The American Health Association altered the CPR order of priority from A-B-C, Airway, Breathing, Compressions to C-A-B. Initiate chest Compressions; check the Airway; commence supportive Breathing. The Breathing now comes last in the CPR trinity.

The updates were presented in a recent pediatric advance life support training class. In that two-day learning exercise we were guided through different life threatening scenarios and how to deal with them. The most common challenge in kids is respiratory distress and failure.

Respiratory failure is when the body is unable to take in adequate oxygen and expel the proper amount of carbon dioxide. It is the break down of the adage: in goes the good air, out goes the bad. Not enough good air goes in and not enough bad air comes out.

In spite of the order in CPR, breathing is being alive. It is the perfect universal symbol of life. Rich and poor, good and bad, wise and foolish, old and young, all breathe; all take in the same molecules. Without good air we all would perish.

In medical school they taught the universality of breathing. There is a calculation called “Caesar’s last breath.” You could pick your own hero from the past, but the idea is the same. Assuming Julius Caesar exhaled a liter of air after Brutus stuck it to him, that volume equals 10²² molecules. That is 10 with 22 zeros trailing after it. Assuming these atoms mixed with all the molecules of the atmosphere, we breathe in one molecule from the Roman Emperor’s last breath (see the Physics World website at or for their calucations). “Et tu, Brute.”

Beyond the universality of breathing there is a larger world of symbols we have about inhaling the good and exhaling the bad. If we figuratively breathe in the beauty of art, music and the world around us and rid ourselves of ugliness, acoustical insults and artificiality, the net gain would be personal betterment.

This is also a powerful picture of pulling in and pushing out. We take in love and exhaust our hatred. We attach to goodness with inhaling and detach from bad dreams, memories of self-doubt and criticism as we let our air escape. Visualize the negative blown away by the gusts of our self-generated emotionally positive hurricanes. Inversely we inhale the worries of others and return reassurance.

Focused breathing is more than just symbolic. Biologically as we slow the muscles of the chest and diaphragm we equally decelerate our thoughts and automatic gunfire of impulses. Our lives become simpler if we concentrate more on breathing and less on our stresses that automatically speed up respiratory rates.

Furthermore, we can’t inhale gold or silver. They are irritating. They would be like asbestos. Large homes and fast cars stick in our airways like a piece of half-chewed steak. If we devote our lives to always sucking in, there would be no good air left and the bad air would be trapped.

In goes the good air and out goes that bad.

This ebb and flow of air inside us is strikingly reminiscent of other natural phenomenon. Waves washing on to a beach and receding, breezes moving the trees back and forth and as the chest rises and falls, so does the sun rise and set.

To bring in more air, our bodies must take in deeper volumes and/or increase our respiratory rate. When we exercise or when we are ill with a fever or stress, our body demands more oxygen and produces more CO2. To make up for acelerated needs, the body increases the rate and/or volume.

All of that is automatic. But what if we were to consciously concentrate on our own breathing and reverse the trend during times of stress? We slow down and decrease the effort. What if we put away all of our worldly cares and just direct our attention on essential in and out of breathing? It would contrast mightily with stressed states or times of illness.

This emulation of the natural rate and depth of breathing takes us back to our genesis. In the creation story shared around the world, humans were jump started into existence by a breath of life. That returns us to CPR and C-A-B, giving the breath of life.

So remember, in spite of the AHA, on any test the answer is always B.

Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for 30 years, and a clinical associate professor of pediatrics at the University of Utah. Email: [email protected]