While mouth-to-mouth breaths have been included in CPR guidelines since the 1960s, overwhelming evidence suggests that bystander mouth-to-mouth resuscitation may do more harm than good. There are three main reasons for this: The first is that the thought of giving rescue breaths makes bystanders less likely to want to perform CPR. The second is that rescue breaths interrupt lifesaving chest compressions. The third is the risk of disease transmission.
To improve survival rates from cardiac arrest, it’s important for business owners, educators, coaches, health club workers, and the general public to understand why mouth-to-mouth is no longer recommended for bystanders and what you should do instead.
Evidence for CPR Without Mouth-to-Mouth Resuscitation
When cardiopulmonary resuscitation following the “ABC” (airway, breathing, circulation) acronym became standardized in the 1960s, it was known that mouth resuscitation was more effective for successful resuscitation than earlier methods that included using a bellows or moving the victim’s arms up and down. However, research covering several thousand victims of sudden cardiac arrest now shows that chest compressions alone are actually more effective for adult victims than chest compressions plus rescue breathing—at least when performed by an untrained bystander.
In 1997, the American Heart Association published a consensus statement for healthcare workers in the Circulation journal recommending hands-only CPR for bystanders. Moreover, research published by Ken Nagao, MD, from Surugadai Nihon University Hospital in Tokyo, and colleagues in 2007 noted that victims were 2.2 times less likely to suffer brain damage when given hands-only CPR[mfn]thelancet.com[/mfn] instead of traditional CPR with rescue breaths.
A Fear of Giving Mouth-to-Mouth Resuscitation Reduces the Likelihood of Bystander CPR
The first reason that mouth-to-mouth resuscitation is no longer recommended is that it discourages bystanders from performing CPR. In the study published by Nagao et al., a staggering 70% of more than 4,000 cardiac arrest victims were not given CPR by a bystander, and other studies indicate that a fear of giving mouth-to-mouth is one of the main reasons that bystanders don’t perform CPR.
Mouth-to-Mouth Resuscitation Interrupts Lifesaving Chest Compressions
The second reason that mouth-to-mouth ventilation is no longer recommended is that it wastes time that would be better spent giving high-quality chest compressions. Most victims of sudden cardiac arrest were breathing normally before the collapse, meaning that they still have enough oxygen in their blood to last for a good 10-12 minutes of chest compressions until emergency medical services arrive.
Mouth-to-Mouth Contact Comes with a Risk of Disease Transmission
The COVID-19 pandemic brought renewed attention to the risk of disease transmission from giving mouth-to-mouth. While emergency services personnel always have ventilation masks on hand, untrained bystanders usually don’t, and giving rescue breaths without protection carries the risk of being infected or infecting the stricken person with a potentially fatal disease. Knowing that hands-only CPR is just as effective—and often more effective than traditional CPR—there is no sense in interrupting lifesaving chest compressions with rescue breaths that could potentially be harmful.
When Mouth-to-Mouth Resuscitation Is Necessary
While mouth-to-mouth is no longer recommended for untrained bystanders, there are some situations in which rescue breathing is necessary:
- Babies and young children suffering cardiac arrest from a non-cardiac cause (non-cardiac causes are often respiratory)
- Near-drowning victims
- Drug overdose victims
- Asthma attacks, poisoning, choking, and carbon monoxide poisoning
In the above cases, there is not enough oxygen circulating in the blood to keep the organs alive until emergency medical personnel arrive, and rescue breathing increases the victim’s chances of survival. In the case of children and babies, research shows that traditional CPR is most effective for SCA victims with a non-cardiac cause[mfn]thelancet.com[/mfn]. For pediatric SCA victims with a cardiac cause, traditional CPR and hands-only CPR are equally as effective.
What to Do When Rescue Breaths Are Required
If the patient is a child, an infant, a near-drowning victim, or the victim of a drug overdose or one of the other situations listed above—and you have received up-to-date CPR training—perform traditional CPR with a ratio of 30 chest compressions to two rescue breaths.
If available, give the rescue breaths through a positive-pressure ventilation mask. These can be purchased online to attach to your keychain and are included with most AEDs, such as the Philips HeartStart FRx, HeartSine Samaritan PAD 350P, and Defibtech Lifeline.
If you are not trained in rescue breathing, give hands-only CPR, send someone to call 911, and allow a trained rescuer to provide the rescue breaths as soon as such a person can be found. Once the trained responder arrives, you can alternate with them providing chest compressions so that neither of you becomes fatigued.
Guidelines for Bystanders: Push Hard, Push Fast, Call 911, and Send for an AED
In the 2020 AHA guidelines for CPR and ECC[mfn]cpr.heart.org[/mfn], traditional CPR with a ratio of 30 chest compressions to two rescue breaths is recommended for trained rescuers treating adolescent and adult patients, and hands-only CPR is recommended for untrained bystanders. The CPR guidelines also state that children (and infants) should receive traditional cardiopulmonary resuscitation with rescue breaths. If you see someone collapse suddenly, this is what you should do.
Step 1: Send for Help
If someone else is there, send them to call 911 and then to fetch the nearest automated external defibrillator (AED). There are usually public access defibrillators in hospitals, police stations, schools, and health clubs. If you are alone and the victim is an adult, call 911 before performing hands-only CPR. If you are alone and the victim is a child, perform CPR for two minutes, call 911, and then resume chest compressions.
Step 2: Perform Hands-Only CPR
To deliver hands-only CPR, find the center of the patient’s chest (between the nipples), place the heel of your strongest hand over the back of the other hand, and push hard to the rhythm of Stayin’ Alive (or about 100 to 120 beats per minute). Each chest compression should depress the victim’s chest by 1.5 inches or 1/3 of the total depth. Make sure the chest rises between each compression.
Step 3: Deploy the AED
Defibrillation in the first few minutes after collapse triples survival rates[mfn]ahajournals.org[/mfn], which is why it’s so important to send for a portable defibrillator as soon as you see someone collapse or find them unconscious. When the defibrillator arrives, stick the electrode pads to the victim’s bare chest in the positions indicated in the diagram on the pads. Then, turn on the device and follow the voice instructions.
For a victim under 8 years of age or 55 lbs (25 kgs), you should use pediatric electrode pads, press the child button on the device, or insert the child/infant key—depending on the device. If no child pads or settings are available, use the regular adult pads.
The AED will prompt the rescuer to continue giving chest compressions until emergency services arrive. When the ambulance arrives, leave the electrode pads attached to the patient and the AED turned on. The paramedics will take it from there.
Hands-Only CPR and Early Defibrillation Are the Best Ways to Save a Life
As the evidence shows, bystander cardiopulmonary resuscitation is most effective when only chest compressions are used, which is why mouth-to-mouth is no longer recommended. If you aren’t trained and you see someone collapse, check that the area is safe, push hard and fast, and call for emergency services and an AED.
If you are in charge of an AED program, consider AED program management to make sure that all of your staff are trained in the most up-to-date CPR guidelines and confident in using a defibrillator. After collapse, chest compressions and defibrillation within the first few minutes lead to the best outcomes for victims of sudden cardiac arrest. Be prepared, prepare those around you, and you may one day save a life.
Information Sources
