Bag-Vavle-Mask problem?

[sportygirl]

On my clinical rotation got to bag a patient on the way to x-ray but the respiratory therapist said that I was bagging to slow and that I should bag once every 6 to 8 seconds. And that the patient was on a vent where the patient needs only about ten breaths per minute.

I learned in CPR that you bag a patient once every 4 to 6 seconds if they have an advanced air way. And when I asked another student that goes to another school he was taught 6 to 8 seconds. But if you do the math if you bag once every 5 seconds it is about 12 times a minute, if you go faster the patient will not get enough air! Less than 4 seconds and then that is to fast.

I was bagging the patient once every 5 seconds that means she was getting 12 breaths a minute. I learned that you count one one-thounds to keep the breathing rate the same well bagging.

Was I right or wrong? What is right? Do I do what I was taught? Dose being on a vent make a difference or not?

[VentMedic]

You titled the Thread "Bag-Valve-Mask" but you said the patient was on a ventilator?

Or was it Non-Invasive Ventilation via a ventilator?

I'm going to go with you meaning Bag to tube. Most of the principles with be the same for either ventilator/ETT or NIV. However if NIV, hopefully there was an NGT in place.

What was the pt's dx? What was the full ventilator settings including MODE? How many ventilator days? What was the chest X-Ray looking like? What was the last ABG on the ventilator?

What was the patient's minute volume on the ventilator? A back up rate means little if they are doing Spontaneous breathing trials or on an APRV mode which may have a set rate of 8 or 10 with an inverse I:E utilizing a demand valve that allows supported breaths at the upper level of pressure. It is not wise to drop the MV far below what the patient requied for homeostasis. If the patient required 22 L/M, that may be what you will have to match.

Also, what was the pt's level of PEEP? PEEP valves on BVTs are very different than the flow PEEP on an ICU vent. The RT may have been wanting to maintain a little intrinsic PEEP to compensate for the inadequacy of a flow retard PEEP valve.

What type of V/Q mismatching did the patient have?

Patients with different lung disorders may require very high RRs and still never be able to blow off their CO2. ARDSnet we may go up to a RR of 35 with low VT and buffer with THAM while allowing for permissive hypercapnia.

We also use High Frequency ventilators that have an oscillating cruising rate of 600 cycles/minute.

Welcome to your introduction to Critical Care medicine where the challenges for the long haul can be very different.

You stated you asked several students about the rate. Did you ask the Respiratory Therapist who had been taking care of the patient on the ventilator to explain anything to you? Many RTs love to teach.

If you are an EMT student, I apolize that my post is a little advanced probably even for some Paramedics. ASK QUESTIONS OF THOSE WHO MAY KNOW the answers when they are within reach! Use the licensed professionals as resources. That is the quickest way to learn when in clinicals.

[sportygirl]

The patient was put on the vent just before I started at 1800 and it was not a vent that we could take into the x-ray room so I was bagging the patient well the Respiratory Therapist went up to the ICU to set up the vent. I am not sure if it will make it different the patient was getting a CT done. I am an EMT student and don't know if there are different rites or not. The respiratory therapist was not very nice to me or the other two students I was told by one of the nurs that she does not like students.

Are things like age and wight going to make it different or not.

VentMedic said

What type of V/Q mismatching did the patient have? What dose this mean?

Also, what was the pt's level of PEEP? What is a PEEP?

There were some other things that were said and I don't know what the mean like ETT, NIV, dx, ABG, RR, VT, THAM

I ask questions at work all the time I ask any and all of the EMT-B's and EMT-P's. I am a Vehicle Service Technician the person who stocks ambulance.

[VentMedic]

You just explained why the RT was not a very friendly type of person. She is covering at least two potentially heavy areas (ED, ICU), setting up equipment for both areas and no sign of backup. She's probably also had pts on a couple of med surg floors as well as the Rapid Response and Code pagers. Nursing probably didn't want to tie up one of their nurses and were of little use to the RT. She had to trust an unlicensed, uncertified EMT-B student with a patient that needs a ventilator in ICU.

I normally enjoy the help of students but I also don't let them or my intubated patients out of my sight if at all possible. That includes students from the schools of RT, Nursing, EMT-P as well as MDs in training. Once the patient is is on a ventilator I relax. My ventilator will usually do what it is told. Although some of the newer ventilators like to agrue that they are the "smart ones" until the over ride button is engaged. The ventilator will also tell me what buttons have been messed with and what alarms have been answered or ignored. It will also be a witness for the committees and courts in cases of adverse medical events resulting in permanent damage or death while on a ventilator.

BTW, did the RT have you bag the patient DURING the CT Scan?

Bookmark this thread and come back to it as you advance your education beyond EMT-B.

When you are in the field without the use of most differential diagnostic equipment, your protocols are general guidelines to get you through unknown situations while hopefully doing the least amount of harm.

There are many factors in the hospital that determines the protocol for ventilator and patient management. RTs may have no less than 50 different protocols for ventilator management strategies. Each protocol may have several variations or pathways to take for different factors presented by patients that don't quite meet the text book definitions.

[firedoc5]

I might be a bit wrong, but one thing I learned working occasionally in RT is that you have to take into consideration how much O2 was going to the bag and being delivered per ventilation. The volume might have been enough to deliver enough O2 to keep the O2 level in normal values. And by vents. by tube is totally different than by mask. You don't get the same level of O2 by mask as you do by tube.

VentMedic, I did have a question for you sort of related to this, and I just wanted to know what you thought. When we would bring in a full arrest, tubed of course, we had a couple of docs that liked it that when we first arrived and the first ABG's were drawn that the O2 were above 100, even up to 110-120. So we were encouraged to hyperventilate in the field until reaching the ER. Of course after being in the ER and and a regular RT would take over they could slow down the resp. rate and get the O2 normal and acid-base balance corrected if it was off too much. Have you heard of this before? I did work in RT part time for about five months. Actually one day they had me in RT, another day in phlebotomy, another day somewhere else, so I never got to get into the more advanced procedures. Barely got use to setting up vents, which I hated with a passion.

[DwayneEMTP]

On my clinical rotation got to bag a patient on the way to x-ray but the respiratory therapist said that I was bagging to slow and that I should bag once every 6 to 8 seconds. And that the patient was on a vent where the patient needs only about ten breaths per minute.

I was bagging the patient once every 5 seconds…

I’m guessing that you meant that you were told you were bagging too fast? That is the more common problem.

I was bagging the patient once every 5 seconds I learned in CPR that you bag a patient once every 4 to 6 seconds if they have an advanced air way. And when I asked another student that goes to another school he was taught 6 to 8 seconds. But if you do the math if you bag once every 5 seconds it is about 12 times a minute, if you go faster the patient will not get enough air! Less than 4 seconds and then that is to fast.

I think you got this backwards. Normally BLS, (as VentMedic mentioned, there are many reasons to change vent rates/volumes (Though I didn’t understand most of what she said either) at cert levels higher than yours, but I think this is what you’re looking for.) with BVM you’ll try for a rate of one ventilation every 4-6 seconds. Once an advanced airway is placed that will drop to about once every 7-8 seconds. Can you break this problem down and tell me why that is? What are the possible differences between using just mask, and using the tube?

I was bagging the patient once every 5 seconds that means she was getting 12 breaths a minute. I learned that you count one one-thounds to keep the breathing rate the same well bagging.

A “normal” person will be expected to breath between 12-20 times per minute, per your current learning. So if we take the person that is breathing 12 times per minute, and they stop breathing, then intuitively it seems that we should breathe for them at a rate of 12/min, right? But there are several things that change when we begin to breathe for them…what do you think they are? Therein lays your answer….Though I’m happy to help.

Let me know what you think and we’ll talk more…

Dwayne

[VentMedic]

VentMedic, I did have a question for you sort of related to this, and I just wanted to know what you thought. When we would bring in a full arrest, tubed of course, we had a couple of docs that liked it that when we first arrived and the first ABG's were drawn that the O2 were above 100, even up to 110-120. So we were encouraged to hyperventilate in the field until reaching the ER. Of course after being in the ER and and a regular RT would take over they could slow down the resp. rate and get the O2 normal and acid-base balance corrected if it was off too much. Have you heard of this before? I did work in RT part time for about five months. Actually one day they had me in RT, another day in phlebotomy, another day somewhere else, so I never got to get into the more advanced procedures. Barely got use to setting up vents, which I hated with a passion.

Physicians usually call for hyperventilation initially because of down time and acidosis (both metabolic and respiratory) that is suspected.

With a BVT to a 100% O2 source, I would expect a PaO2 to be higher. However if it is only 110 mmHg, that will give an idea to the cardiac output and V/Q mismatching or whatever the case might be. 110 mmHg gives you a considerable A-a gradient. ( Look up Alveolar Gas equation. ) Once fluids are infused, pressors started and adequate circulation returns, the body can try to adjust, thus, the ventilations can return to a more appropriate range.

Dwayne,

Thank you for coming in on this also.

For this patient, there is not enough information to determine if this is a ventilation or oxygenation or both type of problem. We don't know the sedation used or the Mode, VT and Rate the pt was doing on the ventilator. It may also have been a Sepsis issue which again affects the lactate, anion gap and SvO2. That also requires special consideration for maintaining oxygenation and ventilation.

However, few here including myself that should not be second guessing what is appropriate for a ventilator patient inside a hospital without knowing more of the diagnostics or diagnosis. I also know that I may change my ventilator strategy several times during the course of the shift as the patient's conditon warrants. That is why we have many different protocols along a college degree and many, many hours of inservices/training by our Medical Director(s) as RTs.

Again, so many factors to consider once the hospital diagnostics are done.

Textbook quidelines are great in the initial phase. Once more information is obtained inside the hospital, the rules that existed for the initial can change quickly. I've had pts deteriote quickly as the PNA or V/Q mismatching progresses rapidly to where I think I am going to have permantently cramped hands from "leaning into" the BVT to keep a patient ventilated/oxygenated until a special vent and/or gas was set up. I've also had PNA patients that were breath 40+/minute to maintain a barely acceptable level of ventilator/oxygenation until intubation is setup for. For those patients, it is a very quick RSI and without ego involvement, the best intubator goes for it. A BVM may be useless on these patients. These patients will usually go straight to an ARDS protocol on a ventilator with high PEEPs, lower VT and a high Rate.

Yeah, I'm throwing some nickel terms out there, but the basic level is very basic with lots more to learn. It is too bad the RT didn't take more time to explain herself because now we are only guessing what that particular situation and the ventilator protocol followed by the RT. It is also very likely that she would have sounded alot like my posts. It may be hard to explain it without referring to lab values or specific disease processes that you have not and probably will not cover in EMT-B.

If you want more help for what to do in the field or initially, then I know several people on this forum who will be willing to give you advice either on or off line.

Don't stop learning. You have just been introduced to one tiny snowflake in the blizzard world of medicine.

[DwayneEMTP]

...We also use High Frequency ventilators that have an oscillating cruising rate of 600 cycles/minute.

See, and once you become a medic you'll come to understand that this only applies as long as your seat back and tray tables are in the upright and locked position.... :wink:

Sportygirl, of course I'm kidding, but I wanted to make sure that you understand that Vent talking over our heads is a compliment, not a back handed insult. She assumes that we want to learn above our certification and current education level and is kind enough to give us all the information we need to do so...and we're always the better for it.

So if you'll take the time to answer my questions, I'll take the next day or so and figure out the things in Vent's post that I didn't/don't understand, and then we can share!

Sometimes new people can get scared away by the very intelligent posts we are blessed with here, but it's important to understand that you're not expected to understand it...you're expected to come to understand it, and then teach it to others...see what I mean?

Thanks Vent for your posts...I'm shamefully weak in respiratory physiology outside of my own little medic world and am grateful that time and again you dedicate the time and effort to keep moving us forward...you're a peach...(and were missed terribly in Florida! Though you weren't there in body, you were often there in spirit as part of our conversations and arguments. :wink: )

Have a great day all!

Dwayne

[MSDeltaFlt]

On my clinical rotation got to bag a patient on the way to x-ray but the respiratory therapist said that I was bagging to slow and that I should bag once every 6 to 8 seconds. And that the patient was on a vent where the patient needs only about ten breaths per minute.

I learned in CPR that you bag a patient once every 4 to 6 seconds if they have an advanced air way. And when I asked another student that goes to another school he was taught 6 to 8 seconds. But if you do the math if you bag once every 5 seconds it is about 12 times a minute, if you go faster the patient will not get enough air! Less than 4 seconds and then that is to fast.

I was bagging the patient once every 5 seconds that means she was getting 12 breaths a minute. I learned that you count one one-thounds to keep the breathing rate the same well bagging.

Was I right or wrong? What is right? Do I do what I was taught? Dose being on a vent make a difference or not?

You were bagging around 12 times per minute. Once every 6-8seconds is 16-20 times per minute. Were you wrong? No. You were doing what you were trained to do. Was the RT wrong? No. She probably had ABG's to tell her what the pt needed.

Now I love having students in the middle of everything. They get so much hands on experience, and you get to teach them all the way through it. However, Vent's right. That RT was probably pulled between 2-3 areas at least. She's been there, and so have I. At times, it ain't fun. Nurses complain about the miles they walk in a shift. They can't touch what RT does in a shift.

Does being on a vent matter? Kind of. The ABG's, CXR matter. The vent will help you on "how" to bag the pt.

If the vent is ventilating fast with high pressures, then you're going to bag fast and possibly squeeze harder than you normally would.

If the pt is assisting the vent, then you'll have to assist the pt with your bagging. You'll have to bag "with" the pt.

If they're on a lot of PEEP, then you'll need to put a PEEP valve on the AMBU bag.

You don't want to bag too slow. Remember swimming underwater and you almost didn't make it back up in time? The pt will be feeling the same thing if you bag too slow.

You also don't want to bag too fast. Ever blow up too many balloons at one time? The pt will be feeling the same thing if you bag too fast.

Simply put, bag as you've been taught until someone, who has more information about the situation than you, instructs you to bag differently. But make sure they have emperical data to back it up.

You did good.

[EMTBASIC_911_911]

Although I never have had to bag a pt, I was taught to squeeze the bag every 3 seconds and to squeeze it at a nice steady pace, not to slow because they wont get enough and not to fast, cuz it will just put too much air in the pt. We were taught also that as long as the pt is getting 12 Breaths a minute were doing something good....Sorry if i couldn't help more...its 5am here lol