ventilation techniques used by lifeguards bo løfgren, md, phd honorary associate professor in...
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Ventilation techniques used by lifeguards
Bo Løfgren, MD, PhDHonorary Associate Professor in Resuscitation and Emergency Medicine
Department of Internal Medicine and Clinical Research Unit
Regional Hospital of Randers, Randers, Denmark
&Research Center for Emergency Medicine
Institute of Clinical MedicineAarhus University Hospital, Aarhus, Denmark
HLR2014 Conference Tylösand, Sweden | June 3-4 | Drowning
Conflict of interest
None to disclose
Resuscitation in drowning
Differs from primary cardiac arrest
Ventilation is a priority
Supplemental oxygen
Ventilation techniques
Mouth-to-mouth ventilation
(MMV)
Mouth-to-pocket maskventilation
(MPV)
Bag-maskventilation
(BMV)
Supraglottic airwayventiation
(SGA)
Orotracheal intubation
(OTT)
PICO: Which ventilation technique?
Among adults and pediatric drowning victims (P), does delivery of ventilation with another specific ventilation technique (I), compared with mouth-to-mouth ventilation (C), change survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, hands-off time (O)?
No clinical studies
Outcome measure
Critical CPR skills for lifesavers
The first and most important treatment of the drowning victim is provision of immediate mouth-to-mouth ventilation.
(…) encourages that airway adjunct methods, such as mouth-to-mask, be taught to lifesavers and used as appropriate.
(…) encourages the training and equipping of lifesavers with oxygen.
The use of oxygen by lifesavers
(…) recommend a non-rebreathing mask with a fixed flow of 15 litres of oxygen per minute for spontaneously breathing victims and a transparent mask with oxygen inlet for patients in ventilatory arrest.
Which ventilation technique?
Mouth-to-pocket maskventilation
(MPV)
Bag-maskventilation
(BMV)
Mouth-to-mouth ventilation
(MMV)
Allow supplementation of oxygen
Aim
To compare different ventilation techniques
on the quality of CPR
Primary outcome measure
Interruptions in chest compressions
Methods
Professional, surf lifeguards (> 18 years)
Recruited from two Lifeguard Services
Annual mandatory CPR re-training
Oral and written consent obtained
Performance not disclosed
Questionnaire – demographics
Study design
Randomized – single rescuer CPR – manikin
MMV, MPV (PocketMaskTM), BMV (theBAG IITM)
Allowed to familiarize with the equipment
3 min.CPR
5 min.rest
3 min.CPR
5 min.rest
3 min.CPR
5 min.rest
Data collected on the beach (laptop/video)
Results
MMV-MPV-BMVn=12
BMV-MMV-MPVn=10
MPV-MMV-BMVn=9
MMV-BMV-MPVn=10
BMV-MPV-MMVn=9
MPV-BMV-MMVn=10
Eligible n=63
Includedn=60
Randomizedn=61
Declined to participate, n=2
Excluded due to nightfall, n=1
MMV: Mouth-to-mouth ventilation | MPV: Mouth-to-pocket mask ventilation | BMV: Bag-mask ventilation
Demographics
Mean age SD (years) 25.4 5.9
Sex (n, %)
Female
Male
20 (33%)
40 (67%)
Certification year (mean SD) 2006 4.4
Years of experience (mean SD) 4.4 4.4
Health care professional (n, %) 7 (13 %)
CPR quality
MMV MPV BMV0
10
20
30
Inte
rru
pti
on
in
CC
(s)
8.91.6 s 10.73.0 s 12.53.5 s
** †
Data are meanSD. *P<0.001 compared to MMV. †P<0.001 compared to MPV.
Chest compressions
MMV MPV BMV0
50
100
150
CC
rat
e (m
in-1
)
11213 min-1 11013 min-1 11214 min-1
MMV MPV BMV0
10
20
30
40
50
60
CC
dep
th (
mm
)
32.18.9 mm 31.78.7 mm 31.59.0 mm
Another benefit from measuring …
32.18.9 mm 31.78.7 mm 31.59.0 mmData are meanSD.
MMV MPV BMV0
20
40
60
80
CC
dep
th (
mm
)
ERC 2005
MPV0
20
40
60
80
CC
dep
th (
mm
)
ERC 2010
Ventilations
*P<0.001 compared to MMV and MPV respectively
MMV MPV BMV0.0
0.5
1.0
1.5
Insp
irat
ory
tim
e (s
)
0.70.2 s 0.70.2 s 0.50.2 s
*
MMV MPV BMV0.0
0.5
1.0
1.5
2.0
Tid
al v
olu
me
(L)
*
0.60.2 L 0.60.3 s 0.40.2 L
*P<0.001 compared to MMV and MPV respectively
Effective ventilations
MMV MPV BMV
91 %(n=515)
79 %(n = 518)
59 %(n=557)
* p0.001, MMV vs MPV, MMV vs BMV and MPV vs BMV
* * *
Conclusion
Mouth-to-mouth ventilation reduces interrup-
tions in chest compressions and produces a
higher number of effective ventilations when
compared to mouth-to-mask and bag-mask
ventilation during lifeguard CPR
Mouth-to-mouth by lifeguards?
Reluctance
Body fluids e.g. vomit, blood etc.
Communicable disease
Ventilation technique
Preferred ventilation technique
Mouth-to-mouth ventilation
Mouth-to-pocket mask ventilation
Bag-mask ventilation
11 (18%)
42 (70%)
6 (10 %)
No reply 1 (2%)
Adelborg & Løfgren Resuscitation 2011;82:618-622
Barrier device
Mouth-to-face-shieldventilation
(MFV)
Mouth-to-pocket maskventilation
(MPV)
Focused training in MPV
MMV MPV0
5
10
15
20
Inte
rru
pti
on
in C
C (
s)
8.91.6 s 10.73.0 s
Inte
rru
pti
on
s in
CC
(s
)MPV
0
5
10
15
20
7.81.3 s
Barrier device
Mouth-to-face-shieldventilation
(MFV)
Mouth-to-pocket maskventilation
(MPV)
Aim
To compare mouth-to-pocket mask and
mouth-to-face shield ventilation on the
quality of CPR
Study design
30 volunteer surf lifeguards (age 25 y; F 9/30)
Oral and written consent obtained
Formally trained in MPV and MFV
Randomized – single rescuer CPR w MPV/MFV
Data from manikin & video recordings
Quality of CPR: interruptions in chest comp
CPR quality
MFV MPV
0
5
10
15In
terr
up
tio
ns
in C
C (
s)
8.61.7 s 6.91.2 s
*
* p<0.0001
Ventilation
MFV MPV
0.0
0.5
1.0
1.5
Tid
al v
olu
me
(L)
MFV MPV
0.0
0.5
1.0
1.5
Insp
ira
tory
tim
e (s
)
Chest compressions
MFV MPV
0
50
100
150
Co
mp
res
sio
n r
ate
(m
in-1
)
MFV MPV
0
20
40
60
80
Co
mp
res
sio
n d
ep
th (
mm
)
Effective ventilations
MFV MPV BMV
82 %(199/242)
100 %(239/240)
59 %(n=557)
*p = 0.0002
* *
Conclusion
Mouth-to-face-shield ventilation increases
interruptions in chest compressions reduces
the proportion of effective ventilations and
decreases delivered tidal volumes when
compared with mouth-to-pocket mask
ventilation.
General study limitations
Manikin study
No body fluids e.g. vomit, blood etc.
Single rescuer scenario
No physical exertion
Overall conclusion
Mouth-to-mouth ventilation
(MMV)
Mouth-to-pocket maskventilation
(MPV)
Future directions
More studies on ventilation techniques
Multiple rescuers/team effort
Supraglottic airway devices (SGA)
Single rescuer over the head-CPR
Clinical data needed
Acknowledgement
John Mogensen, North Zealand Lifeguard Service
Steve Martinussen, Copenhagen Lifeguard Service
Carsten Jørgensen, Aalborg Lifeguard Service
All the surf lifeguards participating in the studies
Financial supportResearch Award from The Christenson-Ceson Family FoundationAarhus University Hospital and Regional Hospital of Randers
HLR2014 Conference Tylösand, Sweden | June 3-4 | Drowning
