What is an agonal gasp?

Agonal Gasps: Recognition and Clinical Significance

Agonal gasps are slow, irregular, and noisy breathing patterns that occur in dying patients, characterized by gasping respirations that mimic grunting, hiccupping, or gasping, and are a sign of cardiac arrest rather than normal breathing. 1

Definition and Characteristics

Agonal breathing represents the last respiratory pattern before terminal apnea and is characterized by:

• Slow, irregular gasping respirations
• Ineffective ventilation efforts
• Abnormal breathing sounds that may be described as:
  • Gasping
  • Grunting
  • Hiccupping
  • Snoring respirations
  • Labored or noisy breathing
  • Occasional breathing
  • Barely/hardly breathing
  • Heavy breathing
  • Strange breathing 1

Clinical Significance

Cardiac Arrest Recognition

Agonal gasps are present in approximately 30-40% of out-of-hospital cardiac arrest cases 1, 2. Their presence has significant implications:

• They are commonly mistaken as signs of normal breathing, leading to:

  • Delayed recognition of cardiac arrest
  • Failure to initiate CPR
  • Reduced survival chances 1

• Agonal gasps are associated with:

  • Witnessed cardiac arrest events
  • Ventricular fibrillation rhythm
  • Better survival outcomes (as they indicate early phase of arrest) 2, 3

Impact on Resuscitation Efforts

The presence of agonal gasps creates challenges for:

1. Bystanders: May incorrectly believe the victim is still breathing normally
2. Emergency dispatchers: May fail to recognize cardiac arrest and not provide CPR instructions
3. Healthcare providers: May delay initiating resuscitation 1, 3

Recognition Guidelines

The American Heart Association recommends:

• Using the combination of unresponsiveness AND absent or abnormal breathing to identify cardiac arrest 1
• Teaching lay rescuers and healthcare providers to recognize agonal gasps as a sign of cardiac arrest, not normal breathing 1
• Training emergency dispatchers specifically on recognizing agonal gasps to improve cardiac arrest identification 1

Improving Recognition

Studies have shown that specific education on agonal breathing improves:

• Diagnostic accuracy for cardiac arrest (90% vs 78% without specific training)
• Likelihood of initiating CPR when appropriate
• Overall cardiac arrest recognition 4

End-of-Life Considerations

In the context of palliative care:

• Families should be informed about agonal breathing in advance so they understand it's part of the dying process
• It's important to clarify that the term "agonal" doesn't necessarily mean the patient is in agony
• Agonal breathing alone is not an indication for increasing opioid doses 1

Common Pitfalls in Cardiac Arrest Recognition

1. Misinterpreting agonal gasps as normal breathing

   • This is reported in up to 50% of non-identified cardiac arrest calls 1

2. Relying solely on pulse checks

   • Pulse checks are unreliable for detecting cardiac arrest
   • Healthcare providers often take too long to check pulses
   • Even professionals may incorrectly assess pulse status 1

3. Failure to follow scripted protocols

   • Omitting questions about consciousness and breathing can lead to missed cardiac arrest cases 1

Practical Recommendations

For healthcare providers:

• Recognize that agonal gasps indicate cardiac arrest, not normal breathing
• Use the combination of unresponsiveness and abnormal breathing to identify cardiac arrest
• Don't rely solely on pulse checks to determine cardiac arrest status

For emergency dispatchers:

• Use scripted protocols with specific questions about consciousness and breathing
• Ask "Is the patient breathing regularly?" to help differentiate agonal gasps
• Provide chest compression-only CPR instructions when cardiac arrest is suspected 1

For public education:

• Teach recognition of agonal gasps using video demonstrations
• Emphasize that any abnormal breathing in an unresponsive person should trigger CPR 1, 4

By improving recognition of agonal gasps across all levels of care, we can enhance cardiac arrest identification and potentially improve survival outcomes.