Exploring the potential impact of real-time ventilation feedback on the quality of manual bag ventilation in routine ICU practice. The FEED-BAG study.

Automatic Mechanical Ventilation vs Manual Bag Ventilation During CPR: A Pilot Randomized Controlled Trial

WE report an oxygen supply tank failure at our institution that occurred during the morning of a busy operating room schedule when medical center oxygen use was maximal.

Objective The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend ventilation rates of eight to ten breaths per minute or two ventilations every 30 compressions, and tidal volumes between 500–600 ml. However, compliance with these guidelines is mainly unknown. The objective of this study is to estimate the proportion of simulated adult OHCA cases that meet guideline-based ventilation targets. Methods We conducted a blinded prospective observational study of standardized simulated cases of EMS-witnessed adult OHCA. During scheduled training sessions, resuscitations were performed by high-quality CPR trained EMS teams composed of four on-duty, full-time EMT/Paramedics from a large urban fire-based EMS agency. A high-fidelity simulation center allowed complete audio and video monitoring from a control room. Rescuers were unaware of the study, or that ventilation practices were being observed. All interventions, including airway and ventilation strategies, were at the discretion of the clinical team. A calibrated Laerdal SimMan 3 G manikin and associated Laerdal Debrief Viewer software recorded ventilation rate, tidal volume, and minute ventilation. Simulations achieving median ventilation rate 7–10 breaths/min, tidal volume 500–600 ml, and minute ventilation 3.5–6 liters/min were considered meeting guideline-based targets. Results A total of 106 EMS teams were included in the study. Only 3/106 [2.8% (95% CI: 0.6–8.0)] of the EMS teams demonstrated ventilation characteristics meeting all guideline-based targets. The median ventilation rate was 5.8 breaths/min (IQR 4.4–7.7 breaths/min) with 26/106 [24.5% (95% CI: 17.2–33.7)] between 7–10 breaths/min. The median tidal volume was 413.5 ml (IQR 280.5–555.4 ml), with 18/106 [17.0% (95% CI: 10.9–25.5)] between 500–600 ml. The median minute ventilation was 2.4 L/min (IQR 1.2–3.6 L/min) with 16/106 [15.1% (95% CI: 9.4–23.3)] between 3.5–6.0 L/min. Conclusion During simulated adult OHCA resuscitation attempts, ventilation practices rarely met guideline-based targets, despite being performed by well-trained EMS providers. Methods should be developed to monitor and ensure high-quality ventilation during actual OHCA resuscitation attempts.

Background: The efficacy of mechanical ventilation during CPR with the combination of active compression-decompression, an impedance threshold device, and head-up positioning, collectively termed automated head-up (AHUP)-CPR, is unknown. Hypothesis: Hemodynamic and ventilatory parameters will be similar with manual bag ventilation (MBV) versus automated bag ventilation (ABV) during AHUP-CPR in a porcine model of cardiac arrest. Aim: Assess the proof-of-concept that ABV is safe and effective during AHUP-CPR. Methods: Nine male and female swine (~40 kg) were anesthetized and ventilated. VF was induced and left untreated for 8 min. AHUP-CPR was performed at 105 compressions/min for 7 min using MBV, followed by 6 min using an automated mechanical bag compressor to deliver 10ml/kg of tidal volume (TV) over 1 sec at 10 breaths/min. Pigs were randomized during ABV to a synchronized (Sync) breath delivered at the start of decompression or an asynchronous (Async) breath. Cerebral perfusion pressure, coronary perfusion pressure, end-tidal CO2, intracranial pressure, esophageal intrathoracic pressure, peak airway pressure (PAP), inspiratory and expiratory TVs as well as arterial blood gases were continuously measured. Values (mean ± SD) were compared by paired and unpaired student’s t-tests with a Bonferroni correction. Results: Parameters during the last minute of MBV and ABV are summarized in the table. No significant differences were observed in hemodynamic and ventilatory parameters, except for PAP and pO2 values which were significantly lower with MBV. No significant differences were also observed between the Sync and Async ABV modes. Conclusion: Manual and mechanical ventilation resulted in overall similar physiological effects. The clinical relevance of the observed significant differences in PAP and pO2 is unclear. Additional studies are warranted to further assess the safety and effectiveness of mechanical ventilation during AHUP-CPR.

The quality of ventilation in ill neonates and the prevention of acute and chronic respiratory complications depends in part on accuracy and stability of ventilatory performance. While mechanical ventilators are manufactured under strict standards, the performance of manual resuscitators is not and depends upon human skills. Performance of MDs and RNs in the ICN in manual bag ventilation was tested with & without monitoring using a manometer Manual ventilation of a Resusci-Baby using a pediatric Ambu-bag® connected to a manometer (Bird #4407)® and transducer with recorder was performed. Ten ICN RNs and MDs were asked to create stable pressure wave forms at a constant rate (30 breaths/min). One minute samples of recordings at 2 pressure levels (15 & 30 cm H20) with & without the performers observing the manometer were analyzed. Watching the manometer, performers could maintain the above low & high pressures in a range of ±2 cm H2O 70 and 74% of the time respectively. Without the ability to monitor their bagging with a manometer, the desired pressure ranges were maintained in only 18 and 14% respectively. Only 2/10 could maintain the low pressures ±2 cm H2O and only 1/10 could maintain the high pressure ±2 cm H2O accuracy without a manometer at a rate of 30/min. Our results demonstrate that accurate (±2 cm H2O) manual ventilation can only be achieved by the use of a manometer in most instances by skilled neonatal caregivers & that all manual ventilation bags must incorporate a pressure manometer for accurate manual ventilation. (Supp. by HD-13279)

A retrospective comparison of mechanical cardio-pulmonary ventilation and manual bag valve ventilation in non-traumatic out-of-hospital cardiac arrests: A study from the Belgian cardiac arrest registry

The efficacy of manual bag ventilation during cardiopulmonary resuscitation (CPR) is often a difficult task to undertake, however, very little is known about its accuracy. Aims The objective of this study was to evaluate operator delivery of ventilation rate, tidal volume and minute volume in a simulated cardiac arrest using two different capacity self-inflating bags in an undergraduate paramedic cohort. Methods An observational single blinded study with third year university undergraduate paramedic students using a mechanical lung model and a simulated adult cardiac arrest to assess their ventilation ability. Students ventilated using 1600 ml and 1000 ml bag for 2 minutes at a rate and tidal volume for a patient undergoing CPR with an advanced airway. Ventilation rate and tidal volume were recorded using an analogue scale with mean values calculated. Results Mean tidal volumes were significantly higher for the 1600 ml bag: 528.4 ml (95% CI 491.3–565.5) versus 648.7 ml (95% CI 603.7–693.7) (P < 0.0001), while no statistically significant differences were found in mean ventilation rates and minute volumes between the two bags. Conclusion Smaller self-inflating bags reduce the incidence of overzealous tidal volumes and produce greater guideline-consistent results for cardiac arrest patients.

Ventilation Is an Important Confounding Variable When End-Tidal Carbon Dioxide Is Used to Help Guide Cardiopulmonary Resuscitation

The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations

Massive leaks in the anesthesia circuit may cause intraoperative hypoventilation and awareness; we experienced this with a disposable CO2 absorber in Perseus A500, which uses turbine ventilation to create positive-pressure ventilation. Consequently, manual ventilation was rendered impossible. During prolonged surgeries, CO2 absorbers may be replaced by a new one. In our case, the replacement had an occult leak. Absorbers should be checked before the exchange, and the econometer or reservoir bag's filling state should be monitored. Anesthesia providers should know an anesthesia machine's dynamics and breathing system to provide appropriate management of such a leak.

Explorative study on lower inflection point dynamics during cardiopulmonary resuscitation: Potential implications for airway management

Manual ventilation with a bag-valve device (BVD) is a Basic Life Support skill. Prolonged manual ventilation may be required in resource-poor locations and in severe disasters such as hurricanes, pandemics, and chemical events. In such circumstances, trained operators may not be available and lay persons may need to be quickly trained to do the job. The current study investigated whether minimally trained operators were able to manually ventilate a simulated endotracheally intubated patient for six hours. Two groups of 10 volunteers, previously unfamiliar with manual ventilation, received brief, structured BVD-tube ventilation training and performed six hours of manual ventilation on an electronic lung simulator. Operator cardiorespiratory variables and perceived effort, as well as the quality of the delivered ventilation, were recorded. Group One ventilated a "normal lung" (compliance 50cmH2O/L, resistance 5cmH2O/L/min). Group Two ventilated a "moderately injured lung" (compliance 20cmH2O/L, resistance 20cmH2O/L/min). Volunteers' blood pressure, heart rate (HR), respiratory rate (RR), and peripheral capillary oxygen saturation (SpO2) were stable throughout the study. Perceived effort was minimal. The two groups provided clinically adequate and similar RRs (13.3 [SD = 3.0] and 14.1 [SD = 2.5] breaths/minute, respectively) and minute volume (MV; 7.6 [SD = 2.1] and 7.7 [SD = 1.4] L/minute, respectively). The results indicate that minimally trained persons can effectively perform six hours of manual BVD-tube ventilation of normal and moderately injured lungs, without undue effort. Quality of delivered ventilation was clinically adequate.

Traumatic brain injury (TBI) is the leading cause of combat casualties in modern war with an estimated 20% of casualties experiencing head injury. Since the release of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury in 1995, recommendations for management of TBI have included the avoidance of routine hyperventilation. However, both published and anecdotal data suggest that many patients with TBI are inappropriately ventilated during transport, thereby increasing the risk of morbidity and mortality from secondary brain injury. Enlisted Air Force personnel with prior emergency medical technician training completing a 3-week trauma course were evaluated on their ability to provide manual ventilation. Participants provided manual ventilation using either an in-situ endotracheal tube (ETT) or standard face mask on a standardized simulated patient manikin with TBI on the first and last days of the course. Manual ventilation was provided via a standard manual ventilator and a novel manual ventilator designed to limit tidal volume (VT) and respiratory rate (RR). Participants were given didactic and hands-on training on the third day of the course. Half of the participants were given simulator feedback during the hands-on training. All students provided 2 minutes of manual ventilation with each respirator. Data were collected on the breath-to-breath RR, VT, and peak airway pressures generated by the participant for each trial and were averaged for each trial. A minute ventilation (MV) was then derived from the calculated RR and VT. One hundred fifty-six personnel in the trauma course were evaluated in this study. Significant differences were found in the participant's performance with manual ventilation with the novel compared to the traditional ventilator. Before training, MV with the novel ventilator was less than with the traditional ventilator by 2.1 ± 0.4 L/min (P = .0003) and 1.6 ± 0.5 L/min (P = .0489) via ETT and face mask, respectively. This effect persisted after training with a difference between the devices of 1.8 ± 0.4 L/min (P = .0069) via ETT. Both traditional education interventions (didactics with hands-on training) and simulator-based feedback did not make a significant difference in participant's performance in delivering MV. The use of a novel ventilator that limits RR and VT may be useful in preventing hyperventilation in TBI patients. Didactic education and simulator-based feedback training may not have significant impact on improving ventilation practices in prehospital providers.

Objective Different types of devices for manual (bag) ventilation are available. But which device is the best to use is still a matter of controversy. Most frequently used devices in Dutch PICU’s include the Self Inflating Bag (SIB) and the Flow Inflating Bag (FIB). The choice of the system seems to be subjective, and depend mostly on unit policy or personal preferences. Studies on manual ventilation in the paediatric population are scarce. We therefore conducted a prospective, observational study to compare both devices with regard to peak pressures generated and consequences on respiratory parameters during manual ventilation of intubated and mechanically ventilated children. Setting A paediatric intensive care unit of an university hospital. Patients Patients admitted to the PICU; intubated with tube size 3.0, 3.5 or 4 and mechanically ventilated were eligible for the study. Interventions Manual ventilation was performed with two devices, a Laerdal Silicone paediatric circuit and a Mapleson C cirucuit. After inclusion, a tap was placed at the end of the manual inflation bag tube allowing for continuous pressure measurements during manual ventilation. Subjects were blinded to pressure recording and no feedback was provided. From each measurement a maximum peak pressure, mean peak pressure (+SD), median peak pressure and a frequency was calculated. Main Results 412 measurements in 39 patients were performed (205/207). Both groups had significant higher peak pressures and median delivered pressure during manual ventilation (for both groups p = . 000) when compared to ventilator settings. Discussion This study demonstrates that in order to perform MH in a safe and effective manner the pressures and volumes generated have to be monitored.

IntroductionManual ventilations during cardiac arrest are frequently performed outside of recommended guidelines. Real-time feedback has been shown to improve chest compression quality, but the use of feedback to guide ventilation volume and rate has not been studied. The purpose of this study was to determine whether the use of a real-time visual feedback system for ventilation volume and rate improves manual ventilation quality during simulated cardiac arrest.MethodsTeams of 2 emergency medical technicians (EMTs) performed two 8-min rounds of cardiopulmonary resuscitation (CPR) on a manikin during a simulated cardiac arrest scenario with one EMT performing ventilations while the other performed compressions. The EMTs switched roles every 2 min. During the first round of CPR, ventilation and chest compression feedback was disabled on a monitor/defibrillator. Following a 20-min rest period and a brief session to familiarize the EMTs with the feedback technology, the trial was repeated with feedback enabled. The primary outcome variables for the study were ventilations and chest compressions within target. Ventilation rate (target, 8–10 breaths/minute) and tidal volume (target, 425–575 ml) were measured using a novel differential pressure-based flow sensor. Data were analyzed using paired t tests.ResultsTen teams of 2 EMTs completed the study. Mean percentages of ventilations performed in target for rate (41% vs. 71%, p < 0.01), for volume (31% vs. 79%, p < 0.01), and for rate and volume together (10% vs. 63%, p < 0.01) were significantly greater with feedback.ConclusionThe use of a novel visual feedback system for ventilation quality increased the percentage of ventilations in target for rate and volume during simulated CPR. Real-time feedback to perform ventilations within recommended guidelines during cardiac arrest should be further investigated in human resuscitation.