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

We have read with great interest the letter by Rottenberg [ ] 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) [ ]. 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 [ ]. This type of respiratory activity is often confused by bystanders as a sign of life, leading to cardiopulmonary resuscitation being withheld [ ]. Checking for signs of circulation involves “looking, listening, and feeling for normal breathing” [ ]. Studies from out-of-hospital CA indicate that agonal breathing may be present in up to 40% of instances [ ]. 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 [ ]. According to current European Resuscitation Council [ ] and American Heart Association [ ] 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 [ ].