# PEEP valve on BVM's



## Jeremy89 (Jan 7, 2010)

Just wondering if anyone here has used a PEEP valve when bagging a pt during ARD?  If you haven't seen em, its a small valve that attaches to the end of the ambu bag where the O2 would otherwise just escape.







We use em all the time in the hospital for pre-intubation oxygenation.  Are we as basics allowed to apply PEEP?, as there are a few contraindications...  But if someone's in respiratory arrest, a little extra PEEP is the least of their problems...


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## TccEMT (Jan 7, 2010)

Never even seen it. So it just up the O2% or does it make the volume more?


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## VentMedic (Jan 7, 2010)

Jeremy89 said:


> We use em all the time in the hospital for pre-intubation oxygenation. Are we as basics allowed to apply PEEP?, as there are a few contraindications... But if someone's in respiratory arrest, a little extra PEEP is the least of their problems...


 
We use the PEEP valve only if it is an *oxygenation* problem that is *pulmonary* and not circulatory.   

It the pt is in a respiratory arrest with falling BP and declining cardiac status, I will be not be using a PEEP valve.   

If the person has relatively normal lungs there is no reason to use a PEEP valve for pre-oxygenation as the medications given may drop the BP and the additional PEEP may further bottom it.


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## Jeremy89 (Jan 7, 2010)

VentMedic said:


> We use the PEEP valve only if it is an *oxygenation* problem that is *pulmonary* and not circulatory.
> 
> It the pt is in a respiratory arrest with falling BP and declining cardiac status, I will be not be using a PEEP valve.
> 
> If the person has relatively normal lungs there is no reason to use a PEEP valve for pre-oxygenation as the medications given may drop the BP and the additional PEEP may further bottom it.



Oh.  I've seen our RCP's do it on many pt's. :-S

But our clientele includes a large number of older pt's with underlying conditions.  Maybe that's why I see it done, i dunno.

But for your everyday asthma exacerbation, you wouldn't use any peep?


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## Jeremy89 (Jan 7, 2010)

TccEMT said:


> Never even seen it. So it just up the O2% or does it make the volume more?



Positive End Expiratory Pressure (as I understand it) keeps a variable amount of pressure in the pulmonary system at the end of the breathing cycle.  This helps keep the alveoli and bronchioles open for better oxygen/CO2 exchange.

Ask Vent if you need more detail


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## VentMedic (Jan 7, 2010)

Jeremy89 said:


> Oh. I've seen our RCP's do it on many pt's. :-S
> 
> But our clientele includes a large number of older pt's with underlying conditions. Maybe that's why I see it done, i dunno.


 
Your RRTs also have access to ABGs and know the oxygenation issues.




Jeremy89 said:


> But for your everyday asthma exacerbation, you wouldn't use any peep?


 
That depends on the air trapping, the oxygenation and the hemodynamics.  One recipe does not fit all patients even with the same "diagnosis".


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## VentMedic (Jan 7, 2010)

Jeremy89 said:


> Ask Vent if you need more detail


 
All about PEEP:

http://www.ccmtutorials.com/rs/PEEP/index.htm


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## MrBrown (Jan 7, 2010)

We have just gotten PEEP, I'm gonna go out on my *** here and say it seems like a poor man's CPAP


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## exodus (Jan 7, 2010)

VentMedic said:


> Your RRTs also have access to ABGs and know the oxygenation issues.
> 
> 
> 
> ...



It sounds like using this device always can only help? If the alveoli remain open longer for more O2 transfer, does not this mean they pt can oxygenate and perfused better?


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## VentMedic (Jan 7, 2010)

MrBrown said:


> We have just gotten PEEP, I'm gonna go out on my *** here and say it seems like a poor man's CPAP


 
Exactly!

That is why we are excited when the better transport vents come out with something other than a resistive valve for PEEP.


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## VentMedic (Jan 7, 2010)

exodus said:


> It sounds like using this device always can only help? If the alveoli remain open longer for more O2 transfer, does not this mean they pt can oxygenate and perfused better?


 
I see you haven't gotten to hemodynamics yet in Paramedic school and hopefully that subject is taught very well.

Also, if you are bagging with 100% O2 and have a PaO2 of 450 mmHg, what more are you trying to accomplish?


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## MrBrown (Jan 7, 2010)

exodus said:


> It sounds like using this device always can only help? If the alveoli remain open longer for more O2 transfer, does not this mean they pt can oxygenate and perfused better?



Oxygenation and ventilation are often confused and the concepts used interchangably. They are not the same thing are infact two different physiologic proceses.

The amount of air breathed in is not the amount of oxygen that will reach the brain and tissues.

- Air is about 21% oxygen, yet in Denver it's lower (I don't know the exact forula to figure out how much lower) so altitude plays a part

- The ability to change pressure inside the thorax is also important; if Stanley my immaginary grey pet elephant sits on your chest you will have a very hard time creating a negative pressure gradient to draw air in as you can't expand the throacic cavity enough. 

- Just because oxygen is inhailed does not mean it will reach the bronchioles, alveoli, blood, cells and tissues. Any number of obstructions may prevent this - eg choking, hypovolemia, obstructive lung disease/pulmonary edema, carbon monoxide poisioning or a haemothorax.

It is also important to recognise that not all the air inhailed will reach the respiratory zone for the oxygen to diffuse out of the alveoli and into the blood.

The lungs have what is called dead space either anatomical (bronchi and bronchioles that do not have alveoli and pulmonary capillaries, I believe this is the first 20 or 21 divisions of the bronhcial tree) or alveolar; alveolar dead space is any buggered alveoli that can't exchange gas either because they have collapsed or are full of puss or the marbles I ate for dinner.

Dead space is an important concept as about 150ml of air will occupy the anatomical dead space at any one time, this will increase if there is additional alveolar dead space such as in infection or APO/CPE.

This is where PEEP (and I believe also CPAP) are important as they only work on *pulmonary* problems by decreasing surface tension and assisting the alveolar surfactant to decrease alveolar dead space and ensure more gas exchange.

Doesn't work on a circulatory issue such as V/Q mismatch or anemia.


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## Shishkabob (Jan 7, 2010)

MrBrown said:


> - Air is about 21% oxygen, yet in Denver it's lower (I don't know the exact forula to figure out how much lower) so altitude plays a part


  Nope.  Every single place you go to in the world will have an air concentration of 21% Oxygen and 78% nitrogen.


The difference is barometric pressure.


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## MrBrown (Jan 7, 2010)

Linuss said:


> Nope.  Every single place you go to in the world will have an air concentration of 21% Oxygen and 78% nitrogen.
> 
> 
> The difference is barometric pressure.



Fascinating


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## VentMedic (Jan 7, 2010)

Linuss said:


> Nope. Every single place you go to in the world will have an air concentration of 21% Oxygen and 78% nitrogen.


 
Unless you decide to go lower than 21% for specific treatment or to simulate high altitude.


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## Melclin (Jan 7, 2010)

May as well post this here as well. 

As a point of (un)interesting trivia...

Oxygen concentration does change with altitude above the turbopause because the thinning atmosphere reduces molecular interaction, allowing the the elements to stratify based on molecular weight.

...

...Prrrobbbably not going to affect Denver though...


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## Jon (Jan 7, 2010)

VentMedic said:


> Exactly!
> 
> That is why we are excited when the better transport vents come out with something other than a resistive valve for PEEP.



Umm... OK. Gonna take the bait.

Are you saying there's a different way to generate PEEP on a transport vent? Or a different setting that accomplishes similar objectives?


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## VentMedic (Jan 8, 2010)

Jon said:


> Are you saying there's a different way to generate PEEP on a transport vent? Or a different setting that accomplishes similar objectives?


 
The setting is generated internally rather than attempting to twist s PEEP valve that resembled the cheap ones on the BVMs in hopes of coming close to the setting desired. 

LTV 1200 is a good example. You can compare it with the LTV 1000 to see the difference.  When transporting patients on higher levels of PEEP like 20 cmH2O, the internal PEEP function generates a more reliable setting.  It is also a lot quieter.


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## Akulahawk (Jan 8, 2010)

Linuss said:


> Nope.  Every single place you go to in the world will have an air concentration of 21% Oxygen and 78% nitrogen.
> 
> 
> The difference is barometric pressure.





VentMedic said:


> Unless you decide to go lower than 21% for specific treatment or to simulate high altitude.


Or you dive... and breathe some type of mixed gas. (air/EAN/Nitrox/Tri-mix)

The concentration of the various gasses you'd breathe at depth can be kind of interesting when compared to sea level... as in, you do NOT want to breathe that same gas blend by percentages when you're AT sea level...

I, for one, find rebreathers interesting...


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## Akulahawk (Jan 8, 2010)

MrBrown said:


> We have just gotten PEEP, I'm gonna go out on my *** here and say it seems like a poor man's CPAP


Poor man's? That's putting it mildly. I'd probably go so far as to call it "Broke Man's"... While it _does_ maintain a positive pressure, I don't think that there's as good control of that pressure. I'd almost call it a crappy Bi-PAP... where you ARE getting some increased pressure above the PEEP during ventilation, that increase wouldn't be as well controlled as you'd find with an actual Bi-PAP unit. Especially if you're bagging by hand...


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## MrBrown (Jan 8, 2010)

Akulahawk said:


> Poor man's? That's putting it mildly. I'd probably go so far as to call it *"Broke Man's"*... ...



"Ambulance, our defecit is now $12 million pa.  What is the exact address of your emergency?"


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## Akulahawk (Jan 8, 2010)

MrBrown said:


> "Ambulance, our defecit is now $12 million pa.  What is the exact address of your emergency?"


Exactly. Give the bean counter a choice between a transport vent that does well controlled PEEP, and a little cheap valve you put on a BVM... that you're only going to use once for say 20 minutes... and you'd be reimbursed the same amount for using either device... the cheap little valve wins. Specialty Transport? The nod goes to the transport vent...


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## VentMedic (Jan 8, 2010)

Akulahawk said:


> Exactly. Give the bean counter a choice between a transport vent that does well controlled PEEP, and a little cheap valve you put on a BVM... that you're only going to use once for say 20 minutes... and you'd be reimbursed the same amount for using either device... the cheap little valve wins. Specialty Transport? The nod goes to the transport vent...


 
Actually it is not always the bean counters but the EMS providers themselves.  If the vent looks "real easy" with cooler knobs then that is their choice rather than a more sophisticated one.  Most won't know the difference between the different valving types or the internal turbine and how flow is delivered to meet demand or not. 

And, how many know the parts of their BVM and what makes a good bag except for how it looks or maybe squeezes?


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## Aidey (Jan 8, 2010)

That is assuming you are in a system where the line employees get any say at all about what gets ordered. I know that we have no say in what brand or style or color of item get ordered where I work. We've replaced out glucometers twice in the last 6 months, and we've had no say, its all been upper management. 

And it's not about features or anything, there was no difference in features between glucometers 2 and 3. It just happened that company 3 offered us a better deal than what we had with company 2.


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## redcrossemt (Jan 8, 2010)

Jeremy89 said:


> Just wondering if anyone here has used a PEEP valve when bagging a pt during ARD?  If you haven't seen em, its a small valve that attaches to the end of the ambu bag where the O2 would otherwise just escape.
> 
> We use em all the time in the hospital for pre-intubation oxygenation.  Are we as basics allowed to apply PEEP?, as there are a few contraindications...  But if someone's in respiratory arrest, a little extra PEEP is the least of their problems...



We have the little PEEP valves for trucks that go out with AutoVent 3000s. Dumbest things in the world. I can't even believe they suggest we use that vent for any sort of transport gig.

As mentioned previously in this thread, a little extra PEEP might make their respiratory problem worse, depending on what their problem is.


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## VentMedic (Jan 8, 2010)

redcrossemt said:


> We have the little PEEP valves for trucks that go out with AutoVent 3000s. Dumbest things in the world. I can't even believe they suggest we use that vent for any sort of transport gig.


 
Are you using that thing for CCT?


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## Jeremy89 (Jan 8, 2010)

Here's a better picture I took just now.  The dial allows you to choose 5, 10, 15 or 20 cmH2O of PEEP.


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## redcrossemt (Jan 8, 2010)

VentMedic said:


> Are you using that thing for CCT?



We have LTV1100s and 1200s for CCT.

However, they do ask crews with the autovent to do routine ventilator transfers when a CCT truck is not available. It's ridiculous.


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## VentMedic (Jan 8, 2010)

redcrossemt said:


> We have LTV1100s and 1200s for CCT.
> 
> However, they do ask crews with the autovent to do routine ventilator transfers when a CCT truck is not available. It's ridiculous.


 
I've had patients tell their horror stories of being transported to and from the subacute with these ventilators.  Unfortunately, some just the match numbers for the basic setting of the ICU or Subacute ventilator and don't notice the other options or even the mode variations between the ventilators. 

We've also had a couple of CCTs using the LTV that did not know there were additional settings on that ventilator besides the obvious on the face.  They thought the "internal stuff" was a "default" of some type.  They had no clue about the rise%, NIV mode or even the apnea, low pressure detection by mode and PEEP alarms.


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## redcrossemt (Jan 8, 2010)

VentMedic said:


> I've had patients tell their horror stories of being transported to and from the subacute with these ventilators.  Unfortunately, some just the match numbers for the basic setting of the ICU or Subacute ventilator and don't notice the other options or even the mode variations between the ventilators.
> 
> We've also had a couple of CCTs using the LTV that did not know there were additional settings on that ventilator besides the obvious on the face.  They thought the "internal stuff" was a "default" of some type.  They had no clue about the rise%, NIV mode or even the apnea, low pressure detection by mode and PEEP alarms.



I've seen many patients made very uncomfortable, anxious, and even sick by "stupid" ventilators. They are *okay* for CPR and for a *few* paralyzed or extremely sedated patients when monitored very closely, depending on the patient's problems and needs.

Whoa, extended feature menu?? Who needs that anyway? Apnea alarm? Rise time? Patient comfort? ...but it's only a 20 minute drive!


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## Jon (Jan 8, 2010)

VentMedic said:


> The setting is generated internally rather than attempting to twist s PEEP valve that resembled the cheap ones on the BVMs in hopes of coming close to the setting desired.
> 
> LTV 1200 is a good example. You can compare it with the LTV 1000 to see the difference.  When transporting patients on higher levels of PEEP like 20 cmH2O, the internal PEEP function generates a more reliable setting.  It is also a lot quieter.


Vent,

The CCT RN vent is a LTV1200, the ALS vent is a LTV1000. We were taught to adjust PEEP on the LTV1000 using the external valve, but to measure it using the vent itself. I can read PEEP on the display and see what it's really set at... for example, the dial may say 10, but it's only giving 7-8 of PEEP.

And before we got the vents, we had 2 classes... a respiratory/vent A&P review and discussion on vent settings, etc by our Doc, and a lecture and practical on the LTV's from a few folks on local SCT teams for pedi and adult.


Oh - FYI - I've got a LTV AND  an Autovent on my truck. The Autovent is for one thing - CPR. That's it.


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## VentMedic (Jan 9, 2010)

Jon said:


> Vent,
> 
> The CCT RN vent is a LTV1200, the ALS vent is a LTV1000. We were taught to adjust PEEP on the LTV1000 using the external valve, but to measure it using the vent itself. I can read PEEP on the display and see what it's really set at... for example, the dial may say 10, but it's only giving 7-8 of PEEP.
> 
> And before we got the vents, we had 2 classes... a respiratory/vent A&P review and discussion on vent settings, etc by our Doc, and a lecture and practical on the LTV's from a few folks on local SCT teams for pedi and adult.


 
Did they tell you about compressible volume and how the vents with external PEEP measure PIP from a zero baseline while other measure from PEEP?  Did they tell you how moisture affects the external valve?  Do you notice fluctuations in VT or PIP?   Did you check if leak leak compensation is switched on?  Did you check if the NIV mode is on?   Is the patient spontaneously breathing?  Is there adequate flow in the system to meet patient demand?  Is there a noticeable negative deflection on inspiration? 




Jon said:


> The Autovent is for one thing - CPR. That's it.


 
As it should be.


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## VentMedic (Jan 9, 2010)

Jon and redcrossemt,

Here is a great webcast that is now available free of charge for your viewing. Since the LTV 1200 is the national stockpile vent, this broadcast was done to provide additional access to information. For those who are interested in disaster management, it shows how warehouses are setup and supplies dispatched to various locations.

The ventilator application portion explains PEEP, the turbine, battery life, gas consumption, expanded menu, temperature, FiO2 fluctuations and altitude.

http://www.aarc.org/education/webcast_central/archives/2009/09_22_2009_ltv_1200.asp

http://www.aarc.org/education/webcast_central/viewer_n.asp?id=0086

The Q&A section also has some good information.


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