Ventilation during resuscitation

Ventilation during cardiopulmonary resuscitation is a key element of emergency medicine and directly influences patient outcomes. For professional emergency responders, the question is not so much whether to ventilate, but rather how to ensure that ventilation during cardiopulmonary resuscitation under high‑stress conditions is safe, guideline‑compliant, and resource-efficient. WEINMANN ventilators used in emergency medical services can provide critical support here and help minimize sources of error.

Why ventilation during cardiopulmonary resuscitation is essential in emergency medicine

Cardiopulmonary resuscitation without ventilation is incomplete. Although chest compressions alone enable oxygen-rich blood to circulate, they cannot replace structured emergency ventilation, which supplies the body with fresh oxygen and ensures the removal of carbon dioxide.

For professional users in emergency medical services, in air rescue, disaster response, and hospital environments, ventilation is therefore an integral part of any resuscitation measures, whenever conditions permit.

Objectives of ventilation during cardiopulmonary resuscitation

Ventilation during cardiopulmonary resuscitation has several medical objectives:

Oxygenation and protection of vital organs

The primary objective of ventilation is oxygenation, i.e., supplying the body with sufficient oxygen to ensure adequate blood flow to vital organs such as the heart and brain. : The primary objective of ventilation is oxygenation - supplying the body with sufficient oxygen to guarantee adequate blood flow to vital organs such as the heart and brain.

Ventilation and prevention of hypercapnia

In addition to supplying oxygen, ventilation also serves to exchange oxygen and carbon dioxide (decarboxylation). This is crucial in order to prevent a build-up of carbon dioxide (hypercapnia), which may result in respiratory acidosis.

Supporting circulation

Ideally, ventilation supports circulation by being performed in synchrony with chest compressions. This can have a positive effect on hemodynamics and improve the overall effectiveness of CPR.

How does ventilation in children differ from ventilation in adults?

Adults are usually resuscitated at a ratio of 30:2, i.e., 30 chest compressions followed by 2 rescue breaths.[1] In children, especially infants and small children, ventilation is much more sensitive and requires even more precise adjustment.

The biggest differences include:

Significantly smaller lung volumes compared to adults
Increased sensitivity to excessive ventilation pressures
Higher oxygen demand per kilogram of body weight
(6–7 ml/kg/min compared to 3–4 ml/kg/min in adults)[2]
Greater impact of minor leakage in the respiratory system

The ventilation must therefore be consistently adjusted to height and body weight. Inaccurate estimates or adult settings may otherwise lead to volutrauma, barotrauma or inadequate ventilation.

The MEDUMAT Standard² ventilator from WEINMANN is suitable for children from 3 kg and enables safe ventilation settings by entering patient height.

Ventilation during cardiopulmonary resuscitation of children and infants

For pediatric resuscitation, follow these cardiopulmonary resuscitation (CPR) guidelines:³

Ventilation: Child > 1 year: 5 initial “effective” ventilations, each over 1 s
Child < 1 year: 5 initial “effective” ventilations, each over 1 s
Newborn: 5 ventilations, each over 2–3 s, then 30/min
Pulse monitoring (no longer than 10 s): Child > 1 year: Carotid artery
Child < 1 year: Brachial artery
Newborn: Umbilical artery
Compression site: Child > 1 year: Lower half of the sternum
Child < 1 year: Lower half of the sternum
Newborn: Lower third of the sternum
Compression method: Child > 1 year: Heel of the hand
Child < 1 year: 2 fingers or both thumbs (two-rescuer method)
Newborn: 2 fingers or both thumbs (two-rescuer method)
Compression rate: Child > 1 year: 100-120/min
Child < 1 year: 100-120/min
Newborn: 120/min
Compression‑to‑ventilation ratio: Child > 1 year: 15:2, lay rescuers 30:2
Child < 1 year: 15:2
Newborn: 3:1
Airway obstruction in a conscious child (if the child is unconscious, resuscitation should be performed!): Child > 1 year: 5 back blows, 5 abdominal compressions
Child < 1 year: 5 back blows, 5 abdominal compressions
Newborn: Suction, no back blows oder thrusts

Study: How ventilation during cardiopulmonary resuscitation improves survival rates

Previous research has focused primarily on chest compressions (“Chest Compression Only”), but it has been shown that ventilation is equally crucial for the outcome.

One study found that ventilation in more than 50% of compression pauses was associated with improved return of spontaneous circulation (ROSC), an increased survival rate and reduced neurological damage.⁴

The heart and brain react very sensitively to an oxygen deficiency, and therefore speedy ventilation with the highest possible oxygen concentration is crucial for avoiding life-threatening damage. ⁵

A cardiac arrest causes the oxygen supply to stop abruptly. Due to their high metabolic rates, the heart and brain exhaust their limited oxygen and energy reserves within minutes.

The study “Bag-Valve-Mask Ventilation and Survival from Out-of-Hospital Cardiac Arrest: A Multicenter Study” by Ahamed Idris et al.⁶looks at the effect of ventilation during resuscitation on the outcome of the patient. According to the study, individuals who were reliably ventilated during compression pauses had higher survival rates and less neurological damage.

For this reason, doing chest compressions without ventilation is not recommended to professional rescuers⁷– quite the contrary: They are advised to start ventilation as early as possible,⁸as there is only a narrow window of approximately 3–5 minutes without oxygen before irreversible brain damage occurs.⁹

Ventilation during cardiopulmonary resuscitation – overview of methods

The guidelines on cardiopulmonary resuscitation tend to come from general recommendations on artificial ventilation. As such, there are also no specific recommendations when it comes to selecting the ventilation mode.

The choice of ventilation method during resuscitation mostly depends on whether or not the patient’s airway is secured.

Unsecured airway

An unsecured airway is kept open manually without a ventilator. In this situation, the following ventilation options are available:

Bag-valve-mask ventilation

A manual method in which oxygen is administered directly via a mask by squeezing a ventilation bag.

Advantages: Quick application
Low weight
Disadvantages: No constant respiratory volume
No constant respiratory rate
Possibility of pressure spikes
Limited sealing
Risk of gastric insufflation
Requires two people
Obstruction of the venous return flow due to asynchronous ventilation

MEDUtrigger

A manual trigger that delivers mechanical breaths via a mask.

Advantages: Manual ventilation with a constant volume
Guideline-compliant, rapid delivery of two consecutive mechanical
Pressure limit and warning signals
Disadvantages: Ventilator required on scene
Less sensory feedback, changes are less directly perceptible

Secured airway

An airway is secured when auxiliary equipment such as a tracheal tube or a supraglottic airway device (SAD) keeps the airway open at all times. Once the airway has been secured, the following ventilation options are available:

Bag‑valve ventilation via tracheal tube

During intubation, the tube can be connected to a bag to enable manual ventilation.

Advantages: Quick application
Low weight
Disadvantages: No constant respiratory volume
No constant respiratory rate
One person required for the ventilation
Possible pressure spikes and obstruction of the venous return flow due to asynchronous ventilation

Volume-controlled ventilation

A mechanical ventilation method in which the tidal volume is preset.

Advantages: Precise adjustment of respiratory volume and constant ventilation rate
No additional person required for ventilation
Disadvantages: Possible pressure spikes and obstruction of the venous return flow due to asynchronous ventilation

Pressure-controlled ventilation

A mechanical ventilation method whereby the ventilation pressure is regulated.

Advantages: Constant ventilation pressure and rate
No additional person required for ventilation
Disadvantages: Possible obstruction of the venous return flow due to asynchronous ventilation

Chest Compression Synchronized Ventilation (CCSV)

A pressure-controlled ventilation mode that is synchronized with the chest compressions and initiates mechanical breaths.

Advantages: Specially developed for resuscitation
Oxygenation and alveolar ventilation improved
Support for perfusion
No additional person required for ventilation
Disadvantages: Airway management with tracheal tube required

Mechanical ventilation during cardiopulmonary resuscitation: which is better?

Traditional manual ventilation still has its place – especially early in CPR or during very short CPR episodes. However, in real-world scenarios involving prolonged CPR, transport, ongoing diagnostics and parallel measures, teams quickly reach their limits:

Difficult mask sealing over extended periods
Significant physical effort
Risk of hyperventilation
Reduced focus on other vital signs and CPR measures

This is where WEINMANN ventilators offer significant advantages in emergency medical services: Once correctly connected, they deliver constant ventilation with controlled pressures and volumes, and continuously monitor essential ventilation parameters. This buys the team valuable time.

This is how WEINMANN supports ventilation during resuscitation

There is now broad consensus that ventilation is an essential part of cardiopulmonary resuscitation and must not be neglected^.10 Despite this realization, adequate implementation remains a challenge.

A study in the USA in 2020 showed that only 3 out of 106 emergency medical teams were able to guarantee guideline-compliant ventilation during simulated resuscitation.¹¹

3 out of 106 emergency medical teams could guarantee guideline-compliant ventilation during resuscitation

In this context, WEINMANN Emergency ventilators offer reliable support for cardiopulmonary resuscitation. Their simple handling means they provide speedy assistance in the race against time, when every second could be the difference between life and death.

MEDUtrigger

WEINMANN improves the efficiency of ventilation during cardiopulmonary resuscitation with an unsecured airway by using MEDUtrigger. The function is available with MEDUMAT Easy CPR, MEDUVENT Standard and MEDUMAT Standard² devices.

The MEDUtrigger allows users to flexibly initiate individual mechanical breaths. A long press on the trigger activates two guideline-compliant mechanical breaths with a maximum duration of five seconds. Unlike bag-valve-mask ventilation, the user is not dependent on a second person to maintain a mask seal. One person can seal the mask with their hands while a ventilator performs the ventilation.

CCSV mode

After securing the airway, WEINMANN’s CCSV mode provides effective respiratory support. This mode synchronously delivers a short mechanical breath for every chest compression. It is synchronized with the compressions, which means that a chest compression rate of 100/min, for instance, is accompanied by a corresponding ventilation rate.

CCSV mode has a number of advantages:

Improved hemodynamics: In comparison with other ventilation modes, resuscitation with CCSV demonstrates improved oxygenation, a normal venous pH value and a significantly higher median arterial blood pressure, which indicates improved hemodynamics.
Improved alveolar ventilation: CCSV can prevent hypercapnia and thus counteract respiratory acidosis.
Improved cerebral oxygenation: CCSV contributes to an increase in cerebral oxygenation during resuscitation.
More precise ventilation: CCSV works with the preset ventilation values without exceeding the set ventilation pressure during resuscitation.

In this way, WEINMANN’s CCSV mode supports reliable ventilation during cardiopulmonary resuscitation.

FAQs

Cardiopulmonary resuscitation follows a step-by-step approach consisting of Basic Life Support (BLS) for laypeople and Advanced Life Support (ALS) with more complex procedures performed by trained professionals, based on the guidelines recommended by the European Resuscitation Council (ERC) and the American Heart Association (AHA).

In BLS the cardiopulmonary resuscitation procedure is based on the principle of “check, call, compress, shock”. ALS builds on these BLS steps and supplements them with additional measures:

The focus remains on chest compressions that are as uninterrupted as possible and, in the case of shockable rhythms, early defibrillation. At the same time, medical professionals secure the airway, perform controlled ventilation, administer medication (including epinephrine for non-shockable rhythms), and actively search for reversible causes of cardiac arrest in order to treat them specifically. In selected cases, extracorporeal CPR (eCPR) can be used as a last resort.

Ventilation during cardiopulmonary resuscitation complements chest compressions at a 30:2 ratio: after 30 chest compressions, give 2 breaths, each lasting about 1 second, until the chest rises visibly. This supplies the body with fresh oxygen, while chest compressions distribute it throughout the circulatory system. Finally, depending on whether the airway is secured or unsecured, different ventilation methods and, if necessary, different ventilators are used.

In professional resuscitation measures, ventilation is always indicated during CPR when both respiratory and cardiac arrest are present and there is no normal spontaneous breathing. In this setting, the combination of chest compressions and artificial ventilation is part of cardiopulmonary resuscitation and is an integral part of the resuscitation process.

Ventilation during cardiopulmonary resuscitation is usually essential. Nevertheless, there are specific situations where it is temporarily not used or where chest compression resuscitation is the primary focus:

Lay resuscitation without equipment: Here, cardiopulmonary resuscitation using only chest compressions (“hands-only CPR”) is recommended in order to lower the inhibition threshold and ensure that resuscitation takes place at all.
Special conditions: Mouth-to-mouth/mouth-to-nose ventilation is only of limited use in cases of massive bleeding, vomiting, or severe facial injuries, for example, and may even increase the risk of aspiration.
Rescuer safety: In cases of high personal risk (e.g., highly infectious disease without personal protective equipment) ventilation procedures involving close contact with the patient can be dispensed with and resuscitation can initially be performed using compression alone until a safe ventilation system is available.

However, in a professional setting with the necessary equipment available, the benefits of ventilation clearly outweigh the risks. The advantages of stable, reproducible ventilation with suitable ventilators are particularly evident in complex situations (e.g., air rescue service, disaster response, medical corps).

Even experienced teams repeatedly make similar mistakes during CPR when it comes to ventilation. These can significantly impair the effectiveness of cardiopulmonary resuscitation:

Ventilation rate too high: If ventilation is too rapid, intrathoracic pressure increases. This reduces venous return to the heart and can significantly impair circulation during cardiopulmonary resuscitation.
Tidal volume too high: Excessive ventilation volumes or pressures promote gastric insufflation. This increases the risk of aspiration and can put additional pressure on the lungs and blood vessels.
Poor mask seal: Poorly fitting masks result in inadequate ventilation: Part of the volume escapes externally instead of entering the lungs. This significantly reduces the oxygen supply.
Asynchronous ventilation during compressions: If ventilation is not coordinated with chest compressions, mechanical breaths and compressions can interfere with each other. Both can worsen coronary and cerebral perfusion.

¹www.grc-org.de/files/Contentpages/document/251217_TB_Reanimation.pdf

²https://www.ai-online.info/images/ai-ausgabe/2008/02-2008/065-074_hoehne_cme.pdf

³https://pmc.ncbi.nlm.nih.gov/articles/PMC7498403/

⁴Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson J, Blackwood J, Wang HE. Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study. Circulation. 2023 Dec 5;148(23):1847-1856. doi: 10.1161/CIRCULATIONAHA.123.065561. Epub 2023 Nov 12. PMID: 37952192.

⁵ Skrifvars MB, Olasveengen TM, Ristagno G. Oxygen and carbon dioxide targets during and after resuscitation of cardiac arrest patients. Intensive Care Med. 2019 Feb;45(2):284-286. doi: 10.1007/s00134-018-5456-6. Epub 2018 Nov 12. PMID: 30421258.

⁶Idris AH, Aramendi Ecenarro E, Leroux B, Jaureguibeitia X, Yang BY, Shaver S, Chang MP, Rea T, Kudenchuk P, Christenson J, Vaillancourt C, Callaway C, Salcido D, Carson

⁷Larsen R. Kardiopulmonale Reanimation [Cardiopulmonary resuscitation]. Anesthesia und Intensivmedizin für die Fachpflege [Anesthesia and intensive care for specialist medical care]. 2016 Jun 14:627–44. German. doi: 10.1007/978-3-662-50444-4_46. PMCID: PMC7531326.

⁸Kardiopulmonale Reanimation bei Erwachsenen [Cardiopulmonary resuscitation in adults] by Shira A. Schlesinger , MD, MPH, Harbor-UCLA Medical Center

⁹https://www.bioeg.de/fileadmin/user_upload/PDF/pressemitteilungen/daten_und_fakten/Faktenblatt_Reanimation_Stand_Oktober_2019.pdf

¹⁰https://pmc.ncbi.nlm.nih.gov/articles/PMC8170637 / https://www.grc-org.de/files/Contentpages/document/Leitlinienkompakt_26.04.2022.pdf

¹¹ Neth MR, Benoit JL, Stolz U, McMullan J. Ventilation in Simulated Out-of-Hospital Cardiac Arrest Resuscitation Rarely Meets Guidelines. Prehosp Emerg Care. 2021 Sep-Oct;25(5):712-720. doi: 10.1080/10903127.2020.1822481. Epub 2020 Oct 6. PMID: 33021857.