CPR Does Not Require “Mouth To Mouth”

Myth: Proper CPR technique should include frequent use of “mouth to mouth” in between compressions.

In fact, the 2010 guidelines set out by the American Heart Association (AHA) do not recommend breathing for someone while performing CPR (and not for your health, as you might think, but for the person experiencing cardiac arrest’s chances of survival). If you’re a person who was trained in CPR a long time ago, you might be familiar with the once staple “15 chest compressions then 2 breaths”. If you followed the 2005 guidelines, then you’re familiar with the “30 compressions then 2 breaths” technique. In both cases, you should throw those out the window.

In 2010, ILCOR (International Liaison Committee on Resuscitation), reviewed hundreds of studies and found that breathing just wasn’t necessary for people when doing CPR. Even for advanced medical personnel, like paramedics and doctors, breathing for someone in cardiac arrest has a limited role. The science behind this seemingly huge shift in treating someone has been around for over a decade, but it has only been recently that people in the U.S. have been paying attention (many European countries changed their recommended method well before the United States).

The purpose of the heart is to move blood around the body and supply our organs and tissues with needed nutrients. We can replace hearts, lungs, livers, kidneys, etc., but in the end, they all are really just working together to keep our brains alive.

The pumping action of the heart creates an internal pressure throughout your vascular system (arteries and veins). This is measured in millimeters of mercury, and is what gets elevated with excessive intake of cheese and beer (mmmm cheese and beer). When we perform chest compressions, we artificially create this pumping by squeezing the heart. The blood is forced out of the heart and into the bloodstream. When we let up on the compression, the closed vascular system siphons blood back into the heart, ready to be pushed out again.

There is a minimum blood pressure that one needs to supply the brain with blood. Numerous studies have shown that it takes about 10 chest compressions in a row to create enough “pressure” to get blood to the brain. The minute you stop chest compressions, like when you are giving someone breaths, the blood pressure goes immediately back to 0. As a result of this, what these studies showed was that the way people performed CPR in the past was only getting blood to the brain 1/3 of the time during compressions. Since the purpose of performing CPR is to allow a person’s brain the opportunity to function again, and getting blood to that brain is the only way to do it, increasing compressions became the treatment of choice.

This was why ILCOR changed their stance on the order of priority in resuscitation. They used to use the age old A-B-C’s (A-airway, B-breathing, C-circulation) as the acronym for what is most important in resuscitation. They now recommend C-A-B to try to emphasize that compressions are much more important than breathing.

Brain cells begin to die approximately 4-6 minutes after blood stops flowing. Every minute after that, a person’s chance of regaining function within those cells goes down by about 10%. Thus, around 10-16 minutes after having ones heart stop, a person will be brain dead. While it is medically possible to get their hearts beating again, there is no benefit to that person at that point. Their brain is dead anyway. If you did, however, get their heart beating, you now have a wonderful garden from which doctors can harvest organs, assuming you’re a donor (and you should be, you won’t be needing those organs anyways when you die or are otherwise brain dead and there are many others who do).

So now you might be wondering, if oxygen is still needed, why aren’t they recommending the “breathing” step now-a-days? At the moment someone goes into cardiac arrest, the brain is still trying to function, but with a less than adequate oxygen capacity. The breathing centers of the brain, specifically the medulla oblongata and the pons region, continue to send signals to the diaphragm in an attempt to keep respiration going. The end result is a breathing rate known as agonal respiration. While this type of breathing is not sufficient to maintain appropriate oxygen levels in someone’s blood for long, it still allows for some exchange of oxygen and carbon dioxide within the lungs.

At the moment of cardiac arrest, there is also an adequate amount of oxygen in the blood to maintain metabolism within the brain for a few minutes. A person’s metabolism will naturally use up this available oxygen over time, but combined with agonal respiration, the result is that there can be enough oxygen within the bloodstream that breathing for someone isn’t necessary while you wait for emergency aid. Unfortunately, the exact amount of time where breathing isn’t necessary isn’t precisely known, varying from study to study.  However, ILCOR looked at studies that used different ventilation to compression ratios, from 15 compressions to 2 breaths, all the way up to 100 compressions to 1 breath, and even no breathing and only compressions, and while every study had differing numbers of survival, the trend was always the same. The least amount of interruption in compressions, even for breathing, the better chance the person had of surviving.

When paramedics or doctors show up, you might think they have countless advanced tools and medicines that will get a person’s heart and brain going again. In actuality, CPR and compressions are the main focus during their attempts at successfully resuscitating someone. Breathing has now become almost an afterthought, something that’s only done after you have enough people to perform chest compressions and put a defibrillator to use. Once that is the case, breathing is then addressed. When breathing is addressed, at no point will chest compressions ever be stopped for the sake of breathing.

Even giving lots of oxygen to people whose hearts do begin working again is starting to show itself to be a dangerous practice. Medical professionals used to give excessive amounts of oxygen to a patient in cardiac arrest as it was the prevailing thought that the more oxygen you could give someone in cardiac arrest, the greater chance oxygen would reach the brain and keep the cells alive (seems reasonable enough). However, current studies are showing that people are having better survival rates (by survival I mean get discharged from the hospital with some sort of brain function) when they get large doses of oxygen withheld from them and simple “room air” is used instead.

So to summarize, because there is usually an adequate amount of oxygen in the blood, for a while, compressions and compressions only is the main focus of good CPR today. While one would think the more oxygen and breathing you can do for someone who isn’t doing it on their own, the better. Studies are now showing that just isn’t the case. So don’t worry about having to French-kiss that 300 pound guy with tobacco on his lips and blood in his mouth. It’s better for him, and you, if you don’t! No more can Squints go to the pool and fake that he’s drowned just to get Wendy Peffercorn to give him mouth to mouth. ‘Cause it’s not gonna happen if she’s properly trained.

*Legal Disclaimer: While I am a paramedic; I teach classes on CPR; and am obviously well versed in emergency medicine and techniques, unfortunately I need a legal disclaimer here, so here it is:  This article contains general information about medical conditions and treatments. The information is not advice, and should not be treated as such. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information in this article…. There, I’ve covered myself.

If you liked this article and the Bonus Facts below, you might also like:

Bonus Facts:

  • There are an average of 383,000 cardiac arrests every year in the United States that occur outside of a hospital. 88% of these occur while the person’s at home.
  • Immediate CPR for someone in cardiac arrest will increase their chance of survival by 300%! Only 32% of out of hospital cardiac arrests receive CPR. Come on people! Push on that chest!  If you’re a “Forever Alone” guy preforming CPR on a woman, it might just be your only chance to touch a lady’s chest without getting slapped!  If she survives, she’ll probably even thank you!  There’s really only upside here. 🙂
  • Only about 8% of people who suffer from a cardiac arrest outside of the hospital will survive to tell the tale. The vast majority of those 8% are people who had adequate CPR performed. Getting the message yet? The American Heart Association is. They train over 12 million people a year on how to perform CPR (I don’t have to train that many, thankfully).
  • 70% of Americans say they don’t do CPR in emergency situations because they feel inadequately trained, or it has been too long since their training, so they’re afraid to do it.
  • A heart attack is not cardiac arrest. Cardiac arrest is when the heart ceases to pump, or beat, because of an abnormal electrical impulse within the heart itself. A heart attack is a lack of blood flow to a specific area of the heart. A heart attack can cause a sudden cardiac arrest, but people who have a heart attack are significantly more likely to survive than those who suffer cardiac arrest.  Either way, if you have chest pain, call 911! Or don’t. Your family might want to practice CPR! (Seriously though, call 911.  If you seem good humored enough, the paramedics might tease you a bit if you were just experiencing a particularly severe case of heart burn or the like, but better safe than dead.)
  • An African-American is twice as likely to experience a cardiac arrest as a Caucasian. They also are twice as likely not to survive.
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  • In the UK, the actor Vinnie Jones fronts public information adverts stating you should pump the chest to the tune of “Stayin’ Alive” by the Bee Gees. I’m sure the video is on certain sharing sites if you’re interested. As well as being useful advice, the adverts are quite funny with Vinnie’s hard-man character.

  • Topside Downes

    Nice work on the Sandlot reference.

  • This is not true, in a cardiac arrest situation you loose 10% chance of survival after every minuet, in this situation the body has around 4minuets worth a oxygen in it, after that you are pumping non oxygenated blood around the body decreasing the chance of that persons survival without adding breaths into the sequence. The vinnie jones advert is for non trained people to get stuck in to try and increase the number of people surviving a cardiac arrest outside the hospital setting. Breaths are vital in the cpr sequence

    • Daven Hiskey

      @James: And your sources for this are? The person who wrote this article is a trained medical professional who specializes in emergency medicine and regularly teaches classes on CPR so I’m inclined to think he probably knows more about this than you do if we’re going to just go with a “his word against yours” type of argument.

      • AHA recommends hands only CPR for someone that wants to help in a cardiac arrest situation, but they are untrained. ALL OTHERS are trained to give compressions, whether they are being trained for the first time or they are seasoned medical professionals. I’m an AHA Instructor.

        • I meant respirations; ALL Others are trained to give respirations and compressions. Only the untrained are being told to give hands only.

    • But a 33% reduction in getting the oxygen-rich blood to the brain as well. Chest compressions will actually force the diaphragm to move and simulate breathing. Not sure that some opinions trump the ones from the American Heart Association. Don’t they issue the CPR Certifications? 😉

  • My recent CPR training confirms that breaths are not essential to CPR. However, I learned that breaths are useful with victims who have stopped breathing due to drowning.

  • For children and infants breathing is needed. And after 5 minutes, it’s needed for adults. So unless you witness the person collapsed in front of you, assume it was past that time limit and breath 2 times every 30 compressions. You shouldn’t be teaching CPR if you don’t mention this.

    • Daven Hiskey

      @Robert: And your qualifications are? I’m just saying, a credentialed medical professional who teaches the subject is also backing up his stance with actual scientific research… so, he’s coming from a pretty strong platform, while you’re coming from the “commenter on the internet” platform, which in general is pretty much the lowest common denominator…

      • The 30:2 compressions to breathing ratio is still something that is done… if you are a medical professional. For layperson CPR training, compressions is the only thing recommended. However, if you take BLS (Basic Life Support) for healthcare providers and ACLS (Advanced Cardiac Life Support), which is also for health care providers, they do want breathing. This is because medical professionals have airways they can put in and bag masks with which they can breathe for the patient. The layperson with no medical knowledge does not have any tools they can use and only their CPR knowledge to draw on, so its better to have compressions and focus on giving high quality CPR. A medical professional has more knowledge to draw on, has likely performed CPR before and knows what to do. In that case… give the breaths to get some oxygen for the patient, but compressions are ALWAYS done first. Never give breaths first since compressions is more important than breathing. 100 compressions a minute is the goal no matter what though and breathing for the patient is much easier to do with 2 rescuer CPR vs. one rescuer since one person can give breaths while the other gives compressions.But solo healthcare providers are still expected to provide breaths. My source? The AHA manual on ACLS which I am certified in and is using the current manual as a reference.

        • Daven Hiskey

          @Aaron: But you see, the author of this article is not only a medical professional, but also teaches CPR classes and even is friends with one of the people who sets the AHA standard. He also teaches classes to doctors on how the standard will be changing soon (before the changes happen) and outlines why, including covering various new studies. As for the current AHA manual, see my comment below to @Commenter on the Internet as to why even the current AHA manual is out of date in terms of what they know to actually be most helpful. It’s kind of funny actually as to their reasons for doing that. 🙂

          • The seasoned instructor you speak of is incorrect. Hands only is being advocated if you are untrained in CPR. ALL OTHERS are being taught to give respirations in addition to compressions. I’m an AHA Instructor.

          • Just want to back you up, since there seems to be controversy. I had BLS training as a medical professional in 2013 and were taught to ONLY perform compressions.

            Generally, I don’t believe breathes are given until a patient is intubated and a bag can be attached. This way, you don’t have to stop compressions for breathes to be administered.

          • Just want to back you up, since there seems to be controversy. I had BLS training as a medical professional in 2013 and we were taught to ONLY perform compressions.

            Generally, I don’t believe breathes are given until a patient is intubated and a bag can be attached. This way, you don’t have to stop compressions for breathes to be administered.

  • I think being taught by my sons pediatrician is enough credentials. There is a difference in the amount of blood between children an adults. Less blood in the body means Less oxygen. They don’t have enough for 4 minutes. A 25 pound toddler has about 1/6 the blood, so that means they have 1/6 the oxygen in their blood. 1/6 of 4 minutes? You’d better give them oxygen or your pumping almost I un-oxygenated blood. It’s common sense. This bit of information needs to be in this article.

    • By that logic, shouldn’t that also mean that their body has less of a demand for oxygen? (fewer cells/tissues/organs, less oxygen needed) That is to say, they have 1/6 the blood yes, but require 1/6 the oxygen an adult does because they have 1/6 the cells. Perhaps, it’s a bit more complex than you’re making it out to seem. I’m not trying to side with either you nor Daven, but I think you need a stronger argument than that (both logic and sources) to sway me.

      • but a babies’ brain when born is 1/3 rd the size of an adult at birth from what i have read, and has twice as many neurons as an adults, and uses much more metabolism proportional to the body than an adult as well, and is almost 80% the size of an adult’s by age three – so there would be an increased demand for oxygen in the brain in babies if what i said can be factually backed up.

  • Commenter on the Internet

    The 2010 AHA Guidelines are different for children and adults. For Pediatric BLS certified Healthcare Providers, the AHA does recommend rescue breaths first if there is a pulse, or compressions first if there is no pulse.

    Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, Berg RA, Sutton RM, Hazinski MF. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S862–S875


    • Daven Hiskey

      @Commenter on the Internet: I actually just took a First Aid and CPR class from Scott and he revealed a funny thing about the AHA Guidelines. Namely, he talked about his conversation with one of the lead people who helps set them. He asked the guy why, given that research says no breaths, in general, are better, they still recommend breathing in certain CPR cases. The answer “We thought it was too drastic a change for people, so thought we’d change the recommendation slowly…” I thought that was kind of funny 🙂 It should also be noted that Scott is working off not only what is currently recommended but what is going to be soon recommended, and even just recently taught a class to professionals on what changes are soon to be made and why.

      • Heh…the recommendations had ALREADY been changing slowly, over decades. The recommended ratio of breaths to compressions was higher when I learned it in 1974 than what it was changed to a few yrs. later. What were they going to do, approach 0 asymptotically?

        If you have 2 people, and neither of their services in phoning EMS is needed (and bleeding has already been ruled out), then, sure, one should check airway & give breaths while the other does compressions, because what else can person #2 do besides attend to respiration? But if you’re alone, it seems now that at no point does respiration become the limiting factor, so default to compressions alone. Depending on body size, compressions do cause a small tide of air into & out of the lungs anyway.

        What I’d like to know is whether anyone’s still doing the precordial thump? It was a mechanical means of defibrillation that sometimes worked if the arrest had happened just seconds previously, like if it happened right in front of you. It was to be done before compressions, but would break either the sternum or some sterno-costal joints!

  • I just checked the Vinnie Jones video….too funny.

  • Does The breathing only apply to a heart attack? My wife had a seizure in her sleep the other night I didn’t do any breathing for her but I did compressions and when the paramedics got here they used the defibrillator and the breathing thingy not sure what they are called they squish it to send air in to the lungs, In any case she was stabilized and is completely fine today in fact she was only in ICU for a few hours before moving her out to a regular room for observation she is there now. SO after reading this I wonder if this is the case for any situation where the heart stops or breathing has become erratic normally after a seizure it takes about 45 seconds to a minute for her to start breathing again, that did not happen this time. I Could not feel any life signs so I called 911 and did compressions until they arrived obviously something worked becasue she is fine so if anyone has any thoughts about this I would gladly like to hear them…

  • this hands only cpr is bullshit!! yeah for cardiac arrest it’s fine but for drowning it should still be used this hands only thing whoever thought it up is a moron and is going to kill people, mouth to mouth is still important and should still be used especially with respiratory problems and drowning!

  • I first learned CPR in 92 at the age of 12 (the joys of growing up with two paramedic parents, I tell ya) and have kept up with it since (because above mentioned parents would still have my hide otherwise). When I recertified in 2010 and was told “No breaths” for the first time it was quite a shock. I thought I’d misheard the instructor at first.

    Another interesting thing I learned growing up around paramedics and seeing the pros do CPR a time or two is that paramedics and ER personnel don’t do it the same way us civvies are taught. If all you’ve been through is the 8 hour training for everyday folks and then see how someone who actually went to school for it does CPR it’s going to look completely wrong to you.

  • This is incorrect. Hands-only CPR is only more effective if you aren’t trained in doing rescue breaths properly

  • I had to do CPR on my husband he was 36 and had sudden death. I tried my best he already passed but I still tried. EMS arrived and said they couldn’t do anything he passed. Very nice to have all this information.

  • This is just unfortunate – spreading misleading information. CCR/Hands only resuscitation is for the LAY person only. The Arizona research allowed the use of BVM, so the study is incorrectly interpreted – oxygen is still given. Biased marketing by the AHA to “come up with a new way” and strut like they reinvented the wheel. I guess the article title isn’t fully bogus… since you said “no MOUTH breaths”. So breaths from another source is necessary? Wisconsin follow up study shows a decline in hands-only effectiveness – one that is barely different with breaths. More research should be done before AHA lobbyists spread misleading information.

    Oh and by the way… If CPR does not require breaths, then how do you account for the “P” in CPR? CPR will always require some sort of oxygen sustenance. No breaths after 4 minutes allows the lungs to begin collapse. Report facts – not bias

  • Interesting how determined some folks are to correct or dispute with others. I’m a retired firefighter/EMT, and a long-time AHA BLS instructor. For all of that time CPR for trained responders has included respirations. Untrained bystanders may have enough to deal with just to do adequate compressions, and hands-only cpr without interruptions for breaths may be sufficient to interrupt the dying process until trained responders can take over.

    Too much misinformation and squabbling over who is right does nothing to improve patient outcomes. Untrained commenters, or trained commenters who were not properly trained, or trained commenters who apparently didn’t understand the training, would do well to watch, read, listen, and learn, and quit confusing those who actually want to be able to possibly save a life.

  • Ahead of time going to lay out my ‘credentials’ since some people seem so obsessed! Did my First Aid at Work qualification EONS ago and also have diploma level anatomy and physiology.

    Have to admit that when I first saw the new advice on CPR I thought that maybe there had been a drop off in attempted resuscitation because of fears about blood borne infections and that SOMETHING was better than nothing. Then I read the above comments that seemed to be from apparently highly qualified people and I began to wonder if I had been unfair.

    I has been stated that there is enough oxygen in the blood for 4-5 minutes so first importance is circulating THAT. The question seems to be “Then what?” It has. occurred to me that the effect of chest compressions is likely to have a not completely dissimilar impact to the natural action of the diaphragm during natural breathing, which is the mechanism by which air is drawn into the lungs in a somewhat similar way that you can squash something rubbery, expel the air and when you release the pressure the air rushes back in. Therefore it is entirely possible that there IS NO 4 minute limit to the usefulness of compression only treatment

    Also it has been my experience that people release what they”know” (even if it is COMPLETELY WRONG!) like pulling teeth!!


  • @Daven Hiskey. I am a nursing student enrolled in an EMT certification course for the fall, I am also in a technical writing class over the summer. For my final project in technical writing I am composing an argumentative case study for hands only CPR. Much of the information contained in this one article is very valuable to me getting an A on my paper. However I haven’t found any data reference for the statements here, is there somewhere I can get access to that information? Also the statement regarding the AHA not wanting to implement such dramatic changes all at once in the comments section, is there any way to verify that as something more than secondhand internet chatter? I would greatly appreciate anything I can use as a valid and credible source. Tanks for your time and consideration.

    • Daven Hiskey

      Some references are below the article. But the primary reference for this article is a paramedic who also teaches CPR classes and is obviously up on all the latest guidelines and studies and what not. If you’d like, I can put you in touch with him.

  • That bit about “paramedics might tease you a bit” needs to be removed and replaced with paramedics will be pleased that you sided with safety by calling immediately, instead of risking precious time self analyzing. All medical staff in house and out want you to call on them if you are experiencing any discomfort at all that is similar to heart attack symptoms.That comment for the few who are worried what others think and would prefer to wait and see may push them further towards that decision.

  • Nice work on the Sandlot reference.