# Artificial Ventilations



## traumaluv2011 (Aug 26, 2011)

I was wondering what other EMTs prefer to use. I was reading up on the airway chapter and I saw an interesting comparison between the two. I would think the best method is to use a BVM based on the ability to use oxygen if available. However, say someone with a basic jump bag came upon an apneic patient as a first responder and they had both a pocket mask with one way valve or a BVM to choose from. 

My book said that manual artificial respiration gives about 16% oxygen per ventilation while a BVM gives 21%. But the manual would give you more tidal volume. So is it better to have more oxygen or have more air going through the lungs? 

I would think more oxygen would seem like the better option.


----------



## NomadicMedic (Aug 26, 2011)

If I had to choose between a mask or a BVM, it's ALWAYS a BVM. 

I'm guessing you're new. Wait 'til you're ventilating a puking person. 

BVM always wins. 


Sent from my iPhone.


----------



## LondonMedic (Aug 26, 2011)

BVM no question.

However, if you're not used to using one and have no experience managing an airway you are more likely to be able to use a pocket mask more effectively, especially if you're alone. Much as they look intuative - mask over mouth & squeeze bag - they actually take a fair bit of practice (on a variety of people) before you can be confident about being able to open the airway adequately, get a good seal and ventilate an appropriate volume at an appropriate rate.

As for your question about oxygen versus volume. Vt is nice to have but it doesn't increase oxygenation in itself, for that you really need a higher fraction of inspired oxygen (i.e 0.21 instead of 0.16) or that oxygen needs to spend longer in the lungs (either positive end expiratory pressure or a lower inhalation to exhalation ratio).


----------



## usafmedic45 (Aug 26, 2011)

Also, increased volume tends to increase the risk of not only gastric insufflation but also damage to the lungs by way of overinflation of the alveoli.  As was said before, BVM over pocket mask any day.


----------



## 8jimi8 (Aug 26, 2011)

no question.  B V M.


----------



## Ewok Jerky (Aug 26, 2011)

n7lxi said:


> i'm guessing you're new. Wait 'til you're ventilating a puking person.
> 
> Bvm always wins.
> 
> Sent from my iphone.



+1.


----------



## ArcticKat (Aug 26, 2011)

BVM, provided you can competently use it and make a seal.  Otherwise pocket mask.


----------



## traumaluv2011 (Aug 26, 2011)

Yea, I'm pretty new to the field. Just got certified a month ago. Thank you for the answers. I will definitely go for a BVM if possible.


----------



## AlphaButch (Aug 27, 2011)

BVM, otherwise I may get dizzy. I also don't like my own vomit, much less someone elses.


----------



## lightsandsirens5 (Aug 27, 2011)

Bag valve. Hands down. After a bit of practice and practical application in the field, you'll be able to use a BVM as, if not more, effectively than a face mask. I know I should jinx myself, but I've never had call to use my face mask. I've always been able to reach the BVM just as quickly. 

Alpha, I know what you mean about vomit. Also, my instructor forever scared me about using a face mask when he told a story about a malfunctioning one way valve allowed a patient to puke into, and fill his mouth up with, vomit. I almost lost it listening to that story. :-S


----------



## ArcticKat (Aug 27, 2011)

On a slightly related issue, does anyone else use an ATV and mask?  That way both hands are free for making a seal.


----------



## NomadicMedic (Aug 27, 2011)

ArcticKat said:


> On a slightly related issue, does anyone else use an ATV and mask?  That way both hands are free for making a seal.



If I'm digging out the vent, they're getting tubed. I try to mess around with a mask as little as possible. 

And I'm curious about the OP's reasoning. If he/she is first on an arrest scene, hands only CPR is the best bet. No need to break out the pocket mask. If they're on a truck, there should be a BVM and some airway adjuncts handy. 


Sent from my iPhone.


----------



## usalsfyre (Aug 27, 2011)

n7lxi said:


> If I'm digging out the vent, they're getting tubed. I try to mess around with a mask as little as possible.
> 
> And I'm curious about the OP's reasoning. If he/she is first on an arrest scene, hands only CPR is the best bet. No need to break out the pocket mask. If they're on a truck, there should be a BVM and some airway adjuncts handy.
> 
> ...



The vent probably delivers far better ventilations though. Consistent, pressure limited, slow and as above, you can use two hands to seal the mask.


----------



## ArcticKat (Aug 27, 2011)

n7lxi said:


> If I'm digging out the vent, they're getting tubed. I try to mess around with a mask as little as possible.



I'm referencing BLS providers.


----------



## NomadicMedic (Aug 27, 2011)

ArcticKat said:


> I'm referencing BLS providers.



Is use of a vent in a BLS providers scope of practice?


Sent from my iPhone.


----------



## usafmedic45 (Aug 27, 2011)

It's not really a "vent".  I believe he's just referring to one of the old oxygen powered PPV devices.


----------



## ArcticKat (Aug 27, 2011)

Nope, pretty sure it's a vent...

http://www.otwo.com/pdf/CAREvent ALS CPAP 2008.pdf

Using an ATV is not in the BLS scope, even with a mask, a BLS provider can administer CPAP though.  It makes little sense to me that a BLS provider can provide crap poor ventilations using a BVM but can't use the ATV to administer better quality ventilations with less complications.

I'm putting together a protocol amendment to include the BLS ATV/mask. wondering if anyone else does it.


----------



## usafmedic45 (Aug 27, 2011)

Oh, OK.  Sorry, you said ATV and I was thinking of something else.


----------



## NomadicMedic (Aug 27, 2011)

The only way a basic can do CPAP here is with a disposable, non adjustable Downs Flow device.  There is a pilot program ongoing to assess it's efficacy when used by BLS providers, prior to ALS arrival. Seems like a no brainer to me. Early CPAP for CHF is vital, and giving that skill to BLS only makes sense.

However, using a parapack vent or similar for BLS airway management in place of a BVM is overkill. If a BLS provider can't effectively manage an airway with a BVM, something in the original education or con ed is missing. I've seen EMTs struggle with maintaining a seal, not being able to jaw thrust an airway when bagging and having all kinds of other basic airway issues. Giving them more stuff to set up and play with detracts from the basic idea, “open the airway and squeeze in a breath 10 to 12 times a minute.” Let's have our EMS Con Ed educators focus more on the skills that EMTs really need, like good airway management, rather than giving them more toys and stuff to play with.


----------



## usalsfyre (Aug 27, 2011)

So here's my thought. Using the BVM during CPR on Annie is relatively easy. Crank her head back, get a plastic on plastic seal and squeeze in as much air as possible to get a visible chest rise. 

Using a BVM WELL, on REAL PATIENTS on the other hand, as we all realize, is a difficult, not easily mastered skill. If you take away when to squeeze the bag, how hard and deep to squeeze the bag  and the actual squeeze itself you are now better able to focus on proper airway positioning and good mask seal, helping to prevent leakage and gastric insuflation. In addition the vent will deliver a consistent, controled 10 bpm as opposed to getting excited and squeezing the heck out of the bag. 

We should know how to use a BVM. But we dont' use Ambu bags onn everyone anymore for a reason. I personally think it's a great idea.


----------



## ArcticKat (Aug 27, 2011)

I've never actually done a timed event, but in my experience it's far quicker to pull out the vent circuit, slap a mask on one end, put the other onto the vent and turn it on than it is to pull out the BVM from the packaging, place a mask on it, hook it up to the oxygen supply, turn on the oxygen supply, make sure the resevoir inflates, and then begin ventilations.

Honestly, I think it's less toys to play with, teach how to use the BVM, make sure they can trouble shoot when it goes wrong, but give them the ATV to use as well.


----------



## 8jimi8 (Aug 27, 2011)

n7lxi said:


> If I'm digging out the vent, they're getting tubed. I try to mess around with a mask as little as possible.
> 
> And I'm curious about the OP's reasoning. If he/she is first on an arrest scene, hands only CPR is the best bet. No need to break out the pocket mask. If they're on a truck, there should be a BVM and some airway adjuncts handy.
> 
> ...




compression only CPR is a gimmick to recruit UNTRAINED bystanders.  Rescue breathing has NOT been dropped from HCP BLS algorithms.

that make sense?


----------



## 8jimi8 (Aug 27, 2011)

ArcticKat said:


> I've never actually done a timed event, but in my experience it's far quicker to pull out the vent circuit, slap a mask on one end, put the other onto the vent and turn it on than it is to pull out the BVM from the packaging, place a mask on it, hook it up to the oxygen supply, turn on the oxygen supply, make sure the resevoir inflates, and then begin ventilations.
> 
> Honestly, I think it's less toys to play with, teach how to use the BVM, make sure they can trouble shoot when it goes wrong, but give them the ATV to use as well.



you don't connect your ventilator to oxygen?


----------



## 8jimi8 (Aug 27, 2011)

usalsfyre said:


> So here's my thought. Using the BVM during CPR on Annie is relatively easy. Crank her head back, get a plastic on plastic seal and squeeze in as much air as possible to get a visible chest rise.
> 
> Using a BVM WELL, on REAL PATIENTS on the other hand, as we all realize, is a difficult, not easily mastered skill. If you take away when to squeeze the bag, how hard and deep to squeeze the bag  and the actual squeeze itself you are now better able to focus on proper airway positioning and good mask seal, helping to prevent leakage and gastric insuflation. In addition the vent will deliver a consistent, controled 10 bpm as opposed to getting excited and squeezing the heck out of the bag.
> 
> We should know how to use a BVM. But we dont' use Ambu bags onn everyone anymore for a reason. I personally think it's a great idea.



I work with a respiratory therapist who doesn't know how to bag properly.


basics are not the only people double fisting a BVM and squeezing until the guy's toes inflate.


----------



## ArcticKat (Aug 27, 2011)

8jimi8 said:


> you don't connect your ventilator to oxygen?



It's always connected, therefore it is not a step required in the process.


----------



## NomadicMedic (Aug 28, 2011)

Sorry. I don't agree. BVM ventilation is a basic skill. If an EMT can't manage an airway with an OPA and a BVM, that's the same as not knowing how to secure a patient on an LSB or apply a traction splint. 

It comes down to poor educational standards and the fact that we live in a world where everyone passes the class. 

They don't need a vent. They don't need more tools that may malfunction. They don't need to clutter up a basic skill with more bells and whistles. 

Just teach them how to bag effectively and refresh the skill every quarter. Problem solved. 


Sent from my iPhone.


----------



## HMartinho (Aug 28, 2011)

When we inflate with a pocket mask, we are entering the carbon dioxide in the lungs instead of oxygen. BMV is a much better and effective, in my opinion. Here in Portugal we only use BVM with oro/nasopharyngeal tube. When the  advanced life support team arrives, the doctor or nurse can intubate, and connect the patient to a ventilator~, or ventilate with a BVM.


----------



## NomadicMedic (Aug 28, 2011)

HMartinho said:


> When we inflate with a pocket mask, we are entering the carbon dioxide in the lungs instead of oxygen.



Wrong. But thanks for playing.

Even without supplemental O2, exhaled air from the provider can still provide sufficient oxygen, up to 16%.


----------



## HMartinho (Aug 28, 2011)

n7lxi said:


> Wrong. But thanks for playing.
> 
> Even without supplemental O2, exhaled air from the provider can still provide sufficient oxygen, up to 16%.



Yes, I know, but the O2 concentration is less than CO2.


----------



## ArcticKat (Aug 28, 2011)

n7lxi said:


> Sorry. I don't agree. BVM ventilation is a basic skill. If an EMT can't manage an airway with an OPA and a BVM, that's the same as not knowing how to secure a patient on an LSB or apply a traction splint.



So, what I understand is that you're saying that giving a provider the tools to do his/her job more effecively in a less complicated way shouldn't happen because they should be able to do their job good enough with the tools they currently have?

I hope you are enjoying your Lifepak 10.


----------



## usalsfyre (Aug 28, 2011)

n7lxi said:


> Sorry. I don't agree. BVM ventilation is a basic skill. If an EMT can't manage an airway with an OPA and a BVM, that's the same as not knowing how to secure a patient on an LSB or apply a traction splint.


I've seen more people who CAN'T effectively manage an airway with the tools above than who can, at all levels. The one group I've seen that universally has this skill set down? Anesthesia providers.



n7lxi said:


> It comes down to poor educational standards and the fact that we live in a world where everyone passes the class.


Agreed, somewhat. But the fact is it's a low use/high risk skill even if we don't think of it that way. If we can attack the problem with engineering controls that ends up being better for the patient.



n7lxi said:


> They don't need a vent. They don't need more tools that may malfunction. They don't need to clutter up a basic skill with more bells and whistles.


The same has been said of glucometers, SpO2, inhaled beta agonists, epi pens and ASA. Do you disagree with basic providers having access to this too? We're not talking about invasive airways, we're talking about the fact the vents a better ventilation tool than a BVM.



n7lxi said:


> Just teach them how to bag effectively and refresh the skill every quarter. Problem solved.


Too many services have no competency requirements. Further I've never had a mannequin that wasn't easier to BVM than a human.


----------



## LondonMedic (Aug 28, 2011)

n7lxi said:


> Just teach them how to bag effectively and refresh the skill every quarter. Problem solved.


I thought I could use a BVM effectively.

Then I did an Anaesthetics job, it took me the best part of three months, anaesthetising between five and twelve patients a day, every day, until I was properly competent.

I don't see how EMS is going to provide even a fraction of that training to it's paramedics, let alone EMTs, firefighters and anyone else who might think they know how to use a BVM and manage an airway.


----------



## 8jimi8 (Aug 28, 2011)

LondonMedic said:


> I thought I could use a BVM effectively.
> 
> Then I did an Anaesthetics job, it took me the best part of three months, anaesthetising between five and twelve patients a day, every day, until I was properly competent.
> 
> I don't see how EMS is going to provide even a fraction of that training to it's paramedics, let alone EMTs, firefighters and anyone else who might think they know how to use a BVM and manage an airway.



can you pass along some of the pearls you earned during your 3 months?


----------



## LondonMedic (Aug 28, 2011)

8jimi8 said:


> can you pass along some of the pearls you earned during your 3 months?


I've done six months in total so far. There's no great secret, it's about practice and having the time and tools (like a waters circuit, cap waveform and volumeters) to receive real time feedback on your airway control. For example, if your airway isn't perfect you can feel the turbulance through the waters and see a small decrease in amplitude of the cap waveform, you can then adjust and see the result. I noticed that in the first week, my middle finger was slightly compressing the digastris muscle and shifting it towards the mandible improved airflow over the tongue. If you do that often enough and for long enough it becomes a habit.


----------



## NomadicMedic (Aug 28, 2011)

ArcticKat said:


> So, what I understand is that you're saying that giving a provider the tools to do his/her job more effecively in a less complicated way shouldn't happen because they should be able to do their job good enough with the tools they currently have?
> 
> I hope you are enjoying your Lifepak 10.



You're honestly telling me that setting up a vent is less complicated then pulling a BVM off the shelf? Not in any system I've *ever* seen, and I've been riding on ambulances since 1989. 

And I'm not saying that providers shouldn't have updated tools. I *am* saying that BASIC level providers should be mandated to master the basic level skills before they get more toys to play with.

And using your example of "doing the job more effectively in a less complicated way", that's why basics have AEDs with no need for provider rhythm interpretation and a big blinking "SHOCK" button.


----------



## ArcticKat (Aug 28, 2011)

n7lxi said:


> You're honestly telling me that setting up a vent is less complicated then pulling a BVM off the shelf? Not in any system I've *ever* seen, and I've been riding on ambulances since 1989.



Yes, I am telling you that, because I know that I can set up the ventilator faster.  Give me a week and I'll let you know if the rest of my crew can do it too.  Oh, and I've been on an ambulance since 1978, not that it makes any difference by any means.



n7lxi said:


> And I'm not saying that providers shouldn't have updated tools. I *am* saying that BASIC level providers should be mandated to master the basic level skills before they get more toys to play with.



Which they do in my jurisdiction.  Our CME has mandatory and voluntary training sessions.  BVMs are mandatory for all level of providers.  Having said that, I've never seen a provider able to provide BVM ventilations better than ATV/Mask ventilations.



n7lxi said:


> And using your example of "doing the job more effectively in a less complicated way", that's why basics have AEDs with no need for provider rhythm interpretation and a big blinking "SHOCK" button.



If that's all that it's about, then why not mandate advanced providers to do the same?  Basics use AEDs because they would otherwise require a semester of cardiology training and ECG interpretation.  Using a BVM vs an ATV would not require anywhere near as much added training because the BLS provider already receives the bulk of that training for the BVM.  So then why can't they use a ventilator too?  Studies have proven that using a vent/mask vs. a BVM has resulted in a significant reduction in gastric insufflation, Airway Pressure, and Mask Leakage.

http://www.ncbi.nlm.nih.gov/pubmed/9737408?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/15141794?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/9547840?dopt=Abstract

If the studies prove that a BVM is not as good as an ATV, does it not make sense to be able to use the ATV instead?

I contend that a BLS (or any) provider with the proper training and understanding can use an ATV/mask sooner, more reliably, with less complicatons, and more effectively than when using a BVM and that CME recertification in the use of an ATV would be less complex.  I also contend that the training required would be no more than an 8 hour home study session and an hour in the lab.


----------



## NomadicMedic (Aug 28, 2011)

And that's the nice thing about the internet, you can have your opinion, and I can have mine.  

Let's look at why this makes sense.

1) A BVM is simple. It's carried in the first in bag, where most BLS providers would have need for it. It sounds as if you leave your vent in the ambulance. Doesn't do any good for an arrest in the house. (which is where I seem to find most of them...)

2) A BVM does not require O2. Now, I agree that a BVM with supplemental O2 is better, but if the bottle is empty, you can still squeeze the bag. Not so much with a vent.

3) Price Point. A disposable BVM is inexpensive. About 15 bucks. A vent for every BLS unit is not. Most private ambulance companies would balk at buying a vent for each BLS unit in the off chance they might need it. (I googled quickly, the price for a new parapak was $5700.)

If your service provides a vent for every crew and the standard of care is having BLS manage an airway with a mask and vent, good on you. 

I think it's a silly argument, frankly. In the majority of cases where a BLS provider will need to ventilate a patient with a BVM, an advanced care provider will be close behind to intubate or the BLS provider can manage the airway with a supraglottic airway such as the King, LMA or Combitube. If the PT requires CPAP, I agree that it should be a basic skill, with a disposable, non adjustable device.

I think we've beat this to death... :deadhorse:


----------



## mikie (Aug 28, 2011)

*Flow Restricted Oxygen Powered Ventilation Device*

Does/has anyone ever used a FROPVD?  I tried one on a Laerdal SimMan recently (while monitoring lung capacity on the sim's controller).  Amazingly easy to use, seemingly effective; also seems easy to cause barotrauma, but none the less, wasn't this a BLS in the past?  

Eats a D tank in minutes though.


----------



## usafmedic45 (Aug 28, 2011)

> I work with a respiratory therapist who doesn't know how to bag properly.
> 
> 
> basics are not the only people double fisting a BVM and squeezing until the guy's toes inflate.



You ever want to watch RTs become insecure at a conference, teach an airway management course and watch how they react when you ask them to bag the dummy.  It's frightening now many of them have forgotten some of the most basic technical skills of the profession.  I'd put it around 50%, although with EMS it tends to be around 70-80% based upon my experiences teaching more or less the same course to both groups.


----------



## ArcticKat (Aug 28, 2011)

n7lxi said:


> And that's the nice thing about the internet, you can have your opinion, and I can have mine.
> 
> Let's look at why this makes sense.
> 
> 1) A BVM is simple. It's carried in the first in bag, where most BLS providers would have need for it. It sounds as if you leave your vent in the ambulance. Doesn't do any good for an arrest in the house. (which is where I seem to find most of them...)



Not sure where the picture will attach here, but it's portable and lasts over an hour on a full D tank.  Ours are installed as to be easily removed from the ambulance as well should we choose to do so.



n7lxi said:


> 2) A BVM does not require O2. Now, I agree that a BVM with supplemental O2 is better, but if the bottle is empty, you can still squeeze the bag. Not so much with a vent.



So then you revert back to the BVM or pocket mask until you change the bottle.



n7lxi said:


> 3) Price Point. A disposable BVM is inexpensive. About 15 bucks. A vent for every BLS unit is not. Most private ambulance companies would balk at buying a vent for each BLS unit in the off chance they might need it. (I googled quickly, the price for a new parapak was $5700.)



And if the company is willing to spend that money to enhance patient care, why can't they?  Mine did.



n7lxi said:


> If your service provides a vent for every crew and the standard of care is having BLS manage an airway with a mask and vent, good on you.





n7lxi said:


> I think it's a silly argument, frankly.



I agree



n7lxi said:


> In the majority of cases where a BLS provider will need to ventilate a patient with a BVM, an advanced care provider will be close behind to intubate or the BLS provider can manage the airway with a supraglottic airway such as the King, LMA or Combitube. If the PT requires CPAP, I agree that it should be a basic skill, with a disposable, non adjustable device.



Maybe where you're from, but not everywhere has a medic a few minutes away, many places have to BLS to the hospital.  



n7lxi said:


> I think we've beat this to death... :deadhorse:



As you wish.  You just seem to have an "all or none" mentality.  It's got to be the BVM only, you you seem to thing I'm saying ATV only when I am not.  Use the ATV, but revert to the BVM when appropriate.  Shrug.


----------



## DESERTDOC (Aug 28, 2011)

BVM:  The bag is the easy part of the operation, the mask, well, not so much.  I have big paws and have to work to get a good seal.


----------



## usalsfyre (Aug 28, 2011)

Retracted, enough's been said.


----------



## DESERTDOC (Aug 28, 2011)

usalsfyre said:


> But would it not be easier with two hands?



Generally speaking, but I am also thinking about being alone and one hand to bag, tear tape, set stuff up, and other to make a good seal.  

On an apnea only patient that is getting tubed, I usullay help my EMT while they pre-oxygenate.  That is ideal and most effective prior to a tube.


----------



## llavero (Aug 29, 2011)

I think that the Bag Valve Mask is the better choice.


----------



## nmasi (Aug 29, 2011)

Just aim the AC vent at their open mouth, problem solved.  You get bonus points if they are hyperthermic and you cool them with it at the same time.


Sorry, only posting funny and sarcastic posts in current months state of >100 degree days.


----------

