It's a common phrase in EMS land, and one that rolls off your tongue smooth and easy: "Assist ventilations." Yessir, that's the phrase. It's usually stuck at the end of a sentence, such as, "Since the patient is only breathing at a rate of six, why don't you go ahead and assist ventilations?" Those last two words are the focus of this month's BTB, as we take apart just what it takes for those words to equate with being a meaningful intervention. Next month, in Part 2, we'll look at a fantastic training technique with which you can markedly increase your skill in regard to assisting ventilations.
It's my belief that proper use of a bag-valve mask is one of the most difficult skills to master in all of prehospital medicine. There are two reasons for this: First, ventilating a patient with a BVM is an infrequently used skill. There are exceptions to that rule, such as systems doing rapid sequence induction intubation (RSI). Their providers typically have some of the highest rates of ventilated patients per year per provider. Another exception would be the systems that serve the poor urban sections of the biggest cities where heroin continues to be the drug of choice. The rest of mainstream EMS systems, therefore, do not get adequate exposure to become and stay proficient with assisting ventilations. Second is the infrequency with which most providers actually practice the skill in a meaningful fashion.
As far as patient population, there are only three types of patients needing assisted ventilations: those not breathing, those breathing too slow and those breathing too fast. Each comes with unique circumstances and challenges.
The NOT Breathing
This is arguably the easiest of the three, because your patient is apneic and unconscious. Open their airway manually and they easily accept an oropharyngeal (OPA) airway. Position the head and neck as circumstances dictate, place and seal the mask, initiate ventilations. The three linchpins to success in this scenario are:
PROPERLY POSITIONING the airway and keeping it properly positioned.
Getting a decent MASK SEAL.
Ventilating at the right rate and depth to maintain adequate oxygen levels while shedding adequate CO2.
In the world of people you find breathing too slow and too shallow, heroin, OxyContin, Vicodin or any of the other opiates or opioids are a frequent cause of hypoventilating patients.
In this setting, you have a spontaneously breathing patient to work with. Depending on how obtunded they are, they may or may not accept the OPA. Without the OPA, the airway is much more difficult to maintain, though an NPA is a viable option.
In most cases, the patient is pretty well out of it, thanks to the combination of the drug effect glued to the effects of hypoxia and hypercarbia, thus making it less challenging to seal the mask, position the head/neck and begin assisting ventilations. Keys to success in this scenario are:
Getting and maintaining proper position.
Timing your breaths so when the patient takes a little one, you follow it and push it in, making it a larger breath.
Breathing fast enough and deep enough to maintain pulse oximetry readings >95% and maintain CO2 between 30-35.
Unquestionably, these are the most challenging of the three patients previously mentioned. The real challenge here is getting in sync with a patient breathing like a hummingbird. This requires some real concentration and excellent BVM skills.
First and foremost, you need to communicate your plan to the patient: "You are breathing way too fast, and together we are going to work to slow your breathing down." Next, let the patient know that you are not going to place the mask, but rather, you are going to put it close enough to his face so he can feel the puffs of air/O2 as you gently squeeze the bag. Again, you must continually talk with your patient, literally on a breath-by-breath basis. "OK, now take a breath. Good...and another. Good job. Oops, you are speeding up again. Slow down and take a breath. Excellent!" It's a combination of coaching and driving the process at the same time.
Once you have the patient in sync, let him know that you are going to place the mask on his face. Again, this requires almost continuous dialogue on your part to keep the patient focused and on task as you seat the mask and begin to assist ventilations. In my experience, it can take 4 or 5 minutes to get the patient to listen and follow your lead. By comparison, if you suddenly decide to seat the mask and begin ventilating, and you are out of sync (he is exhaling and you are trying to ventilate), you will not be successful. A clue to asynchronous ventilations is the fluttering sound the patient's cheeks make, kind of a facial flatulence sound, that tells you that was an ineffective breath. If you continue down this path, the patient just gets increasingly frustrated and more often than not starts breathing faster.
Tune in next month, when we will look at a training technique to tighten up this mysterious skill.
Until next month…
Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.