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.
Seesink J, Thom O, Johnson S, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD. on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force(s).
Oxygen administration following drowning Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, <<INSERT DATE>>. Available from: http://ilcor.org.
In 2015 the ILCOR CoSTR for oxygen administration suggested “CPR with supplemental oxygen administration of the highest possible inspired oxygen concentration (weak recommendation, very-low-quality evidence)” [Soar 2015 e71]. The evidence base informing this recommendation is limited to one 1 observational study [Spindelboeck 2013 770]. An evidence update in 2020 found no new data to change the 2015 recommendation [Berg 2020 S92, Maconochie 2020 A120]. Unlike the majority of adult cardiac arrests and some paediatric cardiac arrest which arise primarily due to a cardiac cause, drowning leading to cardiac arrest is primarily caused by hypoxia. Whether a different approach in the specific circumstances associated with drowning warrants an alternative approach is uncertain.
This 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 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 Jeroen Seesink and Ogilvie Thom 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 drowning2
Oxygen administration before hospital arrival
No oxygen administration before hospital arrival
Critical 9: Survival to discharge / 30 days or later
Critical 8: Survival with favourable neurological outcome to discharge / 30 days or later
Critical 7: 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 as long as there is an English abstract
Database inception to current time.
1A broad definition of cardiac arrest will be used including those who are unconscious and not breathing normally or those requiring resuscitation interventions e.g. chest compressions, defibrillation.
2 Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid
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, 417 titles and abstracts were reviewed. Full text review was conducted for 59 papers (57 from search and 2 from citation searching). No studies were identified which addressed the PICOST question.
When available, we recommend trained providers use the highest possible inspired oxygen concentration during pre-hospital resuscitation for adults and children in cardiac arrest following drowning (Good practice statement).
Justification and Evidence to Decision Framework Highlights
Drowning is the third leading cause of unintentional injury related deaths around the world. Morbidity after initially successful resuscitation is high with many survivors experiencing unfavourable neurological outcomes due to brain hypoxia. Developing evidence-based treatment recommendations to aid those attempting to resuscitate people following drowning is therefore a high priority.
Whilst no direct evidence relating to the use of oxygen during resuscitation from drowning the review team noted:
- Hypoxemia is associated with worse outcomes [Spindelboeck 2013 770, Shenoi 2017 770, Cantu 2018 446, Cohen 2019 446, Bjertnaes 2021 641633, Jung 2003 287]
- Prompt initiation of bystander CPR, meaning a rapid response to reduce hypoxemia, is associated with better outcome in drowning [Gässler 2020 871, Claesson 2014 644, Tobin 2017 39, Fukuda 2019 110, Kyriacou 1994 137, Szpilman 2004 25].
- The use of supplementary oxygen (when it is available) during and after CPR is accepted practice in drowning resuscitation, but in other circumstances (e.g., acute myocardial infarction), there is increasing evidence that prolonged administration of high-concentration oxygen may be harmful [Kilgannon 2010 165, Bellomo 2011 R90, Kilgannon 2011 2717, Elmer 2015 49, Stub 2014 2143].
- There are no adult human studies that directly compare maximal inspired oxygen with any other inspired oxygen concentration in CPR.
The review group considered that the current general acceptance of oxygen to be beneficial during drowning resuscitation is most of all based on the current understanding of the physiology of the hypoxic cardiac arrest mechanism and the decreased oxygen diffusion capacities of the lungs due to aspiration of water or other causes. Given the association between hypoxia and adverse outcomes, the use of oxygen to reduce hypoxia during resuscitation has strong face validity. The group considered it unlikely that the addition of supplemental oxygen during resuscitation would have a large negative effect. At the same time, adding oxygen could increase the complexity of resuscitation algorithms. The group therefore recommends that if oxygen is available, it use is limited to providers trained and practiced in the administration of oxygen during resuscitation.
Oxygen therapy is expensive both in terms of equipment and training required for effective delivery. The use of supplemental oxygen has regulatory restrictions in some countries and access to it may be limited in low and middle income countries. Those responsible for deciding whether to make oxygen therapy available will need to weigh the costs, regulatory requirements, setting, the skills and training needs of those with a duty to respond, the time taken for an advanced life support provider to arrive with oxygen, against the potential but uncertain benefits. Storage of oxygen should be regulated and be part of the training.
Oxygen is available in many aquatic facilities as pools and beaches to be used for drowning resuscitations. In some countries this is legally obliged. Many international organisations as the ILS and DAN have initiated position statements and oxygen provision courses for their members.
Although in a clinical and professional prehospital setting, following return of spontaneous circulation guideline recommend the effect of oxygen should be monitored with pulse oximetry, there is uncertainty about its effectiveness in the early stages after drowning due to movement and hypothermia reducing signal quality. The high-cost low-benefit balance of the additional equipment during initial resuscitation is not in favour of pulse oximetry monitoring during resuscitation (O’Driscoll 2017 11000170, Monteny 2011, 1235).
This treatment recommendation focuses on the use of oxygen during resuscitation from drowning. Following, successful initial resuscitation the review group advocates that providers follow ILCOR’s treatment recommendations for the titration of oxygen following return of spontaneous circulation [https://costr.ilcor.org/docume...].
Bellomo R, Bailey M, Eastwood GM et al. Arterial hypoxaemia and in-hospital mortality after resuscitation from cardiac arrest. Crit Care. 2011;15:R90
Berg KM, Soar J, Andersen LW, et al; Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S92–S139.
Bierens j, Abelairas-Gomez C, Barcala Furelos R et al. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021;162: 205-217
Bjertnaes LJ, Hindberg K, Naesheim TO, et al.; Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med. 2021; 8;article 641633
Cantu RM, Pruitt CM, Samuy N, Wu CL. Predictors of emergency department discharge following pediatric drowning. Am J Emerg Med 2018;36:446-9. Claesson A, Lindqvist J, Herlitz J. Cardiac arrest due to drowning – changes over time and factors of importance for survival. Resuscitation. 2014;85: 644-48
Cohen N, Capua T, Lahat S, Glatstein M, Sadot E, Rimon A. Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning. Eur J Pediatr 2019;178:1379-84.
Elmer J, Scutella M, Pullalarevu R, Wang B, Vaghasia N, Trzeciak S, et al. The association between hyperoxia and patient outcomes after cardiac arrest: analysis of a high-resolution database. Intensive Care Med. 2015;41(1):49-57.
Fukuda T, Ohashi-Fukuda N, Hayashida K, Kukita I. Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest in Japan, 2013-2016. Resuscitation. 2019;141:111-20
Gässler H, Helm M, Hossfeld B, Fisher M. Survival Following Lay Resuscitation. Dtsch Arztebl Int. 2020;117:871-77
Jung CY, ChaSI, Jang SS, et al. Clinical feature of submersion injury in adults. Tubercu Respir Dis 2003;55:287-96.
Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, et al. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010;303(21):2165-71.
Kilgannon JH, Jones AE, Parillo JE et al. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation. 2011;123:2717-2722
Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994;94:137-42
Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric life support: 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2020;156:A120-55
Moller JT, Jensen PF, Johannessen NW, Espersen K. Hypoxaemia is reduced by pulse oximetry monitoring in the operating theatre and in the recovery room. Br J Anaesth. 1992;68(2):146-50.
Montenij LJ, de Vries W, Schwarte L, Bierens J. Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: A preliminary study. Resuscitation. 2011;82(9):1235-8.
O'Driscoll BR, Howard LS, Earis J, Mak V. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017;4(1):e000170.
Shenoi RP, Allahabadi S, Rubalcava DM, Camp EA. The pediatric submersion Score Predicts Children at low risk for injury following submersions. Acad Emerg Med. 2017;24 (12): 1491-1500
Spindelboeck W, Schindler O, Moser A, Hausler F, Wallner S, Strasser C, Haas J, Gemes G, Prause G. Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission. Resuscitation. 2013; 84:770–775.
Szpilman D, Soares M. In-water resuscitation- Is it worthwhile?. Resuscitation. 2004;63: 25-31
Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, Cameron P, Barger B, Ellims AH, Taylor AJ, Meredith IT, Kaye DM; AVOID Investigators. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50. doi: 10.1161/CIRCULATIONAHA.114.014494. Epub 2015 May 22. PMID: 26002889.
Tobin JM, Ramos WD, Pu Y, Wernicki PG, Quan L, Rossano JW. Bystander CPR is associated with improved neurologically survival in cardiac arrest following drowning. Resuscitation. 2017; 115: 39-43
Wang HE, Prince DK, Drennan IR, et al; Resuscitation Outcomes Consortium (ROC) Investigators. Post-resuscitation arterial oxygen and carbon dioxide and outcomes after out-of-hospital cardiac arrest. Resuscitation. 2017; 120:113–118. doi: 10.1016/j.resuscitation.2017.08.244