The 2026 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science With Treatment Recommendations (CoSTR) contains new and updated recommendations across several resuscitation task forces. This focused review examines three selected adult cardiopulmonary resuscitation (CPR) topics: measured breath volume, manual ventilation bag size and routine intravascular volume therapy.
It is a guide to specific changes, rather than a replacement arrest algorithm or a comprehensive account of the paediatric and neonatal sections.
What has changed?
| Topic | Previous position or question | 2026 recommendation |
|---|---|---|
| Measured tidal volume | The prior ILCOR wording described approximately 600 mL per breath. | Suggests 400–600 mL, or 6–10 mL/kg ideal/predicted body weight, when tidal volume can be measured. |
| Manual bag size | A new focused review asked whether smaller bags should replace standard adult bags. | Suggests a standard adult bag with a maximum capacity of 1,500–1,600 mL. |
| Routine intravascular volume | The 2010 recommendation found insufficient evidence for or against routine intravenous fluids during arrest. | Suggests against routine volume therapy during undifferentiated, nontraumatic CPR; suspected pre-arrest hypovolaemia remains an exception. |
All three suggestions are weak recommendations based on very low-certainty evidence. They should not be described as interventions proven to improve survival. 2026 CoSTR
A measured range for the delivered breath
For adults in cardiac arrest, the updated recommendation suggests 400–600 mL per breath, or 6–10 mL/kg of ideal or predicted body weight, when tidal volume can be measured. The weight-based alternative does not use actual body weight.
The practical change is a measured range rather than the older approximate single volume. It does not establish one ideal volume for every patient. During manual ventilation, enough volume to produce visible chest rise remains a practical approach, but chest rise alone may not confirm adequate ventilation, particularly during continuous compressions.
The underlying evidence is heterogeneous and includes observational studies and small trials. Most included patients had advanced airways, limiting certainty when translating results to other ventilation settings. The review did not establish a consistent survival advantage from larger or smaller volumes. Avoid turning a suggested range into an unsupported claim that one exact setting improves outcomes. Ventilation review and recommendation
A standard adult bag—not a full bag with every breath
ILCOR suggests a standard adult manual resuscitation bag with a maximum capacity of 1,500–1,600 mL during adult CPR. This new bag-size recommendation addresses the proposal to use smaller bags to limit ventilation.
Bag capacity and delivered tidal volume are different quantities. The device recommendation does not mean delivering its entire capacity with each squeeze.
The dedicated systematic review found no randomised clinical trials. Its evidence comprised one before-and-after clinical study and two simulation studies. Clinical observations were vulnerable to confounding, while simulation findings were indirect and inconsistent. The review therefore does not establish that a larger device itself causes better survival, but it does not support routinely substituting smaller bags. Bag-size systematic review
For teaching, keep the equipment choice and the delivered breath as separate decisions. A useful demonstration labels the bag's maximum capacity first, then shows the much smaller volume intended for a measured breath.
Routine fluids: a change in the default
The fluid recommendation is narrower than “do not give fluids in cardiac arrest”. It concerns routine intravascular volume therapy during undifferentiated, nontraumatic CPR.
The previous neutral position has changed to a suggestion against routine administration. However, if the clinical circumstances suggest hypovolaemia before arrest, volume therapy may be reasonable. This exception is a good practice statement.
The recommendation should not be extrapolated into a blanket prohibition for traumatic arrest or fluid management after return of spontaneous circulation. These are separate clinical questions. Volume-therapy recommendation
How should teams use these updates?
For an equipment review, check which adult bags are stocked and how their capacity is explained during training. For ventilation teaching, distinguish a device specification from a delivered-volume target. For fluid discussions, ask whether there is a clinical reason to suspect volume depletion rather than treating fluids as an automatic addition to every arrest.
These are implementation considerations, not additional ILCOR recommendations. Local protocol review should preserve the population, timing, recommendation strength and exceptions.
Clinical takeaway
The selected 2026 changes refine three decisions: how much air is delivered when measurable, which bag is selected, and whether volume therapy has a specific indication. Their usefulness depends on retaining the qualifications. A standard adult bag is not an instruction to deliver its full capacity, and avoiding routine fluids does not mean withholding them when pre-arrest hypovolaemia is suspected.
Original consensus
Bray JE, Djarv T, Drennan IR, Greif R, Liley HG, Scholefield BR, et al. 2026 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations: Summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. Published online 5 November 2026; article 111328. doi:10.1016/j.resuscitation.2026.111328 .
The linked online ILCOR topic pages retain draft-status labels; recommendation wording was cross-checked against accessible sections of the final published consensus. This article covers selected adult updates only.