In water resuscitation is providing a victim air while he is being brought to shore, or a boat. It can only be rendered on the surface, by mouth-to-mouth or mouth-to-snorkel. The question on in water resuscitation is if it really saves a victim our adds to his problem. Brain death starts to occur in about three minutes after the victim stops breathing. In water resuscitation is thought to get oxygen to the brain during the tow to boat or shore. This is based upon the assumption that respiratory arrest is the victim’s only problem, the heart is still beating and the rescuer performs the technique right. If the victim is in cardiac arrest, then all in water respirations are going to do is slow down starting definitive therapy. Another concern is if the victim can be gotten out of the water in less than three minutes, but the rescuer stops to try to establish in water respirations and lengthens the towing time to five minutes, without circulation, then irreversible brain damage may have all ready occurred.
Physiological factors also play in water resuscitation. Most near drowning victims have a blocked airway due to laryngospasm, once artificial respirations start the first reaction of the victim may be to throw up. In the water it is hard to clear or even see the airway and vomitus and water may be forced into the lungs by the rescuer. When the bobbing of the victim and rescuer is added to water action, the rescuer might be forcing aspiration with every breath.
Field experiments of trying to tow a resuscitation dummy, and keep water out of the lungs, while preforming in water respirations show it is almost impossible. Time trials of towing and performing good respiration versus towing and starting resuscitation on land or boat show that it takes almost twice as long to get the victim to shore while attempting in water resuscitation. The question is, does the extra time help or hinder the victim?
The question of whether to attempt in water resuscitation or not is based on judgement. It can be assumed that respiratory arrest preceded cardiac arrest in the drowning victim, thus clearing the airway may be all that is needed to start spontaneous respirations. However not all victims encountered are going be classic near drowning victims, and if a MI is the root cause of the near drowning delaying CPR may be detrimental. Judgement must used as to when to start respirations or not, based on distance to shore or boat and the nature of the cause. In all cases always check and clear the airway on every victim found in the water, this may restart breathing. Keep in mind that respiration without circulation is a waste of time and effort.
Never attempt to give air to a non-breathing person underwater, this could result in the victim’s condition being aggravated, by forcing water into the lungs, or stomach. It also endangers the victim and the rescuer to over pressure injury, and greatly slows ascent. That is not to say that there are no methods for underwater resuscitation. Some people advocate it for situations when free ascent to the surface is denied, as in caves, wrecks, and under ice, but it is our opinion the danger to self, and victim is far too great a risk. Use your time to get the victim to the surface and shore where oxygen and definitive therapy can begin.
A SCUBA regulator is not a ventilator. Do not use it as a demand valve, or IPPD. If used as one, there is no guarantee air will enter the lungs. Air escapes out the exhalation ports. If you fully block the ports, a full pressure up to 180 psi over ambient may by infused into the diver’s lungs. Some regulators may over pressure a victim even with the ports open causing lung rupture. It is not recommended that a SCUBA regulator by used to ventilate a victim. There is a method of delivering air to a non-breathing victim underwater with the second stage, but now more research needs to be done in the effects of this technique.
In water CPR has been suggested, but it is best to wait until in shore or on a boat.

The technique of in water respiration is covered here, as to its useability, it is up to the judgement of the rescuer. Every rescue team should train in the technique and do time trials as well as using resuscitation dummies that allow for measurement of water in the lungs. Learn when and when not to use it.
Artificial respiration may need to given while bringing a victim to shore and this is done via mouth-to mouth, or mouth – to – snorkel. Most snorkels work well, but some are too rigid, and some maybe to long. Snorkels with a purge valve require that you block the valve to prevent air from escaping. Mouth-to-snorkel is a resuscitation technique that can be very useful in rough water, or in rivers.
The question of which method is better often comes up, both work fine in theory. However mouth-to-mouth is harder to maintain. Air can be given by mouth-to-snorkel lower in the water, making towing easier. With mouth-to-snorkel the rescuer, and the victim are more horizonal in the water reducing drag, and your heads do not need to be as close, providing better vision of your line of travel, and more buoyancy can be used. Mouth-to-snorkel does require more time to initiate, good dexterity (which decreases with the temperature) and training. Also it is not easy to detect vomit. Rescue teams should train on both methods because different situations may require one over the other. Which method to use is left to the individual rescuer, he should base his discussion on weighing all the factors and amount of training in each.
When Administering In Water Resuscitation:
Rescue team should work together.

One member should hold equipment so none is lost.

If the victim’s mask is clear leave it on.

The primary need of the victim is air.

Do not totally inflate your or the victim’s BCD.

Attempt to remove gear only after ventilating the victim.

Pay attention to wave and swell action.

Watch your direction of travel.

Pull your mask down around neck

Be sure the victim’s face is above the water.

Remember C-spine injury in trauma, try to bring a C-collar out with you in trauma related rescues. C-spin injury maybe a contraindication to in water respiration attempt due to cervical manipulation, which is almost always done.

Pull down the corner of the victim’s mouth to allow it to drain.

Hook your free arm over the victim’s arm nearest you and place your hand against the back of his neck, forming a fulcrum in which to tilt the victim’s head.

Remove the victim’s mask based on the situation, a mask may seal the nose best, and protect the airway from water.

The nose must be sealed with each breath and the head must be slightly extended to open the airway.

If the victim vomits you need to clear it, and the snorkel if used.

IN WATER MOUTH-TO-MOUTH
Press the heel of your hand on his forehead, tilting it back to open the airway.

Pinch nostrils close.

Turn the victim’s body and head towards yourself and give four quick breaths.

Do not drop weights or mess with any equipment, before attempting to give air.

Travel head first with the victim. Forward momentum will help keep water out of the victim’s face.

Be prepared for the victim to vomit.

If you sink underwater while giving a breath, the seal should be water tight enough to prevent water from entering the victim’s mouth.

Be aware the victim may vomit more than once.

MOUTH-TO-SNORKEL
Start by preforming mouth-to-mouth then switch.

First hold your snorkel above the water to be sure it is clear.

Place the snorkel’s flange over the victim’s mouth, it should be between the victim’s lips and teeth.

Seal the nose.

Due to the greater dead air space the rescuer needs to blow slightly harder and longer. If you become dizzy slow down.

If the victim vomits you need to clear him and the snorkel.