Bag and Mask Ventilation By Sakun Rasaily @Ram K Dhamala

Bag and mask Ventilation Presented by Sakun Rasaily,
(Pediatric Nurse, Pediatric ward , B.P. Koirala Institute of Health Science
Dharan, Sunsari (Nepal)

1. BAG and MASK VENTILATION (BMV) Sakun Rasaily , Staff Nurse Pediatric –I B.P. Koirala Institute of Health Science Dharan , Sunsari (Nepal)

2. PRESENTATION OUTLINE INTRODUCTION OF BMV EQUIPMENT & PARTS TYPES / ADVANTAGES/ DISADVANTAGES OF BAG INDICATIONS PROCEDURE TECHNIQUE CONTRAINDICATIONS COMPLICATIONS NURSING MANAGEMENT.

3. INTRODUCTION BAG and MASK VENTILATION: This is the most important airway skill. A basic airway management technique that allows for oxygenation and ventilation of patients until a more definitive airway can be established . Also used in cases where endotracheal intubation or other definitive control of the airway is not possible.

4. C ontd... In the pediatric population, BMV may be the best option for prehospital airway support. BMV ventilation is also appropriate for elective ventilation in the operati on theatre when intubation is not required,   but it is now often substituted by the laryngeal mask airway

5. EQUIPMENT & PARTS OF BMV

6. PARTS OF BMV The BMV consists of The bag : a flexible air chamber , attached to a face mask via a  shutter valve which is squeezed to expel air to the patient .   Mask: a flexible mask to seal over the patients face, Filter and valve : a filter & valve prevent backflow into the bag itself (prevents patient deprivation and bag contamination) 4. Oxygen Reservoir: 5. Pressure Gauge 6. Oxygen Connecting tube

7. Contd ….. P rovide a volume of 6-7 mL/kg per breath (approximately 500 mL for an average adult). F or a patient with a perfusing rhythm, ventilate at a rate of 10-12 breaths per minute. Adult size: 2 litres, Paediatric size:500 ml

8. T YPES OF BAG USED 1.Flow inflating bag (Anaesthesia Bag) Fill s only when oxygen from a compressed source flows into it Depend on a compressed gas source Must have a tight face-mask seal to inflate Use a flow-control valve to regulate pressure-inflation

9. 2.Self inflating bag (AMBU Bag) Fill spontaneously after they are squeezed, pulling oxygen or air into the bag Remain inflated at all times Can deliver positive-pressure ventilation without a compressed gas source . Require attachment of an oxygen reservoir to deliver 100% oxygen

10. Advantages and disadvantages of types of bags Advantages Disadvantages Flow Inflating Bag Delivers 100% oxygen at all times Easy to determine the adequacy of seal Stiffness of lungs can be felt C an deliver PEEP or CPAP Requires a tight seal to remain inflated Requires a gas source to inflate No safety pop-off valve Requires more experience Self Inflating Bag Does not need a gas source to inflate Pressure release valve / Pop – off valve set at 30 – 40 cm H 2 Easier to use Will inflate even without adequate seal Requires a reservoir to deliver 100% oxygen Can not be used to deliver 100% free flow oxygen

11. THE THREE PILLARS OF AIRWAY MANAGEMENT : Patency of Upper Airway : ( airflow integrity ) Protection against aspiration Assurance of oxygenation and ventilation

12. I NDICATION Respiratory failure Failure of ventilation Failure of oxygenation Failed intubation Elective ventilation in the operating room

13. PROCUDURE One hand to maintain face seal position head maintain patency Other hand for ventilation

14. BMV T ECHNIQUE “ Sniffing”position if C-spine OK Thumb + index finger to maintain face seal Middle finger under mandibular symphysis Ring and little finger under the angle of mandible

15. Bag and mask ventilation Yes No Check for inadequate seal; reapply face mask Chest Rise No Chest Rise Yes Check for blocked airway. Reposition head, remove secretions, mouth slightly open Chest Rise Yes No Consider insufficient pressure. Increase pressure; consider intubation

16. Ventilate for 30 seconds Rate 40-60 bpm Increasing HR, visible rise and fall of chest Check heart rate with stethoscope or umbilical palpation for 6 seconds Less than 6 beats (< 60bpm) 6-10 beats (60-100bpm) More than 10 beats (>100 bpm) Continue ventilation Initiate chest compression Consider intubation Continue ventilation Consider intubation Check for spontaneous breathing No Yes Continue positive pressure ventilation Consider intubation Consider OG tube insertion Need of post-resuscitation care Gradually discontinue positive pressure ventilation Provide tactile stimulation Provide free flow oxygen Need of post-resuscitation care

17. W HY SNIFFING POSITION ? Sniffing position allows for greater occipito-atlanto-axial angulation. No exact definition has been established. However, 35 degrees neck flexion and 15 degrees head extension is generally considered worldwide. Sniffing position prevents falling of tongue thus preventing obstruction of the upper airway.

18. B MV DURING CPR During cardiopulmonary resuscitation (CPR), give 2 breaths after each series of 30 chest compressions until an advanced airway is placed. Then ventilate at a rate of 8-10 breaths per minute. Give each breath over 1 second. If the patient has intrinsic respiratory drive, assist the patient’s breaths. In a patient with tachypnea , assist every few breaths. Ventilate with low pressure and low volume to decrease gastric distension.

19. C RICOID PRESSURE C ricoid pressure consistency cy should be maintained not in all but in emergency cases while appling BVM . It is the backward Pressure on cricoid cartilage with a force of 30-40 newtons This pressure is meant to compress the esophagus and reduce the risk of aspiration. However, it does not completely protect against regurgitation, especially in cases of prolonged ventilation or poor technique. Care must be taken to avoid excessive pressure, which can result in compression of the trachea.

20. BMV VENTILATION: ASSESSMENT OF ADEQUACY Observe the chest rise and fall Good bilateral air entry Improving color Lack of air entering the stomach Feeling the bag Pulse oximetry (oxygen saturation)

21. CONTRAINDICATIONS In the case of complete upper airway obstruction. BVM ventilation is relatively contraindicated after paralysis and induction (because of the increased risk of aspiration ). C aution is advised in patients with severe facial trauma and eye injuries. In addition, foreign material (e.g. gastric contents) in the airway may lead to aspiration pneumonitis . In these circumstances, alternative approaches, including endotracheal intubation, may be necessary.

22. PREDICTORS OF A DIFFICULT AIRWAY : BMV Upper airway obstruction Edentulous patients Beard H/O Snoring Obese Elderly >70 years Facial burns, dressings, scarring Poor lung mechanics resistance or compliance

23. DIFFICULT AIRWAY A DAGE The first response to failure of bag-mask ventilation is always “ better ” bag-mask ventilation optimize airway position , triple airway maneuvre (head tilt, chin lift, jaw thrust) place Oropharyngeal and Nasopharyngeal airways two-handed technique try lifting head off pillow to open airway Generate as much positive pressure as possible wi th out inflating the stomach

24. C ontd... If bag and mask still fails: Intubate If C ant ventilate, cant intubate *Larngeal mask airway *Cricothyroidotomy *N eedle Cricothyroidotomy and Transtracheal Je t Ventilation

25. COMPLICATIONS OF BMV R elated to over-inflating or over-pressurizing the patient, which can cause: Hypoventilation/ Hyperventilation Inflated a ir in the stomach (called gastric insufflation ) L ung injury from over-stretching (called volutrauma ) L ung injury from over-pressurization (called barotrauma ) Lung aspiration Air Embolism

26. NURSING MANAGEMENT: Promote respiratory function. Monitor for complications Prevent infections. Provide adequate nutrition. Monitor GI bleeding.

27. PROMOTE RESPIRATORY FUNCTION Auscultate lungs frequently to assess for abnormal sounds.   Suction as needed.V /S recording and reporting. Turn and reposition every 2 hours. Secure ETT properly. Monitor ABG value and pulse oximetry .

28. Suction of an Artificial Airway To maintain a patent airway To improve gas exchange. To obtain tracheal aspirate specimen. To prevent effect of retained secretions. ( Its important to OXYGENATE before and after suctioning)

29. MONITOR FOR COMPLICATIONS   Assess for possible early complications Rapid electrolyte changes. Severe alkalosis. Hypotension secondary to change in Cardiac output.   Monitor for signs of respiratory distress: Restlessness Apprehension Irritability and increase HR.

30. CONTD………   Assess for signs and symptoms of barotrauma(rupture of the lungs) Increasing dyspnea Agitation Decrease or absent breath sounds. Tracheal deviation away from affected side . Decreasing PaO2 level .   Assess for cardiovascular depression: Hypotension Tachy . and Bradycardia Dysrhythmias .

31.   PREVENT INFECTION Maintain sterile technique when suctioning. Monitor color, amount and consistency of sputum. PROVIDE ADEQUATE NUTRITION Begin tube feeding as soon as it is evident the patient will remain on the ventilator for a long time. Weigh daily. Monitor I&O .   MONITOR FOR GI BLEEDING Monitor bowel sounds. Monitor gastric PH and hematest gastric secretions every shift.

32. INTRODUCTION OF BVM EQUIPMENT & PARTS OF BVM TYPES / ADVANTAGES/ DISADVANTAGES OF BAG INDICATIONS PROCEDURE TECHNIQUE CONTRAINDICATIONS COMPLICATIONS NURSING MANAGEMENT. Summary

33. ANY Questions PLZ!!!

34. R EFERENCES http://emedicine.medscape.com/article/80184-overview www.proceduresconsult.com/.../bag-mask-ventilation-EM-082-procedur es https://en.wikipedia.org/wiki/ Bag _valve_ mask https://meds.queensu.ca/central/assets/modules/basic-airway-management/bagmask_ventilation.html www.ncbi.nlm.nih.gov/pubmed/14717873 www.slideshare.net

35. Thank You!!!