Compression-Only CPR

The moments after a heart attack make all the difference between life and death. There is no time to wait for lifesaving action.

Still, while the American Red Cross trains more than 12 million health care providers and lay people in cardiopulmonary resuscitation (CPR), only about one-third of those who suffer an out-of-hospital arrest receive bystander CPR.1

More training can increase these odds, but a recent emphasis on compression-only CPR may also help to shift these statistics. In fact, the American Heart Association emphasizes early chest compressions as the initial critical element of CPR instead of the previously taught method of assessing the patient’s airway, breathing, and then circulation (ABC). The organization now focuses on CAB, which stands for circulation-airway-breathing, as a direct response to compression-only research that concludes more lives could be saved with a prompt restoration of coronary and cerebral blood flow.1

Removing the ick factor

Providing mouth-to-mouth respiration can be a highly personal and frightening endeavor, especially if you are helping someone you don’t know. Many bystanders list fear of diseases as a barrier for performing mouth-to-mouth ventilation during attempted resuscitation for cardiac arrest.2 Bystanders also cited alcohol scents, vomitus, and recent flu outbreaks as additional barriers to performing mouth-to-mouth ventilations.2

In a study to determine the willingness of laypeople to provide compression-only CPR vs. standard CPR, researchers surveyed young college students’ attitudes regarding the two methods.3 After these participants were trained using both methods, researchers administered a survey. They found either type of CPR training increased bystander willingness to provide CPR, but bystanders preferred compression-only CPR.

By teaching compression-only CPR, health care workers may be able to allay some of the fears associated with such a highly personal but necessary endeavor. Of course, these methods won’t ameliorate all fears. For example, studies also list fears of litigation and doing more harm than good as possible barriers.

Survival rates

In multiple studies on out-of-hospital cardiac arrest, researchers found no statistical difference for those receiving compression-only CPR and those receiving standard CPR after one month of follow-up.2,4-6

In two studies, emergency dispatchers instructed bystanders involved in out-of-hospital cardiac arrest events to do compression-only or standard CPR. These randomized studies of witnessed out-of-hospital cardiac arrest showed that giving instructions for compression-only CPR doesn’t significantly improve the outcome of patients when compared with standard CPR.7,8

However, both research groups consistently found evidence that compression-only CPR did improve survival rates (32 percent vs. 26 percent) in those subgroups of patients who had a shockable arrest rhythm vs. those with a non-cardiac arrest cause. Laypeople, without medical training, will likely not be able to identify these subgroups. Since compression-only CPR does not seem to adversely affect outcomes, this additional subgroup could further benefit from the use compression-only CPR as a basic standard.

Historical overview of cardiopulmonary resuscitation

    We can trace present-day respiratory and cardiac resuscitation techniques to writings in the Babylonian Talmud between 200 B.C. and 400 A.D.

    However, one of the earliest recorded applications of CPR as we know it today was described in 1858, when a young Hungarian woman was resuscitated when a professor of surgery created a surgical airway and then compressed the anterior chest wall with one hand for six minutes. He then detected a pulse and the patient returned to consciousness.

    Long considered the father of CPR, Peter J Safar, MD, a Baltimore City Hospital anesthesiologist, combined his research in management of the airway with the work of Johns Hopkins researchers, William Kouwenhoven, Guy Knickerbocker, and James Jude, to invent cardiopulmonary resuscitation.

    Not long after realizing the value of CPR, Dr. Safar collaborated with Asmund Laerdal, a toymaker from Stavanger in Norway, and invented Resusci-Anne, a CPR manikin.

    Resusci-Anne has provided hundreds of thousands of individuals around the world with a device that allows a standardized approach to CPR training.

    Throughout his life, Dr. Safar continued to provide research related to ventilation and circulation.

    Over the years, guidelines and consensus statements from the medical community and the American Heart Association have improved and added to the knowledge provided through Dr. Safar’s original work on the scientific basis for CPR.

    – Sally F. Whitten, BS, RRT

Neurological function and outcomes

Although surviving cardiac arrest is an important outcome, an essential secondary assessment should include evaluation of neurological status. In a randomized controlled study, researchers found favorable neurological outcomes in patients who received compression-only CPR compared to those who received standard CPR.8

In the SOS-KANTOS study, physicians conducted neurological assessments on patients without knowing the method of CPR provided. 6 The study showed favorable neurological outcomes (by subgroup analysis), when comparing compression-only CPR vs. standard methods. With independent assessment, the compression-only CPR group had significantly higher neurological outcomes than those who received standard CPR. Similar survival rates to standard CPR, combined with positive neurological outcomes, are important markers of the efficacy of compression-only CPR.

Ease of use

As support for compression-only CPR increases, we also need to assess the ability of bystanders to apply this new technique, which can be physically taxing. Older individuals are often the first responders for spouses experiencing a cardiac arrest. Thus, researchers sought to appraise fatigue levels for compression-only CPR and standard CPR.

Researchers assessed retired health care workers’ ability to provide compression-only CPR and standard CPR on manikins in a prospective, randomized cross-over study.9 The study looked at 17 retired health care workers who provided CPR for nine minutes. The qualitative and quantitative data indicated that the number of chest compressions delivered for both methods declined over time, but overall, more compressions were delivered when participants performed standard CPR.This small study provides important information about bystander fatigue, but it should be viewed with some caution due to the small study size. This identified concern may require additional research.

American Heart Association changes

Recent studies have determined that despite four decades of training, our current approach to cardiopulmonary resuscitation could be improved. Teaching compression-only CPR to the general public, who may be the first line of defense in a cardiac arrest event, may increase the public’s willingness to step in and provide medical aid, and therefore, give patients a better chance of survival.

Compression-only CPR is easier to teach, eliminates barriers to initiating CPR, including the need for mouth-to-mouth ventilation, and improves neurological outcomes in survivors.


1. American Heart Association. CPR Statistics. CPR and Sudden Cardiac Arrest. April 26, 2010.

2. Ramaraj R, Ewy GA. Rationale for continuous chest compression cardiopulmonary resuscitation. Heart. 2009;95:1978-82.

3. Cho GC, et al. The effects of basic life support education on laypersons’ willingness in performing bystander hands only cardiopulmonary resuscitation. Resuscitation. 2010;81:691-94.

4. Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L. Survival is similar after standard treatment and chest compression only out-of-hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116:2908-12.

5. Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only) cardiopulmonary resuscitation: A call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. Circulation. 2008; 117:2162-67.

6. SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): An observational study. Lancet. 2007;369:920-26.

7. Rea TD, et al. CPR with chest compression alone or with rescue breathing. The N Eng J Med. 2010;363(5).423-33.

8. Svensson L, et al. Compression-only CPR or standard CPR in out-of-hospital cardiac arrest. N Eng J Med. 2010;363(5):434-42.

9. Heidenreich JW, Bonner A, Sanders AB. Rescuer fatigue in the elderly: Standard vs. hands-only CPR. J Emerg Med. 2010; Advance online publication.

Sally Whitten, BS, RRT, is the manager of respiratory care at Maine Medical Center in Portland, Maine.