Smaller BVMs?

[tniuqs]

You don't suggest people are unaware of the difference between oxygenation and ventilation let alone ventilation and perfusion?!?!?! He has an FiO2 of 90%, PEEP of 10cm, but he's still hypoxic?

I may be wrong but I sense <sarcasm?> back at you bro, so how do you get .90 Fi02 on a self inflating BVM or a JR ?

And can one cause Auto PEEP with say "wide open flow meter" or 15 + lpm on a BVM ?

I so hope you get that job btw!

VentMedic

I will elaborate a little more on the low VT ventilation. For the cardiac, the theory is not to hyperinflate and do smooth even flows with low pressure. For ARDS, we may do a very rapid flow to hold similar to a square wave pattern to increase airway MAP and thus, hopefully increase oxygenation. However, that may require much pharmacological support to accomplish this as a high PEEP is also used in conjunction with the low VT to improve oxygenation and reduce atelectasis.

Great stuff

But an RRT Slam is now must be in order (to be fair) ... I can tell you that I took me 3 years I my OLD ICU (note the past tense part) to have in included in respiratory report "include trope levels" and right next to MAP = Mean Airway Pressure, Oh so don't get me going.

Many card in hand ACLS ICU RNs would get noses right out of joint pulling ABGs and believing this was a "static" measurement, and that recording MV and SpO2 and ETCO2 were rather important, this @ 04:00 hours was ABG / ie blood work time on a 30 bed unit that only took 2 years to change policy ...argh.

NB: Many respirologist ie pulmonary medical intesivists type(s) believe that Oxygenation = MAP, provided CO not affected to drastically.

cheers

ps maybe we need to invent a Smart "monitor" in line with every BVM and voice activated ? I will get back to you

[kevkei]

I may be wrong but I sense <sarcasm?> back at you bro, so how do you get .90 Fi02 on a self inflating BVM or a JR ?

Who said anything about a BVM or JR? First, I can't assume anyone doing BVM ventilation has an absolute closed system, it was an arbitrary number to prove a point. Sarcasm yes to a point. But practically speaking, prehospitally if you are flowing only enough O2 to keep the resevoir inflated, or preferrably giving an appropriate amount of FiO2 based on patient need (not all pts need 100% O2). Sarcasm to indicate a VQ mismatch perhaps?

And can one cause Auto PEEP with say "wide open flow meter" or 15 + lpm on a BVM ?

Are you suggesting it may be possible to think outside the box???? Considering physiological PEEP on the healthy individual is ~ 5 cm and a high flow rate of any type would be higher, ahhh... um... I guess.... Yea.

Would this perhaps be why a JR should only be used with a pressure gague?

[melclin]

Perhaps it is my lack of skills with a plastic brain but searches to these studies is sub optimal, if you could be so kind as provide a link.

This is for the first : http://www.biomedcen...m/1471-227X/9/4

and the second : http://www.paramedic...;journal_uid=41

(its the one down the bottom. I can't seem to get access at the moment for some reason)

Sorry I didn't post sooner, I had a little seniors moment with the user control panel

1- PC = Presser Control (type) Ventilation with a flow inflating "bagger" and VT is subject to R= Resistance and C= Compliance)If a Paramedic is to use this mode of ventilation best get further training as a member of this website for quite some time the group as a whole (well in this Ventilation subject area) seriously lacking education (I hope that most using PC will recognize that one can ventilate a brick !)and without monitoring devices/ watching chest rise, or belly rise (in the non intubated) and the addition of pulse oximetry and ETCO2 well. if you think this is far from the truth ? It does happen far more frequently than you can fathom and unrecognized besides I have the court cases to prove it.

2 VC = Volume Control Ventilation ... well I have a little scenario on a little course I developed for Paramedics: Called Transport Ventilation in the Flight Environment ... would you guess that based on the 5 to 7 ml per kg that 90 % of Paramedic students FAIL ... when presented with a Patient that is 200 kgs .. HUGE FAIL!

This is where I start then titrate PIP > 40 to achieve Plateau pressures less than 32 cmH20 "in the fresh Intubated" and non complicated pulmonary patient.

This is an interesting division, that I've not heard come up before at uni. A little more reading is in order for me perhaps.

To the OP could you please explain APPV or IPPV (is that intermittent positive pressure ventilation?)

Assisted Positive Pressure Vents and Intermittent PPV: The gospel according to Ambulance Victoria (AV) states that IPPV involves ventilating in between the pts spontaneous resps, and APPV is assisting the pt's spontaneous resps - 'topping up the tidal' as its put. I have no idea if these are valid terms outside their use in AV or where their meanings stand in terms of best practice.

I understand PRCV, APRV, PC, VC, Control, PS, CPAP, and SIMV (a few more oldies too)... but APPV has got me scratching my balding head?

Comparing 1 PC and 2 VC is like comparing apples to oranges in the first place unless one has volume measuring devices in line as well as pressure ...

http://www.lifesavin...c.com/em100.htm well IMHO is a toy and also should hit file "G" the Carevent ATV has nice colours on the twisty knobs again belong in file "G" for anything more than a transport across the street (I call them the Educated Fire Fighter) as far less extubations enroute.

Honestly I have no idea why if these are published studies why one would wish to remain "private" just the drift of the convo suggests that yet just another capitalized approach, inventing another gimmick as in the Smart Bag IMHO should recycled into gargbage bags ! http://www.otwo.com/prod_bmv.htm

His agenda of getting the bags changed bothers me, because it reaks of "paramedics being too stupid to use the right equipment, so we'll change the equipment". I also disagree with his methodology in a number of ways and I didn't really want to bag him specifically in a public forum where he can't reply, especially given the delicate politics of the department, to which I am a relative newcomer.

ILCOR are standards set for those that rely purely on the dummied down for the Paramedic Masses AND so that every RN can get a card for their wallet. Its not a gospel,and its a consensus and vast majority of those with input a cardiologists or ER Mds ... hint: the footnotes are an indicator.

Really a rhetorical question, short answer of course the type of airway is a variable and what type of lung simulator are we talking here computer sim or one with mechanical springs, just a query is all.

Its primarily mechanical. It does have rather a lot of adjustable settings regarding compliance and some plugs that might be attachable to a computer. In the study thought, it was purely mechanical and he visually recorded the vent values as they happened.

1- I believe chbare is referring to Vd/Vt ie deadspace ventilation with the use of variable airways, I will not put words in his mouth persay.

2- Quote Ventmedic: "For the OP, it sounds like that researcher is trying to build a better mouse trap with the BVM to achieve lower VTs, limited flow and lower pressures" Agreed Fully, education is the long term answer not another I am too stupid to use my brain and the sense of touch and need another plastic invention.

3- Vent goes into great depth to explain compliance compensation, deadspace ventilation and different strategies in the ARDS patient errors in the CCT situation this is why Respiratory Therapy is now a 3 year degree program and a 2 week course for a CCT patch ... is a band aid fix at best, s if one cannot run an LTV like a piano ... get off the bird !

I take your point about the education. However, there are still practical considerations. Playing devils advocate here, if medics are over ventilating during cardiac arrest and having them use smaller bags would immediately fix that problem, then why not? We have no equipment to measure flow and pressure in the field, wouldn't it be more effective to use equipment that was more conducive to the desired practice. Would it be so difficult to change bags if you got a ROSC?

<snip>

what happens if you have a ROSC? Do you change BVM size?

Excellent point. I might put that too him. I'm not sure why that didn't occur to me, and it certainly will have occurred to him so I'm sure he'll have an answer. Would it be that difficult to change bags? I mean why not just say yeah, sure, change the bag to a 1600 when you get a ROSC?

I will elaborate a little more on the low VT ventilation. For the cardiac, the theory is not to hyperinflate and do smooth even flows with low pressure.

Thank you nicely put.

[Kiwiology]

I think the whole debate is a wank personally.

What is the main aim in ventilation? Perfusion maintenence in the event of return of spontaneous circulation.

Evidence has shown that perfusion rates decrease by approx 50% at the time of arrest. This means we need to maintain less Oxygen during the arrest.

Will the size of the bag really effect this? No. In the until an ETT is insitu, you cannot gaurentee the amount of oxygen actually entering the lungs. Poor seals, lack of effective jaw thrust, head tilt can lead to air being pumped into the stomach.

Studies that the current guidlines are written from show there should be a primary focus on compression, even before defibrillation in some cases.

To me this makes the who debate mute. What would be more interesting is to see how effective -placing a high concentration mask on a pt & see how much O2 enters the system through partial pressure changes with cardiac compressions.

You think everything is an opportunity to wank mate - mind you, that's not a crime

I do meet you halfway here; average inspiration is what, 600ml?

People are idiots, so if we give them a big bag they will squeeze the whole thing (which is exactly what the ambo's here found was happening) and massively hyperventilate the patient (potentially, as you say, oxygenation/ventilation are not the same thing)

Smaller bag should fix that problem, but again, whether it does any benefit is another thing altogether, but it couldn't hurt.