Original Article. Summary. Introduction. K. Adelborg, 1 K. Bjørnshave, 2 M. B. Mortensen, 3 E. Espeseth, 4 A. Wolff 5 and B.

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1 Original Article doi:1.1111/anae A randomised crossover comparison of mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation by surf lifeguards in a manikin K. Adelborg, 1 K. Bjørnshave, 2 M. B. Mortensen, 3 E. Espeseth, 4 A. Wolff 5 and B. Løfgren 6,7 1 Senior House Officer, 3 Research Fellow, 4 Medical Student, Department of Cardiology, 2 Medical Student, 5 Medical Doctor, 6 Honorary Associate Professor, Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark 7 Specialist Cardiology Registrar, Department of Internal Medicine and Clinical Research Unit, Regional Hospital of Randers, Randers, Denmark Summary Thirty surf lifeguards (mean (SD) age: 25.1 (4.8) years; 21 male, 9 female) were randomly assigned to perform min of cardiopulmonary resuscitation on a manikin using mouth-to-face-shield ventilation (AMBU â LifeKey) and mouth-to-pocket-mask ventilation (Laerdal Pocket Mask TM ). Interruptions in chest compressions, effective ventilation (visible chest rise) ratio, tidal volume and inspiratory time were recorded. Interruptions in chest compressions per cycle were increased with mouth-to-face-shield ventilation (mean (SD) 8.6 (1.7) s) compared with mouth-topocket-mask ventilation (6.9 (1.2) s, p <.1). The proportion of effective ventilations was less using mouth-toface-shield ventilation (199/242 (82%)) compared with mouth-to-pocket-mask ventilation (239/24 (1%), p =.2). Tidal volume was lower using mouth-to-face-shield ventilation (mean (SD).36 (.2) l) compared with mouth-to-pocket-mask ventilation (.45 (.2) l, p =.6). No differences in inspiratory times were observed between mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation. In conclusion, mouth-to-face-shield ventilation increases interruptions in chest compressions, reduces the proportion of effective ventilations and decreases delivered tidal volumes compared with mouth-to-pocket-mask ventilation.... Correspondence to: B. Løfgren bo.loefgren@ki.au.dk Accepted: 4 March 214 Introduction Drowning is the third leading cause of death worldwide, and a major health concern accounting for more than 4 fatalities each year [1]. Overall, out-ofhospital cardiac arrest carries a poor prognosis with < 1% surviving to hospital discharge [2]. The survival rate for the drowning victim in cardiac arrest is even more dismal, with one-month survival of approximately 5% [3]. Bystanders and lifeguards play an important role resuscitating drowning victims, thus victims reaching hospital have a better outcome [4]. As a majority of drowning victims have cardiac arrest secondary to hypoxia, reversing hypoxia as rapidly as possible and minimising interruptions in chest compressions is imperative to limit the degree of organ damage. The most optimal ventilation technique among surf lifeguards is currently unknown, and in recent years, this area of research has received limited The Association of Anaesthetists of Great Britain and Ireland

2 Adelborg et al. Use of face-shield and pocket-mask by lifeguards Anaesthesia 214, 69, attention [5, 6]. Due to the risk of disease transmission and the fear of direct contact to body fluids, surf lifeguards may be reluctant to perform rescue breathing using mouth-to-mouth ventilation [7, 8]. Using mouth-to-face-shield ventilation () or mouth-topocket-mask ventilation () may be reasonable. Surf lifeguards are recommended to ventilate using with a supplementation of oxygen [9]. This recommendation is based on expert consensus and on limited evidence. The aim of this study was to compare the effect of and ventilation on cardiopulmonary resuscitation (CPR) quality among surf lifeguards. Methods Participants were recruited from three surf lifeguard organisations in Denmark. Only surf lifeguards in active service (working seasonable May until September) aged 18 years old or above were considered eligible for participation. Participation was voluntary/ unpaid and the performance of each surf lifeguard was anonymised. According to the Danish National Committee on Biomedical Research Ethics, no approval from an ethical review committee was necessary. All participants gave oral and written informed consent. After inclusion, participants were formally trained in using (Ambu â LifeKey; Ambu, Ballerup, Denmark) and (Pocket Mask TM ; Laerdal, Stavanger, Norway) for approximately 15 3 min in total. They were randomly assigned to perform min of single-rescuer CPR using and. Each 3-min session was separated by a short break of approximately 5 min. All data were collected from a resuscitation manikin (Ambu TM Man; Ambu) connected to a laptop. As previously described, data were extracted using Ambu CPR Software and a custom-made software algorithm [1]. The manikin was calibrated between each CPR session. To investigate the ratio of effective ventilations (defined as visible chest rise), video recordings were obtained. Two independent researchers evaluated all ventilation attempts. Interruptions in chest compressions (no-flow time), tidal volume, inspiratory time, chest compression depth and chest compression rate were calculated from the second to the fifth compression ventilation cycles. Based on a pilot study (n = 8, SD = 1.6 s), it was calculated that 14 participants would be required to detect a 1.5 s difference in no-flow time at a significance level of.5 and a power of 9%. D Agostino Pearson s test was used to test for normality. Student s t-test and Wilcoxon rank-sum test were used as appropriate. Categorical variables were compared using McNemar s test. Two-tailed p <.5 was considered as indicating statistical significance. All calculations were completed using GraphPad Prism (version 5.1; GraphPad Software, La Jolla, CA, USA) and Quick- Calcs Online Calculators for Scientists ( graphpad.com/quickcalcs/mcnemar1.cfm). Results In total, 3 surf lifeguards were included and randomised in the study. Following randomisation, 22 participants were allocated to perform CPR in the sequence using followed by, while the remaining participants performed CPR using followed by. Participants characteristics are presented in Table 1. Data on CPR quality when using and are shown in Fig. 1. Mean (SD) noflow time was greater with (8.6 (1.7) s) than with (6.9 (1.2) s, p <.1). Both the ratio of effective ventilations ( 199/242 (82%) vs 239/ 24 (1%), p =.2) and the delivered tidal volume (.36 (.2) l vs.45 (.2) l, p =.6) were decreased using compared with. No differences in inspiratory times were Table 1 Characteristics of the surf lifeguards included in the study (n = 3). Values are mean (SD) or number. Age 25.1 (4.8) Female 9 Surf lifeguard certification; year 28 (4.6) Surf lifeguard experience; years 4.2 (4.5) Healthcare professional 8 Basic life support training in the last 3 years* 17 Educational level Sixth form college level 18 Craftsman 1 Higher education; < 2 years 1 Higher education; years 5 Higher education; > 5 years 5 *Basic life support training in addition to mandatory surf lifeguard training. 214 The Association of Anaesthetists of Great Britain and Ireland 713

3 Adelborg et al. Use of face-shield and pocket-mask by lifeguards 15 (a) 1.5 (b) * * No-flow time (s) 1 5 Tidal volume (l) Compression depth (mm) (c) Compression frequency (min 1 ) (d) * Figure 1 Performance of the surf lifeguards using mouth-to-face-shield ventilation () and mouth-to-pocket-mask ventilation (): (a) interruptions in chest compressions per cycle (no-flow time), *p <.1; (b) tidal volume, *p =.6; (c) compression depth; (d) compression rate, *p =.8. observed between and. Although surf lifeguards delivered a faster chest compression rate using (mean (SD) 18 (16) min 1 ) compared with (12 (11) min 1, p =.8), no differences between the ventilation techniques in chest compression depth ( 51.4 (1.1) mm vs 5.7 (8.6)) were observed. Discussion This study demonstrates that was associated with increased interruptions in chest compressions, reduced effective ventilation ratio and decreased delivered tidal volumes compared with. To the best of our knowledge, no previous studies have addressed the impact of and on CPR quality among surf lifeguards. In this study, the no-flow time was reduced by 1.7 s in each cycle of chest compressions and ventilations. Assuming a response time of the Emergency Medical Services of 2 min, it can be calculated that the total no-flow time is increased by 1 min and 22 s using compared with. Interruptions in chest compression reduce the likelihood of survival after cardiac arrest, e.g. a 5 s decrease in pre-shock pause increases the odds of successful defibrillation by 86% [11]. Therefore, the European Resuscitation Council recommends that interruptions should not exceed 5 s [4]. In case of hypoxia, administration of quality ventilations, i.e. effective ventilation ratio and an appropriate tidal volume of.5.6 l, is important [4]. The recommended tidal volume was almost obtained when ventilating using, but this was not the case when surf lifeguards ventilated using. Our results indicate that CPR quality deteriorates when using compared with. In contrast to our results, one study showed no differences in the delivered tidal volume, degree of stomach inflation and peak airway pressure among high school students using and [12]. Another study reported a reduced tidal volume with compared with, but laypersons using were still able to achieve ventilation with a tidal volume of.69 l [13]. In another study using two faceshield devices, tidal volumes of.64 l and.77 l were delivered, while ventilating using a third face-shield The Association of Anaesthetists of Great Britain and Ireland

4 Adelborg et al. Use of face-shield and pocket-mask by lifeguards Anaesthesia 214, 69, failed to result in appropriate tidal volumes [14]. The last two studies were conducted according to the European Resuscitation Council Guidelines on Resuscitation (2) in which a tidal volume of.7 1. l was recommended [15], whereas no recent studies have evaluated the effect of according to current recommendations [4]. Previously, we have reported that mouth-to-mouth ventilation reduces interruptions in chest compression (8.9 s per cycle) and increases the effective ventilations compared with and bagvalve mask ventilation among surf lifeguards [8]. In the absence of a pocket mask, mouth-to-mouth ventilation is a reasonable alternative ventilation technique among surf lifeguards. Rescue breathing and CPR training is safe for the provider, and the risk of disease transmission is very low. Potential infectious agents include human immunodeficiency virus (HIV), Salmonella infantis, Staphylococcus aureus, severe acute respiratory syndrome, meningococcal meningitis, Helicobacter pylori, Herpes simplex virus, cutaneous tuberculosis, stomatitis, tracheitis, Shigella and Streptococcus pyogenes. Transmission of hepatitis B virus, hepatitis C virus, HIV and cytomegalovirus has not been reported [4]. The risk of disease transmission and discomfort of possible direct contact with body fluids may explain the reluctance of lifeguards to perform rescue ventilations. Accordingly, and have been suggested as alternative ventilation techniques. Ventilating using enables the rescuer to provide supplemental oxygen, and this is recommended when resuscitating a drowning victim suffering from hypoxia. Currently, is believed to be a reasonable alternative ventilation technique. Several devices are commercially available, but no single technique has been proven to be superior [4]. Based on our results, should not be considered as an equivalent ventilation technique among surf lifeguards. In contrast, an alternative to, that also allows supplementation of oxygen and minimises the risk of disease transmission, is ventilation using a supraglottic airway device [16]. However, so far, no studies have compared with ventilating using supraglottic airways on CPR quality, and this should be investigated in future studies. This was a manikin study, so data need to be validated in a clinical resuscitation scenario. Mouth-toface-shield ventilation is not a part of the training curriculum of the surf lifeguards, and this may have influenced the results. However, by giving all participants training before the test, this possible bias was minimised. Finally, we did investigate the use of ventilation techniques in a single-rescuer scenario only and assessed only one type of face-shield device; the sessions were conducted outside the beach and the potential long-term loss of CPR skills was not investigated. This study showed that increases interruptions in chest compressions, reduces the proportion of effective ventilations and decreases delivered tidal volumes when compared with. Accordingly, CPR quality is impaired using compared with among surf lifeguards. Acknowledgements We thank Chief lifeguard of the North Zealand Surf Lifeguard Service, John Mogensen and Chief lifeguard of Aalborg Surf Lifeguard Service, Carsten Jørgensen, for excellent collaboration. We are grateful to all the surf lifeguards who volunteered to participate in the study and we wish to thank Torben Rehder and Daniel Bidstrup for assistance. Funding The study was supported by the Institute of Clinical Medicine, Aarhus University, Denmark, Aarhus University Hospital, Denmark, the Regional Hospital of Randers, Denmark and the Christenson-Ceson Family Foundation. References 1. Violence and Injury Prevention: Non-communicable Diseases and Mental Health: Fact Sheet on Drowning. Geneva: World Health Organization, injury_prevention/other_injury/drowning/en/index.html (accessed 4/3/214). 2. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circulation: Cardiovascular Quality and Outcomes 21; 3: Claesson A, Lindqvist J, Ortenwall P, Herlitz J. Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services Resuscitation 212; 83: Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 21 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 21; 81: Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 21 Section 8. Cardiac 214 The Association of Anaesthetists of Great Britain and Ireland 715

5 Adelborg et al. Use of face-shield and pocket-mask by lifeguards arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 21; 81: Warner DS, Bierens JJ, Beerman SB, Katz LM. Drowning: a cry for help. Anesthesiology 29; 11: Ornato JP, Hallagan LF, McMahan SB, Peeples EH, Rostafinski AG. Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Annals of Emergency Medicine 199; 19: Hew P, Brenner B, Kaufman J. Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. Journal of Emergency Medicine 1997; 15: International Lifesaving Federation. Statements on the Use of Oxygen by Lifesavers filefield/medical_policy_8.pdf. (accessed 27/6/212). 1. Adelborg K, Dalgas C, Grove EL, Jorgensen C, Al-Mashhadi RH, Lofgren B. Mouth-to-mouth ventilation is superior to mouthto-pocket mask and bag-valve-mask ventilation during lifeguard CPR: a randomized study. Resuscitation 211; 82: Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 26; 71: Paal P, Falk M, Gruber E, et al. Retention of mouth-to-mouth, mouth-to-mask and mouth-to-face shield ventilation. Emergency Medicine Journal 28; 25: Paal P, Falk M, Sumann G, et al. Comparison of mouth-tomouth, mouth-to-mask and mouth-to-face-shield ventilation by lay persons. Resuscitation 26; 7: Simmons M, Deao D, Moon L, Peters K, Cavanaugh S. Bench evaluation: three face-shield CPR barrier devices. Resuscitation 1995; 3: Handley AJ, Monsieurs KG, Bossaert LL. European Resuscitation Council Guidelines 2 for Adult Basic Life Support. A statement from the Basic Life Support and Automated External Defibrillation Working Group and approved by the Executive Committee of the European Resuscitation Council. Resuscitation 21; 48: Adelborg K, Al-Mashhadi RH, Nielsen LH, Dalgas C, Mortensen MB, Løfgren B. A randomised crossover comparison of manikin ventilation through Soft Seal â, i-gel TM and AuraOnce TM supraglottic airway devices by surf lifeguards. Anaesthesia 214; 69: The Association of Anaesthetists of Great Britain and Ireland

ANZCOR Guideline 6 Compressions

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