# Quick asthma scenario q from school...



## bunkie (Sep 29, 2009)

Would have posted in the other thread but its a little scary there right now.

Last night during a scenario I was an asthma pt, 9 on my pain scale. Wheezing, struggling to breathe. Inadequate respiration's.

Now, should I not have been treated with a BVM? Because my girl gave me a NRM and the evaluator never said anything about it being wrong. We've been taught if its _adequate_, *NRB*. If its _inadequate_, *BVM*. So now I'm confused.

Thanks in Advance.


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## VentMedic (Sep 29, 2009)

What was the cause of her pain?  Do you mean 9 on a Dyspnea scale?


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## MrBrown (Sep 29, 2009)

The problem with asthma is *not* getting air in but rather, getting air *out* which is a common misconception (and one I was lead to believe at first).

An asthmatic patient is using acessory muscles and thier intercostals to draw air in, but they do not have the strength required to force it out.  As a result they become very tired and hypercapenic which (eventually) will cause them to stop breathing because the high level of carbon dioxide will overwhelm the chemoreceptors that control voluntary respiration.

You should be using a nebuliser mask and not a non-rebreather because you can't neb ipatropium or salbuatmol through a NRB 

If the patient stops breathing you want to bag them *very* slowly to avoid dynamic hyperinflation, if that happens you're gonna run into our good friend PEA. I have been taught 6 breaths a minute and no more.

Hope that helps.


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## VentMedic (Sep 29, 2009)

If the person is still alert, you will have a difficult time placing a BVM over their face.  They already feel like they are sufficating.  As well, this patient may want to be in a tripod position to assist their accessory muscles.  Taking them out of that position may not benefit them.    Also, you may not be able to bag them very easily as their airways are narrowed and/or mucus filled.  If the patient does go unconscious, you may still have a difficult time bagging them. Air may also follow the path of least resistance which will be the stomach so care must be taken for that also.


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## Melclin (Sep 29, 2009)

After having glossed over the other thread I think saying this might lead to a bit of an explosion...but are we to assume you don't have albuterol/atrovent?

I'm not sure I understand why your be using a BVM on a conscious asthma pt seeing as though their problem is more likely to be with expiration rather than inspiration, not to mention that its a nightmare trying to breath through a BVM - surely it just makes matters worse. 

We only _ventilate_ pts when they are apneic. Otherwise it's supplemental O2 with nebulised salbutamol/atrovent.

Which leads me to something I've been wondering, how do you guys over there put people on ~100% O2?


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## Melclin (Sep 29, 2009)

MrBrown said:


> If the patient stops breathing you want to bag them *very* slowly to avoid dynamic hyperinflation, if that happens you're gonna run into our good friend PEA. I have been taught 6 breaths a minute and no more.



Do you guys advocate "gentle lateral chest pressure" in dynamic hyperinflation over there (NZ and the US). Its a pretty contentious issue here.


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## MrBrown (Sep 29, 2009)

If the patient is severely hypoxemic you should be nebulising salbutamol but if you are unable to do so, then use a non-rebreather mask.

If the patient goes into resp arrest you should bag them slowly to avoid overinflation of the lungs and cardiac arrest.

The balance of risk here is rapid transport and arrange for advanced backup to meet you enroute if they can intercept you significantly faster than you can deliver the patient to hospital; the patient needs bronchodialators, adrenaline, some of those sexy designer steriods like hydrocortisone and perhaps intubation.


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## MrBrown (Sep 29, 2009)

Melclin said:


> Do you guys advocate "gentle lateral chest pressure" in dynamic hyperinflation over there (NZ and the US). Its a pretty contentious issue here.



Nope.


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## EMSLaw (Sep 29, 2009)

Melclin said:


> After having glossed over the other thread I think saying this might lead to a bit of an explosion...but are we to assume you don't have albuterol/atrovent?
> 
> I'm not sure I understand why your be using a BVM on a conscious asthma pt seeing as though their problem is more likely to be with expiration rather than inspiration, not to mention that its a nightmare trying to breath through a BVM - surely it just makes matters worse.
> 
> ...



Nebulizers, and essentially all medications, are outside the scope of practice of an EMT-Basic in the US.  If the patient has a prescribed asthma inhaler, Basics can administer it to them.

A BVM (if connected to an oxygen tank, of course) will provide 100% O2.  You don't have to squeeze the bag.  Nasal canula, NRB mask, and BVM are the only three options, really.  Well, or a rescue mask with O2 port, but I haven't seen that used on an ambulance, it's more a first responder thing.


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## MrBrown (Sep 29, 2009)

Melclin said:


> I'm not sure I understand why your be using a BVM on a conscious ...pt



I'd sure too like to know mate ... I've heard some US folk say they would use it for tachypneic patients to see if they will "comply" with it.


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## thowle (Sep 29, 2009)

How many times per minute were you breathing?  What was the breath like?  Solid inhale, decreased exhale?  What was Sp02?  It all depends on what the real situation was and is...

From my understanding, in an alergic asthma reaction of course the smooth muscles constrict causing the airway to be comprimised by making is smaller than what it already is, not to mention the possibility of airway edema and increased mucus production while ige immunoglobulins try to win the stimulant challenge. 

As for BLS, I'd say just give oxygen 100% by NRB, monitor, if breathing drops, vent  BVM but, remember what's happening.

It's like trying to force a golfball down a garden hose.. kinda.. well, not really.. but it's constricted.. so even if you try to PUSH the air down it, you're only helping them by alleviating a lot of their musscle usage in respirations; you probably can't really push more air than they were able to.


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## MrBrown (Sep 29, 2009)

thowle said:


> ...an alergic asthma reaction...



If I may mate, that's not "asthma" thats anaphylaxis


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## thowle (Sep 29, 2009)

MrBrown said:


> If I may mate, that's not "asthma" thats anaphylaxis



That could be correct; but what I meant was allergen stimulated asthma, otherwise known as "Allergic (extrinsic) Asthma".


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## MrBrown (Sep 29, 2009)

thowle said:


> That could be correct; but what I meant was allergen stimulated asthma, otherwise known as "Allergic (extrinsic) Asthma".



Fair enough mate.


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## thowle (Sep 29, 2009)

MrBrown said:


> Fair enough mate.



You be right though   What I initially said would be anaphylactic.


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## VentMedic (Sep 29, 2009)

Let me continue this over here since it is a similiar discussion. These are important issues that should be understood when treating different diseases. 



> Originally Posted by *MasterIntubator*
> Maybe so.... but out of the 100 or so cases of interest that I am my *fellow trained EMT-Bs have had, we have had success.*


 
By this, I take it you mean you got them to the hospital alive?
For many asthmatics, they need some nebulizers, steroids and fluids. However, one should not think asthma is not a serious disease because you haven't seen status or one decompensate. 

As an EMT-B, you probably had no option but to bag if a patient stops breathing. For the breathing asthmatic however, that may NOT always be the best treatment. If one does choose to bag someone they should understand compliance and resistance as it pertains to the disease process. It is a little more than just squeezing a bag. Do you NOT understand what is meant by pathophyisology or disease process and how to apply it to whatever equipment you are using? 



> Originally Posted by *MasterIntubator*
> And as far as barotrauma, it did not make a difference what mechanical delivery method was used ( BLS/ALS/Anesthesiology circuit/NPPV/brochos/etc ). What we did find out, is that many of them did not decompensate further with assisted BVM, even with trained inexperienced folks. Some did... even in the ER setting. So that leads me to believe that sometimes you can't do anything to help those folks


 
One must understand the difference between BAROTRAUMA and VOLUTRAUMA. 

An asthmatic can hold their own for quite awhile which is why this leads some to believe what they did in the field "fixed" the patient or it was a save. Decompensation is not a good thing and it should be avoided. This is why EDs usually have immediate access to HeliOx, BANs and the ability to get different medications. Once an asthmatic starts to decompensate, if the ED does not have much advance technology, the patient may die or at the very least end up with 2 chest tubes which then only complicates the situation further. 



> Heck, if you want to get exotic, might as well place pressure along the thorcic cavity to assist in expiratory effort.


 
Nothing exotic about this either as it is done in other countries as well as being trialed in this country. 




> In my BLS days, I have had many of the same questions and problems. We had less ALS folks to jibber jabber physiological effects and analyze the 'whys' and 'what fors' during an emergency. I knew about the basic physiology as taught. Anything greater was doctor stuff.
> But ya know.... it freakin worked when you needed it the most.
> Than as time went on, I learned more and why... but things have not changed that much... I am just more aware and have better understanding.


 
Again, another downfall in EMS is this BLS and ALS mess. Being BLS is not an excuse for not being aware of the complications of using a BVM or not having a basic (not as in BLS) understanding of the disease processes. 




> Holy crap we can get out panties in a bunch over a *rare barotrauma*. ( the top FASC docs still can't agree on it )
> That is why I wasted the time to put in my first writing about training... obtaining skills... and not be over zealous. I am sure one of the *professional* EMTs who has studied had read it fully and got the point


 
Barotrauma? There is nothing exotic about this. Doctors do argree it and *VOLUTRAUMA* exists. What can't be agreed upon is the best treatment and technology for it. 

We STRIVE to make both BAROTRAUMA and VOLUTRAUMA "rare". This is why we spend over $50K for each ventilator and have many different gases and medications available. 



> Just like with all the posts... there is something in them all for someone. Learn it all young folks, learn ALL the ways. It will come.


 
This I agree with but one should not just view the BVM as a simple little BLS tool. It should be understood well as any other piece of medical equipment. 

Understanding the disease processes and knowing one's limitations can not be stressed enough. Getting an SpO2 on an asthmatic DOES NOT necessarily mean you are winning the war. You may not even be winning that battle if you have not lung sounds indicating air movement with that SpO2 of 100%. 

There are a few disease processes that may just require a quick RSI and placement on the best technology available with the appropriate gases and medications.

In the ED, we just know we can not spend much time bagging a severe asthmatic, ARDS and some PNAs including PCP and that from a potent strain of Influenza A. 

However, I can use a BVM a cardiac arrest patient with no active pulmonary disease or a COPD patient for as long as it takes to finish a code, intubate or transfer to a more appropriate place for intubation. I just know the types of patients that I prefer not to prolong bagging or in some cases do as little BVM as possible.


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## VentMedic (Sep 29, 2009)

EMSLaw said:


> A BVM (if connected to an oxygen tank, of course) will provide 100% O2. *You don't have to squeeze the bag.* Nasal canula,


 
Unless you are carrying an Ayres, Jackson Reese or anesthesia type bag, just placing a self inflating bag on their face can be called suffication. There must be a tight seal and they must be able to generate between -20 to -40 cmH2O of pressure to open the valve and receive oxygen.


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## VentMedic (Sep 29, 2009)

What's the use?  Just like the other thread I'm wasting my time because the posts will be deleted if they are too technical.


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## Lifeguards For Life (Sep 29, 2009)

VentMedic said:


> What's the use?  Just like the other thread I'm wasting my time because the posts will be deleted if they are too technical.



i'm not fully sure why the other thread got locked, granted i did not read it all.


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## MrBrown (Sep 29, 2009)

EMSLaw said:
			
		

> A BVM (if connected to an oxygen tank, of course) will provide 100% O2. You don't have to squeeze the bag.



WTF dude seriously; the only kind of er .... dealies, i dno that do that are in the operating room.

Yes, *squeeze the bag*!


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## Lifeguards For Life (Sep 29, 2009)

MrBrown said:


> WTF dude seriously; the only kind of er .... dealies, i dno that do that are in the operating room.
> 
> Yes, *squeeze the bag*!



yes, you have to squeeze the bag.... A BVM does not function quite the same way as a NRB


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## Melclin (Sep 30, 2009)

I was wondering because when we want to give ~100% (used also for vents of all kinds) we use our closed circuit gear. Its like what you'd see in a OR with in and out paths on the mask and a separate balloon style bag. You can breath spontaneously through them and gauge the resps by how much the bag infates/deflates etc.

I think I may have asked this before, but does anyone else use these?







Unless you're using different BVM to us you really don't want to put one on a person who is trying to spontaneously breath. Try it out yourself. It bloody hard work. Even for a healthy person.

VENT: Whats this about posts being deleted for being to technical? Thats BS! Are you serious? Tell me where too complain and I'll scream like a banshee.


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## MrBrown (Sep 30, 2009)

Melclin said:


> Whats this about posts being deleted for being to technical? Thats BS! Are you serious? Tell me where too complain and I'll scream like a banshee.



One of the asthma threads got wiped out


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## mycrofft (Sep 30, 2009)

*Vent, don't get discouraged. Good stuff there.*

Here's .02$:
Oxygen ported pocket or rescue masks: Their plastic goes bad, stock plain ones and BVM's. If you have room for a cylinder you have room for a BVM. BE SURE TO HAVE AIRWAYS, BVM's are remarkably more effective with them. (NOTE: most BVM masks and pocket masks are interchangeable, same sized fitting).

Always weigh treatment and condition against time. What time frame do you have, how fragile is the pt, how fast will ths tx work and how long to do it?

Don't do anything silly parenterally. 

If the pt is not crashing but is caught early, a calm patient in a cool (not cold) dry (not arid) environment can turn around for the better. Yelling, barging around and cutting/ripping/jumping are not conducive to this.

PS: Suspect pt of having put their metered dose inhaler on "full auto" before you arrived and loaded themselves with rescue or daily agent. I've seen pt's killed by alupent OD when their problem wasn't asthma but CAD and they self-DX/Rx'ed.


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## EMSLaw (Sep 30, 2009)

VentMedic said:


> Unless you are carrying an Ayres, Jackson Reese or anesthesia type bag, just placing a self inflating bag on their face can be called suffication. There must be a tight seal and they must be able to generate between -20 to -40 cmH2O of pressure to open the valve and receive oxygen.





MrBrown said:


> WTF dude seriously; the only kind of er .... dealies, i dno that do that are in the operating room.
> 
> Yes, *squeeze the bag*!




Since you two seem to think I'm out of my mind, I will quote from the American Red Cross.  This is on pg. 77 of the CPR for the professional rescuer book:



> *Bag-Valve-Mask Resuscitators *
> 
> A BVM can be used on a person who is breathing or not breathing.  By using a BVM with emergency oxygen attached to an oxygen reservoir bag, you can deliver up to 100 percent oxygen to the victim.  The BVM can be held by a breathing victim to inhale the oxygen or you can squeeze the bag as the victim inhales to deliver more oxygen.



So, as usual, everyone goes flying off the handle around here...  Feel free to say the ARC got it wrong, but according to them, you DO NOT have to squeeze the BVM for it to work if the patient is breathing on his or her own.


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## VentMedic (Sep 30, 2009)

EMSLaw said:


> So, as usual, everyone goes flying off the handle around here... Feel free to say the ARC got it wrong, but according to them, you DO NOT have to squeeze the BVM for it to work if the patient is breathing on his or her own.


 

Did you not read my post? 



> Originally Posted by *VentMedic*
> 
> 
> _Unless you are carrying an Ayres, Jackson Reese or anesthesia type bag, just placing a self inflating bag on their face can be called suffication. *There must be a tight seal and they must be able to generate between -20 to -40 cmH2O of pressure to open the valve and receive oxygen.*_


 
*Know how your equipment works before you use it to determine if it is the CORRECT equipment and the CORRECT use for that patient. *

*Do not assume you can use the "self inflating" BVM for every patient as you have described. You can fatique and stress them to failure or worse. *

The BVM and the very basic principles of its function should have been discussed in your EMT class. If the use of the basic tools are not known, the EMT then has a serious problem as their school's training has failed them.


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## Melclin (Sep 30, 2009)

> you can squeeze the bag as the victim inhales to deliver more oxygen



True in theory, but its actually pretty hard to get right in such a way as it makes the problem better. Get a mate to try and vent you comfortably. Its not easy.



> The BVM can be held by a breathing victim to inhale the oxygen



Give it a shot on yourself...and you'll see that its BS. Unless of course you're using a different kind of BVM which seems unlikely.


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## rescue99 (Sep 30, 2009)

bunkie said:


> Would have posted in the other thread but its a little scary there right now.
> 
> Last night during a scenario I was an asthma pt, 9 on my pain scale. Wheezing, struggling to breathe. Inadequate respiration's.
> 
> ...



Depends...we're you altered and not maintaining your airway at the time?


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## EMSLaw (Sep 30, 2009)

VentMedic said:


> Did you not read my post?
> 
> 
> *Know how your equipment works before you use it to determine if it is the CORRECT equipment and the CORRECT use for that patient. *
> ...



No, I missed it, but I see it now that you made it bigger and in color!  

I'm not saying you can use it for every patient.  But there are circumstances in which a BVM can be used for a breathing patient without squeezing the bag to assist them in breathing.  Or you can gently squeeze the bag to help them.  Or, if they stop breathing, you can use the bag to breathe for them in the "normal" way.  All of those are valid uses of the BVM, no?  I was only saying, in response to a post that I have forgotten now, that you can use a BVM to deliver 100% O2 to a patient, breathing or not.  I will gladly add the caveat, "under certain circumstances."


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## VentMedic (Sep 30, 2009)

I also noticed your reference was from the ARC and not the AHA.  I haven't taken an ARC course in many, many years for CPR.


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## mycrofft (Sep 30, 2009)

*On older BVM's straight through O2 was a physical possibility.*

Not those filled wsith foam, though.

The "reservoir" does not have to fill on simple cheaper BVM's for oxygen to come through, but it will need to displace the ambient air in the bag (not reservoir) before the pt gets much benefit. I think the pt, if anxious and conscious, is going to take the bag and throw it at you first. BVM to rescusitate, mask to oxygenate.

It is a sign of progress that the old suggestions of the rescuer wearing a nasal cannula to use a rescue mask in order to deliver more O2 has not surfaced here!  

PS: I've fixed, bought and used these for years, I know wherefrom I speak.


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## bunkie (Sep 30, 2009)

rescue99 said:


> Depends...we're you altered and not maintaining your airway at the time?



Had an airway and was A&Ox4. I want to make sure I'm doing it the right way when I'm out there.


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## rescue99 (Sep 30, 2009)

bunkie said:


> Had an airway and was A&Ox4. I want to make sure I'm doing it the right way when I'm out there.



A NRB is appropriate the initial action in this situation.


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## MrBrown (Sep 30, 2009)

rescue99 said:


> A NRB is appropriate the initial action in this situation.



Agreed yes, if you are unable to neb atrovent or salbutamol *and* the patient is conscious then a NRB is appropriate.


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## bunkie (Sep 30, 2009)

rescue99 said:


> A NRB is appropriate the initial action in this situation.





MrBrown said:


> Agreed yes, if you are unable to neb atrovent or salbutamol *and* the patient is conscious then a NRB is appropriate.



Thanks Rescue and MrBrown.  We did resp emergencies in the book last night and a lot of the confusion was cleared up as well.


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## rescue99 (Sep 30, 2009)

bunkie said:


> Thanks Rescue and MrBrown.  We did resp emergencies in the book last night and a lot of the confusion was cleared up as well.



You are welcome..and sorry about the typos!  See what nice gets us?? 
Ask and ye shall receive ^_^


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