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The purpose of this study was to evaluate the effect of real-time audio ventilation feedback on the survival of patients with an out-of-hospital cardiac arrest (OHCA) during advanced cardiac life support (ACLS) performed by paramedics. This research was a prospective randomized controlled study performed in Busan, South Korea, from July 2022 to December 2022. This study included 121 patients, ages 19 and up, who were transferred to the study site, excluding 91 patients who did not receive CPR under a doctor's direction as well as those who had a '(DNR)' order among 212 adult CA patients. OHCA patients' clinical prognosis was compared by being randomly assigned to either a general manual defibrillator (NVF) group (N = 58) or a manual defibrillator with an audio ventilation feedback (AVF) group (N = 63). To verify the primary outcome, the cerebral performance category (CPC), return of spontaneous consciousness (ROSC), 30h survival, and survival discharge were compared. Multivariate logistic regression was conducted to analyze the association between the audio-feedback manual defibrillator (AVF) and the ROSC of OHCA patients. This study analyzed 121 patients among 212 OHCA patients. The ROSC (AVF group: 32 {26.4%} vs. NVF group: 21 {17.3%}), 24 h survival (AVF group: 24 {19.8%} vs. NVF group: 11 {9.0%}), and survival discharge (AVF group: 12 {9.9%} vs. NVF group: 6 {4.9%}) were higher in the AVF group than the NVF group. However, upon analyzing CPC scores in the surviving patients between the two groups, there was no significant difference (AVF group: 4.1 ± 1.23 vs. NVF group:4.7 ± 1.23, p = 1.232). Multivariate logistic regression analysis showed that the use of AVF was associated with a higher ROSC (odds ratio {OR}, 0.46; 95% confidence interval {CI}, 0.23–0.73; p < 0.01) and higher survival at 30 h (OR, 0.63; 95% CI, 0.41–0.98; p = 0.01). [ABSTRACT FROM AUTHOR]