Does CPR Still Require Mouth-to-Mouth Resuscitation?

CPR, which stands for cardiopulmonary resuscitation, has saved countless lives since its inception in the 1960s. For most of that history, mouth-to-mouth resuscitation—which involves tilting the person’s head back, pinching their nose, and breathing into their mouth—was an integral part of the process.

Over the last 15 years, however, CPR without mouth-to-mouth resuscitation has risen in popularity. So why the change—and when exactly is rescue breathing still necessary?

What Is “Hands-Only CPR”?

In 2008, the American Heart Association (AHA) revised its recommendations for bystanders who witness an adult collapse: They should skip mouth-to-mouth and instead opt for “hands-only CPR,” in which they continually administer chest compressions on the victim until emergency medical services arrive. For those in the know, the update was a long time coming. The AHA had been researching the efficacy of hands-only versus traditional CPR since the 1990s, and the results from three 2007 studies supported a pivot to hands-only.

The aim was partially to remove barriers that keep bystanders from performing CPR. Not only are people reluctant to swap mouth germs with a stranger, but the two-factor process can be tough to remember even if you are trained; you might hesitate to help because you’re worried about getting it wrong and doing more harm than good. 

The directions for hands-only CPR couldn’t be more straightforward. Basically, you call 9-1-1, and then press on the victim’s chest at a rate of 100 to 120 presses per minute—roughly the tempo of the Bee Gees song “Stayin’ Alive,” as The Office so memorably taught us—until a professional can take over. Moreover, hands-only CPR focuses on the biggest priority for anyone suffering from cardiac arrest: keeping blood circulating to their brain and other vital organs.

Despite what headlines suggested, the AHA wasn’t advising that everyone do away with mouth-to-mouth resuscitation in every scenario. According to the guidelines, hands-only CPR should be used “if a bystander is not trained in CPR” or “if the bystander was previously trained in CPR but is not confident in [their] ability to provide conventional CPR” with both chest compressions and rescue breaths. Any confident, trained bystander could choose hands-only or conventional CPR. 

The announcement also listed situations in which mouth-to-mouth resuscitation was especially important—namely, any “asphyxia-precipitated cardiac arrest, such as those associated with drowning, trauma, airway obstruction, acute respiratory diseases and apnea, [drug overdoses], pediatric arrests, and prolonged cardiac arrest.” In short, if you collapse because you aren’t getting enough oxygen, then you really need oxygen.

But as Dr. Michael Sayre, an emergency medicine professor and the head of the AHA committee in charge of the policy shift, told NBC News at the time, “Something is better than nothing.” If there’s nobody around who can do conventional CPR to resuscitate someone after a near-drowning, for example, at least do hands-only CPR to keep their blood pumping until the ambulance gets there.

ABC to CAB

While mouth-to-mouth resuscitation is still taught in CPR training classes, there has been a slight change in the steps. The mnemonic initialism used to be ABC, which stood for airway, breathing, chest compressions: First you tilt the head back and lift the chin to open the airway, then you administer rescue breaths, and finally you start chest compressions. But in 2010, the AHA reordered the letters to CAB: chest compressions first, followed by airway opening and rescue breathing.

“In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions,” the AHA explained.

CPR Boston put it in slightly simpler terms: “Just like you can hold your breath for a minute or two without having brain damage, victims of cardiac arrest can go a minute or two (actually a lot longer than that) without taking a breath. What [they] really need is for that blood to get flowing again.”

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