CHESTCHEST NewsCHEST responds to American Heart Association’s 2021 Interim Guidance

CHEST responds to American Heart Association’s 2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19

The timely initiation of high-quality cardiopulmonary resuscitation (CPR) is the bedrock of effective treatment for victims of cardiac arrest. Rapid CPR, accompanied by defibrillation when appropriate, leads to improved outcomes, with higher odds of successful return of spontaneous circulation (ROSC) and greater likelihood of neurologic recovery.

In its most recent updated guidance on the provision of basic and advanced cardiac life support during the ongoing COVID-19 pandemic, the American Heart Association (AHA) appropriately re-emphasizes the importance of rapid, high-quality CPR. However, the AHA also states that chest compressions in CPR should be initiated regardless of whether the rescuer has appropriate personal protective equipment (PPE), specifically recommending that “ chest compressions should not be delayed for retrieval and application of a mask or face covering for either the patient or provider.”1 We must respectfully disagree with this change in public health recommendation.

At the time of this writing, the Omicron variant is the prevailing form of SARS-CoV-2 in the United States.2 While data continue to emerge, it seems clear that Omicron is more likely to evade immunity from prior infection and vaccination.3 In its guidance, AHA states that chest compressions without PPE “is likely low risk to the compressor,” but no evidence is provided to support this statement; the references provided for the statement refer to studies and a systematic review related to SARS and MERS (two distinct viruses with different risk profiles).4-6 A stronger evidentiary basis must be employed when an increased potential for risk to health care workers (HWCs) is present.

For in-hospital cardiac arrests, PPE is both widespread and easily accessible in a majority of settings. Most hospitals require clinical staff always to wear medical masks in patient care areas. In the unlikely event that a rescuer did not have a medical mask available during an in-hospital arrest, the time needed to don a mask and eye protection before chest compressions would almost certainly be very brief.

For out-of-hospital arrests with bystander CPR, PPE availability and mask usage will likely be lower, but, without study and substantiation, we cannot state that the risk is low. Regarding PPE use for emergency medical system (EMS) personnel, we assert that there is no suitable reason for EMS to lack PPE when responding to an emergency when we are 2 years into a pandemic.

Looking at other best practices in patient care, we assume that AHA continues to recommend rescuers wear gloves during CPR, despite the low risk of contracting HIV or viral hepatitis. We also assume that EMS personnel approaching an active tactical environment are still expected to wait for the scene to be secure before entering. With regards to risk to personnel, the CPR situation should be viewed similarly.

Health care workers (HCWs), particularly those in emergency medicine and critical care settings, continue to bear extraordinary burdens during the COVID-19 pandemic. Our professional organizations must advocate for both our patients and for our colleagues.

We acknowledge that the risk of death from COVID-19 to HCWs is low, but the risk of infection may be high, especially during times of high community transmission. Additionally, HCWs infected with SARS-CoV-2 place their patients and communities at risk and are unavailable to care for patients during their isolation. This is particularly critical considering ongoing staff shortages in many health systems.

Based on what the AHA has demonstrated, we believe there is insufficient evidence to change the current standard of practice and hope that HCWs will be permitted to take the brief time required to apply a proper surgical mask, eye protection, and gloves. We respectfully disagree with the AHA’s position, and we urge them to update their guidance after more thorough, evidence-based exploration of the harms and benefits to patients and HCWs. We urge the AHA to join CHEST and other leading medical societies in advocating for proper PPE and the protection of first responders during the pandemic.


1. Hsu A, Sasson C, Kudenchuk PJ, et al. 2021 Interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19. Circ Cardiovasc Qual Outcomes. 2021;14:e008396.

2. Centers for Disease Control and Prevention. COVID-19 Data Tracker. . Accessed online Dec 31 2021.

3. CDC COVID-19 Response Team. SARS-CoV-2 B.1.1.529 (Omicron) Variant - United States, December 1-8, 2021. MMWR Morb Mortal Wkly Rep. 2021;70:1731-1734.

4. Abrahamson SD, Canzian S, Brunet F. Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome. Crit Care. 2006;10:R3.

5. Killingley B, Horby P. New and emerging respiratory virus threats advisory group. Accessed online May 20, 2021.

6. Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020;151:59-66.