The volume delivered by a pediatric bag would be considered inadequate by the old CPR guidelines, that insisted on at least one liter per ventilation. Is this really inadequate?
What kind of tidal volumes are used for vent settings? Usually 400 ml to 500 ml, with the bariatric setting of maybe 600 ml. The pediatric bag has the volume written on it somewhere, but some of the the best indicators of the appropriateness of the bag is the response of the patient.
Chest rise?
Stomach rise?
Stomach returns to where it was before?
Skin color improving?
Heart rate improving?
Level of consciousness improving?
Et cetera.
Why use the pediatric bag instead of the adult bag?
If you have tried to intubate a patient, who has been aggressively ventilated by someone who doesn’t know when to say when, then you know what I mean. After the lungs are filled, the rest of the volume will fill the stomach. And not all of the volume goes into the lungs to begin with. When there is too much of anything in the stomach, something has to come out. The word for this is vomit. No longer smells as good as when it went into the stomach. Not the perfect accessory to the EMS wardrobe. Not something that contributes to good gas exchange in the lungs of the patient. Expect some of it to end up in the lungs of the patient.
Positioning can make a big difference in where the oxygen goes, but adjunct devices can help. An NPA (NasoPharyngeal Airway) or OPA (OroPharyngeal Airway) can be helpful in directing the oxygen to the lungs, instead of the stomach. Some people insist that these devices are essential. I disagree. Using the proper tool may mean not using any of these. One of the problems with their use is the stimulation of the gag reflex, which can produce vomiting. It is better to avoid vomiting and use other methods to direct the oxygen to the right place. If you can place an OPA or NPA without irritating the patient, go ahead. Both work to move the tongue away from the back of the throat, where it may be acting as a barrier to ventilation. Positioning can be a jaw thrust, head tilt, placing something under the shoulders or the head to reposition things better . . . .
Another advantage of the jaw thrust is that it can be very painful, just what is needed to stimulate the not quite conscious patient to the level of alertness that allows the patient to protect his own airway. The patient protecting his own airway is the best airway control available, as long as the patient is able to maintain it.
Using the pediatric bag makes it more difficult to overinflate the lungs, but it is still possible to directly ventilate the stomach with each squeeze. So, while this may help with some parts of airway management, it is not a panacea. Airway management is the skill that depends most on assessment, so all of the tools designed to make airway management fool proof do not work.
A skilled operator is essential to ventilate a patient with a BVM.
One device that is suggested as a way to avoid squeezing the bag to forcefully and essentially forcing the oxygen into the stomach is a BVM with a flow restricting valve. I used one of these at a conference and I liked it, but since I have not used one on a real patient I am hesitant to recommend it.
Is this something that leads to better airway management? I have seen people, both in and out of the hospital, who squeeze the bag too forcefully and too fast. Would this improve their bagging, or just cause them to create different problems?
Here is a link to a review of the Smart Bag by Greg Schaffer. He does some presentations at the EMS conferences and is not someone to promote something he doesn’t believe in.
If anyone has any real world feedback, please let me know with comment or an email.
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Like this blog…keep up the good work.
nj ems,Thank you. I will try.
Hmmm…This post comes as a shock! You are usually quick to make the case against tossing out the baby with the bathwater (a la OLMC ass-clownery). Doth mine eyes deceive, or are you suggesting that my toys come with warning labels, my scissors be replaced with the round-tip variety, governors be installed on all my transmissions, and my big scary adult ambu-bags be restricted to the diminutive flavors- just so the baby gorilla doesn’t make boo boos with the airway?”Mongo make hard skweezy on bag, hey, look!… hot dogs!”I suppose your crowbar is poised menacingly betwixt my none-too-dead-nor-cold fingers and my happiness too!(that’s a warm gun, for you non Beatles fans!)Say it ain’t so!Instead of idiot-proofing the equipment, we should just equipment-proof the idiots!If you can’t learn to do it right, then perhaps a career in foreign policy advising is more your speed.Problem solved, and my stock in Laerdal stays safe đ
Some EMS workers use excessive speed in the performance of their duties —- should we install governors that limit the top speed in EMS vehicles to 55 MPH?No !! The industry should only hire people with a thorough understanding of their discipline, and mastery of all related psycho-motor skills —– even if it means that EMS workers, pilots, scientists, etc. might not ‘look like America’. It is a broken stratification process in the hiring system, not the technology, which is responsible for most of the iatrogenic effects in the healthcare system.I believe that well trained clinicians could manage (in the short term! – prehospital) all cases requiring respiratory assistance / artificial respiration with an adult size bag.
vince, I made my reply a post of its own.
ld,I have not advocated quotas, or any other form of avoiding assessing competence.I have not made any of the suggestions, that you seem to attribute to me.
Yes you have, you just don’t realize it :)We had a saying when I worked in law enforcement —– which was around the time that many departments were transitioning from wheel guns to semi-autos —— ‘if you can’t do the job with six — you can’t do the job.”Bottom line —- you need skilled clinicians in EMS, not more tech (toys) to compensate for a lack of ability.
ld,The use of waveform capnography is an example of a tool that helps you do the job better. People were able to intubate before waveform capnography. The ability to assess placement improved with the addition of waveform capnography. Of course, if you feel that tradition is more important than patient care, then we will never agree.
You fascinate the hell out of me. This post is great.
ee,Thanks for the kind words. You keep a lot more people fascinated than I do.
way to be ahead of your time rogue medic. This is becoming a general thought in EMS. Why use the wrong piece of equipment….general adult volume vs. Large adult volume. Looks like a few people were scared…weird since I thought people were in EMS to help others, not their own ego. Science and the Medical world go hand n hand. We should all be ready to do the right thing for patients, especially when those giving the care, and yes the ones with the most years of experience, are the ones most likely to be doing it wrong during a 911 call.