Are breaths indicated during cardiopulmonary resuscitation (CPR) initiated by a civilian in a public setting prior to emergency medical services (EMS) arrival?

Civilian Bystander CPR: Breaths Are Optional, Not Required

For civilian bystanders performing CPR in public prior to EMS arrival, hands-only CPR (chest compressions without breaths) is the recommended approach, though trained rescuers who are confident and willing may add rescue breaths at a 30:2 ratio. 1

Algorithm for Civilian Bystander Response

For Untrained Bystanders

• Provide hands-only CPR exclusively - push hard and fast in the center of the chest at least 100 compressions per minute, with minimal interruptions 1
• Do not attempt rescue breaths 1
• Continue compressions until an AED arrives or EMS takes over 1

For Trained Bystanders Who Are Confident

• Either approach is acceptable: hands-only CPR (Class IIa) OR conventional CPR with 30 compressions to 2 breaths (Class IIa) 1
• The key criterion is confidence in delivering rescue breaths with minimal interruptions to chest compressions 1
• If uncertain about ability to perform high-quality compressions while managing breaths, default to hands-only CPR 1

For Trained Bystanders Who Lack Confidence

• Provide hands-only CPR only 1
• Do not attempt rescue breaths if this will compromise compression quality or cause hesitation 1

Evidence Supporting This Approach

The American Heart Association's position evolved based on several critical factors:

Compression quality is paramount. All cardiac arrest victims must receive, at minimum, high-quality chest compressions of adequate rate (at least 100/min) and depth (at least 2 inches) 1. The primary benefit of CPR for adults who suddenly collapse is generating blood flow to the brain and heart 1.

Breaths cause significant delays. Research demonstrates that even trained professionals take 10-14 seconds to deliver "two quick breaths," far exceeding the intended 4-second guideline 2, 3. This dramatically reduces the number of compressions delivered per minute - trained paramedics delivered only 44 compressions/minute with standard CPR versus 88/minute with continuous compressions 3.

Outcomes are equivalent for sudden cardiac arrest. A large randomized trial of 1,941 patients found no significant difference in survival to hospital discharge between compression-only CPR (12.5%) and compression-plus-breathing CPR (11.0%) 4. There was actually a trend toward better outcomes with compression-only for cardiac causes (15.5% vs 12.3%) and shockable rhythms (31.9% vs 25.7%) 4.

Dispatcher instructions should emphasize compressions. The AHA strongly recommends that dispatchers provide chest compression-only instructions to callers for adults with suspected cardiac arrest 1. This approach is easier to teach over the phone and increases bystander willingness to act 1.

Important Caveats and Exceptions

Suspected asphyxial arrests require breaths. When cardiac arrest is likely due to respiratory causes (drowning, pediatric arrests, prolonged arrest), ventilations become more critical 1. However, for the typical adult sudden collapse in public - presumed cardiac origin - compressions alone are sufficient 1.

Risk of harm is minimal. Serious injury from bystander CPR in patients not actually in cardiac arrest is uncommon (1-2%), while failure to provide CPR to true cardiac arrest victims is lethal 1. The benefit-risk ratio strongly favors aggressive initiation of compressions 1.

The 30:2 ratio remains valid for those who choose it. If a trained bystander opts to provide rescue breaths, the compression-to-ventilation ratio should be 30:2 1. However, excessive ventilation must be avoided, and compressions should be minimally interrupted 1.

Practical Implementation

The shift to emphasizing hands-only CPR addresses multiple barriers to bystander action: fear of disease transmission from mouth-to-mouth contact, difficulty coordinating complex psychomotor skills, emotional distress, and lack of confidence 1. By simplifying the task to "push hard and fast," more bystanders are likely to act 1, 5.

Bottom line: Civilian bystanders should focus on immediate, high-quality chest compressions. Breaths are not indicated unless the rescuer is trained, confident, and can deliver them without significantly interrupting compressions. When in doubt, compressions alone save lives. 1