Resuscitation 81 (2010) 1214–1215
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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Continuous chest compression resuscitation in arrested swine
with upper airway inspiratory obstruction: Conclusion sup-
ported by data?
Sir,
We read with interest the study of Ewy et al.,1 comparing
“24-h survival rates and neurological function of swine in cardiac
arrest treated with one of three forms of simulated basic life sup-
port CPR”. The investigators found no difference in neurological
outcome between constant chest compressions (CCC) with and
without obstructed airways and standard 30:2 basic life support
(BLS). They conclude that their “findings support the recommenda-
tion that following the activation of emergency medical services,
continuous chest compressions should be recommended for all
bystanders who witness unexpected cardiac arrest.” As the authors
point out, a limitation of the study is that with the high number of
survivors (28) and the low number of animals (30) the possibility
of a ‘beta error’ (false-negative) cannot be ruled out. In our view a
(pre-hock) statistical power analysis should have been performed
to justify that the study was powered to detect a relevant, pre-
defined difference in outcome between the three groups. As it is,
without this power analysis one has little or no indication to what
level of support these data give for (1) the hypothesis that airway
obstruction during CCC has no impact on 24-h post-resuscitation
neurological outcome, or (2) the hypothesis that outcome with CCC,
with or without obstructed airways, is as good or better than with
standard 30:2 BLS. Therefore we deem that it is unknown whether
the above-mentioned recommendation is supported by the data
presented in this study.
Further, 42 hypothesis tests were performed. In our view the
authors should have underlined the high probability of false pos-
itive findings with this many tests, or, alternatively, adjusted the
required level of significance accordingly to account for the mul-
tiple testing. The conservative, but commonly used, Bonferroni
correction would have lead to a required level of significance of
0.05/42 = 0.00119. This would have left only 3 p-values significant,
instead of 12 as it is currently presented. The three correspond-
ing detected differences indicate a large negative effect of airway
obstruction on blood gas parameters, as would be expected given
that it prohibits passive ventilations and thereby gas exchange. Fol-
lowing this a possible interpretation of the data from this study is
that over 9 min the efficacy of CCC is affected negatively by airway
obstruction.
Conflict of interest statement
The author has no conflict of interests to declare.
0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
Reference
1. Ewy GA, Hilwig RW, Zuercher M, et al. Continuous chest compression resuscita-
tion in arrested swine with upper airway inspiratory obstruction. Resuscitation
2010;81:585–90.
Kenneth Gundersen ∗
Norwegian Air Ambulance Foundation/Department
of Electrical and Computing Engineering, University
of Stavanger, Post Office Box 4036 Stavanger, Norway
∗ Tel.: +47 51832056; fax: +47 51831750.
E-mail address:Kenneth.gundersen@uis.no
22 April 2010
doi:10.1016/j.resuscitation.2010.04.038
Reply to Letter: Continuous chest compression resuscitation in
arrested swine with upper airway inspiratory obstruction: Con-
clusion supported by data?
Sir,
We appreciate the letter by Kenneth Gundersen and agree that
based on the small number of swine in each subgroup studied
in our experimental paper entitled “Continuous chest compres-
sion resuscitation in arrested swine with upper airway inspiratory
obstruction”1 that one cannot (and we did not) conclude that Con-
tinuous Chest Compression (CCC) is the preferred method for basic
life support of subjects with primary cardiac arrest. This study, as
we noted under the sub-section “limitations”, has the potential for
a significant beta error.
We did conclude that this study added supportive evidence to
our numerous previous studies in our realistic swine model of
out-of-hospital cardiac arrest (OHCA) that CCC basic life support
resulted in better survival than the decades old basic CPR “guide-
lines” that recommended mouth-to-mouth assisted ventilation and
chest compression when each set of chest compressions are inter-
rupted a realistic 15 s to deliver the 2 ventilations advocated in all
previous Guidelines.2–5 The possible exception to this statement
is when 30:2 Guidelines CPR is initiated during the first 3 min of
arrest.5
However, like most others Kenneth Gundersen focused on the
significantly poorer blood gases in the subgroups with upper airway
inspiratory obstruction rather than the outcome; 24-h neurologi-
cally intact survival. It has been repeatedly observed, that in the
absence of gasping (when experimental animals are paralyzed) the
blood gasses are significantly worse with CCC than with chest com-
pression plus ventilation. Never-the-less, in non-paralyzed swine
 Letter to the Editor / Resuscitation 81 (2010) 1214–1215
the prolonged interruptions of chest compressions (16 s for lay
individuals)6 during Guidelines CPR results in more brain damage
and poorer survival.4 On the other hand, if continuous chest com-
pressions are begun early the subject gasps and the blood gases are
equivalent (note Table 1).1
Our realistic swine model of out-of-hospital cardiac arrest
results in gasping following cardiac arrest, much like has been
reported, but inadequately appreciated in man. Clark et al. reported
gasping in 55% of human with OHCA.7 We found that individuals
with OHCA who gasp during CPR have a significantly higher sur-
vival rate.8 Of note is the recent report of a man with OHCA who
had neurologically normal survival following 26 min of continuous
chest compressions.9 This individual was noted to be gasping and
moaning most of this time.9 If chest compressions are begun early
and not interrupted, gasping is common.
To make the gasping noise, the tongue cannot totally provide
inspiratory obstruction. So our study was a “worse case scenario”
when there was total and complete inspiratory obstruction.1
In 2003, in-spite of numerous Guideline changes, in Arizona
the overall OHCA survival to hospital discharge rate of 3%. Based
on our extensive laboratory findings, the Resuscitation Research
Group of the University of Arizona Sarver Heart Center and the Ari-
zona Department of Health Services began a statewide program.
The lay component of this effort was CCC-CPR with no MTM ven-
tilation for all bystanders witnessing adults in cardiac arrest.10
Over a 5-year period, there was no increase in those performing
Guidelines CPR but there was a significant increase in the number
of bystanders who performed CCC-CPR. We reported at the 2009
American Heart Association Resuscitation Science Symposium that
survival to hospital discharge was significantly better when CCC-
CPR was performed than when Guidelines recommended CPR
with rescue breathing was given by bystanders.10 These Statewide
changes were made, based on the findings in our realistic swine
model of OHCA.
Conflict of interest statement
Dr. Ewy is coinvestigator of an unrestricted grant from the
Laerdal Foundation, Stavanger Norway. Dr. Kern is the principal
investigator of an unrestricted grant from the Laerdal Foundation,
Stavanger Norway and is on the Scientific Advisory Committee of
Zoll, Inc. (significant) and PhysioControl, Inc. (nonsignificant).
1215
References
1. Ewy GA, Hilwig RW, Zuercher M, et al. Continuous chest compression resuscita-
tion in arrested swine with upper airway inspiratory obstruction. Resuscitation
2010;81:585–90.
2. Kern KB, Ewy GA, Voorhees WD, Babbs CF, Tacker WA. Myocardial perfusion
pressure: a predictor of 24-hour survival during prolonged cardiac arrest in dogs.
Resuscitation 1988;16:241–50.
3. Berg RA, Kern KB, Sanders AB, Otto CW, Hilwig RW, Ewy GA. Bystander
cardiopulmonary resuscitation. Is ventilation necessary? Circulation 1993;88:
1907–15.
4. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of contin-
uous chest compressions during cardiopulmonary resuscitation: improved
outcome during a simulated single lay-rescuer scenario. Circulation 2002;105:
645–9.
5. Ewy GA, Zuercher M, Hilwig RW, et al. Improved neurological outcome with con-
tinuous chest compressions compared with 30:2 compressions-to-ventilations
cardiopulmonary resuscitation in a realistic swine model of out-of-hospital car-
diac arrest. Circulation 2007;116:2525–30.
6. Assar D, Chamberlain D, Colquhoun M, et al. Randomized controlled trials of
staged teaching for basic life support. 1. Skill acquisition at bronze stage. Resus-
citation 2000;45:7–15.
7. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of agonal
respirations in sudden cardiac arrest. Ann Emerg Med 1992;21:1464–7.
8. Bobrow BJ, Zuercher M, Ewy GA, et al. Gasping during cardiac arrest in humans
is frequent and associated with improved survival. Circulation 2008;118:
2550–4.
9. Steen-Hansen JE. Favourable outcome after 26 minutes of “Compression only”
resuscitation: a case report. Scand J Trauma Resusc Emerg Med 2010;
18:19.
10. Bobrow BJ, Spaite DW, Mullins T, et al. The impact of state and national
efforts to improve bystander CPR rates in Arizona. Circulation 2009;120:
S1443.
Gordon A. Ewy a,b,∗
Karl B. Kern a,b
a University of Arizona College of Medicine’s Sarver
Heart Center, University of Arizona College of
Medicine, Tucson, AZ, United States
b Department of Medicine, University of Arizona
College of Medicine, Tucson, AZ, United States
∗ Corresponding author at: Department of
Medicine, University of Arizona College
of Medicine, Tucson, AZ, United States.
E-mail address:gaewy@aol.com (G.A. Ewy)
11 May 2010
doi:10.1016/j.resuscitation.2010.05.012