue, the cause is usually ventricular fibrillation where, instead of beating regularly, the organ quivers and cannot pump blood to the brain. Under these circumstances, only chest compressions can move blood, and thus oxygen, to the brain.

What about helping the victim breathe? Doctors have found that within the first few minutes of cardiac arrest, blood within the heart and its big arteries and veins have enough levels of oxygen, even if breathing is not assisted. Thus, just maintaining circulation, not breathing, in the first five minutes after cardiac arrest is sufficient.

Has CCR been found to work elsewhere? In a study published in Circulation, in which Tokyo doctors treated 7,138 patients felled by cardiac arrests outside of a hospital setting, CCR saw the best survival rates in terms of recovery with normal brain function.

This was a very large study published in a respected journal. Unfortunately, it was rushed to publication only in abstract form at the time the 2005 AHA guidelines were being considered. Without actual details of the study, the AHA decided to recommend CCR only 'if the individual is unwilling or unable' to perform CPR.

In Singapore, National Resuscitation Council chairman Teo Wee Siong feels that Singapore is not ready to advise CCR over CPR just yet. He agrees with the AHA on recommending CCR only in cases where people are unwilling or unable to perform CPR.

One of the criticisms that have been levelled against the CCR camp is that the arguments used by Dr Ewy are overly grounded in his published experiments, which involve some 169 swine rather than placebo-controlled trials in humans.

But such trials are difficult to carry out since how soon CCR or CPR is initiated in cardiac arrests outside of hospitals is often difficult to establish with certainty.

Anyway, while physicians continue to debate the issue, you could very well save someone if you are willing to pump chests - even if you are averse to mouth-to-mouth.