Determining when to ventilate

[sylus]

Hey, I'm training to be an EMT-Basic and I'm still having some trouble in determining when to assist the patients ventilations and when to just do a nonrebreather mask. I am a little confused because I have been taught that if their breathing rate is under 8 or over 28, that their ventilations should be assisted. Is this still true if they are semi-concious? Is it okay to ventilate a patient who is not unconcious? Is it okay to insert a nasopharyngeal airway is someone who is not unconcious? Can anyone help me out with basic determining factors on whether to give nonrebreather or assisted vents? I have idea but I'm hoping people can give me reinforcement so I have a better idea of how to make my decisions.

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[scabiesnrabies]

Is it okay to insert a nasopharyngeal airway is someone who is not unconcious?

Yes, you can't use the oropharyngeal on a conscious person because they'd have a gag reflex.

You ahould assist ventilations on a conscious patient if they aren't breathing adequately on their own (breathing too fast or too slow with inadequate tidal volume, trouble speaking, irregular breathing pattern, etc). If the patient is able to breathe on their own, just use the nonrebreather.

 

[greytmedic]

For testing purposes you choose the answer that says ventilate if the resp. rate is under 8 or over 28.

 

[igcgnerd]

It is the same concept for the npa insertion. on practicals, the only time u use an airway (npa) is in a altered patient with the rr less than 8 or greater than 28 and in unconscious (absent gag reflex) patients

 

[greytmedic]

It is the same concept for the npa insertion. on practicals, the only time u use an airway (npa) is in a altered patient with the rr less than 8 or greater than 28 and in unconscious (absent gag reflex) patients

Not all unconscious pt's will have an absent gag reflex and you can use an nasal trumpet (npa) on someone with a gag reflex. You can not use a j-tube (opa) on a pt with a gag reflex.

 

[greytmedic]

There will usually be two variations to this test question. The fist question will be for a conscious person and the answer is to ventilate any conscious person with resp. under 8 or over 28. The other variation of the test question is for an unconscious person still breathing and the answer is to ventilate any unconscious person no matter the resp. rate.

Here is the real world stuff. Mechanical ventilation of a pt with a BVM who is still actually breathing is dependent on a couple of things that you will find in a quality assessment. First, an unconscious (not responding to any stimuli) pt gets some type of airway dependent on gag reflex. I will usually start to bag these pts if the reason the person is unconscious is not corrected quickly because we usually will go for some type of drug assisted intubation. A person who is still somewhat conscious (lethargic but will respond) will get an airway if they can't maintain their own airway (snoring resp, aspiration risk, etc) and will then also get sedated and intubated if the reason can not be immediately corrected. A lethargic pt that is maintaining their own airway will be further assessed for breathing quality. If this looks familar, but you can't quite figure out why you might want to review "ABC's." The breathing of the person is assessed, but this includes more than just rate. Quality, rate, depth, rhythm, color etc. are assessed and even an SpO2 (do not use as sole basis for any decision) is obtained. If the person has no signs of decreased O2, usually a NRB will suffice in the real world. Signs of decreased ventilation or hypoxemia will get a BVM. This of course is only based on my experience and SOP's, this may vary area to area and have many different opinions depending on who you work with. The key point in determing any kind of treatment or intervention is a quality history and assessment that takes into account all findings. But the real world is often different than any tests you will take, so until you are working on the street, go by what the book tells you.

Now, when you use a BVM on a person who is still breathing I find it is best to try and time the ventilations with the start of an inspiration. The key is to try and get good air movement into the lungs, not the stomach. Bagging too hard and too fast will probably result in gastric distension and you getting puked on. Use a nice easy squeeze on the bag and watch for good chest rise. If you aren't getting good ventilation, make sure the airway is open and try again. A little Magnum PI will help too (I know, bad joke). Sellick's maneuver (cricoid pressure) will help pinch off the esophagus and get the trachea in line with the pharynx. These are just suggestions and are the views of me and me alone. If these don't help or screw you up later in life, too bad.

 

[sphincter tone]

If you're having trouble ventilating a patient, don't be afraid to stick in two NPAs and an OPA if you can. It looks kinda funny but it works.

 

[deleted6669]

If you're having trouble ventilating a patient, don't be afraid to stick in two NPAs and an OPA if you can. It looks kinda funny but it works.

AGREE- years ago rosen( em guru) used to say that a pt didn't need to be intubated until he had deceasing sats with 2 npa's, an opa, and max 02 by bvm....that was before RSI though. I'm guessing he intubates a lot more folks not in full arrest now that it's much easier

 

[Jambi]

One more helpful hint, using a BVM properly requires more than one person. Yes it can be done with one person, it is however, very difficult to gain good bag compliance. Two people are really needed to do it correctly. One person maintaining mask seal and airway position, the other squeezing the bag.

I have never seen anyone in the field ventilate a patient by themselves and gain good consistent BVM compliance.

And as said above, airway position in key to BLS airway management.

 

[igcgnerd]

Yes it can be done with one person, it is however, very difficult to gain good bag compliance.

thank god for large hands

 

[Jambi]

...large hands

Good for so many things

 

[QuikClot]

The clinical answer as to when to ventilate, as opposed to the test answer, is; you ventilate when the patient has tired to the point that exhaustion is beginning to compromise their ventilatory effort.

If you attempt to assist, and the patient's own breathing interferes, then they are not exhaused and an NRB is indicated. If they allow you to assist or take over their breathing, then you do so (it is also diagnostic information).

I think the best indication of when a patient is approaching the point of ventilatory compromise (besides slow or ineffectual respirations) is depression in the LOC. Of course, with your chronic asthmatics and such, there is a easier way -- just ask them. They know when they're getting tired.

 

[jwk]

One more helpful hint, using a BVM properly requires more than one person. Yes it can be done with one person, it is however, very difficult to gain good bag compliance. Two people are really needed to do it correctly. One person maintaining mask seal and airway position, the other squeezing the bag.

I have never seen anyone in the field ventilate a patient by themselves and gain good consistent BVM compliance.

And as said above, airway position in key to BLS airway management.

Using a BVM properly does not REQUIRE more than one person. If you consistently need two people to ambu a patient, then your mask technique is poor. It takes practice and experience to do it well.

 

[24FF1313]

thank god for large hands

Second that...

I can, and do perform single-person BVM ventilations quite successfully.

 

[Unlimited415]

In real life, I would say you should make a judgement call based on your overall assessment of the patient. Don't just go, he's breathing at 8, bag him! Or he's up to 24, he needs a BVM.

Check to see if how they're doing. Do they look and sound like they're really not taking in enough air...cyanotic, poor tidal volume, acting like they're choking...gasping for air even though airway is clear or are they tolerating it all very well or are they just excited and it looks like they're going to calm down.

Let them know what you're doing and they'll often welcome your ventilations, since they can't take good breaths by themselves.