In Reply to Dr Cianchetti

To the Editor:

We thank Dr Cianchetti for his inquiry and interest in drowning resuscitation. ¹ The method he describes is, in fact, one of the original forms of drowning resuscitation, dating back to the ancient Egyptians. Depictions of this method can be found in stone carvings in the Pylon of the Ramesseum, dated to 1237 BCE. In this piece, the Great of Aleppo is being held upside down in an effort to drain water from his lungs after a drowning. ² In the time since this carving, our understanding and treatment of drowning have improved, especially with the development of modern cardiopulmonary resuscitation, but ancient methods such as these persist. It does not take much effort to find modern videos of lay-rescuers and professional rescuers holding drowned children and adults upside down as an initial resuscitative technique.

Now is the point in the letter where I should direct readers to the evidence disproving such a method, but unfortunately there is little. Because this is a method that cannot be ethically studied, and given the overall paucity of data on the effectiveness of traditional (and even modern) methods following a drowning, we are primarily left with assumptions and expert opinion based on our understanding of drowning physiology. We know that hypoxemia is the primary cause of morbidity and mortality in drowning. ³ We also know that the duration of hypoxemia correlates with neurologic outcome and mortality. For these reasons, any maneuvers or actions that delay the reversal of this hypoxemia may increase the risk of worsening neurologic damage and mortality. ⁴ This is why methods such as abdominal thrusts (Heimlich maneuver), which were at one time recommended for the initial resuscitation of drowning patients, are currently discouraged. ⁵

As you alluded to, the evidence concerning the actual volume and effect of water aspiration are murky at best; additionally, many of the studies done in animals have used forced aspiration of large volumes, which may not be applicable to humans. The prevalence of laryngospasm, as well as differences in fluid shifts due to water salinity, are also not well understood. Most importantly, considering real-world education and treatment application, we believe that focusing on these minute details may cause a responder to miss the forest for the trees—or, in this case, the ocean for the waves. Given the effect of hypoxemia duration on patient outcome, it makes sense that the initial treatments can have the greatest effect on outcome. For this reason, we advocate strongly for focusing primarily on the initiation of positive pressure ventilations in patients not breathing adequately after a drowning. ⁶ We strongly advocate for avoiding maneuvers and treatments that may take the focus away from initiating these ventilations, such as abdominal thrusts, continuous suctioning, and spinal “immobilization.” If initial attempts at ventilation are unsuccessful, maneuvers to clear the airway may be initiated with the goal of reattempting ventilations as soon as possible.

In Dr. Cianchetti’s letter, he is not wrong in stating that “Putting a child upside down delays mouth-to-mouth breathing for a few seconds, a delay that is probably irrelevant.” In discussions on drowning resuscitation, we scratch and claw at these seconds, much like stroke and cardiac arrest scientists; however, those of us who deal with all of these diseases know “a few seconds” probably is not, in fact, the division between life and death. What does divide life from death in these diseases is the presence of a provider who has a sound understanding of the presenting pathophysiology and well-practiced skill. We believe firmly that the only way to optimize treatment on a global scale is to keep the message simple and clear: Minimize time to the reversal of hypoxemia. By advocating for maneuvers and treatments that delay time to ventilation, we run the risk of adding to the numerous other misguided use of “seconds” that are often encountered during a resuscitation. In the end, these can add up to have a profound effect on the clarity of the message and, most importantly, on patient outcome.