GASP! Agonal Breathing Common, Predicts Survival After Out-of-Hospital Cardiac Arrest

November 27, 2008

November 27, 2008 (Tucson, AZ) - Someone stricken with out-of-hospital cardiac arrest might still be gasping for air, but that's no reason for witnesses to avoid jumping in with chest compressions, according to researchers who studied the phenomenon [1]. On the contrary, that initial period of distressed breathing might last only minutes but provides the best chance for resuscitation efforts to succeed and allow the patient to survive to hospital discharge, suggests a retrospective analysis published online November 24, 2008 in Circulation.

About a third of more than 1200 cases of witnessed out-of-hospital cardiac arrest attended by Arizona emergency medical services (EMS) over a recent three-year period were characterized by gasping, "often referred to as snoring, snorting, gurgling, or moaning, or as agonal, barely, labored, noisy, or heavy breathing," report the authors, led by Dr Bentley J Bobrow (Mayo Clinic College of Medicine, Phoenix, AZ, and University of Arizona Sarver Heart Center, Tucson). Gasping was most frequent in the early minutes after the patients collapsed.

The patients who gasped, compared with those who didn't, were overall three times more likely to survive to hospital discharge, but were five times more likely if they received bystander cardiopulmonary resuscitation (CPR).

Gasping is an indication that you're doing a great job and you shouldn’t stop.

The incidence and prognostic implications of gasping at cardiac arrest are underappreciated, a shortfall in public education that can delay or discourage bystander participation, according to Bobrow et al. "It is not uncommon to hear anecdotal reports that bystanders (even medical professionals) failed to initiate CPR because they concluded that the patient was still breathing and therefore did not have a cardiac arrest," they write. (Their study, however, does not show this.)

The gasping is a sign of poor but marginally adequate cerebral perfusion, and it is promising whether it starts as the patient collapses or only after the beginning of CPR, according to coauthor Dr Gordon A Ewy (University of Arizona Sarver Heart Center). Lay people who initiate CPR tend to be startled if gasping occurs, believing the patient is "waking up," and then often stop what they are doing, he said to heartwire . But, "gasping is an indication that you're doing a great job and you shouldn’t stop."

In a review of records from the Phoenix Fire Department Regional Dispatch Center, the authors observed that 44 of 113 cases (39%) of witnessed and unwitnessed out-of-hospital cardiac arrests were characterized by abnormal breathing.

They looked at the phenomenon's prevalence in relation to EMS response times for 1218 cases of witnessed out-of-hospital cardiac arrest occurring in Arizona from 2004 to 2007. Whether EMS personnel observed gasping was inversely related to how soon they arrived after the patient's collapse.

Gasping was associated with a significantly increased odds of survival to hospital discharge, the study's primary end point--whether or not, but especially if, bystander CPR was performed.

Odds Ratio (OR) for Survival to Discharge (Primary End Point) for Gaspers vs Nongaspers, by CPR Status

Outcome by group Gaspers Nongaspers OR (95%CI)a p

Overall (n) 191 1027    
- Survival to discharge (%) 28.3 7.8 3.4 (2.2-5.2) <0.001
Bystander CPR (n) 77 404    
- Survival to discharge (%) 39 9.4 5.1 (2.7-9.4) <0.001
No bystander CPR (n) 114 623    
- Survival to discharge (%) 21 6.7 2.4 (1.2-4.3) <0.01

a Adjusted for age, sex, location of cardiac arrest, bystander CPR vs no bystander CPR, collapse-to-EMS-arrival time, and VF vs no VF.

Gasping was observed by EMS personnel in 33% of cases when collapse occurred with EMS on the scene, and the rate steadily decreased with EMS arrival times: 20% for <7 minutes, 14% for 7 to 9 minutes, and 7.5% for >9 minutes. The odds ratio for gasping with EMS arrival >9 minutes after collapse was 0.30, compared with <7 minutes (p<0.001) after adjustment for age, sex, whether bystander CPR was performed, location of cardiac arrest, and whether VF was documented.

Ewy is among the principal advocates of what he calls cardiocerebral resuscitation for arrest of cardiac origin, characterized most notably by an emphasis on chest compressions uninterrupted by assisted breathing. The technique, as previously reported by heartwire , was recently endorsed by the American Heart Association as being about as effective as the traditional method involving compressions plus "mouth to mouth" resuscitation.

But proponents of the chest-compression-only method say it is superior, not only in being more successful but in encouraging bystanders to attempt it in the first place. In fact, Ewy said, the current study was designed, in part, to help get the public and providers to see abnormal breathing as a reason to initiate or continue CPR rather than a reason to stop or avoid it.

Ewy has no industry-related disclosures; of his coauthors, Dr Robert A Berg  (University of Arizona Sarver Heart Center) discloses grant support from Medtronic and Dr Karl B Kern  (University of Arizona Sarver Heart Center) reports being on the scientific advisory committees of Zoll and PhysioControl.

  1. Bobrow BJ, Zuercher M, Ewy GA, et al. Gasping during cardiac arrest in humans is frequent and associated with improved survival. Circulation. Published online before print November 24, 2008. Abstract

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