MSDeltaFlt
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No harm. No foul.
BVM on breathing pt
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Common sense with understanding what is normal and not normal is a great compliment to a good assessment. Unfortunately EMS has spent more time worrying about "certs" than education or the real "basics" for understanding each skill or protocol.
Actually, anyone working with any type of oxygen equipment should know what FiO2 is. The BVM can be varied from an FiO2 of 0.40 to 1.0 by the reservoir bag or tube.
PEEP is also now available as a built in feature that can be changed on many BVMs. Unfortunately, very few are given much education about PEEP and its appropriate use also at either EMT or Paramedic level.
The BVM is also misunderstood and used as a "free - flow" O2 delivery device. Many don't realize that the patient will not receive flow unless a very tight seal is made and the patient can generate almost -20 cmH2O pressure to open the valve. There are free flow bags using Jackson-Reese type circuits which one may see in hospitals used by Anesthesiologists and RRTs.
Many are also unfamiliar with the amount of volume in ml that a bag can deliver or how the pop-off is used. Some bags also include a safety valve for air entrainment.
Very few take the time to read the package insert for their BVM. Most assume a BVM is a BVM and all are the same.
ETCO2 may be necessary to become familiar with at least at a very introductory level if you are working an ALS truck with a Paramedic. It can be a useful tool just like the pulse ox but also should not replace commonsense and physical assessment.
Actually, anyone working with any type of oxygen equipment should know what FiO2 is. The BVM can be varied from an FiO2 of 0.40 to 1.0 by the reservoir bag or tube.
PEEP is also now available as a built in feature that can be changed on many BVMs. Unfortunately, very few are given much education about PEEP and its appropriate use also at either EMT or Paramedic level.
The BVM is also misunderstood and used as a "free - flow" O2 delivery device. Many don't realize that the patient will not receive flow unless a very tight seal is made and the patient can generate almost -20 cmH2O pressure to open the valve. There are free flow bags using Jackson-Reese type circuits which one may see in hospitals used by Anesthesiologists and RRTs.
Many are also unfamiliar with the amount of volume in ml that a bag can deliver or how the pop-off is used. Some bags also include a safety valve for air entrainment.
Very few take the time to read the package insert for their BVM. Most assume a BVM is a BVM and all are the same.
ETCO2 may be necessary to become familiar with at least at a very introductory level if you are working an ALS truck with a Paramedic. It can be a useful tool just like the pulse ox but also should not replace commonsense and physical assessment.
Vent, would you mind going into the PEEP and its appropriate use a bit more...
thanks
PEEP: Positive End Expiratory Pressure
Definition: Maintains pressure phase above ambient pressure during the expiratory phase of ventilation and helps prevent the collapse of the small airways and alveoli.
On the BVM it is an expiratory flow retard valve at a preset value by an additional valve to attach or a fixed adjustable valve.
This link gives an overview of PEEP which is used on almost all ventilator patients. It also describes CPAP.
http://virtual.mjc.edu/lylet/242/PEEP.htm
The link is from an RT education site which has other notes that might be of interest with many more links.
http://virtual.mjc.edu/lylet/242/
CPAP is Continuous Positive Airway Pressure so it is present at both inspiration and expiration.
In the presence of low BP, questionable pneumo, or airtrapping and hyperinflation, PEEP is not recommended with the BVM. It can help with CHF, Pulmonary Edema and various V/Q mismatches from PNA and other causes of ARDS. Again, caution when there are cardiac output or low BP issues. Usually if oxygenation is a problem 5 cmH2O may help somewhat without too many side effects.
If a patient is on PEEP on a ventilator, the PEEP valve on the BVT is usually set to match the PEEP on the ventilator. 5 cmH2O is usually a maintenance level and it is not always necessary to match.
COPD patients attempt their own form of "PEEP" with pursed lip breathing to increase oxygenation.
Babies also attempt to increase their oxygenation when distressed by "grunting" which creates a flow retard through the glottis.
Definition: Maintains pressure phase above ambient pressure during the expiratory phase of ventilation and helps prevent the collapse of the small airways and alveoli.
On the BVM it is an expiratory flow retard valve at a preset value by an additional valve to attach or a fixed adjustable valve.
This link gives an overview of PEEP which is used on almost all ventilator patients. It also describes CPAP.
http://virtual.mjc.edu/lylet/242/PEEP.htm
The link is from an RT education site which has other notes that might be of interest with many more links.
http://virtual.mjc.edu/lylet/242/
CPAP is Continuous Positive Airway Pressure so it is present at both inspiration and expiration.
In the presence of low BP, questionable pneumo, or airtrapping and hyperinflation, PEEP is not recommended with the BVM. It can help with CHF, Pulmonary Edema and various V/Q mismatches from PNA and other causes of ARDS. Again, caution when there are cardiac output or low BP issues. Usually if oxygenation is a problem 5 cmH2O may help somewhat without too many side effects.
If a patient is on PEEP on a ventilator, the PEEP valve on the BVT is usually set to match the PEEP on the ventilator. 5 cmH2O is usually a maintenance level and it is not always necessary to match.
COPD patients attempt their own form of "PEEP" with pursed lip breathing to increase oxygenation.
Babies also attempt to increase their oxygenation when distressed by "grunting" which creates a flow retard through the glottis.
thank you Vent!
question about the low cardiac output scenarios... i am assuming that PEEP will raise intrathoracic pressures somewhat, resulting in a further decrease in preload... is this what you are referring to? why it is not indicated in low cardiac output situations?
Clinical review: Positive end-expiratory pressure and cardiac output
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16356246
To quote an old addage ; " THE ONLY STUPID QUESTION IS THE ONE NOT ASKED . " This site is a great learning resource for everyone associated with EMS . Keep in mind we have students on the site who may not have covered this topic yet or they still feel shaky on it . Learning's a lifelong process and it certainly doesn't stop when you get your cert . It's better to ask any questions you have here than not have the knowledge when it's needed . Instead of getting frustrated at folks asking questions , help them out . EMT's and Medics aren't made from cookie cutters , and they all learn at different rates . Some pick it up easier than others .
tydek07
Forum Captain
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Hello,
It depends on what your pt looks like and if their body is doing fine with breathing 8-10/min. For very healthy people, that may be a norm. for them. We have all heard treat you pt, not your equipment. Well same thing can be applied, Treat your pt, not their vitals. Everyone has different "norm vitals", so you cannot go just by the numbers.
So to answer your question, yes you can bag an alert patient if the need is there, but if they are alert, probably not going to have to help them along. If the person is breathing, but with AMS, work with their breathing. When they take a breath, give them a breath, then give them a couple breaths inbetween their own breaths. Just try and get the rythym down.
So like always, depends on the situation, isn't that how every ems questions is answered, haha.
Have a good day,
It depends on what your pt looks like and if their body is doing fine with breathing 8-10/min. For very healthy people, that may be a norm. for them. We have all heard treat you pt, not your equipment. Well same thing can be applied, Treat your pt, not their vitals. Everyone has different "norm vitals", so you cannot go just by the numbers.
So to answer your question, yes you can bag an alert patient if the need is there, but if they are alert, probably not going to have to help them along. If the person is breathing, but with AMS, work with their breathing. When they take a breath, give them a breath, then give them a couple breaths inbetween their own breaths. Just try and get the rythym down.
So like always, depends on the situation, isn't that how every ems questions is answered, haha.
Have a good day,
Meursault
Organic Mechanic
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The first time I saw FiO2 mentioned, it took me a second to make the connection, because my EMT text and various state materials use percentage of O2 without a label. Apparently we're too stupid to divide.
Interesting link, too.
I just had a call the other night with a pt in heart failure that couldn't breathe. Got there and standing, he could breathe with accessory muscle use. Sat him down and he quickly degraded. Sats were like 80% and his lungs were swimming in fluid that when he coughed up, was pink-tinged...and there was lots of it.
He was conscious and I bagged him for 20 minutes to the hospital while he complained at a rate of 3 words per breath while pleading to stand up in the bus, but it kept him alive. I had a SP02 monitor on him to monitor his pulse because I thought for sure he was going to tank before we got to the big H. Then I bagged for 20 minutes in the hospital while they pushed NTG and lasix.
As earlier stated, we treat the pt and not the monitor. You bag because the pt isn't getting adequate oxygen intake on their own and you just do your best to get the Cx pt to agree with it....and be sure you bag when they inspire; don't force it.
He was conscious and I bagged him for 20 minutes to the hospital while he complained at a rate of 3 words per breath while pleading to stand up in the bus, but it kept him alive. I had a SP02 monitor on him to monitor his pulse because I thought for sure he was going to tank before we got to the big H. Then I bagged for 20 minutes in the hospital while they pushed NTG and lasix.
As earlier stated, we treat the pt and not the monitor. You bag because the pt isn't getting adequate oxygen intake on their own and you just do your best to get the Cx pt to agree with it....and be sure you bag when they inspire; don't force it.
BossyCow
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As part of a class, we assisted each other's breathing with a BVM. It's a very educational experience and is also a wonderful team building excercise.
I have found with many asthma pts the assistance with a BVM not only doesn't cause anxiety, but can relieve it. As an Asthma pt myself, I know that the anxiety I feel during an asthma attack is usually a side effice of the effort it is taking to breathe. When the BVM is used, the effort I have to use to breathe is lessened and consequently so is my anxiety.
I have found with many asthma pts the assistance with a BVM not only doesn't cause anxiety, but can relieve it. As an Asthma pt myself, I know that the anxiety I feel during an asthma attack is usually a side effice of the effort it is taking to breathe. When the BVM is used, the effort I have to use to breathe is lessened and consequently so is my anxiety.
how is the asthma patient positioned as your are doing that?
BossyCow
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On the stretcher, in a seated position.
I've both done it and had it done to me. Since its only an assist with their breathing, you don't need to be as particular about a full seal on the face. You are just giving a bit of pressure to augment their breathing.
In class, we put blankets down on the floor and do it lying down.
I've both done it and had it done to me. Since its only an assist with their breathing, you don't need to be as particular about a full seal on the face. You are just giving a bit of pressure to augment their breathing.
In class, we put blankets down on the floor and do it lying down.
ok... i was going to say.... take an asthmatic with a bad attack... no way there going to let you lay them down...
Maybe in a perfect world, but I'd settle for EMTs who know the indications and contraindications of the medications they have, know where to find the mask part of the BVM after taking the bag part out of the bag, or understand the importance of a good assessment first.
In the end, knowing how to fiddle with the FiO2 of your BVM or having read the insert card that comes with it doesn't mean jack if you can't recognize that your patient's respirations are inadequate, and the pt needs to be bagged.
As far as bagging an asthma pt... I'm not going to touch that one.
Omarsobh: As a first responder, bagging a conscious, breathing patient is going to be outside of your scope of practice, or outside of the skills you are trained to perform. If you are responding in an official capacity (I.E. FD, PD, Lifeguard, etc... I'm inclined to believe you're not because of your age, but who knows...) then you are legally obligated to only practice within the scope of your training, and can be held accountable if you exceed your training and the patient has a negative outcome. In any case, this is not something you should be doing with the training you have.
I'm not trying to be a ****, and I know this isn't the answer to your question, but it's something to look out for.
As far as whether or not a patient will become agitated if you try to bag them while they are conscious (for low resps)... in my experience, if a patient has enough energy to be combative, they are probably not hypoxic enough to merit bagging!
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What makes you think that bagging a conscious, breathing patient is outside of his scope of practice as a first resopnder, or that they are not taught the skills necessary? This is a fundamental objective for FR's in Washington state. Scope of practice varies from area to area, so please remember that before you make all encompassing statements.
Fiddle with the FiO2 of the BVM? I think you have just given your own example of not being familiar with the equipment.
I do apologize for not making the FiO2 statement clearer for some. I have seen EMT(P)s arriving without the reservoir and have had them state that they always remove it because it just gets in the way. If the reservoir is not attached on the BVM, with O2 running at 15L, the most FiO2 you can expect from the BVM is 0.40 due to air entrainment.
Neonatal and Pediatric teams may remove the tail or reservoir bag for some patients where giving too much oxygen may be an issue. Usually these SPECIALTY TEAMS use a blender to provide more precise concentrations of oxygen.
As far as the insert card, most assume the BVM is a simple piece of equipment and never really understand how to make the most of it or how to check if the BVM is defective.
If you do not know your equipment and how to use it effectively including the BVM, the patient is not going to get the full benefit once respiratory failure is recognized.
Hypoxic refers to oxygenation. A patient can still have adequate oxygenation but lack in ventilation. That is where the assistance comes in.
True if the patient is fighting you it would be a mute point to restrain provided they have enough ventilatory drive to breathe on their own or they are capable of protecting their airway. Of course for ALS situations where this may involve head injury or for flight, sedation and an ETT may be the way to go for those circumstances.
Not every patient scenario will be text book. There is no reason one can not ask questions before they come across something they did not encounter in class or clinical.
That has been discussed in the link to the other thread earlier and as BossyCow stated, positioning and gaining the patient's confidence is key.
I do not believe the EMS profession has achieved an elitist status to where we devour our young who have valid questions They are the next generation of professional Paramedics.
Well, after looking up the WA state FR protocols (they have protocols?!) you appear to be correct. That's the most progressive set of FR standards I've ever seen. Excuse my generalization.
Is our poster from WA? I don't know.
In my experience as an AHA instructor, first responder training usually translates to first aid, CPR with AED, and maybe oxygen admin or epi-pen training. This training is not adequate to be bagging a conscious, breathing patient, or most importantly, to decide whether or not to bag a conscious, breathing patient.
It's really interesting to me that WA doesn't have albuterol nebs for EMT-Bs, for example, but has such a complete set of protocols for FRs and a statewide FR curriculum.
Wooah, sorry if that came off sounding that way. As someone who took my basic class at 17 and had to wait to achieve licensure, I assure you it's not a question of elitism. What I meant was that I doubted a 14 y/o would have to worry about not being covered by good samaritan laws because he was responding to an incident while on duty in some capacity, but was more likely to be a bystander who assisted at a scene.
All valid points on FiO2, but I maintain that I'd rather see EMT classes effectively teach how to make a good seal on a BVM and provide adequate ventilation and spend more time on recognition of serious emergencies than the nuances of their equipment, which most often varies from unit to unit, anyway.
In other words:
True, but I would argue that the damages resulting from failure to recognize respiratory failure, especially for EMT-Bs and FRs, far outweigh the negative consequences of not knowing the semantics of FiO2, tidal volume, PEEP, ETCO2, etc.
BossyCow
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Yes I am from WA state and not a FR but an EMT-B. I am also a CPR/FA instructor, Wilderness EMT instructor and Medical Officer for my small rural fire department.
And as far as neb treatments, we can assist a pt with neb treatments if they have the prescription already. If not, with the permission of our MPD, we have been able to provide it for those who have no script, but only on a case by case basis.
In WA state there is a huge variation between the type of area any given department is serving. While the state regulations are a basis, each individual region makes their own protocols with the cooperation of the MPD's from the receiving facilities in that region.
FR is a dying breed in these parts. The amount of time and training is almost the same as what is required for EMT-B so few departments are willing to invest in a FR class when for about the same amount of time and money they can have an EMT-B. At least on my side of the I-5 corridor, there are few FR left.
And as far as neb treatments, we can assist a pt with neb treatments if they have the prescription already. If not, with the permission of our MPD, we have been able to provide it for those who have no script, but only on a case by case basis.
In WA state there is a huge variation between the type of area any given department is serving. While the state regulations are a basis, each individual region makes their own protocols with the cooperation of the MPD's from the receiving facilities in that region.
FR is a dying breed in these parts. The amount of time and training is almost the same as what is required for EMT-B so few departments are willing to invest in a FR class when for about the same amount of time and money they can have an EMT-B. At least on my side of the I-5 corridor, there are few FR left.