Ventilator to BVM transition Best Practice
Question# 778
I am writing to seek guidance and support on situations where I am required to transition patients from ventilators to manual BVM ventilation. While performing this crucial task, I have noticed that patients often exhibit fear and anxiety during the transition. Their eyes convey a sense of apprehension also reflected in their vital signs, and I am keen on finding ways to make this transfer more comfortable for them. I am seeking advice on best practices for smoothly transitioning patients from a ventilator to manual ventilation. Additionally, any insights on effectively addressing the emotional aspects of this process, such as reducing patient anxiety, as well as attempting to match ventilator settings as best as possible would be highly valuable. Your expertise in this matter would contribute significantly to improving patient care and ensuring a more seamless transition to acute care centers.
Answer:
Firstly, it is important to determine the needs of the patient and if they are the right candidate for being transitioned to BVM for transport or if another method may be more appropriate. Some questions you could consider posing are: do I require an escort? Has this patient been manually ventilated during transport in the past and how did it go? Could this patient benefit from sedation or anxiolytic medications? Would this transfer be better covered by a CCP paramedic? Obtaining answers for these questions may better help you prepare for this call.
One of the most important things to begin with when planning to disconnect someone from their ventilator and begin ventilating manually for them with your BVM, is explaining everything that you are going to do to your patient. It is important that these conscious patients are aware and understand the steps you are about to take before they are done. This will help with managing some of their anxiety in those first crucial steps of the handover.
Secondly, ensure that you are completely prepared for each step of the disconnect and reconnect before you begin anything. Increasing you or your partners stress during the transition will increase the anxiety of the patient. During this key step it is important to remain calm and speak out loud each step you are performing so that everyone is aware.
Thirdly, have a plan and make sure that everyone involved knows their role. Speaking out loud as you move through each step will also help people keep on track and ensure that no steps get skipped. This shows control over the scene, and again will add to a patient feeling safe that everyone is aware of what is going to happen.
Lastly, it’s important to know the ventilating rate that your patient is receiving from their ventilator. While some patients may be able to utilize their hands to provide real-time feedback on your rate and pressure of ventilations, others may not. Ensure to get this vital info from the facility staff prior to disconnecting. Consider practicing the rate and depth of breaths you plan to provide this patient prior to disconnecting anything. It is imperative that paramedics are aware of the dangers of BVM ventilations such as barotrauma and volutrauma.
Barotrauma can occur in any patient that we bag too aggressively, being conscious of the amount of air volume we are providing our patients is vital. Different sized hands and differing grip strengths will make this different for everyone. Barotrauma, high pressure ventilation, causes alveolar rupture and subsequent pneumothorax and biotrauma, which refers to the release of inflammatory mediators and is detrimental to lung.
Something else to consider is volutrauma or lung overdistension of normal alveoli with excessive tidal volume. This can adversely affect hemodynamics in patients by increasing intrathoracic pressure, decreasing venous return, and negatively impacting cardiac output and is detrimental to lung.
It is important to understand that it is not just pressure and volume that we need to be mindful of when ventilating patients, but also rate. It is recommended that we provide approximately 1 breath every 5-6 seconds. ILCOR/AHA/Heart and Stroke guidelines for ventilation recommends 6-7 mL per kg of IDEAL body weight – do be mindful of additional challenges with obese patients and those with lung comorbidities as their needs can be slightly different. Utilizing the EtCO2 waveform capnography as well as monitoring oxygen saturations will help prevent hypoxia, hypercapnia, or hypocapnia, which could exacerbate any anxiety the patient is already feeling.
Be aware of the airway resistance as well and keep track of any changes to it throughout the call. Facility staff may also be aware of increased resistance in different patients and acquiring this information prior to handover is good practice.
Lastly, if the patient is still anxious about the switchover and there is a physician on scene, it may be worth asking for a small amount of sedation to help the patient. If you are an ACP crew, a BHP consult is also an option available to you to utilize midazolam.
In conclusion, communication is a key point when managing these types of calls. Communication with the patient, with facility staff, and with your partner. Clear and concise communication throughout this call will help reduce everyone’s anxiety and allow for a smooth transition from ventilator to BVM ventilations.
One of the most important things to begin with when planning to disconnect someone from their ventilator and begin ventilating manually for them with your BVM, is explaining everything that you are going to do to your patient. It is important that these conscious patients are aware and understand the steps you are about to take before they are done. This will help with managing some of their anxiety in those first crucial steps of the handover.
Secondly, ensure that you are completely prepared for each step of the disconnect and reconnect before you begin anything. Increasing you or your partners stress during the transition will increase the anxiety of the patient. During this key step it is important to remain calm and speak out loud each step you are performing so that everyone is aware.
Thirdly, have a plan and make sure that everyone involved knows their role. Speaking out loud as you move through each step will also help people keep on track and ensure that no steps get skipped. This shows control over the scene, and again will add to a patient feeling safe that everyone is aware of what is going to happen.
Lastly, it’s important to know the ventilating rate that your patient is receiving from their ventilator. While some patients may be able to utilize their hands to provide real-time feedback on your rate and pressure of ventilations, others may not. Ensure to get this vital info from the facility staff prior to disconnecting. Consider practicing the rate and depth of breaths you plan to provide this patient prior to disconnecting anything. It is imperative that paramedics are aware of the dangers of BVM ventilations such as barotrauma and volutrauma.
Barotrauma can occur in any patient that we bag too aggressively, being conscious of the amount of air volume we are providing our patients is vital. Different sized hands and differing grip strengths will make this different for everyone. Barotrauma, high pressure ventilation, causes alveolar rupture and subsequent pneumothorax and biotrauma, which refers to the release of inflammatory mediators and is detrimental to lung.
Something else to consider is volutrauma or lung overdistension of normal alveoli with excessive tidal volume. This can adversely affect hemodynamics in patients by increasing intrathoracic pressure, decreasing venous return, and negatively impacting cardiac output and is detrimental to lung.
It is important to understand that it is not just pressure and volume that we need to be mindful of when ventilating patients, but also rate. It is recommended that we provide approximately 1 breath every 5-6 seconds. ILCOR/AHA/Heart and Stroke guidelines for ventilation recommends 6-7 mL per kg of IDEAL body weight – do be mindful of additional challenges with obese patients and those with lung comorbidities as their needs can be slightly different. Utilizing the EtCO2 waveform capnography as well as monitoring oxygen saturations will help prevent hypoxia, hypercapnia, or hypocapnia, which could exacerbate any anxiety the patient is already feeling.
Be aware of the airway resistance as well and keep track of any changes to it throughout the call. Facility staff may also be aware of increased resistance in different patients and acquiring this information prior to handover is good practice.
Lastly, if the patient is still anxious about the switchover and there is a physician on scene, it may be worth asking for a small amount of sedation to help the patient. If you are an ACP crew, a BHP consult is also an option available to you to utilize midazolam.
In conclusion, communication is a key point when managing these types of calls. Communication with the patient, with facility staff, and with your partner. Clear and concise communication throughout this call will help reduce everyone’s anxiety and allow for a smooth transition from ventilator to BVM ventilations.