Manual resuscitatorsManual resuscitatorscase study case study 

by Elizabeth Kelley Buzbee by Elizabeth Kelley Buzbee RRT RCP-NPS RCPRRT RCP-NPS RCP

Kingwood College Respiratory Kingwood College Respiratory Care departmentCare department

Your patient is an 18 year old WM who Your patient is an 18 year old WM who has just had an accident on his has just had an accident on his motorcycle. He was not wearing a helmetmotorcycle. He was not wearing a helmet

He comes into the ER. What do you want He comes into the ER. What do you want to do first?to do first?

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Assess his respiratory rate. If his Assess his respiratory rate. If his respiratory rate is less than 8 bpm, or he is respiratory rate is less than 8 bpm, or he is not breathing we need to start manual not breathing we need to start manual resuscitationresuscitation

Check his heart rate and if he has no Check his heart rate and if he has no pulse, start CPRpulse, start CPR

Your patient has a respiratory rate of zero. Your patient has a respiratory rate of zero. You need to start manual resuscitation.You need to start manual resuscitation.

What type of patient interface do you use? What type of patient interface do you use?

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You use a mask, but as soon as possible You use a mask, but as soon as possible we need to intubate him so that we can we need to intubate him so that we can bag the endotracheal tubebag the endotracheal tube

How do you test the bag for proper How do you test the bag for proper function?function?

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Occlude the patient connector and Occlude the patient connector and squeeze the bag; you should feel some squeeze the bag; you should feel some resistance because the gas cannot go resistance because the gas cannot go anywhereanywhereCheck the 02 flow meter and check the 02 Check the 02 flow meter and check the 02 line.line.Make sure there is a reservoir on the inlet Make sure there is a reservoir on the inlet of the bagof the bag

Due to the nature of this patient’s injuries, Due to the nature of this patient’s injuries, you must protect his spinal cord by what you must protect his spinal cord by what procedure?procedure?

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to protect the spinal cord, you do not hyper to protect the spinal cord, you do not hyper extend the head; rather from the head of the extend the head; rather from the head of the bed, you place index fingers on the angles bed, you place index fingers on the angles of the lower jaw. of the lower jaw.

Pull the jaw forward without tilting the head Pull the jaw forward without tilting the head or twisting it. This is the jaw thrust or twisting it. This is the jaw thrust

When you put the mask on the patient’s When you put the mask on the patient’s face you see that the mask doesn’t extend face you see that the mask doesn’t extend down to the patient’s mouth.down to the patient’s mouth.

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Adjust the mask so that the eyes aren't Adjust the mask so that the eyes aren't touched & seal is present.touched & seal is present.

If the mouth is still not covered, the mask If the mouth is still not covered, the mask is too small, get one that fits over the nose is too small, get one that fits over the nose and the mouthand the mouth

You get a good mask and when you press You get a good mask and when you press on the inflatable seal, you see that the on the inflatable seal, you see that the mask is tight. When you squeeze the bag, mask is tight. When you squeeze the bag, you expect what to happen?you expect what to happen?

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Gas should flow into the patient’s mask Gas should flow into the patient’s mask and his chest should riseand his chest should rise

When you press on the bag, you see that When you press on the bag, you see that the chest doesn’t rise. What do you do?the chest doesn’t rise. What do you do?

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Check the bag against your hand for leaks.Check the bag against your hand for leaks.

Repositions the mask on the face and bag Repositions the mask on the face and bag again…if that doesn’t workagain…if that doesn’t work– Reposition the head and bag againReposition the head and bag again– Reposition the head a third time and bag againReposition the head a third time and bag again– Check the mouth for obstructions like blood or teeth. Check the mouth for obstructions like blood or teeth.

Sweep the mouth, or suction debris from the mouthSweep the mouth, or suction debris from the mouth– Get the patient intubated as soon as possibleGet the patient intubated as soon as possible

While you are bagging at a rate of 12 bpm, While you are bagging at a rate of 12 bpm, you watch the chest rise and fall. The you watch the chest rise and fall. The patient vomits into the mask. What do you patient vomits into the mask. What do you do?do?

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Take the mask off the face, shake out the Take the mask off the face, shake out the vomitus and get someone to suction the vomitus and get someone to suction the mouth.mouth.

Ask the doctor if we can intubate the Ask the doctor if we can intubate the patient so that we can avoid this next timepatient so that we can avoid this next time

The doctor places a 7.5 endotracheal tube The doctor places a 7.5 endotracheal tube between the patient’s vocal cords and you between the patient’s vocal cords and you inflate the cuff, now you:inflate the cuff, now you:

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Take the mask off the bag and apply the Take the mask off the bag and apply the endotracheal tube adaptor to the bag and endotracheal tube adaptor to the bag and give breathesgive breathes

now you see that the chest rises when you now you see that the chest rises when you squeeze and falls when you release the squeeze and falls when you release the bag.bag.

What respiratory rate do you pick?What respiratory rate do you pick?

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Respiratory Rate between 10- 12 bpmRespiratory Rate between 10- 12 bpm

Bag once every 5 seconds so that there is Bag once every 5 seconds so that there is time for the patient to exhale time for the patient to exhale

While you are bagging the patient, another While you are bagging the patient, another RCP listens to breath sounds. He tells you RCP listens to breath sounds. He tells you that he hears bilateral breath sounds and that he hears bilateral breath sounds and that they are equal and clear.that they are equal and clear.

You:You:

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You are pleased. That is what you want to You are pleased. That is what you want to hear.hear.

Case study # 2Case study # 2

Your patient is a 55 year old WF with a long Your patient is a 55 year old WF with a long history of pulmonary disease. She has been history of pulmonary disease. She has been breathing harder and faster all day and now her breathing harder and faster all day and now her respiratory rate is at 40 bpm and it is shallow. respiratory rate is at 40 bpm and it is shallow. Her skin is blue and her heart rate is fast [135 Her skin is blue and her heart rate is fast [135 bpm] . bpm] . When a blood gas is drawn, you see that the 02 When a blood gas is drawn, you see that the 02 is dropping and the C02 is rising.is dropping and the C02 is rising.The doctor wants to intubate this ladyThe doctor wants to intubate this ladyWhat do you do?What do you do?

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You need to mask bag her because the You need to mask bag her because the act of intubation is an invasive procedure act of intubation is an invasive procedure that requires some pre-oxygenationthat requires some pre-oxygenation

When you test the bag, you notice that When you test the bag, you notice that after you squeeze the bag, it takes 10 after you squeeze the bag, it takes 10 seconds to re-inflate. What is the seconds to re-inflate. What is the problem?problem?

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The inlet to the bag is obstructed so that The inlet to the bag is obstructed so that the recoil is too slow—get another bagthe recoil is too slow—get another bag

When you hyperextend her head, you When you hyperextend her head, you notice that her false teeth are rattling notice that her false teeth are rattling around in her mouth.around in her mouth.

What do you do?What do you do?

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Remove the false teeth because they are Remove the false teeth because they are an obstruction in the upper airwayan obstruction in the upper airway

You see that the manual resuscitator has You see that the manual resuscitator has no reservoir on the inlet.no reservoir on the inlet.

Is this a problem?Is this a problem?

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You cannot get Fi02 of 80-100% even with You cannot get Fi02 of 80-100% even with a high flow rate if you don’t have an 02 a high flow rate if you don’t have an 02 reservoirreservoir

You are pleased to see that the manual You are pleased to see that the manual resuscitator’s one-way valve is a resuscitator’s one-way valve is a _________ because that is the easiest for _________ because that is the easiest for the patient to open with her breathingthe patient to open with her breathing

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Duck billDuck bill

The doctor intubates this patient with a 7.0 The doctor intubates this patient with a 7.0 endotracheal tube and inflates the cuff. endotracheal tube and inflates the cuff. You bag at a rate of 12 bpm, and when You bag at a rate of 12 bpm, and when you listen to the chest you hear distant you listen to the chest you hear distant breath sounds & wheezing over the entire breath sounds & wheezing over the entire chest. The exhalation goes on right up chest. The exhalation goes on right up until you squeeze the bag for the next until you squeeze the bag for the next breath.breath.You do what?You do what?

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Slow down the breathing from 12 bpm to Slow down the breathing from 12 bpm to 10 and listen again.10 and listen again.If the patient exhales until the next breath If the patient exhales until the next breath he will air trap and that can lead to he will air trap and that can lead to barotraumabarotraumaIf he is still exhaling till then next breath If he is still exhaling till then next breath slow down to 8 bpm.slow down to 8 bpm.Ask for a drug to combat the Ask for a drug to combat the bronchospasmbronchospasm

You know that while you are bagging this You know that while you are bagging this adult patient that the possible tidal adult patient that the possible tidal volumes you can get with this bag are:volumes you can get with this bag are:

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800-1200 ml 800-1200 ml

Someone increases the 02 flow rate from Someone increases the 02 flow rate from 10 lpm to 15 lpm. If the bag was not made 10 lpm to 15 lpm. If the bag was not made correctly, this excessive flow rate would do correctly, this excessive flow rate would do what?what?

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Jam the valve open so that the one way Jam the valve open so that the one way valve cannot work properlyvalve cannot work properly

When you start bagging your patient, you When you start bagging your patient, you noticed that there was a certain amount of noticed that there was a certain amount of pressure against your hand as you pressure against your hand as you squeezed.squeezed.

Now you notice that the pressure seems to Now you notice that the pressure seems to have increased and that it is harder to bag have increased and that it is harder to bag the patient.the patient.

What do you do?What do you do?

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Listen to breath sounds.Listen to breath sounds.

If wheezing, then patient’s driving If wheezing, then patient’s driving pressures are rising. Give bronchodilator & pressures are rising. Give bronchodilator & slow down to prevent airtrappingslow down to prevent airtrapping

If breath sounds show diminished breath If breath sounds show diminished breath sounds in the basal [bottom] of the lung sounds in the basal [bottom] of the lung and no wheezes, the patient’s lung and no wheezes, the patient’s lung compliance may risen—the lung is stiffercompliance may risen—the lung is stiffer