Australian

Resuscitation
Council

INFANT COMPRESSION-VENTILATION
RATIOS
Jim Tibballs
Resuscitation Officer, RCH
Convenor, Paediatric Sub-Committee,
Australian Resuscitation Council (ARC)
ARC Paediatric Representative
International Liaison Committee on Resuscitation (ILCOR)

Australian
Resuscitation
Council

Compression-ventilation ratios for infants

WHY do we have different ratios?

Research Science to Reality

Evidence
Evaluation
ILCOR

Guidelines
ARC, ERC, AHA

EVIDENCE

Courses, Manuals
APLS, PALS
JT 2011

Australian
Resuscitation
Council

Research Science to Reality

Evidence
Evaluation
ILCOR

Guidelines
ARC, ERC, AHA

NO GOOD EVIDENCE

Courses, Manuals
APLS, PALS
JT 2011

Australian
Resuscitation
Council

ARC Neonatal Guideline 13.1

Australian
Resuscitation
Council

The exact age at which paediatric techniques

and in particular, compression-ventilation ratios,
should replace neonatal methods is unknown,
especially for very small premature infants.
For term infants beyond the newborn period,
and particularly in those with known or
suspected cardiac aetiology of their arrest,
paediatric techniques may be used (Class B,
Expert Consensus Opinion)

ARC Paediatric guideline 12.1

Australian
Resuscitation
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Cardiorespiratory Arrest - Compression-ventilation ratio for CPR

The exact age at which compression-ventilation ratio should replace
that used for newborns is not certain, especially for small premature
infants
Infants whose cardiorespiratory physiology is in transition from an intrauterine environment at birth to several hours after birth, i.e.,
newborns, should be managed as per neonatal guidelines 13.1-13.10
with a compression-ventilation ratio of 3:1
Infants aged more than a few hours beyond birth should be managed
according to paediatric guidelines, particularly with a compressionventilation ratio of 15:2 in the settings of pre-hospital, emergency
department, paediatric wards and paediatric intensive care units
(Class A, Expert Consensus Opinion)2

ARC Paediatric guideline 12.1

Australian
Resuscitation
Council

Cardiorespiratory Arrest - Compression-ventilation ratio for CPR

With the exception of newborns, all infants with known or suspected cardiac
aetiology of cardiac arrest should be managed according to paediatric
guidelines regardless of location (Class A, Expert Consensus Opinion) 2
with a compression-ventilation ratio of 15:2 if not intubated and (with)
continuous compressions without interruption if intubated 2
Infants in cardiac arrest secondary to hypoxaemia should be treated initially
with positive pressure ventilation and oxygen (Class A, Expert
Consensus Opinion)

How did the ratios arise?

We tried to simulate spontaneous cardiac output and
ventilation
Heart rate
Respiration
Ratio
range
rate range
newborn
100 -160
40 - 60
2.6
3:1
1w 3 mo
80 -160
30 - 40
3.4
3 mo 2 yr

80 -140

20 - 40

3.7

2 yr 10 yr

60 -100

14 - 24

4.2

>10 yr

50 -100

12 - 20

4.7
5:1

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Australian
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For newborns 3:1

For other infants, children and adults 5:1

BUT
For artificial cardiac output
External cardiac compression achieves about onethird of normal stroke volume

Ventilation
Spontaneous ventilation is by negative pressure
which encourages venous return
Artificial (mechanical) ventilation is by positive
pressure which discourages venous return

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CPR CURRENT RECOMMENDATIONS

Australian
Resuscitation
Council

Newborns

3:1 (90 comp, 30 breaths/min)

Infants & Children

15:2 (comp rate 100/min)

(interrupted BLS, continuous ALS)

Adults

30:2 (comp rate 100/min)

(interrupted BLS, continuous ALS)

Drivers of change

Outcomes of adult cardiac arrest - poor

Research on ratios
End-tidal CO2 (PetCO2) monitoring

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Interruption of external cardiac compression

Australian
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In 176 arrests
External Cardiac Compression
not given during 48% of arrest time

Australian
Resuscitation
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In 67 arrests
For 24% of arrest time, no External Cardiac
Compression

For 59% of arrests, ventilation rate >20/min

PROSC, %

Effects of interrupting chest compression on

calculated probability of successful defibrillation
during out-of-hospital cardiac arrest
50
45
40
35
30
25
20
15
10
5

n=156

5
10
15
Duration of hands-off, seconds/minute

Eftestol T et al: Circulation 2002;105:2270-3

20

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Australian
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Observational study of 60 adult in-hospital and out-of-hospital arrests

ROSC from defibrillation is associated with shorter delay between
interruption of external cardiac compression and DC shock. Odds ratio
1.86 (1.10-3.15) for every 5 second decrease in delay
Resuscitation 2006; 71: 137-145

Adverse effect of pre-shock pause

JT 2011

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Australian
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Important to NOT interrupt

external cardiac compression

JT 2011

Australian
Resuscitation
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Why such adverse effects of

hands off ?

Australian
Resuscitation
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Interruptions to compressions are

bad
Are common
Reduce survival
Reduce probability of successful defibrillation

should be minimised

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Australian
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Ventilation during CPR

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Circulation. 2004;109: 1960-1965)

Results not due

to hypocarbia

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Resuscitation
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The mantra for external cardiac compression

PUSH HARD!
PUSH FAST!
DONT INTERRUPT!
DONT VENTILATE NORMALLY!

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Resuscitation
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Research on compression-ventilation ratios

Compression-ventilation ratios

Australian
Resuscitation
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Different C:V ratios investigated in animal

models, mannequins and computer simulations
(100:2; 50:2; 50:5; 15:2; 30:2; 5:1)
30:2 shorter time to return of spontaneous
circulation and better oxygen delivery (animal
models)

Mathematical modelling favours 30:2 for oxygen

transport

Effects of low compressionventilation ratios, eg, 5:1

1. Too much "hands off" during CPR (adult studies only)
2. Interrupts external cardiac compression causing BP to
fall to zero
3. Too much ventilation in proportion to a limited cardiac
output.
4. Impedes venous return and hence cardiac output.
5. Causes hypocarbia and cerebral vasoconstriction.

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Australian
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JT 2011

Australian
Resuscitation
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JT 2011

Australian
Resuscitation
Council

External cardiac compression achieves about

one-third of normal stroke volume

 so how much ventilation is

needed (for V/Q matching)?
If
then
If
then

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100% blood flow

100% ventilation = 100-120mL/min/kg

30% 30%
blood flow
30% ventilation

= 30-36mL/min/kg

= 6/min x 5-6 mL/kg

Adequate chest rise in adult is 5-6 mL/kg

CONCLUSIONS
Do not need to give normal ventilation
Normal ventilation in cardiac arrest is harmful
because it:
Far exceeds V/Q matching requirement
Impedes venous return
Detracts from external cardiac compression

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Australian
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Importance of end-tidal CO2 monitoring

Predicting outcome from adult

cardiac arrest

Australian
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When ROSC occurs, end-tidal CO2 (PetCO2)

increases (2 studies)
Level of PetCO2 predicts ROSC (13 studies)
PetCO2 <10 mmHg associated with low
probability of survival (7 studies)

Partial pressure of end-tidal carbon dioxide successfully

predicts cardiopulmonary resuscitation in the field: a
prospective observational study. Kolar et al., Crit Care 2008; !2: R115

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737 intubated cases out-of-hospital cardiac arrest

After 20 minutes of CPR:
402 cases of ROSC when PetCO2 mean 33+/-9 mmHg
335 cases of non-ROSC when PetCO2 mean 7+/-2 mmHg
PetCO2 <14 mmHg reliably predicts (100%) non-ROSC
PetCO2 >14 mmHg reliably predicts (100%) ROSC

Assessing effectiveness of CPR

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Non ROSC low end-tidal CO2

ROSC normal end-tidal CO2

Krep H, Mamier M, Breil

M, et al. Resuscitation.
2007;73(1):86.

JT 2011

End tidal CO2 is a quantitative measure of

cardiac arrest. Sehra et al., PACE 2003; 26: 515-617

31 adults

Defibrillator
implantation

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Australian
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Principles of Guideline Formulation

Survival = Science x Education x Implementation

JT 2011

Australian
Resuscitation
Council

Why 15:2, not 30:2 ratio for infants

and children?

Why 15:2 not 30:2 for paediatrics?

Australian
Resuscitation
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No human evidence

Consensus with adult scientists NOT achieved. (Paediatricians not

persuaded by cardiac arrest studies in animals, mannekin or computer
simulations)
Rationale conjecture:
Paediatric ventilation requirement greater than adult
Hypoxic arrest, not sudden arrhythmia arrest, more common in
paediatric practice
In out-of-hospital paediatric cardiac arrest (Kitamura et al., Lancet 2010;
375: 1347)
Survival from asphyxial cause better (7.2%) with standard CPR
(7.2%) vs compression-only CPR (1.6%) vs no CPR (1.5%)
Survival from cardiac cause same with standard CPR (9.9%) vs
compression-only CPR (8.9%) vs no CPR (4.1%)

15:2 previously used for children (one-person rescue)

But ventilations after intubation

Australian
Resuscitation
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ILCOR
reduce
2010

AHA
8-10/min (no circ)
12-20/min (circ)

ARC & NZRC

10/min

ERC
10-12/min

JT 2011

ALS CURRENT RECOMMENDATIONS

(intubated)
Newborns

Infants
Children

Adults

Australian
Resuscitation
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3:1 (90 comp, 30 breaths)

compressions interrupted

10:1 (100 comp, 10 breaths)

compressions continuous
10:1, 15:1 (100 comp, 10-6 breaths)
compressions continuous

Australian
Resuscitation
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... What is the best ratio for infants?

#*&^!
Whatever achieves adequate simultaneous
pulmonary blood flow and ventilation

Australian
Resuscitation
Council

Always monitor PetCO2 !

During infant CPR whatever ratio

Fine tune compressions and ventilation
Absent PetCO2
? Not intubated
Low PetCO2
? Excessive ventilation
? Inadequate compressions
? Both of above
High PetCO2

Australian
Resuscitation
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If in true cardiac arrest

Newborns at birth
Cardiopulmonary resuscitation
Newborns beyond birth

Cardiopulmonary resuscitation

Australian
Resuscitation
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... the debate will continue, after all

Il nest pas ncessaire de tenir les choses
pour en raisonner
(Pierre Beaumarchais. Le Barbier de Sville)

Its not necessary to understand things in

order to argue about them