Quick asthma scenario q from school...

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bunkie

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Would have posted in the other thread but its a little scary there right now.

Last night during a scenario I was an asthma pt, 9 on my pain scale. Wheezing, struggling to breathe. Inadequate respiration's.

Now, should I not have been treated with a BVM? Because my girl gave me a NRM and the evaluator never said anything about it being wrong. We've been taught if its adequate, NRB. If its inadequate, BVM. So now I'm confused.

Thanks in Advance. :)
 
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MrBrown

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The problem with asthma is not getting air in but rather, getting air out which is a common misconception (and one I was lead to believe at first).

An asthmatic patient is using acessory muscles and thier intercostals to draw air in, but they do not have the strength required to force it out. As a result they become very tired and hypercapenic which (eventually) will cause them to stop breathing because the high level of carbon dioxide will overwhelm the chemoreceptors that control voluntary respiration.

You should be using a nebuliser mask and not a non-rebreather because you can't neb ipatropium or salbuatmol through a NRB :)

If the patient stops breathing you want to bag them very slowly to avoid dynamic hyperinflation, if that happens you're gonna run into our good friend PEA. I have been taught 6 breaths a minute and no more.

Hope that helps.
 
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VentMedic

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If the person is still alert, you will have a difficult time placing a BVM over their face. They already feel like they are sufficating. As well, this patient may want to be in a tripod position to assist their accessory muscles. Taking them out of that position may not benefit them. Also, you may not be able to bag them very easily as their airways are narrowed and/or mucus filled. If the patient does go unconscious, you may still have a difficult time bagging them. Air may also follow the path of least resistance which will be the stomach so care must be taken for that also.
 
Melclin

Melclin

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After having glossed over the other thread I think saying this might lead to a bit of an explosion...but are we to assume you don't have albuterol/atrovent?

I'm not sure I understand why your be using a BVM on a conscious asthma pt seeing as though their problem is more likely to be with expiration rather than inspiration, not to mention that its a nightmare trying to breath through a BVM - surely it just makes matters worse.

We only ventilate pts when they are apneic. Otherwise it's supplemental O2 with nebulised salbutamol/atrovent.

Which leads me to something I've been wondering, how do you guys over there put people on ~100% O2?
 
Melclin

Melclin

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MrBrown said:
If the patient stops breathing you want to bag them very slowly to avoid dynamic hyperinflation, if that happens you're gonna run into our good friend PEA. I have been taught 6 breaths a minute and no more.
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Do you guys advocate "gentle lateral chest pressure" in dynamic hyperinflation over there (NZ and the US). Its a pretty contentious issue here.
 
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MrBrown

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If the patient is severely hypoxemic you should be nebulising salbutamol but if you are unable to do so, then use a non-rebreather mask.

If the patient goes into resp arrest you should bag them slowly to avoid overinflation of the lungs and cardiac arrest.

The balance of risk here is rapid transport and arrange for advanced backup to meet you enroute if they can intercept you significantly faster than you can deliver the patient to hospital; the patient needs bronchodialators, adrenaline, some of those sexy designer steriods like hydrocortisone and perhaps intubation.
 
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EMSLaw

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Melclin said:
After having glossed over the other thread I think saying this might lead to a bit of an explosion...but are we to assume you don't have albuterol/atrovent?

I'm not sure I understand why your be using a BVM on a conscious asthma pt seeing as though their problem is more likely to be with expiration rather than inspiration, not to mention that its a nightmare trying to breath through a BVM - surely it just makes matters worse.

We only ventilate pts when they are apneic. Otherwise it's supplemental O2 with nebulised salbutamol/atrovent.

Which leads me to something I've been wondering, how do you guys over there put people on ~100% O2?
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Nebulizers, and essentially all medications, are outside the scope of practice of an EMT-Basic in the US. If the patient has a prescribed asthma inhaler, Basics can administer it to them.

A BVM (if connected to an oxygen tank, of course) will provide 100% O2. You don't have to squeeze the bag. Nasal canula, NRB mask, and BVM are the only three options, really. Well, or a rescue mask with O2 port, but I haven't seen that used on an ambulance, it's more a first responder thing.
 
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MrBrown

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Melclin said:
I'm not sure I understand why your be using a BVM on a conscious ...pt
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I'd sure too like to know mate ... I've heard some US folk say they would use it for tachypneic patients to see if they will "comply" with it.
 
thowle

thowle

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How many times per minute were you breathing? What was the breath like? Solid inhale, decreased exhale? What was Sp02? It all depends on what the real situation was and is...

From my understanding, in an alergic asthma reaction of course the smooth muscles constrict causing the airway to be comprimised by making is smaller than what it already is, not to mention the possibility of airway edema and increased mucus production while ige immunoglobulins try to win the stimulant challenge.

As for BLS, I'd say just give oxygen 100% by NRB, monitor, if breathing drops, vent BVM but, remember what's happening.

It's like trying to force a golfball down a garden hose.. kinda.. well, not really.. but it's constricted.. so even if you try to PUSH the air down it, you're only helping them by alleviating a lot of their musscle usage in respirations; you probably can't really push more air than they were able to.
 
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VentMedic

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Let me continue this over here since it is a similiar discussion. These are important issues that should be understood when treating different diseases.

Originally Posted by MasterIntubator
Maybe so.... but out of the 100 or so cases of interest that I am my fellow trained EMT-Bs have had, we have had success.
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By this, I take it you mean you got them to the hospital alive?
For many asthmatics, they need some nebulizers, steroids and fluids. However, one should not think asthma is not a serious disease because you haven't seen status or one decompensate.

As an EMT-B, you probably had no option but to bag if a patient stops breathing. For the breathing asthmatic however, that may NOT always be the best treatment. If one does choose to bag someone they should understand compliance and resistance as it pertains to the disease process. It is a little more than just squeezing a bag. Do you NOT understand what is meant by pathophyisology or disease process and how to apply it to whatever equipment you are using?

Originally Posted by MasterIntubator
And as far as barotrauma, it did not make a difference what mechanical delivery method was used ( BLS/ALS/Anesthesiology circuit/NPPV/brochos/etc ). What we did find out, is that many of them did not decompensate further with assisted BVM, even with trained inexperienced folks. Some did... even in the ER setting. So that leads me to believe that sometimes you can't do anything to help those folks
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One must understand the difference between BAROTRAUMA and VOLUTRAUMA.

An asthmatic can hold their own for quite awhile which is why this leads some to believe what they did in the field "fixed" the patient or it was a save. Decompensation is not a good thing and it should be avoided. This is why EDs usually have immediate access to HeliOx, BANs and the ability to get different medications. Once an asthmatic starts to decompensate, if the ED does not have much advance technology, the patient may die or at the very least end up with 2 chest tubes which then only complicates the situation further.

Heck, if you want to get exotic, might as well place pressure along the thorcic cavity to assist in expiratory effort.
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Nothing exotic about this either as it is done in other countries as well as being trialed in this country.


In my BLS days, I have had many of the same questions and problems. We had less ALS folks to jibber jabber physiological effects and analyze the 'whys' and 'what fors' during an emergency. I knew about the basic physiology as taught. Anything greater was doctor stuff.
But ya know.... it freakin worked when you needed it the most.
Than as time went on, I learned more and why... but things have not changed that much... I am just more aware and have better understanding.
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Again, another downfall in EMS is this BLS and ALS mess. Being BLS is not an excuse for not being aware of the complications of using a BVM or not having a basic (not as in BLS) understanding of the disease processes.


Holy crap we can get out panties in a bunch over a rare barotrauma. ( the top FASC docs still can't agree on it )
That is why I wasted the time to put in my first writing about training... obtaining skills... and not be over zealous. I am sure one of the professional EMTs who has studied had read it fully and got the point
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Barotrauma? There is nothing exotic about this. Doctors do argree it and VOLUTRAUMA exists. What can't be agreed upon is the best treatment and technology for it.

We STRIVE to make both BAROTRAUMA and VOLUTRAUMA "rare". This is why we spend over $50K for each ventilator and have many different gases and medications available.

Just like with all the posts... there is something in them all for someone. Learn it all young folks, learn ALL the ways. It will come.
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This I agree with but one should not just view the BVM as a simple little BLS tool. It should be understood well as any other piece of medical equipment.

Understanding the disease processes and knowing one's limitations can not be stressed enough. Getting an SpO2 on an asthmatic DOES NOT necessarily mean you are winning the war. You may not even be winning that battle if you have not lung sounds indicating air movement with that SpO2 of 100%.

There are a few disease processes that may just require a quick RSI and placement on the best technology available with the appropriate gases and medications.

In the ED, we just know we can not spend much time bagging a severe asthmatic, ARDS and some PNAs including PCP and that from a potent strain of Influenza A.

However, I can use a BVM a cardiac arrest patient with no active pulmonary disease or a COPD patient for as long as it takes to finish a code, intubate or transfer to a more appropriate place for intubation. I just know the types of patients that I prefer not to prolong bagging or in some cases do as little BVM as possible.
 
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VentMedic

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EMSLaw said:
A BVM (if connected to an oxygen tank, of course) will provide 100% O2. You don't have to squeeze the bag. Nasal canula,
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Unless you are carrying an Ayres, Jackson Reese or anesthesia type bag, just placing a self inflating bag on their face can be called suffication. There must be a tight seal and they must be able to generate between -20 to -40 cmH2O of pressure to open the valve and receive oxygen.
 
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VentMedic

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What's the use? Just like the other thread I'm wasting my time because the posts will be deleted if they are too technical.
 
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MrBrown

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EMSLaw said:
A BVM (if connected to an oxygen tank, of course) will provide 100% O2. You don't have to squeeze the bag.
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WTF dude seriously; the only kind of er .... dealies, i dno that do that are in the operating room.

Yes, squeeze the bag!
 
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