# BVM and OPA question



## Prince (May 11, 2015)

Hey guys.  I am new to this website.  I just became an EMT and got a job with a BLS/ALS company.  I have a quick question for anyone that can help answer my question. Lets say if a patient has a OPA or NPA inserted while using a BVM.  Do you still do head tilt chin lift while using a BVM with an OPA or will the OPA do the job and you don't need to tilt the head??


Thanks for answering my question.


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## COmedic17 (May 11, 2015)

It depends if you are getting Good compliance and if the air is going into the lungs.... And not the stomach I guess.


Typically when people are taught to "bag" a patient, they are taught the CE method (to position your fingers) to maintain a good seal and open the airway. If someone's head is tilted down its difficult to get good compliance. 


And if you fill someone's stomach up with air- your going to have a very bad day.


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## Prince (May 11, 2015)

Okay.  Got ya.  Thanks!


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## cprted (May 11, 2015)

YES!  OPAs and NPA are "airway adjuncts," they help you keep a clear airway, they don't do the job for you.  You'll still need to apply a head tilt and/or jaw thrust to maintain a good airway in most cases.  Apply a good seal and make sure you're lifting the patient's face up into the mask, not pushing the mask down onto the patient's face.


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## LACoGurneyjockey (May 11, 2015)

You should have them in a head tilt chin lift position the entire time you're bagging until an advanced airway (ET/King/Combi) is in place. The OPA is only there to keep their tongue from falling back over their airway.


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## medicaltransient (May 11, 2015)

Yes you need good head position. As others stated mask seal is very important also. I prefer 2 person bvm. This skill can be a life saving maneuver if done properly.


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## Accelerator (May 13, 2015)

Adjuncts do not obviate the need for proper head positioning. Often times it's difficult to get an opa in place without proper head positioning. It also will help your medic to go ahead and put them in the proper position. They may be preparing to insert an advanced airway while you are bagging them. You can save them a step.


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## COmedic17 (May 15, 2015)

medicaltransient said:


> Yes you need good head position. As others stated mask seal is very important also. I prefer 2 person bvm. This skill can be a life saving maneuver if done properly.


2 person is nice, however, that will rarely/never happen in the back of a squad. Any additional riders will have designated duties.


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## Tigger (May 15, 2015)

COmedic17 said:


> 2 person is nice, however, that will rarely/never happen in the back of a squad. Any additional riders will have designated duties.


If we are going to bring someone in without an advanced airway in place you can bet that someone will be brought along to ensure that two person BVM happens. Healthcare providers as a whole (outside of anesthesia) are awful at one person BVM, and being in a moving vehicle does not improve that. Not hard to squeeze the bag when you're taking a break from compressions.


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## COmedic17 (May 15, 2015)

If I'm running a code, I have a CPR person On the bench, someone at the bench drawing meds, and one airway person. 

I have limited space to utilize. And if it's so bad that I would need to completely bag someone,they are getting an advanced airway regardless. 

But there's no way in hell in going to have room for two on airway, And everyone else back there.


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## Tigger (May 15, 2015)

Just another reason not be transporting codes. Having one person for compressions is not nearly enough.


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## Accelerator (May 15, 2015)

Tigger said:


> Just another reason not be transporting codes. Having one person for compressions is not nearly enough.



I 100% agree. Even with three people in the back I've never been impressed with the quality of compressions that are possible while bouncing down the road. Our agency is contemplating permitting us to work on a scene and call our own cease efforts. It's odd we don't have that since we're permitted to pronounce DOAs.

I've requested orders for cease efforts several times and the only time it was granted was once when transport was impossible.


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## Carlos Danger (May 16, 2015)

COmedic17 said:


> It depends if you are getting Good compliance and if the air is going into the lungs.... And not the stomach I guess.
> 
> 
> Typically when people are taught to "bag" a patient, they are taught the CE method (to position your fingers) to maintain a good seal and open the airway. *If someone's head is tilted down its difficult to get good compliance.*



It sounds like what you are referring to as "compliance" is really an issue of airway obstruction from less-than-adequate positioning. Lung and chest-wall compliance should never be a problem, outside of a patient with lung disease or some sort of restrictive thoracic disease or severe truncal obesity. 

The biggest problem that most people have with mask ventilation is not maintaining an open airway - that's what happens when your head positioning is not right, or, the "head is tilted down". It takes quite a bit of practice to simultaneously hold a good mask seal and a good head position, especially with one hand. In some patients it is really hard, even for people who do it every day.

If you have to choose one or the other (a good seal or good head position), always choose a good head position. This is because you can usually still generate some airway pressure with a small mask leak, and if the airway is open and you have high oxygen flows, you may get the benefit of some apneic oxygenation, even if you aren't ventilating that well. Most importantly, if the airway is not open, your good mask seal is meaningless.....you aren't going to get flow into the lungs, and you very well may end up with it going into the gut.

Basic airway adjuncts are very helpful, and I can't say this enough: LMA's are seriously under-appreciated in the prehospital setting.


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## Tigger (May 16, 2015)

Meanwhile EMS will encourage single person BVM "because you're learned it in basic school."


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## Akulahawk (May 16, 2015)

Remi said:


> It sounds like what you are referring to as "compliance" is really an issue of airway obstruction from less-than-adequate positioning. Lung and chest-wall compliance should never be a problem, outside of a patient with lung disease or some sort of restrictive thoracic disease or severe truncal obesity.
> 
> The biggest problem that most people have with mask ventilation is not maintaining an open airway - that's what happens when your head positioning is not right, or, the "head is tilted down". It takes quite a bit of practice to simultaneously hold a good mask seal and a good head position, especially with one hand. In some patients it is really hard, even for people who do it every day.
> 
> ...


If the patient tolerates an OPA, I have to agree. Not to mention that learning to place the LMA is not that difficult.


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## Accelerator (May 16, 2015)

Remi said:


> Basic airway adjuncts are very helpful, and I can't say this enough: LMA's are seriously under-appreciated in the prehospital setting.




Supraglottic airways are often overlooked because it's considered a "basic skill." A lot of medics consider it a faux pas to use king airways or LMAs and tunnel vision on the intubation.


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## Carlos Danger (May 16, 2015)

Accelerator said:


> Supraglottic airways are often overlooked because it's considered a "basic skill." A lot of medics consider it a faux pas to use king airways or LMAs and tunnel vision on the intubation.



I know. And that's part of the reason why prehospital intubation outcomes are so poor.


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## 9D4 (May 17, 2015)

Has anyone seen the video of the one person, two handed BVM technique? I got laughed at during my medic internship for implementing it, but it was a ton easier to maintain a good seal.
I can't seem to find it. Basically you use both hands for the mask and "chicken wing" the bag with your forearm against your side to squeeze it.
The only down fall I had is you have to be at a raised position from the pts head. It was hard to do it while sitting in the airway seat of the ambo (I only tried that once though. So may be a practice makes perect deal.). It just didn't seem like an adequate tidal volume from the position I was in.


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## jwk (Jun 7, 2015)

9D4 said:


> Has anyone seen the video of the one person, two handed BVM technique? I got laughed at during my medic internship for implementing it, but it was a ton easier to maintain a good seal.
> I can't seem to find it. Basically you use both hands for the mask and "chicken wing" the bag with your forearm against your side to squeeze it.
> The only down fall I had is you have to be at a raised position from the pts head. It was hard to do it while sitting in the airway seat of the ambo (I only tried that once though. So may be a practice makes perect deal.). It just didn't seem like an adequate tidal volume from the position I was in.


My guess is you can't possibly deliver a reasonable tidal volume with this technique - and you'll look like a dork.


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## NomadicMedic (Jun 7, 2015)

How about the FATS technique? Face and thigh squeeze. Works well, and is actually taught in the Seattle EMT programs.  ...or was


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## Gurby (Jun 7, 2015)

Tigger said:


> Meanwhile EMS will encourage single person BVM "because you're learned it in basic school."



I was shocked when I did my OR time during medic clinicals and had much more trouble with the BVM than I did with intubating.  "BLS skill"...


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## JPINFV (Jun 8, 2015)

Gurby said:


> I was shocked when I did my OR time during medic clinicals and had much more trouble with the BVM than I did with intubating.  "BLS skill"...


One of the advantage of the bags on the anesthesiology machines is that they're flow inflated bags. No seal, no bag. 

Also, a good seal will induce a head tilt often anyways. You lift the face to the mask, not squish the mask to the face.


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## DesertMedic66 (Jun 8, 2015)

JPINFV said:


> One of the advantage of the bags on the anesthesiology machines is that they're flow inflated bags. No seal, no bag.
> 
> Also, a good seal will induce a head tilt often anyways. You lift the face to the mask, not squish the mask to the face.


That took me soo long to figure out. I had the anesthesiologist saying "squeeze the bag" but there was no bag for me to squeeze. Finally they told me how it works.


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## Bullets (Jun 9, 2015)

Akulahawk said:


> If the patient tolerates an OPA, I have to agree. Not to mention that learning to place the LMA is not that difficult.



Yeah but LMAs, at least the ones with the big inflatable doughnut on the end kinda stink. I feel as if they are to easily dislodged. Weve pretty much gone away from them and replaced them with the King. Though those newish iGels look slick, has anyone played with them


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## NomadicMedic (Jun 9, 2015)

Bullets said:


> Yeah but LMAs, at least the ones with the big inflatable doughnut on the end kinda stink. I feel as if they are to easily dislodged. Weve pretty much gone away from them and replaced them with the King. Though those newish iGels look slick, has anyone played with them



Yeah. We've moved to iGels for SGA airways. They're pretty slick.


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## Carlos Danger (Jun 9, 2015)

JPINFV said:


> One of the advantage of the bags on the anesthesiology machines is that they're flow inflated bags. *No seal, no bag.*



It certainly facilitates learning to mask well.

FWIW.....during my anesthesia training, learning to mask really well was considered _absolutely fundamental_......in contrast, in my paramedic training, it was like "yeah, you should be pretty good at this....but whatever, let's just intubate the manikin."


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## PotatoMedic (Jun 9, 2015)

I do think a lot more time needs to be spent on how to get a good seal.  I almost wish I could just spend a day in the OR practicing that.  I will say the experience I did get in the r has made my bvm skills a lot better.  But I also now know I really didn't know what I was doing, no do many emt's.


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## JPINFV (Jun 9, 2015)

Remi said:


> It certainly facilitates learning to mask well.
> 
> FWIW.....during my anesthesia training, learning to mask really well was considered _absolutely fundamental_......in contrast, in my paramedic training, it was like "yeah, you should be pretty good at this....but whatever, let's just intubate the manikin."


EMS: Must get ET tube in.

Anesthesiologist: Air goes in, air goes out is more important than a PVC challenge.


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