Rescue Breathing?

[tcripp]

Tcripp, why would you use O2 on this patient at this point in the scenario?

Excellent question, Dwayne. And the best answer I can give you is that that is what my Clinical Manager would want to see happen. If I've gone to the trouble of taking away the breathing for my patient, why not provide all that I can in return?

After intubation, in this patient, why a BVM?

As I wrote in the earlier post, I'm presuming that I've taken the patient's airway because of the hyperventilation...so I would BVM to control the breathing.

Kind of a crappy scenario when you are told "this is what you did" now justify it. Guess that is what I get for biting.

Conversely we as Paramedics are told we must "think first" and not just "blindly do"?

I guess I need to go back and see what I wrote because I thought I had written that nothing we do is black and white and I most likely wouldn't even have RSI'd that patient. OH, wait...I had that patient the other day. Well, no 30 RR, but rather unconscious/unresponsive with a GCS of 3 with a possibility that the patient OD - no proof either way. BP was pretty much 120/80, HR was 72, RR 22, ETCO2 was 40 and SPO2 on room air was 98%. I BLSd the airway. The patient came to...and was later discharged without being admitted. Had I taken her airway, that is not how that scenario would have ended.

[kohlerrf]

Frankly I agree with DwayneEMTP but this is not the question not the question every one?

Does everyone with an ET tube in their throat pre-hospital get vetilated at 10-12 breaths per minute regardless of their condition and must we maintian an ETCO2 of 40 +/-. What if you cant maintain an ETCO2 of 40 +/- with a rate or 10-12? Please don't tell me that there is someone out there that thinks they can accurately control the tidal volume with a manual BVM! Should pre intubation ETCO2 reading be the ventilation target?

[usalsfyre]

To echo everything above..

Unless your intubating for primarily "respiratory" reasons, the post-intubation ventilation target should be to match the pre-intubation ventilation status. The easiest way to do this with what's described is match ETCO2.

The patient will need support, as you've significantly raised the patients WOB.

To tniuqs or chbare, in the absence of a vent, would allowing the patient to breathe spontaneously through something like a Jackson Rees with a spring PEEP valve be better than trying to Ambu bag the hell out of him? My gut instinct is no, your looking at further bumping WOB because there's no inspiratory support, but stuffs not always as intuitive at it seems.

Edited August 24, 2011 by usalsfyre

[kohlerrf]

Thank you "Usalsfyre" for stepping up! You can treat my family members any day. Intubation is just a mechanical act to protect and allow us to take control of the airway it does not give us licence to fool with mother nature. in the absence of any other information the default "AHA Rescue Breathing" might be adequate but in this scenario this is not the case. Further more just as important as what we know about this patient is to realize what we don't know about this patient in determining the best course of treatment given our limited tools in the field. I am not entirely sure that ETCO2 is the panacea either but so far barring specifically a traumatic head injury head injury I think maintenance of pre intubation numbers is key here with one caveat, 02 Saturation should not be ignored. With all the pitfalls of pulsoximitry accepted through at least clinical observation or other means we must maintain an confirm a saturation of at least 95% at all cost. We can now see that respiratory rate is a tertiary concern here and it should be driven to what ever will maintain the pre-intubation numbers. And along with what "DwayneEMTP" said Im not sure i would of hooked up oxygen to the BVM either, and had the patient woke from the paralytics and began to breath on his own again I may have made the patient comfortably numb and just draped a 1 ply 4x4 over the opening to the tube to filter particulates and let him continue to breath on his own as long as he maintained his numbers and not used a BVM. There are real dangers of positive pressure ventilation and I always prefer the patient to have a negative intra thoracic pressure on inspiration.

[Paramagic]

I have to disagree with intubating and leaving the tube open to air. You have just increased the work of breathing significantly in someone who is already demonstrating a presumed compensatory mechanism to acidosis. This is setting this patient up for imminent respiratory failure and potentially cardiac arrest as his acidosis increases. This patient needs inspiratory support to reduce his fatigue (and acid production and PEEP to improve ventilation to ensure that CO2 gets out of there.

EtCO2, in the absence of in-field ABG is indeed what we should be using as a target for post-intubation ventilation management, with an understanding that there are going to be differences between EtCO2 and PaCO2. However this gradient is dynamic, so again, without ABG we just have to make an educated guess and get on with it.

Respiratory rate is not of tertiary concern, it is one of your primary concerns in this patient as RR is what dictates ventilation, and ventilation in this patient is of paramount importance. We don't increase ventilation by increasing tidal volume; all that does is cause lung injury.

If we want to improve oxygenation with just a BVM, we have 2 options: an FiO2 of .21 or an FiO2 of 1. Not ideal, but if that is what we have to work with, then we just have to make the best of it.

I'm not sure what the 'dangers' of positive pressure ventilation are. Sure, there are some downsides, like a decrease in venous return from the increased intra-thoracic pressure affecting perfusion, but this can be remedied with some fluid and/or pressors. The dangers of leaving this patient breathing on his own are much greater. If you had a PEEP valve on your BVM and could try to synchronise some support with their respirations you may be able to support them, but I have always found this to be rather difficult.

[tniuqs]

Unless your intubating for primarily "respiratory" reasons, the post-intubation ventilation target should be to match the pre-intubation ventilation status. The easiest way to do this with what's described is match ETCO2.

The patient will need support, as you've significantly raised the patients WOB.

Really have you with a tube has WOB really significantly raised, nope IMHO you have protected an airway.

To tniuqs or chbare, in the absence of a vent, would allowing the patient to breathe spontaneously through something like a Jackson Rees with a spring PEEP valve be better than trying to Ambu bag the hell out of him? My gut instinct is no, your looking at further bumping WOB because there's no inspiratory support, but stuffs not always as intuitive at it seems.

Whoo nelly ... I just read this and am under the influence or the dreaded pirate grog, Caribbean rhum ... but most seriously.

Ok so this patient needed Airway protection with a GCS of 3 .. good with that, ETI awesome, stay off the VAP it is the proven gold standard.

I would concure with chbare that PS or sensitively set trigger for AC would be the best way to match the WOB, and ETCO2 and well with a GCS of 3 not bucking the tube the patient is telling you something .. that said are you using long acting paralyticis i.e. Roc, Trac, Roc or Pav as one could screw up and plumet PH and increase Co2s something in DKA you really don't want to see.

But you don't have an AC trigger on a vent

Yup wean his O2 down to maintaining sats of > 93% ... really no need to hyper oxygenate, as Dwayne suggest's we are Hyperoxia is that the best case senario ? but certainly sure, 5 of PEEP is physiological.

Paramajgc is also correct: re: ETCO2,

in the absence of in-field ABG is indeed what we should be using as a target for post-intubation ventilation management, with an understanding that there are going to be differences between EtCO2 and PaCO2. However this gradient is dynamic, so again, without ABG we just have to make an educated guess and get on with it.

Respiratory rate is not of tertiary concern, it is one of your primary concerns in this patient as RR is what dictates ventilation, and ventilation in this patient is of paramount importance. We don't increase ventilation by increasing tidal volume; all that does is cause lung injury.

If I could add its Minute Volume not tidal volume and RR.

The dangers of leaving this patient breathing on his own are much greater. If you had a PEEP valve on your BVM and could try to synchronise some support with their respirations you may be able to support them, but I have always found this to be rather difficult.

zactly ... watch the "duck valve" very closely and support as required in lou of the non long acting paralytics as they may be a complication to good patient care.

When the rhum wears off will follow this thread suspected DKA, serousy is not an easy, simplistic topic.

cheers

[Paramagic]

Really have you with a tube has WOB really significantly raised, nope IMHO you have protected an airway.

You have protected the airway, but you have also increased work of breathing. Flow is proportional to the fourth power of the diameter, and inversely proportional to length (Poiseulles law) When we place the tube we have decreased the diameter of the airway, and we have increased the length of the airway, so to have the same flow the workload must increase: it's simple physics. And this is just the tube, it's not taking into account any increased deadspace from the circuit.

If I could add its Minute Volume not tidal volume and RR.

Indeed; my point was that to increase minute volume to ensure adequate ventilation we need to increase the rate, not the tidal volume, in order to avoid lung injury.

When the rhum wears off will follow this thread suspected DKA, serousy is not an easy, simplistic topic.

I hope it doesn't bite back too hard!

[chbare]

Agree with increased WOB, but just want to nit pick a bit. Poiseuille's law is only a gross approximation. It is a reasonably good approximation when considering incompressible, Newtonian fluids and laminar flow patterns, but a gross approximation otherwise. However, I agree with the "spirit" of it's relevance.

[mobey]

Would also like to point out to Dwayne, that a tube placed below the cords and open to the atmosphere is a great "highway" for pathogens to get directly to the fragile airways.

[Paramagic]

Agree with increased WOB, but just want to nit pick a bit. Poiseuille's law is only a gross approximation. It is a reasonably good approximation when considering incompressible, Newtonian fluids and laminar flow patterns, but a gross approximation otherwise. However, I agree with the "spirit" of it's relevance.

Indeed, I guess when I said "simple physics" what I really meant was fiendishly complex and poorly understood fluid dynamics, but really for the purposes of understanding some airway resistance stuff, it's a reasonably good concept. If you have something better or simpler to describe resistance to flow, I would love to hear it!