# Assisted Ventilations with BVM?



## Cody1911 (May 10, 2013)

Have a quick question here! So if I am right on this... Let's say I respond to a PT having difficulty breathing. He is speaking full sentences, and is alert and calm. A nasal cannula would be the right choice here. 

If PT becomes visibly short of breath speaking 3-4 word sentences having increased respiratory distress I would apply a Nonrebreather. If the PT didn't tolerate that what would you go to? Would you hook him back up to a cannula? 

Also, if the PT goes into severe respiratory distress speaking only 1-2 word sentences and becomes diaphoretic would you start a BVM? How do you use a BVM at this point since he is still breathing but it's just extremely inadequate. Everytime he takes a breath do you squeeze the BVM to assist him? or do you still use the rule of about 10-12/min? I assume you would do it everytime he breaths right?

if the PT goes into respiratory arrest obviously it would be assisted ventilations 10-12 per min for an adult. 20 per min on a child with a BVM

My question though is if you are using a BVM on a PT who is still breathing do you squeeze it everytime they breathe or do you do you just stick to the 10-12 per min rule? 

I should also know this... but I remember reading not to use oxygen powered ventilation devices on infants or children. So no nasal cannulas or nonrebreathers on them? Why is this?

Thanks a bunch guys.


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## Ecgg (May 10, 2013)

Is this for EMT-B or Paramedic class?


In reality the cause of respiratory distress will determine proper oxygenation/ventilation interventions.


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## Aidey (May 10, 2013)

In simple terms, titrate to SpO2. Don't base it off how many words the pt is speaking. Words per sentence tells you how fast they are breathing, not how much oxygen they need. 

Assisting a breathing pt with a BVM is best done in pts who are getting exhausted. Try putting a BVM over the face of a anxious asthma attack who is speaking 1-2 word sentences and see what happens. If you're lucky you'll only get hit with the BVM. 

Nasal cannula and non rebreathers can definitely be used in peds. I think you misunderstood what you were reading.


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## DesertMedic66 (May 10, 2013)

I've only had one patient who allowed us to ventilate him while he was conscious, that patient has also been on a vent for 10 years...

I've yet to have a conscious patient tolerate a BVM.


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## chaz90 (May 10, 2013)

Nasal cannulas and NRBs are not considered oxygen powered devices and are perfectly appropriate for children. In fact, you'll find everyone carries pediatric NC and NRB for this exact purpose. I think this rule is referencing FROPVDs, which you don't really see in EMS anymore. I don't quite understand where that "rule" came from anyway as jet ventilations are frequently used on infants. 

For BVM rates, this is another thing that depends on the situation like everything else in medicine. If your patient is breathing 4 times a minute, support each of his breaths with BVM assistance, but also supplement his inherent rate with additional breaths of your own for a total of 12ish per minute. If your patient is breathing shallowly and inadequately at 40/minute, create a better rate for her using the BVM. This may be more difficult, but if they really need the BVM assistance, they probably won't fight you too hard.


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## Arovetli (May 10, 2013)

Back in the day before CPAP, BVM assisted ventilation was more common.

You would gently bag when the patient breathed, or every couple of breaths, hoping to assist the work of breathing. Use caution.

If they are not tolerating a NRB, doubtful they will tolerate you applying an even bigger device to their face.

Oxygen powered is referring to the contraptions that use the full power of the compressed 02 in the tank to deliver air. A cheap ventilator, which raises too much risk of barotrauma. FROPVD/MTV/ATV.


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## Cody1911 (May 10, 2013)

Thank you all so much for the awesome replies. I did read that wrong... It meant oxygen powered ventilation devices. I was starting to wonder there... Didn't make much sense. :lol: Just read that wrong. 

Got it now! Thanks a bunch guys


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## Arovetli (May 10, 2013)

DesertEMT66 said:


> I've only had one patient who allowed us to ventilate him while he was conscious, that patient has also been on a vent for 10 years...
> 
> I've yet to have a conscious patient tolerate a BVM.



Concur.

I saw some aspiring heroes give it the good college try, but have never seen success.


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## Cody1911 (May 10, 2013)

On a side note... I just read "A nonrebreather mask requires adequate breathing to pull oxygen into the lungs. it DOES NOT provide ventilation to a patient who is not breathing (Obviously) OR who is breathing inadequately. Then it shows a picture of an EMT using a BVM on a guy who seems to be in respiratory failure but not respiratory arrest. The only time I have ever seen a BVM used on a PT was when they were not breathing. Cardiac arrest etc. EDIT: and I seen it used one other time when the PT was unconscious. She was going down the tubes pretty quick.


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## SpecialK (May 10, 2013)

Cody1911 said:


> Let's say I respond to a PT having difficulty breathing. He is speaking full sentences, and is alert and calm. A nasal cannula would be the right choice here.



Difficulty in breathing and hypoxaemia are not the same.  Difficulty in the physical process of breathing (ventilation) is not an oxygenation problem; although obviously the two are intimately connected however the two are very different, very separate processes; one mechanical and one physiological thus meaning somebody who has poor airway and/or poor breathing (such as somebody who has coma and traumatic brain injury) may actually be well oxygenating. 

If somebody has difficulty in breathing, for example they have a flail chest, but are oxygenating satisfactorily then there is no indication for oxygen.  



Cody1911 said:


> If PT becomes visibly short of breath speaking 3-4 word sentences having increased respiratory distress I would apply a Nonrebreather. If the PT didn't tolerate that what would you go to? Would you hook him back up to a cannula?



If the patient is severely hypoxeamic then yes, a non-rebreather (reservoir) mask is appropriate; examples would be somebody who is in acute pulmonary edema.  

If they don't tolerate it and/or are becoming a bit aggravated/lash'y out'y then their hypoxaemia is likely to be very severe.  In this circumstance you should optimise their ability to oxygenate (e.g. sitting somebody who is in CHF over the stretcher, giving them some GTN or giving somebody who is asthmatic some salbutamol etc) and taking them to the hospital, or calling for RSI if you have such provided somebody RSI qualified can locate you significantly faster than you can deliver the patient to the hospital.    



Cody1911 said:


> Also, if the PT goes into severe respiratory distress speaking only 1-2 word sentences and becomes diaphoretic would you start a BVM? How do you use a BVM at this point since he is still breathing but it's just extremely inadequate. Everytime he takes a breath do you squeeze the BVM to assist him? or do you still use the rule of about 10-12/min? I assume you would do it everytime he breaths right?



Assisting somebody who is spontaneously ventilating is over rated and over used; it carries significant risk and often makes things worse because you end up fighting with the patient and doing more harm than good because it is very uncomfortable for the patient.

The underlying cause that this person is speaking in 1 word sentences needs to be fixed; e.g. (again) dependent positioning, reservoir mask oxygen and GTN for somebody who has CHF.  

Once again, oxygenation is more important than ventilation; somebody can be breathing 2 times a minute but still oxygenating at 100% SpO2 with an ETCO2 of 30 mmHg and in the short term pre-hospital that is acceptable.  

If their oxygenation is very inadequate then CPAP or RSI are far better alternatives than attempting to assist ventilation with a bag mask.  If you do not have these options and your patient is very hypoxaemic and oxygenation is inadequate you can place a bag mask onto their face (take a large combine dressing, empty a couple sterile water snapules onto it to wet it and cut the middle out, put it around the patients mouth and nose and then put the mask over it, this vastly improves the seal between the patients face and the bag mask, I believe its the polarity principle, same as when you put a thin film of water on two lab slides and they become very difficult to separate)



Cody1911 said:


> if the PT goes into respiratory arrest obviously it would be assisted ventilations 10-12 per min for an adult. 20 per min on a child with a BVM



Words are inadequate to express the importance of this but if you are hand ventilating somebody you *must* think about each breath and not just blindly squeeze the bag.  

For adults the rate is 8-10 a minute, squeeze the bag then think "release. release, release" and squeeze the bag again.  

In children the rate is faster, 16-20 breaths a minute, same principle but this time only two "releases" between squeezes.

*If asthma is the problem ventilate a 6/min and no faster; this is very important to prevent dynamic hyperinflation*



Cody1911 said:


> My question though is if you are using a BVM on a PT who is still breathing do you squeeze it everytime they breathe or do you do you just stick to the 10-12 per min rule?



Again, oxygenation is the primary concern so if their oxygenation is acceptable then there is no need to hand ventilate them as we can tolerate sub optimal ventilation in the short term.



Cody1911 said:


> I should also know this... but I remember reading not to use oxygen powered ventilation devices on infants or children. So no nasal cannulas or nonrebreathers on them? Why is this?



Whoever told you this is wrong.  What I think they mean is no demand powered oxygen devices; the risk here is that children and neonates have very small lungs and are much more at risk of barotrauma than an adult.  

While I have never seen such a device except in American textbooks (and even then it looked very antequated) I do believe the entonox cylinders are an example of these; i.e. no gas will flow until you breathe in.


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## Akulahawk (May 11, 2013)

SpecialK hit many of the points I was going to make earlier. After I left actively working in the field, CPAP became into much greater use. There have been a (very) few patients that I actively assisted their respiratory efforts with a BVM that I would have immediately reached for a CPAP mask had that been available. Think of it as "_every one of those patients would have had a CPAP trial!"_ 

Also, you really do have to be very careful about ventilating patients with asthma. Air trapping is a HUGE problem with them, and ventilating them too frequently will lead to  hyperinflation and barotrauma. 

I once worked for a company that still had OPBD's (Demand Valve Mask) in their inventory but never had them out on the trucks. I did once hook one up to the O2 port on the truck and gave it a try. The flow rate was quite high and easily kept up with my demand. Here's where they have problems... they can be manually triggered and they won't stop until you let go. That has HUGE potential to cause massive barotrauma (and they have). Believe me, lungs aren't meant to handle that much pressure (50 psi). They burst.


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## Brandon O (May 11, 2013)

SpecialK said:


> Difficulty in breathing and hypoxaemia are not the same.  Difficulty in the physical process of breathing (ventilation) is not an oxygenation problem; although obviously the two are intimately connected however the two are very different, very separate processes; one mechanical and one physiological thus meaning somebody who has poor airway and/or poor breathing (such as somebody who has coma and traumatic brain injury) may actually be well oxygenating.
> 
> If somebody has difficulty in breathing, for example they have a flail chest, but are oxygenating satisfactorily then there is no indication for oxygen.



I would discourage this type of thinking.

Although you're correct that not all dyspnea will result in hypoxia, differentiating that is not easy. I'm all in favor of intelligent providers who don't apply care by spatula, but getting to the point where you withhold supplemental oxygen from a dyspneic patient because you don't think they need it is a step too far.

Perhaps most importantly, looking at a distressed patient with a normal O2 saturation and saying, "they're fine" is like arguing that a man who fell from a plane doesn't need a parachute because he hasn't hit the ground yet. Oxygen saturation is a critical physiological endpoint and won't deteriorate as long as the body has compensatory resources to mobilize, but that doesn't mean there's no battle being fought or no need to assist. Managing insults before decompensation is the whole reason we're here, and if we don't recognize compensatory efforts as signs of an underlying pathology, we'll be blind to most problems until the patient has one foot in the grave.


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