Artificial Ventilations

[ArcticKat]

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]

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.

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

that make sense?

 

[8jimi8]

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]

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]

you don't connect your ventilator to oxygen?

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

 

[NomadicMedic]

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]

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]

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]

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]

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]

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.

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.

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.

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]

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]

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]

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]

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]

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.

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.

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]

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]

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]

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]

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.

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.

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.

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.

I agree

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.

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.