Is Mouth-to-Mouth Still a Requirement for CPR?

Since the 1960s, CPR (cardiopulmonary resuscitation) has been a lifesaving technique, and for much of its history, mouth-to-mouth resuscitation was a key component. This process involves tilting the person's head back, pinching their nose, and breathing into their mouth.

However, over the past 15 years, CPR without mouth-to-mouth has gained traction. So what prompted this shift, and when is rescue breathing still required?

What exactly is 'Hands-Only CPR'?

In 2008, the American Heart Association (AHA) updated its guidance for bystanders who witness an adult collapse: rather than performing mouth-to-mouth, they should focus on 'hands-only CPR,' which involves giving continuous chest compressions until emergency services arrive. For those familiar with the process, this update had been anticipated for some time. The AHA had been investigating the effectiveness of hands-only CPR versus traditional CPR since the 1990s, with three studies in 2007 providing strong support for this shift.

The goal was partly to eliminate obstacles that prevent bystanders from administering CPR. Many people are uncomfortable with the idea of exchanging mouth germs with a stranger, and the two-step process can be difficult to recall, even for trained individuals. This hesitation can lead to a reluctance to help, due to the fear of making a mistake or causing more harm than good.

The instructions for performing hands-only CPR are incredibly simple: first, call 9-1-1, then apply chest compressions at a rate of 100 to 120 per minute—about the speed of the Bee Gees' 'Stayin' Alive,' as famously illustrated by The Office—until help arrives. The main goal of hands-only CPR is to maintain blood flow to the brain and other vital organs in cases of cardiac arrest.

Despite some media reports, the AHA wasn't suggesting that mouth-to-mouth should be completely abandoned in every situation. According to the guidelines, hands-only CPR should be used “if a bystander is not trained in CPR” or “if the bystander was trained in CPR but lacks confidence in their ability to perform traditional CPR” involving both chest compressions and rescue breaths. Anyone confident in their CPR training could opt for either hands-only or conventional CPR.

The announcement also highlighted cases where mouth-to-mouth resuscitation is especially crucial—such as in cases of 'asphyxia-precipitated cardiac arrest,' which includes drowning, trauma, airway obstruction, respiratory diseases, apnea, drug overdoses, pediatric arrests, and prolonged cardiac arrest. In summary, if a collapse occurs due to a lack of oxygen, providing oxygen becomes vital.

As Dr. Michael Sayre, an emergency medicine professor and chair of the AHA committee responsible for the policy change, explained to NBC News at the time, “Something is better than nothing.” For instance, if no one around can perform traditional CPR after a near-drowning, at least hands-only CPR will help keep blood circulating until paramedics arrive.

ABC to CAB

Although mouth-to-mouth resuscitation is still included in CPR training, there has been a small adjustment to the steps. The mnemonic used to be ABC, standing for airway, breathing, and chest compressions: first, tilt the head back and lift the chin to open the airway, then provide rescue breaths, and finally begin chest compressions. However, in 2010, the AHA revised the order to CAB: chest compressions first, followed by opening the airway and giving rescue breaths.

The AHA explained, 'In the A-B-C sequence, chest compressions are often delayed as responders open the airway for mouth-to-mouth or retrieve a barrier device or other ventilation tools. Switching the sequence to C-A-B ensures chest compressions start sooner, with only a minimal delay in ventilation until the first cycle of compressions is complete.'

CPR Boston simplified it: 'Just as you can hold your breath for a minute or two without causing brain damage, cardiac arrest victims can also go for a minute or more without breathing. What they truly need is for their blood to begin circulating again.'