Agonal Respiration and CPR

The Irony of Agony: Rethinking Agonal Respiration and Its Implications for Dispatcher-led Instructions for Deployment of CPR.

“Is the Patient Breathing?”

The scene is all too familiar. Whether at home with close friends and family or in a crowded social atmosphere surrounded by strangers, a seemingly otherwise healthy individual suddenly collapses and slips into a state of unconsciousness and unresponsiveness.  During this course of events, a bystander decides to help the unconscious person, and thus, calls emergency services for help.  

The dispatcher, in an attempt to guide the responder into performing lifesaving maneuvers, asks the following question:  “Is the patient breathing?”  How the dispatcher interprets the caller’s response to this four-word question has great implications as to the outcome of this emergency.  Indeed, those four simple interrogative words hold the power of life and death.

What is Agonal Breathing?

Simply put, agonal breathing is most accurately described as the gasping process of the autonomic nervous system when the human body enters in a state of extreme distress, such as cardiac arrest or respiratory failure during end-stage lung cancer.  This process is known as agonal respiration or agonal breathing.  However, this is nominally misleading, as agonal breathing is not really breathing at all.  

On the contrary, this process is nothing more than irregular, sporadic gasping which occurs because the brain continues to send signals to the respiratory muscles despite the fact where, in cases of cardiac arrest, the heart has already stopped and the patient is clinically dead. 

Implications of Agonal Breathing

Despite the negative connotation of the title, when it comes to instances of cardiac arrest, agonal breathing is actually associated with a higher rate of survival if correctly identified and proper resuscitation is started immediately^[1]. Taking this into account, it is understandable how this autonomic process has profound implications for bystander responders and dispatchers of these cardiac events. It starts from the way cardiopulmonary resuscitation (CPR) training is conducted, includes the method and delivery of telephone-led dispatcher instruction, and impacts the deployment of defibrillation devices during the critical stages of the event.

Confusion Surrounding Agonal Breathing

First, in order to understand the importance of correct identification of agonal respiration, it is important to understand the nature, physiology, and confusion of the event. This phenomenon can be associated with many very serious conditions, such as cerebral ischemia, hypoxia, anoxia, or cardiac arrest. As noted above, when a person experiences sudden cardiac arrest, even though the heart has stopped, the neurotransmitters of the brain may still send instructions to the respiratory musculature as a survival method, despite the person being “clinically dead.”

There can be much confusion where this is concerned, as agonal breathing is not always present (roughly present in half of cardiac arrest cases), and should not be considered a marker for determining whether or not the patient is breathing, despite the “respiration” or “breathing” portion of its name. Because of this confusion, the problem here arises when a bystander responder–who is most likely to be present during a sudden cardiac event–is unable to distinguish agonal breathing from actual or labored breathing or some other presentation of respiratory distress, and then fails to perform CPR after deeming the victim still has “signs of life.”

Due to this, if a bystander mistakenly identifies agonal breathing for a sign of life, potentially deadly complications can arise. For this reason, CPR guidelines have been updated to lessen the emphasis on checking for “signs of breathing” as a mainstay of the criteria for initiating CPR as part of resuscitation, choosing to place emphasis now on the quality of the perceived “breaths.”

This subtle but profound shift is the official realization if agonal respiration is mistaken for breathing, most bystander responders will not initiate CPR. In fact, according to the University of Arizona’s Sarver Heart Center, “a person who is gasping is not OK – they need chest compressions.”^[2]

Keeping this in mind, it is also imperative 9-1-1 dispatchers be accurate in both understanding the symptoms via responder-provided descriptors over the phone, as well as in providing the correct instructions given to these callers who are reporting symptoms which could be identified as agonal breathing. In an ideal situation, when someone has a sudden cardiac event such as cardiac arrest, there would be a person to perform CPR, a person to call emergency services, an on-site automated external defibrillator (AED), as well as a person who is trained in the use of the AED. Unfortunately, a perfect world does not exist, and if it did, the discussion of cardiac arrest would be nonexistent in the first place, so resourcefulness and educated decision-making can literally be the difference between saving a life and losing one.

Generally, a bystander who witnesses cardiac arrest and agonal breathing will at least call for help. Also, more and more public centers of gathering and commerce have become equipped with life-saving AED devices, so with proper instruction from a 9-1-1 dispatcher, coupled with the accessibility of AED devices, many victims of sudden cardiac arrest have a higher probability of time-critical treatment, which in turn correlates to a higher chance of survival.

Outdated CPR Deployment Methods Still in Use

Humans are in a much more advantageous position, when compared to the times of sprinting to payphones and desperately shouting for the help of a physician or other medical professional who may be out and about nearby. Nevertheless, all of the technology in the world has the potential to become meaningless if dispatcher-led instructions rely on the outdated models of yesteryear.

As mentioned above, the guidelines for CPR deployment have changed to reflect current trends in research. For instance, in 2015, the American Heart Association updated dispatcher recommendations to read as follows: “To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim’s absence of responsiveness and quality of breathing (normal versus not normal). If the victim is unresponsive with absent or abnormal breathing, the rescuer and the dispatcher should assume the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal gasps across a range of clinical presentations and descriptions.^[3]

The main change here is the emphasis on the assumption of cardiac arrest if the signs point in that direction, but are not clearly defined. However, a quick internet search for “CPR guidelines” will return information from 2011, when the American Red Cross still instructed lay responders in their CPR training manuals to check for breathing (not stressing quality), and if breathing is present, open the victim’s airways and monitor for a change in his/her condition while awaiting emergency services.^[4]

Clearly, using the 2011 model from the Red Cross (based on the 2010 guidelines), a person in cardiac arrest with agonal gasping who was misidentified as still breathing may not receive CPR in the time-critical manner necessary to increase survival rates. Also, as mentioned above, if emergency services dispatchers are not well-trained in discerning a layperson’s description of the symptoms of agonal breathing, the dispatcher may be prone to give advice to the patient which is counterproductive and/or downright dangerous.

Implications of Outdated CPR Practices on Patients

The fact many of these outdated manuals are still in use certainly compounds the challenges for consistency in the training of dispatchers, and in turn, in the consistency and efficacy of bystanders in providing life-saving techniques. The implication for a patient who receives chest compressions during agonal breathing, through effective bystander response backed up by a well-trained 9-1-1 dispatcher with clear instructions, is an increased chance of survival versus one who receives assistance from a bystander provided with misinformation and/or incorrect instruction. Hence, because gasping is a survival mechanism of the body, a person who is gasping is in somewhat of a better position than a person who does not.

In fact, recent data shows, “out of 481 patients in cardiac arrest who received bystander CPR, 39 percent of gaspers survived, but only 9 percent of those who did not gasp survived.^[5] Now, based on that information, the implications of incorrect identification of gasping are staggering. If a person who is gasping is thought to be breathing, CPR will not be performed, and the patient’s chances to survive due to this critical treatment during this critical period of time lower significantly.

Now, let’s examine the above study population of 481 patients in cardiac arrest in a different, and somewhat hypothetical, manner. To do this, let’s assume out of these 481 patients, only 200 of them are correctly identified as being in agonal respiration either from a responder alone or from dispatcher-led instruction to a responder. From the above statistics, with the correct use of CPR and/or AED, 39% of these 200 victims – or roughly 78 – will survive. While definitely not a majority, this is an almost fourfold overall chance of survival of 10.6% for EMS-treated cardiac arrests as a whole.^[6]

Now, out of the remaining 281 patients, imagine all are gaspers, but are incorrectly identified as suffering from choking, labored breathing, or respiratory distress instead of agonal breathing due to cardiac arrest. They do not receive CPR or emergency defibrillation with an AED. Every minute these types of treatment are delayed, the chance of survival decreases by seven to ten percent! The implication here, based on the overall survival rate above, is these patients would most certainly expire!

In reflection of the opening example, it is clear the stakes of correct identification of the symptoms of agonal respiration by the responder coupled with accurate training and relaying of instruction by the 9-1-1 dispatcher is essential to the survival of the suffering patient. Therefore, in order to relay correct instruction, it is important 9-1-1 dispatchers ask the appropriate question to differentiate agonal breathing from cardiac arrest from other unusual distressed breathing patterns using up-to-date CPR protocol, and, in turn, instruct the responder in the appropriate manner as to whether or not to begin chest compressions until the AED, EMS team or both arrive on the scene.

Proving the Best Chance of Survival for Patients Exhibiting Agonal Breathing

With the correct training and clear instructions to callers, the 9-1-1 dispatcher can interpret the answer to this powerful four-word question and give instruction with confidence. When the caller – the bystander responder – describes signs of life, and gasping is one of the signs described, the dispatcher can skillfully guide the caller into performing chest compressions until AED and EMS arrive. As noted above, when this is done, the patient has almost a four-fold increase in their chance of survival.

Now, with that said, the overall rate of survival is not very impressive for sudden cardiac arrest. Even so, shouldn’t every patient suffering from this horrible, instantaneous condition have the advantage of competent emergency response dispatchers? Shouldn’t every patient have increased survival chances through competent instructions, especially when the single-largest prerequisite to this boost in survival is simply employing the use of updated training material?

The implications of not implementing these instruction manual updates are enormous for the patient and the responder alike while the goal is crystal clear: not a single unnecessary death due to misidentification of signs of life, including agonal respirations. With the information and updated protocol so widely available to the general population, there is no excuse for outdated and incomplete training of 9-1-1 dispatch operators. As such, every 9-1-1 dispatcher should have a personal copy of the latest American Heart Association updates at their disposal as well as committed to memory.

Access to this free resource, coupled with complete training for proper questioning for and identification of signs of life versus functions of the autonomic nervous system has the potential to save an untold number of lives worldwide; and clearly, implementation of such procedures and training is the key to standardizing protocol to include instructions for immediate chest compressions upon hearing a description of gasping from the caller in question.

1. ^[1]AED Challenge. Recognizing Cardiac Arrest: More Than Meets the Eye. Retrieved from https://www.aedchallenge.com/articles/recognizingsca.php↩
2. ^[2]Univ. of Arizona: Sarver Heart Center (2015). Gasping Is Not Breathing! Retrieved from https:// https://heart.arizona.edu/gasping-not-breathing↩
3. ^[3]American Heart Association (2015). Guideline Updates for CPR and ECC. Retrieved from https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf↩
4. ^[4]American Red Cross (2011). Adult First Aid/CPR/AED Manual. Retrieved from https://www.redcross.org↩
5. ^[5]Univ. of Arizona: Sarver Heart Center (2015). Gasping Is Not Breathing! Retrieved from https:// https://heart.arizona.edu/gasping-not-breathing↩
6. ^[6]Sudden Cardiac Arrest Foundation (2015). Sudden Cardiac Arrest: A Healthcare Crisis. Retrieved from https://www.sca-aware-org↩