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Are physicians able to recognition ineffective (agonal) breathing as element of cardiac arrest?

Published:March 03, 2016DOI:https://doi.org/10.1016/j.ajem.2016.03.002
      We have read with great interest the letter by Rottenberg [
      • Rottenberg E.M.
      Does the absence of gasping upon emergency medical services arrival indicate the need for endotracheal intubation?.
      ] concerning on the absence of gasping upon emergency medical services arrival as a predictor of the need to endotracheal intubation. Agonal breathing is brainstem reflex and the last respiratory pattern that occurs during the early stages of cardiac arrest (CA) [
      • Fukushima H.
      • Imanishi M.
      • Iwami T.
      • Kitaoka H.
      • Asai H.
      • Seki T.
      • et al.
      Implementation of a dispatch-instruction protocol for cardiopulmonary resuscitation according to various abnormal breathing patterns: a population-based study.
      ]. Agonal breathing is defined as ineffective, gasping respirations. Lay persons’ descriptions of agonal breathing are varied and included terms of gasping, wheezing, groaning, snorting, weak breathing, occasional breathing, irregular breathing, and poor breathing [
      • Bång A.
      • Herlitz J.
      • Martinell S.
      Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases.
      ]. This type of respiratory activity is often confused by bystanders as a sign of life, leading to cardiopulmonary resuscitation being withheld [
      • Bång A.
      • Herlitz J.
      • Martinell S.
      Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases.
      ]. Checking for signs of circulation involves “looking, listening, and feeling for normal breathing” [
      • Perkins G.D.
      • Handley A.J.
      • Koster R.W.
      • Castrén M.
      • Smyth M.A.
      • Olasveengen T.
      • et al.
      Adult basic life support and automated external defibrillation section collaborators. European Resuscitation Council guidelines for resuscitation 2015: section 2. Adult basic life support and automated external defibrillation.
      ]. Studies from out-of-hospital CA indicate that agonal breathing may be present in up to 40% of instances [
      • Bång A.
      • Herlitz J.
      • Martinell S.
      Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases.
      ]. The length of time during which the victims will continue to have agonal respiration varies with the CA circumstances. It is noteworthy that the failure to recognize agonal breathing as a sign of CA leads to delays in the initiation of resuscitation which are associated with poorer outcomes [
      • Bång A.
      • Herlitz J.
      • Martinell S.
      Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases.
      ]. According to current European Resuscitation Council [
      • Perkins G.D.
      • Handley A.J.
      • Koster R.W.
      • Castrén M.
      • Smyth M.A.
      • Olasveengen T.
      • et al.
      Adult basic life support and automated external defibrillation section collaborators. European Resuscitation Council guidelines for resuscitation 2015: section 2. Adult basic life support and automated external defibrillation.
      ] and American Heart Association [
      • Kleinman M.E.
      • Brennan E.E.
      • Goldberger Z.D.
      • Swor R.A.
      • Terry M.
      • Bobrow B.J.
      • et al.
      Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
      ] guidelines for cardiopulmonary resuscitation, if there are no signs of circulation or if the rescuers are unsure, they are advised to start chest compressions. Moreover, agonal breathing was associated with a witnessed collapse, ventricular fibrillation, and discharge alive from hospital [
      • Rottenberg E.M.
      Does the absence of gasping upon emergency medical services arrival indicate the need for endotracheal intubation?.
      ].
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