# Correct setup for bagging in a treatment



## zzyzx (Jun 15, 2012)

Which of the following 3 ways is the correct method for setting up a breathing treatment to a BVM. 

(Hopefully the attached photos are there.)


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## zzyzx (Jun 15, 2012)

#3 photo


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## NYMedic828 (Jun 15, 2012)

None of the above I'd say because your nebulizer must remain upright for it to function.

The second you turn it sideways everything will just pour out and what remains wont nebulize because it isn't at the bottom of the purple disc.

You would need a 90 degree elbow and a tube at the face mask/ tube connection.


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## MedicBender (Jun 15, 2012)

You may be able to make the first one work if you have 2 people bagging. The piping should be flexible enough for you to hold the neb upright.


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## STXmedic (Jun 15, 2012)

Whichever way that lets you get the medicine in 

I'd go with the first picture you uploaded (mask-extender-neb-bag). This would give you the most control over keeping the neb upright, as was mentioned by NY. You don't need an elbow, but you do have to stay cognizant of the orientation of the neb.


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## Christopher (Jun 15, 2012)

zzyzx said:


> Which of the following 3 ways is the correct method for setting up a breathing treatment to a BVM.
> 
> (Hopefully the attached photos are there.)



Your first image was the closest, but they actually make swivel connectors for this purpose. We have them in our Pyxis at work. I'll try and take a picture tomorrow on shift for you.


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## zzyzx (Jun 15, 2012)

Sorry, should have stated that I meant for the nebulizer to held upright in each photo.

Now that I think about it, not all the setups would work for a patient who is not sitting upright but is supine.


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## Cawolf86 (Jun 15, 2012)

None of those are correct. You need a 90 degree elbow connector as prior stated.


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## zzyzx (Jun 15, 2012)

If the patient is sitting, all 3 could be used with the neb held upright, and if the patient is supine, then #1 would work. What I'm wondering is if the tubing makes any difference.


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## Christopher (Jun 15, 2012)

zzyzx said:


> What I'm wondering is if the tubing makes any difference.



You technically are introducing deadspace which could make the BVM less effective...if you're still squeezing the whole bag and delivering 1 million liters of tidal volume


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## zzyzx (Jun 18, 2012)

I've been told that you should use a spacer (like a 2-inch connector) between the BVM and the nebulizer. Is there any truth to that? What would the purpose of that be?


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## socalmedic (Jun 18, 2012)

number one would be best, but as stated there is alot of dead space. I have only tried to bag a Tx once, didnt work well. all other times, if bagging is needed so is epi, so i just bag with O2 give the epi and once they can maintain their own airway the CPAP is getting put on with a neb.


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## 18G (Jun 19, 2012)

I've tried the same thing before and standard nebulizer kits on the ambulance don't really work for interfacing with a BVM. I have found neb kits that do include the elbow piece and all items required for it to work properly with a BVM though. And these kits weren't anymore price wise than standard nebulizers. 

This is one of the many things they tell you to do in Paramedic school yet never think it's important to actually show you how its done.


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## Christopher (Jun 19, 2012)

18G said:


> I've tried the same thing before and standard nebulizer kits on the ambulance don't really work for interfacing with a BVM. I have found neb kits that do include the elbow piece and all items required for it to work properly with a BVM though. And these kits weren't anymore price wise than standard nebulizers.
> 
> This is one of the many things they tell you to do in Paramedic school yet never think it's important to actually show you how its done.



We carry something sorta like these, albeit not the same (ours is more like a swivel connector with some expandable tubing):

BVM Assist Kit
Nebulizer BVM Kit


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## TransportJockey (Jun 20, 2012)

Am I the only one here who has never even heard of bagging in a neb? Just not something that was ever discussed or taught around here.


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## Handsome Robb (Jun 20, 2012)

TransportJockey said:


> Am I the only one here who has never even heard of bagging in a neb? Just not something that was ever discussed or taught around here.



Really? It works pretty well, takes some coaching though that's for sure. Only done it once and the guy still ended up getting RSI'd at the ER the minute we walked through the door but I was able to keep his SpO2 above 90 until we got there when it was low 80s on 6lpm nasal cannula plus 6 lpm through a neb/NRB setup.


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## mycrofft (Jun 20, 2012)

*I don't know (formally)*

# Three with adapters to allow the BVM to be operated, to reduce dead space, seems the best. (Bad choice of words).

My concern would be that lack of energetic exhalation would make for static air in the resp tree, so medicine would not get far enough down to make best effect. This is a concern with asthmatics and COPD'ers at all times, and I would think especially when they may be unconscious. IV would be better if you have to assist or replace inhalations.


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## OzAmbo (Jun 20, 2012)

mycrofft said:


> # Three with adapters to allow the BVM to be operated, to reduce dead space, seems the best. (Bad choice of words).
> 
> My concern would be that lack of energetic exhalation would make for static air in the resp tree, so medicine would not get far enough down to make best effect. This is a concern with asthmatics and COPD'ers at all times, and I would think especially when they may be unconscious. IV would be better if you have to assist or replace inhalations.



I agree, just bagging the mist in isn't going to do anything if they bremain hyoer inflated. In fact the last status asthmatic i saw we couldn't bag her at all, but having the nebuliser mask on while giving her lateral chest thrusts was enough to keep air moving.

Mind you, the nebuliser has such low efficacy in status patients due to the amount of secretions, minimal air movement and narrowed bronchioles im not really sure it made that much of a difference, the IMI adrenaline and IV salbutamol did that for us.


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## mycrofft (Jun 20, 2012)

Yeah, don't throw a drowning man a life preserver you have to blow into to inflate.

I've had people tipping into status who cleared enough to use a neb after their epi shot, and the rest was HX, other than being put into the infirmary for Q4 hr vitals including breath sounds and ready access to nurses.


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## MSDeltaFlt (Jun 21, 2012)

Zz, 

Go with #1.  It will work with a supine pt.  And don't worry about the increased deadspace volume. It wont be enough to be a negative factor.  20, maybe 30, cc is not that much.  You'll be fine.

Now the trick is to bag a neb in on an intubated pt.  I've got pics. Just can't remember where I put them.  However, if memory serves, you'd use the setups like in your pics #1 or #2, but you'll also need a 15mm straight-line adapter to fit onto ETT.

Hook AMBU & neb up and you're golden.


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## socalmedic (Jun 21, 2012)

MSDeltaFlt said:


> Zz,
> 
> Go with #1.  It will work with a supine pt.  And don't worry about the increased deadspace volume. It wont be enough to be a negative factor.  20, maybe 30, cc is not that much.  You'll be fine.
> 
> ...



you should need the 15mm adapter anyway to fit the blue tube to the bvm mask.


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## epipusher (Jun 21, 2012)

I agree with the answer that whatever works best for you and your patient in the particular situation.


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## MSDeltaFlt (Jun 21, 2012)

socalmedic said:


> you should need the 15mm adapter anyway to fit the blue tube to the bvm mask.



Not necessarily.  It depends on the individual makes and models of the equipment you're using.  And then there are companies that sell entire kits just for this purpose.  Though I haven't seen any personally. I've just read on other forums that they're out there... for the right price.


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## BigBad (Jun 22, 2012)

We use an in-line neb


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## mycrofft (Jun 22, 2012)

Anyone here a resp tech or know one with BVM experience?


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## STXmedic (Jun 22, 2012)

mycrofft said:


> Anyone here a resp tech or know one with BVM experience?



VentMedi-oh, wait... I think USAF.... Nevermind... :unsure:


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## Handsome Robb (Jun 22, 2012)

PoeticInjustice said:


> VentMedi-oh, wait... I think USAF.... Nevermind... :unsure:



:lol: I see what you did there.


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## socalmedic (Jun 22, 2012)

MrBrown might know, or medicRob... definitely medicRob.


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## socalmedic (Jun 22, 2012)

mycrofft said:


> Anyone here a resp tech or know one with BVM experience?



I know of lots of RTs with BVM experience... none of them are any good at it. Have you ever seen an RT bag a patient.  but on a slightly serious note, whats the actual question? I may be able to get you an answer.


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## MSDeltaFlt (Jun 22, 2012)

mycrofft said:


> Anyone here a resp tech or know one with BVM experience?



Me.


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## mycrofft (Jun 22, 2012)

Ah, kinda thought so. Thanks! Does the BVM/RX thing really work?


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## MSDeltaFlt (Jun 23, 2012)

mycrofft said:


> Ah, kinda thought so. Thanks! Does the BVM/RX thing really work?



It won't fix the problem completely, but when they're locked up tighter 'n' a drum, it definitely helps.


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## Handsome Robb (Jun 23, 2012)

mycrofft said:


> Ah, kinda thought so. Thanks! Does the BVM/RX thing really work?





MSDeltaFlt said:


> It won't fix the problem completely, but when they're locked up tighter 'n' a drum, it definitely helps.




I know it's anecdotal but in the one patient I have bagged treatments into it warded off complete respiratory arrest and kept his SpO2% decent until we got to the ER where he was promptly RSI'd which I'm not able to do in my system.


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## MSDeltaFlt (Jun 23, 2012)

NVRob said:


> I know it's anecdotal but in the one patient I have bagged treatments into it warded off complete respiratory arrest and kept his SpO2% decent until we got to the ER where he was promptly RSI'd which I'm not able to do in my system.



Exactly.


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