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This guideline is applicable to adults, children and infants.

Normal breathing is essential to maintaining life. Victims who are gasping or breathing abnormally and are unresponsive require resuscitation.1

Causes of ineffective breathing of acute onset

  1. Top of page
  2. Causes of ineffective breathing of acute onset
  3. Assessment of breathing
  4. Rescue breathing
  5. Risks
  6. References

Breathing may be absent or ineffective as a result of:

  • • 
    direct depression of/or damage to the breathing control centre of the brain
  • • 
    upper airway obstruction
  • • 
    paralysis or impairment of the nerves and/or muscles of breathing
  • • 
    problems affecting the lungs
  • • 
    drowning
  • • 
    suffocation.

Assessment of breathing

  1. Top of page
  2. Causes of ineffective breathing of acute onset
  3. Assessment of breathing
  4. Rescue breathing
  5. Risks
  6. References

There is a high incidence of abnormal gasping (agonal gasps) after cardiac arrest.1[LOE IV] Lay rescuers and health care professionals should use a combination of unresponsiveness and absent or abnormal breathing to identify the need for resuscitation.1[Class A; LOE: Expert consensus opinion]

The rescuer should:

  • • 
    LOOK for movement of the upper abdomen or lower chest
  • • 
    LISTEN for the escape of air from nose and mouth
  • • 
    FEEL for movement of the chest and upper abdomen

Movement of the lower chest and upper abdomen does not necessarily mean the victim has a clear airway. Impairment or complete absence of breathing may develop before consciousness is lost by the victim. [Class A; Expert Consensus Opinion]

Rescue breathing

  1. Top of page
  2. Causes of ineffective breathing of acute onset
  3. Assessment of breathing
  4. Rescue breathing
  5. Risks
  6. References

If the unconscious victim is unresponsive and not breathing normally after the airway has been opened and cleared, the rescuer must immediately commence chest compressions and then rescue breathing. Give 30 compressions and then two breaths allowing about one second for each inspiration following the Australian Resuscitation Council and New Zealand Resuscitation Council Basic Life Support Flowchart (Guideline Cardiopulmonary resuscitation).1,2[Class A; LOE III-2]

If unwilling or unable to perform ventilations, rescuers should continue compression only CPR.1[Class B; LOE Expert Consensus Opinion]

Mouth to mouth

Kneel beside the victim's head. Maintain an open airway (refer to Guideline Airway).

Take a breath, open your mouth as widely as possible and place it over the victim's slightly open mouth. Whilst maintaining an open airway pinch the nostrils (or seal nostrils with rescuer's cheek) and blow to inflate the victim's lungs. Because the hand supporting the head comes forward some head tilt may be lost and the airway may be obstructed. Pulling upwards with the hand on the chin helps to reduce this problem.

For mouth to mouth ventilation, it is reasonable to give each breath in a short time (one second) with a volume to achieve chest rise regardless of the cause of cardiac arrest.1[Class B; LOE IV, extrapolated evidence] Care should be taken not to over-inflate the chest. [LOE: Expert Consensus Opinion]

Look for rise of the victim's chest during each inflation. If the chest does not rise, possible causes are:

  • • 
    obstruction in the airway (inadequate head tilt, chin lift, tongue or foreign material);
  • • 
    insufficient air being blown into the lungs;
  • • 
    inadequate air seal around mouth and or nose.

If the chest does not rise, ensure correct head tilt, adequate air seal and ventilation. Following inflation of the lungs, lift your mouth from the victim's mouth, turn your head towards the victim's chest and listen and feel for air being exhaled from the mouth and nose.

Mouth to nose

The mouth to nose method may be used where the rescuer chooses, the victim's jaws are tightly clenched, or when resuscitating infants and small children.

The technique for mouth to nose is the same as for mouth to mouth except for sealing the airway. Close the victim's mouth with the hand supporting the jaw and push the lips together with the thumb. Take a breath and place your widely opened mouth over the victim's nose (or mouth and nose in infants) and blow to inflate the victim's lungs. Lift your mouth from the victim's nose and look for the fall of the chest; listen and feel for the escape of air from the nose and mouth.

If the chest does not move, there is an obstruction, an ineffective seal, or insufficient air being blown into the lungs. In mouth to nose resuscitation a leak may occur if the rescuer's mouth is not open sufficiently, or if the victim's mouth is not sealed adequately. If this problem persists, use mouth to mouth resuscitation. It may be found that blockage of the nose prevents adequate inflation. If this occurs, mouth to mouth resuscitation should be used.1,2[Class A; LOE IV]

Mouth to mask

Mouth to mask resuscitation is a method of rescue breathing which avoids mouth to mouth contact by the use of a resuscitation mask. Rescuers should take appropriate safety precautions when feasible and when resources are available to do so, especially if a victim is known to have a serious infection (e.g. HIV, tuberculosis, Hepatitis B virus or SARS).3[Class A; LOE IV]

Position yourself at the victim's head and use both hands to maintain an open airway and to hold the mask in place to maximise the seal. Maintain head tilt and chin lift. Place the narrow end of the mask on the bridge of the nose and apply the mask firmly to the face.

Inflate the lungs by blowing through the mouthpiece of the mask with sufficient volume and force to achieve chest movement. Remove your mouth from the mask to allow exhalation. Turn your head to listen and feel for the escape of air. If the chest does not rise, recheck head tilt, chin lift and mask seal.

Failure to maintain head tilt and chin lift is the most common cause of obstruction during resuscitation.

image

Mouth to mask method (Reproduced Courtesy of European Resuscitation Council)

Mouth to neck stoma

A person with a laryngectomy has had the larynx (voice box) removed and breathes through a hole in the front of their neck (stoma). A stoma will be more obvious when the victim is on the back for Rescue Breathing and the head is put into backward tilt. If a tube is seen in the stoma, always leave it in place to keep the hole open for breathing and resuscitation.

The rescuer should place their mouth over the stoma and perform rescue breathing as described above. If the chest fails to rise, this may be due to a poor seal over the stoma, or the victim having a tracheostomy rather than laryngectomy thus allowing air to escape from the mouth and nose or a blocked stoma or tube. If stoma or tube is blocked use back blows and chest thrusts in an attempt to dislodge the obstruction (Refer to Guideline Airway). [Class A; LOE Expert Consensus Opinion]

Risks

  1. Top of page
  2. Causes of ineffective breathing of acute onset
  3. Assessment of breathing
  4. Rescue breathing
  5. Risks
  6. References

No human studies have addressed the safety, effectiveness, or feasibility of using barrier devices to prevent victim contact during rescuer breathing.3 Nine clinical reports advocate the use of barrier devices to protect the rescuer from transmitted disease: three studies showed that barrier devices can decrease transmission of bacteria in controlled laboratory settings.3[Class A; LOE extrapolated evidence]

The risk of disease transmission is very low and initiating rescue breathing without a barrier device is reasonable. If available, rescuers should consider using a barrier device.3[Class A; LOE IV, extrapolated evidence]

References

  1. Top of page
  2. Causes of ineffective breathing of acute onset
  3. Assessment of breathing
  4. Rescue breathing
  5. Risks
  6. References
  • 1
    Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT, Nola JP, Travers AH. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010; 81: e48e70.
  • 2
    de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D, On behalf of the Paediatric Basic and Advanced Life Support Chapter Collaborators. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81: e213e259.
  • 3
    Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, Ma MHM, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT, on behalf of the Education, Implementation, and Teams Chapter Collaborators. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81: e288e330. http://www.resuscitationjournal.com