Mouth-to-Nose Resuscitation: A Step-by-Step Guide

Mouth-to-Nose Resuscitation, also termed mouth-to-nose ventilation, functions as a critical intervention for re-establishing respiration in individuals experiencing respiratory failure. This discourse delves into the technique's procedural steps, its scope of application, and how it diverges from other forms of resuscitative measures.

What is Mouth to Nose Resuscitation?

Mouth and Nose Breathing in the form of Mouth-to-Nose Resuscitation offers a secondary route for delivering rescue breaths when the conventional mouth-to-mouth method proves impractical or inappropriate. Here, the rescuer administers breaths by creating an airtight seal with their mouth around the recipient's nose, subsequently inflating the lungs via the nostrils, all while ensuring an unobstructed airway.

Within the realm of emergency healthcare, nose and mouth resuscitation is often endorsed by medical experts as an efficacious alternative, particularly when mouth-to-mouth resuscitation is either unfeasible or less favored. Although the latter remains the gold standard for ventilatory assistance, the former finds its niche in particular scenarios.

A caveat to consider is that Mouth and Nose Resuscitation should be executed with prudence, exclusively by those proficient in first aid protocols and resuscitative techniques.

‍

What is the difference between Mouth to Mouth and Mouth to Nose Resuscitation?

Mouth-to-nose resuscitation and mouth-to-mouth resuscitation are both forms of rescue breathing used to assist someone who is not breathing or experiencing respiratory distress. The primary difference between the two techniques lies in the placement of the rescuer's mouth and the recipient's nose or mouth:

• In mouth-to-nose resuscitation, the rescuer seals their mouth around the person's nose instead of their mouth. The rescuer then breathes into the person's nose, effectively delivering air into their lungs. This technique is useful when the person's mouth is injured or inaccessible due to facial trauma, or in situations where the rescuer feels uncomfortable or reluctant to perform mouth-to-mouth resuscitation.
• In traditional mouth-to-mouth resuscitation, the rescuer covers the person's mouth with their own mouth, creating an airtight seal. They then deliver rescue breaths, allowing air to enter the person's lungs. This method has been widely taught and used in CPR training for many years and is still considered the standard technique in most cases.

Advantages of Mouth-to-Nose Resuscitation

• In cases of facial trauma: If the person has injuries to their mouth or jaw, performing mouth-to-nose resuscitation is a better option as it avoids causing further discomfort or worsening the injuries.
• Hygiene concerns: Some people feels uncomfortable performing mouth-to-mouth resuscitation due to concerns about the risk of infection or transmission of diseases. Mouth-to-nose resuscitation offers an alternative that feels more hygienic.
• Psychological comfort: For some rescuers, providing mouth-to-nose resuscitation might feel less intimate or emotionally distressing than mouth-to-mouth resuscitation, making them more likely to initiate rescue breathing when needed.

Indications for Mouth to Nose Resuscitation

Mouth-to-nose resuscitation is preferred over other methods in specific situations involving infants, children, and adults. Here are some scenarios where mouth-to-nose resuscitation could be the method of choice:

1. Infants and young children: In cases involving infants and young children, mouth-to-nose resuscitation is preferred due to their smaller facial features. It is challenging to create a proper seal during mouth-to-mouth resuscitation on a small child, and the nose might provide a more effective entry point for the rescuer's breaths.
2. Facial injuries or fractures: When the person has facial injuries or fractures, mouth-to-nose resuscitation is more appropriate. This is applicable to all age groups, including infants, children, and adults. It helps avoid causing further harm or discomfort to the injured person.
3. Dental issues: In cases where the person has extensive dental work, mouth-to-nose resuscitation is preferred to avoid dislodging dental appliances or causing harm to dental structures.
4. Unknown medical history and infectious diseases: In situations where the person's medical history is unknown or there is a suspicion of potentially contagious diseases, some rescuers opt for mouth-to-nose resuscitation to minimize direct contact. This is particularly relevant when dealing with adults or children in public spaces or emergency situations where the rescuer cannot be certain about the person's health status.
5. Individuals with oral obstructions: If the person has an oral obstruction, such as foreign objects blocking the mouth or airway, mouth-to-nose resuscitation might offer a better chance of providing ventilation while avoiding interference with the obstruction.

‍

How to do Mouth to Nose Resuscitation?

Here's a step-by-step guide on how to perform mouth-to-nose resuscitation:

Step 1: Assess the Situation

Ensure the area is safe for both you and the victim. Check for any potential hazards or dangers, and call for emergency medical help immediately.

Step 2: Position the Victim

Lay the victim on their back on a firm surface, such as the ground or a flat floor. Ensure their head and neck are in a neutral position, with the airway aligned.

Step 3: Clear the Airway

Gently tilt the victim's head backward and lift their chin to open the airway. If there are any visible obstructions, such as vomit or foreign objects, carefully remove them using your fingers (if possible) or the "finger sweep" technique.

Step 4: Create a Seal with Your Mouth

Place your mouth completely over the victim's mouth and nose to create an airtight seal. Make sure there are no gaps between your lips and the edges of the victim's mouth and nostrils to prevent air leakage.

Step 5: Deliver Rescue Breaths

Take a normal breath and then exhale into the victim's mouth and nose. Watch for the chest rise as you deliver each breath. Each breath should be enough to make the chest visibly rise but not overly forceful. For adults and children, deliver breaths over 1 to 1.5 seconds, and for infants, deliver breaths over 1 second.

Step 6: Observe Chest Movement

After delivering each breath, watch the victim's chest to see if it rises and falls. If the chest does not rise, reposition the head to ensure the airway is open, and check if the victim's mouth and nose are fully sealed during rescue breaths.

Step 7: Repeat Rescue Breaths

Continue delivering rescue breaths at a rate of 10 to 12 breaths per minute for adults, 12 to 20 breaths per minute for children, and 20 breaths per minute for infants. Maintain this rhythm until the victim starts breathing on their own, emergency medical help arrives, or you are too exhausted to continue.

Step 8: Monitor the Victim

While performing mouth-to-nose resuscitation, continuously monitor the victim's responsiveness, breathing, and circulation. If they start breathing on their own, place them in the recovery position and wait for medical assistance.

What is the recommended ratio of compressions to ventilations using Mouth-to-Nose resuscitation in CPR?

The recommended ratio of compressions to ventilations using Mouth-to-Nose resuscitation in CPR is 30 compressions to 2 ventilations for one-rescuer CPR. This means that after every 30 chest compressions, the rescuer should provide 2 rescue breaths through the victim's nose.

Do you need equipment for Mouth to Nose Resuscitation?

Mouth-to-nose resuscitation does not require any specialized equipment. However, certain tools are used to enhance the safety and effectiveness of the resuscitation process. The primary goal of these tools is to prevent infection transmission and provide a safer environment for both the rescuer and the victim. Here are some necessary equipment and their roles:

1. Pocket Mask or Barrier Device: The barrier device allows the rescuer to perform mouth-to-nose resuscitation without direct contact with the victim's mouth and nose. It is important when the rescuer is providing aid to a stranger or in situations where there is a higher risk of infectious diseases. Some pocket masks come with an oxygen inlet, allowing the rescuer to deliver oxygen along with the rescue breaths. This is beneficial in cases where the victim requires a higher concentration of oxygen, such as during cardiac arrest or respiratory distress.

2. Face Shield: A face shield is a clear plastic shield that covers the rescuer's mouth and nose. It provides a protective barrier between the rescuer and the victim during mouth-to-nose resuscitation. Similar to the pocket mask, the face shield helps prevent the transmission of infectious agents from the victim to the rescuer.
3. Gloves: Wearing disposable gloves is essential during any resuscitation procedure. They protect the rescuer from direct contact with bodily fluids, which could carry pathogens. Gloves should be worn whenever providing first aid, including mouth-to-nose resuscitation.

What are the Alternatives for Mouth to Nose Rescue Breathing?

There are several alternative methods of ventilation used in resuscitation, each with its own appropriateness in specific situations. While mouth-to-nose resuscitation is a valuable technique, it is not always the most suitable option. Let's explore some alternatives and their appropriateness:

‍

Mouth-to-Mouth Resuscitation

Mouth-to-mouth resuscitation is a commonly known and widely practiced method. It involves the rescuer placing their mouth over the victim's mouth and delivering rescue breaths. This technique is appropriate when the victim's mouth and airway are accessible and there are no concerns about potential infection transmission. It is commonly used for adults and children in cardiac arrest or respiratory distress.

Mouth-to-Mask Resuscitation

Mouth-to-mask resuscitation involves using a face mask with a one-way valve that covers the victim's mouth. The rescuer breathes into the mask, and the one-way valve prevents exhaled air from entering the rescuer's mouth. This technique is suitable when a barrier is needed to prevent direct contact but mouth-to-mouth ventilation is not possible or preferred. It is often used in healthcare settings and for trained rescuers.

Bag-Valve-Mask (BVM) Resuscitation

The Bag-Valve-Mask (BVM) device is a handheld device equipped with a self-inflating bag and a face mask. It requires two rescuers to operate effectively, one to hold the mask on the victim's face and the other to squeeze the bag to deliver breaths. BVM resuscitation is appropriate in situations where the rescuer needs to provide positive pressure ventilation with higher oxygen concentration, such as in advanced life support scenarios or when an oxygen source is available.

For infants, the mouth-to-mouth-and-nose ventilation technique proves more effective than bag-valve-mask ventilations during CPR simulations conducted by nursing students with an infant model.

Can Mouth to Nose Resuscitation be used on a pet, such as a dog or cat?

Yes, mouth-to-nose resuscitation is used on pets, including dogs and cats, in emergency situations where they are not breathing or experiencing respiratory distress. The technique is similar to performing mouth-to-nose resuscitation on humans, but it requires some adjustments to account for the anatomical differences between humans and animals.

Yes, mouth-to-nose resuscitation is used on pets, including dogs and cats, in emergency situations where they are not breathing or experiencing respiratory distress. The technique is similar to performing mouth-to-nose resuscitation on humans, but it requires some adjustments to account for the anatomical differences between humans and animals.

Are there any cultural or religious considerations that might affect the acceptance or practice of mouth-to-nose resuscitation?

There are cultural or ethical considerations that could influence the choice of mouth-to-nose resuscitation over mouth-to-mouth resuscitation. These considerations vary based on cultural beliefs, religious practices, and individual preferences. Here are some factors to consider:

1. Modesty and Gender Norms: In certain cultures or religious practices, there are specific rules regarding physical contact between individuals of different genders. Mouth-to-mouth resuscitation involves direct contact between the rescuer's mouth and the victim's mouth, which might be seen as inappropriate or violate modesty norms. In such cases, mouth-to-nose resuscitation is preferred as it allows for rescue breathing without direct mouth-to-mouth contact.
2. Infectious Diseases and Hygiene Concerns: Some cultures have heightened concerns about infectious diseases and the potential transmission of germs. Mouth-to-nose resuscitation, which avoids direct contact with the victim's mouth, is perceived as a safer option in terms of infection control.
3. Cultural Taboos: Cultural taboos or traditional beliefs influence the willingness to perform mouth-to-mouth resuscitation. People from certain cultures or communities have reservations about performing mouth-to-mouth resuscitation due to spiritual or traditional reasons, and mouth-to-nose resuscitation could be considered a more acceptable alternative.
4. Animal Resuscitation: In certain cultures, there is a deep bond between humans and animals, and rescuers might attempt resuscitation on pets or animals in distress. Mouth-to-nose resuscitation could be considered a more appropriate method in such cases, as it aligns better with the anatomy of animals.
5. Specific Religious Beliefs: In some religions, there is a specific teachings or interpretations that influence the choice of resuscitation technique. Rescuers might prefer mouth-to-nose resuscitation if it aligns with their religious principles.

‍

It is essential to respect cultural and ethical considerations when providing emergency first aid. Rescuers should be aware of and sensitive to these factors when choosing the appropriate resuscitation method. Training in various resuscitation techniques, including mouth-to-mouth and mouth-to-nose resuscitation, helps rescuers adapt their approach based on cultural and ethical considerations.

‍

What research studies or clinical trials have been conducted to evaluate the efficacy and outcomes of mouth-to-nose resuscitation in real-world emergency situations?

Research studies and clinical trials evaluating the efficacy and outcomes of mouth-to-nose resuscitation in real-world emergency situations are somewhat limited. However, there have been studies examining the effectiveness of various forms of artificial respiration, including mouth-to-nose resuscitation. A recent study recommends the mouth-to-nose ventilation, specially for Infants.

The study focuses on two cases of sudden infant death syndrome (SIDS) and one case of apparent life-threatening apnoea. Resuscitation efforts were made using the mouth-to-mouth route in all cases. Two cases resulted in gastric distension, with milk reflux into the airway. In one case, the mother switched to mouth-to-nose ventilation when unable to cover the baby's nose and open mouth with her own mouth. The case where mouth-to-nose ventilation was used had a positive outcome.

‍

Can mouth-to-nose resuscitation be safely administered to someone who has experienced trauma to the face or mouth?

Yes, mouth-to-nose resuscitation is a safer alternative in situations where the person has experienced trauma to the face or mouth. In cases of facial trauma, performing mouth-to-mouth resuscitation exacerbate injuries or cause discomfort to the victim. Mouth-to-nose resuscitation bypasses the injured area, potentially reducing the risk of further harm and allowing effective ventilation to continue. However, rescuers should always assess the situation carefully and adapt their approach based on the individual's condition and the extent of their injuries.

Importance of CPR and First Aid Training

Mouth-to-Nose resuscitation is typically taught as part of a comprehensive CPR course that covers various life-saving techniques. CPR training increases confidence and preparedness, enhances workplace safety, and promotes community health. Having trained individuals available in various settings contribute to a safer environment and legal compliance. Ultimately, CPR and First Aid training make a significant difference in critical situations, improving the chances of survival and overall public health.

You can receive training in Mouth-to-Nose resuscitation as part of first aid courses offered by various organizations and institutions such as the American Heart Association (AHA), the American Red Cross, National or Local Emergency Response Agencies, Community centers, health clinics, hospitals, and other healthcare organizations conducts first aid training courses for the public. There are also various online platforms that offer certified first aid courses, some of which include Mouth-to-Nose resuscitation training. However, it is essential to ensure that the online course is from a reputable organization.

‍

Sources:

Tonkin SL, Gunn AJ. Failure of mouth-to-mouth resuscitation in cases of sudden infant death. Resuscitation. 2001 Feb;48(2):181-4. doi: 10.1016/s0300-9572(00)00257-4. PMID: 11426480.

Santos-Folgar M, Otero-Agra M, Fernández-Méndez F, Hermo-Gonzalo MT, Barcala-Furelos R, Rodríguez-Núñez A. Ventilación durante la reanimación cardiopulmonar en el lactante: ¿boca a boca y nariz o con bolsa autoinflable? Un estudio cuasiexperimental [Ventilation during cardiopulmonary resuscitation in the infant. Mouth to mouth and nose, or bag-valve-mask? A quasi-experimental study]. An Pediatr (Engl Ed). 2018 Nov;89(5):272-278. Spanish. doi: 10.1016/j.anpedi.2017.12.014. Epub 2018 Feb 21. PMID: 29429863.