When to transition from non rebreather to bag valve mask?

[theodog]

Usually in the ICU, the times I've had to bag a pt. involved the pt. being on a ventilator and there being a malfunction of some sort that required us to bag him/her until the problem could be solved. Alternatively, during a code, when a pt. stopped breathing all together, of course we bag until intubation, etc.

My question regards the situation where a pt. is not ventilated, and suffers respiratory distress. At what point would you transition from a 100% NRB to an ambu bag if the pt is still technically breathing on their own, but they are still in severe distress?

Example, HR shoots up to 140's, pt. is diaphoretic, cold, and clammy. Breathing includes strange hiccough-ing type sounds. In a situation i experienced recently, the patient progressed from tachy to NSR but then on to Brady and eventually asystole for a few brief moments. Of course, after asystole we proceded to the ambu bag and even with the spontaneous return of a heartbeat, we continued to bag and then intubate the patient.

I realized I had a little bit of a question on whether it is ok to bag a patient who is still breathing for themselves?

As in, we don't give chest compressions to an adult who still has a pulse.

Do we bag a patient who is still breathing on their own but in respiratory distress?

All my other experiences with bagging had involved no breathing at all or ventilated patients.

Comments appreciated.

[TigerGalLE, BSN, RN]

In BLS it states that you should give rescue breaths for patients who are agonal breathing. And not to confusing agonal breathing for adequate respirations. So I'd say if the patient's respirations are not life sustaining then you should bag the patient.

[detroitdano]

I leave the NRB on if they are effectively breathing. By effective I mean actually taking in a decent tidal volume, tachypneic or not. Agonal shallow breathing merits bagging them.

If they're breathing on their own but are severely tachypneic and you know intubation is minutes away, you're not accomplishing anything bagging them. The oxygen you give them probably isn't going to change much, plus have you ever tried bagging a restless hypoxic patient with the BVM? Good luck! By that time their main issue is going to be with CO2 not O2.

[dmc_rrt]

I agee with dano. Prior to intubation, if the pt can hold their sats close to 100% by breathing on their own, then use the NRBM. Bagging can cause increased anxiety, and gastric insufflation.

[ObtundedRN, BSN, RN]

I've had to assist ventilations before on a conscious patient, but this was out in the field. It was an elderly woman with COPD and asthma. Would've put her on CPAP but she wasn't conscious enough for it, so I assisted ventilation. She soon found herself intubated, but it worked very well until then. Its just like assisting ventilations on a patient with a tracheostomy who is conscious, you coach them, and try to breath with them. But in the hospital setting, if they get that bad, they probably should've been emergently intubated before your patient ever went asystole.

[Creamsoda, ASN, RN]

Well it sounds like they were in resp distress and eventually coded. So I would imagine their sats would have been dropping for them to get tachy, then brady then asystole. So unless this happened really quickly it seems they should have been electively intubated before they got so bad. Your not just gonna bag them for a bit to get their sats up then stop as theyre gonna desat anyway. If you need to bag is for a reason. Obviously something else is wrong. What was the hold up? If they are breathing and sats are good then no I wouldnt bag, but if theyre starting to decompensate and sats are dropping and not with it anymore then yes start bagging, call rapid response/ MD or whatever you would call and intubate.

[Zaphod, BSN, RN]

If I see the sats dropping, patient is AMS, not effectivly breathing I start bagging right away. I call resp. for ABG, ER doc for intubation(after notyfiing MD) and bag until they come to intubate. Otherwise you are gonna have a full code on your hands.

[Diprivan*Diva]

In BLS and ACLS alike, you bag a patient who does not have effective respirations. Spontaneous breaths that are shallow, too slow or too fast, have no air movement, and crappy sats are classified as aganol. Bag em! Sometimes they will resist- this is normal because it feels un-natural to have air forced into your lungs with no sedation. However, respiratory distress warrants rescue breaths. Try to get them tubed before you have to call a code.

PS. Don't forget to hook up your bag to 100%fiO2.....

[theodog]

Looking back on it, this patient never actually did desat, although he sure looked in enough distress. It all did happen very fast. Thanks for the input, I appreciate the comments.

[mskate]

I have bagged awake people, I do not wait for someone to become agonal to bag them. If they are breathing ineffectively, if their mechanics are ineffective, etc... I allow a person to sit up and using a few different techniques to maintain a seal - I will bag them from above their heads or standing at the side of the bed. If you are bagging an awake patient, it will require a lot of communication with them and a lot of focus to synchronize the bagging with their own respiratory efforts. If I have a person who has been breathing on a non-rebreather but is now sucking air, I will bag them to assist the effort.

If you are having to bag someone, you will need to intubate them, however. It is only a bridge to a tube, but you do not have to wait for your patient to code before you assist their breathing. Its also nice to bag them before they lose consciousness because you will be able to do coordinate the intubate nicely and don't generally need to do an emergency rapid sequence intubation.

[theodog]

thanks, that's exactly the info i was looking for. appreciate it!