Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy.
The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable.
Sempsrott J, Szpilman D, Liu L, Bierens J, Bray J, Perkins GD. on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force. Compression-only CPR vs Standard CPR with Compressions and Ventilations following drowning. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, December 04, 2022. Available from: http://ilcor.org.
In 2015 the ILCOR CoSTR for Chest Compression-Only CPR Versus Conventional CPR (BLS 372) stated “We recommend that chest compressions should be performed for all patients in cardiac arrest (strong recommendation, very-low-quality evidence). We suggest that those who are trained and willing to give rescue breaths do so for all adult patients in cardiac arrest (weak recommendation, very-low-quality evidence)”. [Travers 2015 S59]. An evidence update in 2017 found no new data to change the 2015 recommendation [Ashoor 2017 112]. In 2020, there was no new evidence to change the 2015 recommendation.[Olasveengen 2020 S41].
In 2017, a SysRev [Ashoor 2017 112] and an ILCOR Pediatric CoSTR [Olasveengen 2017 201] [Olasveengen 2017 e424] were published on the topic of compression-only CPR compared with conventional CPR for infants and children. Refer to those publications for details of the evidence summary and task force considerations [Olasveengen 2017 201] [Olasveengen 2017 e424] [Ashoor 2017 112]. The ILCOR CoSTR for Pediatric Basic Life Support Chest Compression-Only CPR Versus Conventional CPR recommendations were unchanged in 2020 and stated: We suggest that bystanders provide CPR with ventilation for infants and children younger than 18 years with OHCA (weak recommendation, very low-quality evidence)[Maconochie 2020 S146]. We recommend that if bystanders cannot provide rescue breaths as part of CPR for infants and children younger than 18 years with OHCA, they should at least provide chest compressions (good practice statement).
None of the previous ILCOR reviews examined this issue specifically in drowning patients. Whether a different approach in the specific circumstances associated with drowning warrants an alternative approach is uncertain.
The current review was initiated following a request from the ILCOR BLS Task Force as part of a series of reviews relating to drowning.
The continuous evidence evaluation process for this Consensus on Science with Treatment Recommendations (CoSTR) started with a scoping review of the literature [Bierens 2021 205]. Following the completion of the scoping review, the decision was taken to progress to a systematic review. The systematic review was registered with PROSPERO CRD42021259983. The PICO question was developed by a group of drowning experts and approved by the ILCOR BLS Task Force. The search strategy was developed and run by Samantha Johnson. The results of the search strategy were reviewed and development of this CoSTR was conducted by Justin Sempsrott, David Szpilman, Li Lei, in collaboration with Joost Bierens and Gavin Perkins. The CoSTR was reviewed and agreed by Basic Life Support and Paediatric Task Forces.
Adults and children in cardiac arrest1 following drowning
Compression Only CPR
Standard CPR (Compressions and Ventilations)
Survival with favourable neurological outcome to discharge / 30 days or later
Survival to discharge / 30 days or later
Return of spontaneous circulation (ROSC)
Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.
Unpublished studies (e.g., conference abstracts, trial protocols), manikin studies, narrative reviews and animal studies were excluded.
All years and all languages are included if there is an English abstract
Database inception to current time.
PROSPERO Registration CRD42021259983
Consensus on Science
A search of Medline, Pre-Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials identified references. After de-duplication, 730 titles and abstracts were reviewed. Full text review was conducted for 24 papers (22 from search and 2 from citation searching). Two studies [Fukada 2019 166; Tobin 2020 1] were identified which addressed the PICOST question, both studies examined bystander CPR. Meta-analysis was not possible due to heterogeneity between the two studies.
Fukada et al [Fukada 2019 166] presented observational evidence for 5,121 adults and children who received chest compressions following cardiac arrest due to drowning in Japan between January 2013 and December 2016. Participants were divided into two groups, those that received conventional CPR which included ventilations (n=968) and those that received compression-only CPR (n=4,153), with 928 patients from each group included in a propensity-matched analysis.
Tobin et al [Tobin 2020 1] presented evidence for 548 persons who received chest compressions following cardiac arrest due to drowning in the US between January 2013 and December 2017. Participants were divided into two groups, those that received conventional CPR which included ventilations (n=239) and those that received compression-only CPR (n=309), and results were adjusted for age.
For the critical outcome of survival with a favourable neurological outcome at discharge/30-days, we identified very-low certainty evidence (downgraded for serious risk of bias) from both observational studies.[Fukada 2019 166; Tobin 2020 1] Both studies assessed survival with a favourable neurological outcome using the Glasgow-Pittsburgh cerebral performance category (CPC) at one month. A CPC score of 1-2 was considered a favourable neurological outcome and scores of 3-5 were considered a poor outcome.
Overall, there was no statistical difference in either study for this outcome. In the propensity-matched analysis conducted by Fukada et al [Fukada 2019 166], 70 (7.5%) in the conventional CPR group had a CPC score of 1-2 compared to 61 (6.6%) in the compression-only CPR group (relative risk ratio [RR]=1.15, 95% CI 0.82 to 1.60; p=0.42). In Tobin et al. [Tobin 2020 1], 59 (24.7%) patients in the conventional CPR group had a favourable neurological outcome compared to 50 (16.2%) patients in the compression-only CPR group (adjusted odds ratio [aOR]=1.35, 95% CI 0.86 to 2.10; p=0.19). A post-hoc subgroup analysis by Tobin et al. [Tobin 2020 1] showed conventional CPR was associated with greater adjusted odds of favourable neurological outcome in children aged 5 to 15 years (aOR=2.68; 95% CI, 1.10 to 6.77; p= 0.03).
For the critical outcome of survival to hospital discharge/30-days, we identified very-low certainty evidence (downgraded for serious risk of bias) from two observational studies. [Fukada 2019 166; Tobin 2020 1]
Fukada et al [Fukada 2019 166] reported 97 (10.5%) in the conventional CPR group survived at 30 days compared to 80 (8.6%) in the compression-only CPR group (RR=1.21; 95% CI, 0.91 to 1.61, p=0.18). Tobin et al [Tobin 2020 1], 71 (29.7%) in the conventional CPR group and 56 (18.1%) in the compression-only CPR group survived to hospital discharge (aOR=1.54; 95% CI, 1.01 to 2.36, p=0.046).
For the critical outcome of survival (return of spontaneous circulation) to hospital admission we identified very-low certainty evidence (downgraded for serious risk of bias) from two observational studies. [Fukada 2019 166; Tobin 2020 1]
There was no statistical difference in either study for this outcome. Fukada et al [Fukada 2019 166] reported 98(10.6%) in the conventional CPR group survived to hospital admission compared to 83 (8.9%) in the compression-only CPR group (RR=1.18; 95% CI, 0.89 to 1.56, p=0.24). There was also no difference seen between groups in Tobin et al [Tobin 2020 1], with 127 (53.1%) in the conventional CPR group surviving to hospital admission compared to 133 (43.1%) in the compression-only CPR group (aOR=1.29; 95% CI, 0.91 to 1.84, p=0.16).
For lay responders, the treatment recommendation for CPR in drowned OHCA patients who have been removed from the water remains consistent with CPR for all patients in cardiac arrest [Maconochie 2020 S410; Olasveengen 2020 S41] (Good Practice Statement):
- We suggest that bystanders commence CPR with compressions rather than ventilations in adults with cardiac arrest [Olasveengen 2020 S41].
- We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest [Olasveengen 2020 S41].
- We suggest that bystanders provide CPR with ventilation for infants and children younger than 18 years with OHCA [Maconochie 2020 S410].
- We recommend that if bystanders cannot provide rescue breaths as part of CPR for infants and children younger than 18 years with OHCA, they should at least provide chest compressions [Maconochie 2020 S410].
For healthcare professionals and those with a duty to respond to drowning (e.g. lifeguards), we recommend providing ventilations in addition to chest compressions if they have been trained and are able and willing to do so (Good Practice Statement).
Justification and Evidence to Decision Framework Highlights
In making the decision to follow standard BLS treatment recommendations the review group and Task Force considered the following:
- Cardiac arrest from drowning is due primarily to anoxia. [Bierens 2016 147; Vanden Hoek 2010 e405; Soar 2010 1407] Therefore, as with pediatric out-of-hospital cardiac arrest where asphyxia is the predominant etiology [Atkins 2009 1484; Young 2004 157; Sirbaugh 1999 174; Kuisma 1995 141], providing ventilation in OHCA due to drowning is important. [Szpilman 2004 25]
- Whilst no randomized clinical trial (RCT) was found, the two observational studies that examined the effect of conventional versus compression-only CPR in OHCA due to drowning were subject to a high risk of bias and were considered very low certainty of evidence.
- The significant finding in the subgroup data in children in the study by Tobin must be interpreted with caution due to the small sample size.
- As noted in the 2020 CoSTR publication, simulation and observational studies favor commencing CPR with compressions over airway and breathing, including two of three simulation RCTs reporting faster times to commencement of rescue breaths when starting with compressions. [Olasveengen 2020 S418]. While the faster times may have a beneficial effect in a primary cardiac arrest, it is unclear what the impact is of faster times is when anoxic / hypoxic blood is circulated as will happen in a cardiac arrest following drowning.
- A previous systematic review supports the concept that conventional CPR may offer a greater chance for neurologically favorable survival than CO-CPR in children aged <1 year; while a multicentered European study showed increased survival to hospital discharge when bystanders had performed ventilation [Ashoor 2017 112; Grässner 2019 218].
- The impact of one standard of basic life support training and the simplification using a single approach for teaching, learning and recalling how to perform CPR.
- Bystanders are more likely to be willing to perform compression-only CPR [Bray 2017 58] and familiarity with chest compression-only CPR has become widespread in some parts of the world [Grassner 2019]. It is simple to teach, learn, remember, and perform [Sayre 2008 2162, Nishiyama 2008 90, Iwami 2015 415, Fukuda 2016 2060]. Nevertheless, conventional CPR with compressions and ventilations (CV-CPR) is preferred when the bystander is capable and trained.
- High-quality evidence is required to examine the impact of the type of CPR on OHCA patient outcomes overall and in subgroups (e.g. children).
Attachment: BLS Drowning CPR v CCC ETD
Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA, Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119:1484-91
Ashoor HM, Lillie E, Zarin W, Pham B, Khan PA, Nincic V, Yazdi F, Ghassemi M, Ivory J, Cardoso R, Perkins GD, de Caen AR, Tricco AC; ILCOR Basic Life Support Task Force. Effectiveness of different compression-to-ventilation methods for cardiopulmonary resuscitation: A systematic review. Resuscitation. 2017;118:112–125.
van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJ. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. 2005 Nov;83(11):853-6. Epub 2005 Nov 10. PMID: 16302042; PMCID: PMC2626470.
Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, Claesson A, Dunne C, Elsenga HE, Morgan P, Mecrow T, Pereira JC, Scapigliati A, Seesink J, Schmidt A, Sempsrott J, Szpilman D, Warner DS, Webber J, Johnson S, Olasveengen T, Morley PT, Perkins GD. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021 May;162:205-217. doi: 10.1016/j.resuscitation.2021.01.033. Epub 2021 Feb 4. PMID: 33549689.
Bierens JJ, Lunetta P, Tipton M, Warner DS. Physiology Of Drowning: A Review. Physiology (Bethesda). 2016 Mar;31(2):147-66. doi: 10.1152/physiol.00002.2015. PMID: 26889019.
Bray JE, Smith K, Case R, Cartledge S, Straney L, Finn J. Public cardiopulmonary resuscitation training rates and awareness of hands-only cardiopulmonary resuscitation: A cross-sectional survey of Victorians. EMA 2017;29:58-64
Fukuda T, Ohashi-Fukuda N, Kobayashi H, Gunshin M, Sera T, Kondo Y, Yahagi N. Conventional Versus Compression-Only Versus No-Bystander Cardiopulmonary Resuscitation for Pediatric Out-of-Hospital Cardiac Arrest. Circulation. 2016;134:2060-2070.
Fukuda T, Ohashi-Fukuda N, Hayashida K, Kondo Y, Kukita I. Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning. Resuscitation. 2019;145:166-174.
Gräsner JT, Wnent J, Herlitz J, Perkins GD, Lefering R, Tjelmeland I, Koster RW, Masterson S, Rossell-Ortiz F, Maurer H, Böttiger BW, Moertl M, Mols P, Alihodžić H, Hadžibegović I, Ioannides M, Truhlář A, Wissenberg M, Salo A, Escutnaire J, Nikolaou N, Nagy E, Jonsson BS, Wright P, Semeraro F, Clarens C, Beesems S, Cebula G, Correia VH, Cimpoesu D, Raffay V, Trenkler S, Markota A, Strömsöe A, Burkart R, Booth S, Bossaert L. Survival after out-of-hospital cardiac arrest in Europe - Results of the EuReCa TWO study. Resuscitation. 2020 Mar 1;148:218-226. doi: 10.1016/j.resuscitation.2019.12.042. Epub 2020 Feb 3. PMID: 32027980.
Iwami T, Kitamura T, Kiyohara K, Kawamura T. Dissemination of Chest Compression-Only Cardiopulmonary Resuscitation and Survival After Out-of-Hospital Cardiac Arrest. Circulation. 2015;132:415-22.
Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital cardiac arrests--epidemiology and outcome. Resuscitation. 1995;30:141-50.
Nishiyama C, Iwami T, Kawamura T, Ando M, Yonemoto N, Hiraide A, Nonogi H. Effectiveness of simplified chest compression-only CPR training for the general public: a randomized controlled trial. Resuscitation. 2008;79:90-6.
Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, Chung SP, Considine J, Couper K, Escalante R, Hatanaka T, Hung KKC, Kudenchuk P, Lim SH, Nishiyama C, Ristagno G, Semeraro F, Smith CM, Smyth MA, Vaillancourt C, Nolan JP, Hazinski MF, Morley PT; Adult Basic Life Support Collaborators. Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl_1):S41-S91.
Olasveengen TM, de Caen AR, Mancini ME, Maconochie IK, Aickin R, Atkins DL, Berg RA, Bingham RM, Brooks SC, Castrén M, Chung SP, Considine J, Couto TB, Escalante R, Gazmuri RJ, Guerguerian AM, Hatanaka T, Koster RW, Kudenchuk PJ, Lang E, Lim SH, Løfgren B, Meaney PA, Montgomery WH, Morley PT, Morrison LJ, Nation KJ, Ng KC, Nadkarni VM, Nishiyama C, Nuthall G, Ong GY, Perkins GD, Reis AG, Ristagno G, Sakamoto T, Sayre MR, Schexnayder SM, Sierra AF, Singletary EM, Shimizu N, Smyth MA, Stanton D, Tijssen JA, Travers A, Vaillancourt C, Van de Voorde P, Hazinski MF, Nolan JP; ILCOR Collabo- rators. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Resuscitation. 2017;121:201–214. doi: 10.1016/j.resuscitation.2017.10.021
Olasveengen TM, de Caen AR, Mancini ME, Maconochie IK, Aickin R, Atkins DL, Berg RA, Bingham RM, Brooks SC, Castrén M, Chung SP, Considine J, Couto TB, Escalante R, Gazmuri RJ, Guerguerian AM, Hatanaka T, Koster RW, Kudenchuk PJ, Lang E, Lim SH, Løfgren B, Meaney PA, Montgomery WH, Morley PT, Morrison LJ, Nation KJ, Ng KC, Nadkarni VM, Nishiyama C, Nuthall G, Ong GY, Perkins GD, Reis AG, Ristagno G, Sakamoto T, Sayre MR, Schexnayder SM, Sierra AF, Singletary EM, Shimizu N, Smyth MA, Stanton D, Tijssen JA, Travers A, Vaillancourt C, Van de Voorde P, Hazinski MF, Nolan JP; ILCOR Collaborators. 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommen- dations Summary. Circulation. 2017;136:e424–e440. doi: 10.1161/CIR. 0000000000000541
Maconochie IK, Richard Aickin R, Mary Fran Hazinski MF, Dianne L Atkins DL, Robert Bingham R, Thomaz Bittencourt Couto TB, Anne-Marie Guerguerian A, Vinay M Nadkarni VM, Kee-Chong Ng KC, Gabrielle A Nuthall GA, Gene Y K Ong GYK, Amelia G Reis AG, Stephen M Schexnayder SM, Barnaby R Scholefield BR, Janice A Tijssen JA, Jerry P Nolan JP, Peter T Morley PT, Patrick Van de Voorde PV, Arno L Zaritsky AL, Allan R de Caen AR, Pediatric Life Support Collaborators. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S140–S184
Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. American Heart Association Emergency Cardiovascular Care Committee. Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117:2162-7.
Sirbaugh PE, Pepe PE, Shook JE, Kimball KT, Goldman MJ, Ward MA, Mann DM. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999;33:174-84.
Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJ, Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010 Oct;81(10):1400-33. doi: 10.1016/j.resuscitation.2010.08.015. PMID: 20956045.
Szpilman D, Soares M. In-water resuscitation— is it worthwhile? Resuscitation 2004;63:25-31.
Tobin JM, Ramos WD, Greenshields J, Dickinson S et all. Outcome of Conventional Bystander Cardiopulmonary Resuscitation in Cardiac Arrest Following Drowning. CARES Surveillance Group. Prehospital and Disaster Medicine. 2020;35:141-147.
Tobin JM, Ramos WD, Greenshields J, Dickinson S, Rossano JW, Wernicki PG, Markenson D, Vellano K, McNally B; CARES Surveillance Group. Outcome of Conventional Bystander Cardiopulmonary Resuscitation in Cardiac Arrest Following Drowning. Prehosp Disaster Med. 2020 Apr;35(2):141-147. doi: 10.1017/S1049023X20000060. Epub 2020 Jan 24. PMID: 31973778.
Travers AH, Perkins GD, Berg RA, Castren M, Considine J, Escalante R, Gazmuri RJ, Koster RW, Lim SH, Nation KJ, Olasveengen TM, Sakamoto T, Sayre MR, Sierra A, Smyth MA, Stanton D, Vaillancourt C; Basic Life Support Chapter Collaborators. Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015 Oct 20;132(16 Suppl 1):S51-83. doi: 10.1161/CIR.0000000000000272. PMID: 26472859.
Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S829-61. doi: 10.1161/CIRCULATIONAHA.110.971069. Erratum in: Circulation. 2011 Feb 15;123(6):e239. Erratum in: Circulation. 2011 Oct 11;124(15):e405. PMID: 20956228.
Young KD, Gausche-Hill M, McClung CD, Lewis RJ. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatrics. 2004;114:157–64.