using a bvm on a conscious pt.?

[jbullfrog09]

my question comes from an odd emergency

I had an elderly male nursing home pt. upon arrival he was alert but not oriented and lying supine. we were called for "sudden onset" of respiratory distress. the pt.'s respiratory rate was 36bpm, labored w/rails, and medics were unavailable. Pt has a hx of CHF and weeping pedal edema. i applied a NRB at 15lpm w/ partial bag deflation and sat him all the way up. i monitored his airway with out any change in his status. rapid transport to the ER which is 4 miles away. the RN yelled at me for not having medics and not using a BVM to slow down the respirations. i was always told not use a BVM on a conscious pt, and i felt the pt really didn't need to be bagged.

i get mixed signals from different medical professionals MD's, RN's, EMT-P's, and a respiratory tech(who agreed with my actions) on this subject.

the general census that i've obtained is that for an unconscious pt. we bag at 28bpm

for the conscious pt it varies from 28 to 40bmp for when we are supposed to bag.

can someone help shed some light on on this taboo subject.

[Canadian Caesar]

I guess it will depend on the patient.

- Will the patient tolerate you assisting his ventilations with the BVM?

- Or does the suffocating sensation of the mask only cause him to panic and make the situation worse?

- Was the patient's condition improved enough just from the change from lying supine that a BVM was no longer required?

These are what I think of as important questions that will tell you a lot more about wether or not a BVM is required than some arbitrary number in a textbook will.

[Timmy]

A resp rate of 36 is what you’d call inadequate breathing. While the patient is breathing, his breathing to fast for the oxygen to be any good. Using a BVM w/ 100% 02 or even IPPV for assisted ventilation is a good idea. What was his GSC and SP02?

Do a test on your self, breath in and out really fast and see how long it takes to get lightheaded, there’s not enough oxygen getting to your brain.

[Dustdevil]

Do a test on your self, breath in and out really fast and see how long it takes to get lightheaded, there’s not enough oxygen getting to your brain.

Do this test on yourself: Try to bag a ventilation in while you are breathing out.

[mobey]

Or take a really deep breath.. then bag yourself!!

you gotta be careful with this stuff, ever blown up a balloon till it popped?

[VentMedic]

Unless you have a bag like a Jackson-Reese circuit, it can be difficult to bag a conscious and alert patient. Jackson-Reese is a free flow bag like you see in some Neonatal units but larger, in the OR, ICUs and ED for intubation. For the standard BVM, you would have to make a tight seal and match breath for breath until you could overcome their ventilatory drive. If they have to fight against the valve of the bag, which on most bags takes a minimum of -20 cm H2O to open, they will become more anxious and increase O2 consumption at both a systemic and ventilatory level.

If by some chance the patient allowed this and you were able to match breath by breath, you could gradually increase the VT of each breath until possibly slowing his rate but still giving the same minute volume with the bigger breaths. So the shallow and rapid breathers may present as easier to over ride their effort if matched with gradual increase of VT provided they will allow for the tight mask seal.

And then there is that aspiration thing you have to worry about when using the BVM.

The NRBM is actually not a "high flow" mask. It is limited by design at 15 liters or whatever you put into it. Many patients have a Minute Ventilation demand of well over 20 liters/minutes when in distress.

This is where the old Elder demand valve could actually be very useful provided the EMT(P) knew what they were doing with them.

It all depends on the quality of each breath. 36 is nothing for someone with metabolic acidosis such as DKA. For a DKA patient, if they were maintaining their own pH, I encourage them to "keep on breathing"(kussmaul respirations not panting) until the lines are in and the fluid/meds are hanging. They must keep their pH about 7.0 and their body knows that. To do that they must get their PaCO2 down as low as possible. I do not interfere because I doubt if even my ICU ventilators could do a better job. If they wear out then yes that is another story.

Pts with PNA, especially PCP(Pneumocystis Carinii Pneumonia), have very high RRs. They may need intubation but again it would be very difficult to ventilate AND oxygenate them by standard BVM. These pts are usually an immediate tube when they are sedated down.

People also use the word ARDS loosely. When a pt is going into ARDS, they too are a difficult BVM job. Their lungs are "whiting out" to where ventilation and oxygenation are difficult for even the ICU ventilators.

These patients will fight to maintain adequate oxygenation and ventilation for as long as they can. Until you are adequately prepared with effective alternatives, their own bodies may do a better job than most "skilled" providers with a BVM.

[streethealer535]

My though is this... sounds like the patient has some Pulmonary adema from CHF.. (no lung sounds stated)

The treatment for CHF: Lasix, Nitro, C-Pap

Lasix is not going to do much if your only 4 min down the road and the medics were unavailable right? not your fault last time I checked

Nitro is going to help but only if you can assist. pt might not have had there own and agin not your fault medics not available.

As for C-Pap... what is it really but a little pressure to assist in ventilation... get were I am going with this... Bagging can do the same thing... I have had CHF Patients actually bag themselves. (I prefer to do the bagging but sometimes patients need this) Hold the mask and tell them to squeeze as they breath in. sound crazy right... well trust me it works... exspecialy when you don't have C-Pap.

Now if the patient is breathing fast cause they are scared (they tend to get that way when we can't breath) then helping them will slow their resps.

As for the RN YELLING at you I have a pet peeve with higher level providers Yelling instead of educating... its kind of useless to yell at someone for doing something "wrong" and not telling them what is "right".

JJ

[ERDoc]

You absolutely can bag a conscious pts. However, there is no magic number. As long as they can adequately oxygenate and ventilate they will probably be fine on NRB (for now). It's a judgement call. If they are working to breathe and are cyanotic, it would probably be a good time to help them. I try to tell them when I am going to do a breath so that they can try to breathe in at the same time.

[VentMedic]

As for C-Pap... what is it really but a little pressure to assist in ventilation... get were I am going with this... Bagging can do the same thing... I have had CHF Patients actually bag themselves. (I prefer to do the bagging but sometimes patients need this) Hold the mask and tell them to squeeze as they breath in. sound crazy right... well trust me it works... exspecialy when you don't have C-Pap.

JJ

Bagging is NOT CPAP (Continuous Positive Airway Pressure) unless you have a continuous flow bag like a mod. Jackson Reese. The biggest mistake on UNconscious patients providers make is holding a standard BVM over a patient's face for "continuous CPAP". That is not how that works and it is called suffication. Even with a resistive PEEP valve in place on the BVM, it is not CPAP. Know your equipment and how/why it works.

Let's also not confuse the terminology beteen CPAP and IPPV. Those are two totally different things with different affects for effectiveness.

If you do not have a tight seal on the face mask, which that is what bothers the patient most usually, you are just giving them a "puff of oxygen". I've seen that enough also. For that you might as well just give them the NRBM instead of teasing them.

Now for positioning so a patient can bag themselves. It is much easier if they do this with an ETT or trach. Most adults lack good muscle tone to keep their arms raised for very long. If they bring the bag to the chest they have a tendency to tilt the head forward, thus the risk of ventilating their stomach. Guess what that leads to? The pt will have decreased ventilatory space in the lungs as the belly inflates and later aspiration with or without intubation. Of course they can get an uncomfortable NG placed (or OG if they are on a ventilator later).

If the patient is anxious, talking to them for reassurance may help their breathing more than the BVM. However, if the patient is acidotic from some metabolic reason their body is not going to let them slow down. More effective breathing to enhance minute ventilation can improve some situations. If you bag, you must match the minute ventilation or you will get them into more difficulty by dropping their pH quite rapidly. Biggest pet peeve is watching a paramedic "coaching" a DKA to take sloooow breaths. What do you want a pH of 6.0 which they aren't that far from? Deep and more effective breaths to keep their CO2 low and their pH up for just a little while longer would be nice also.

As ERDoc said, it is a judgement call. Just don't panick if not every patient responds to bagging like you would expect them to. Always have plans B and C ready to go.

[jbullfrog09]

Thank you all for your input. i feel much better about my actions. oh the lung sounds were rails all the way up, a GCS 5, and sitting up the pt only stopped the gurgling.