So in prior posts, I have discussed the jerry-rigged “ultimate” BVM. But there is a better way–the creation of a manufactured BVM that helps us not kill patients.
It would have the following characteristics:
Facets of the Ultimate BVM
Additional New Information
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hey Scott thanks for the great vodcast! There is one BVM that may have the valve issue figured out that you are talking about. Its a Laerdal BVM that was used in Monash’s oxygen delivery study with Nicholas Chrimes group. I believe these BVM gives 96% FiO2 during spontaneous ventilation. https://www.laerdal.com/us/products/medical-devices/airway-management/laerdal-silicone-resuscitator/
Not ideal but its a better start than what you have I believe.
not sure what valve problem you are talking about. our bvm and many others provides 100% fio2 during spont vent.
Sorry I was under the impression that your patients couldn’t spontaneously ventilate with your current BVM and receive greater than 95% FiO2. Sorry I misunderstood that part of the vodcast. Thanks for clarifying!
I’m not sure if you’ve seen a ParaPAC ventilator, but the vent circuit it uses has nearly all of the features you asked for on the “patient side” of the bag. I’d be willing to bet that if you attached a BVM instead of the ParaPAC to the circuit, you’d be very close to the final design of the “Ultimate BVM”.
I would suggest not using the standard adult BVM and switching to the standard peds BVM with a PEEP. Peds BVM more reliably deliver Vt consistent with lung protective ventilation. Here some research I’ve completed with BVMs. http://www.tandfonline.com/doi/full/10.1080/10903127.2016.1227003 Here’s an abstract from a recent poster we just presented at NAEMSP Scientific Assembly on grip technique with Adult and Peds BVMs. I couldn’t get a working hyperlink so I copied it for you. 160. Can Grip Technique and Bag Size Improve Volume Delivered with a Bag-Valve-Mask by EMS Providers? Melissa Kroll, Jyotirmoy Das, Jeffrey Siegler, Washington University/ Barnes-Jewish Hospital Category of… Read more »
I know its not technically a BMV but most of the features you want are provided with a Mapleson F breathing circuit
– continuous flow
– flexible tubing
– minimal resistance to breathing & ‘feel’
– manual control of PEEP & CPAP
– manual control of lung volume
– distal end tidal monitoring
But its disadvantages
– learning curve
– needs oxygen supply to ventilate – always need a manual BMV
yep, but the Mapleson circuits are not ideal either for the reasons you mentions and additional:
https://emcrit.org/racc/what-the-heck-is-a-mapleson-b-circuitu-probably-shouldnt-care/
but the F is better than most of them. Didn’t know you could attach PEEP valve, where in the circuit do you fit it or do you have them with peep valve integrated, the ones I have seen don’t have it.
Hi Scott, Thanks for this Vodcast, I always enjoy your thoughts and discussions regarding airway Equipment. Some of my thoughts regarding your design wishes: What you need would be a very sophisticated valve system. I don’t think it is possible mechanically without electronics. You wish: No outflow valve for the oxygen source. There usually are three valves at the site between the reservoir and the self-inflating bag, and the O2 connector normally also sits at this location: One valve for inflow only, one for outflow only and a one-way valve preventing air from the bag to flow backwards toward the… Read more »
Alexander,
Wow! Incredible comments! Everything you say is completely logical. Hopefully there is some clever way around all of these issues. I am curious how the mapleson f circuit mentioned above works. everything seems to make sense except how that device generates peep and how a ppv can be given without blowing out the pt lungs, both of which seem to be impossible giving its design. that circuit solves most of the problems but i can’t get my mind around those two issues
So I’ve worked out two separate solutions either of which should get the job done. If you are interested, contact me with your email at emcrit.org/contact
very cool, scott
thank you
tom
Hi Scott,
Love your innovative spirit. Regarding the extension tubing connecting the BVM with the mask: Wouldn’t that increase the dead space? You would need an exhalation port on the mask or a two limb system to minimize that problem.
can’t really imagine caring at all at that minimal amount of deadspace which will be filled by a near fully oxygenated portion of the patient’s exhale
Thanks Scott, an interesting talk. I take your previous comments on mapleson circuits, but what you’re describing here is a Mapleson C with an in line self inflating bag, used with a catheter mount and HMEF. It’ll have the advantage of working without an oxygen source, but the disadvantages of less tactile volume and compliance. I’m not sure from your comments: have you tried using them for a week or two? This would be fairly standard for use in most of the UK. Intersurgical, for example, do a pretty good setup, though I’m not sure if it’s available in the… Read more »
yes that is it exactly–mapleson with self-inflating bag, no rebreathing, and titrated PEEP is exactly what I want. They are available in the US and I have used them extensively. One person for using the bag without squeezing or with straps during negative pressure ventilation. For PPV, 2 people required for any circuit if there is bag squeezing involved. Continuous flow obviates the need for squeezing so pt may be better served by two hands on mask even during reox.
Mercury Medical – Small Adult BVM with PEEP, Manometer, Pop Off Valve, Timing Light, Extension Tubing and a sweet face mask. Will send pic if you would like. Some Assembly Required.
Has any company developed the ultimate BVM that you can simply purchase since you posted this vidcast?
should be out this year through pulmodyne
Thanks for this great video! So am I understanding this right? All current BVM models don’t support flow to the facemask during apneic oxygenation (with open airway)? So if we do not use THRIVE, the patient does not get any flow at all?
Do you have any article which supports this, because I cannot find anything – even the manufacturers don’t mention anything about it.
Hey Scott, can you use BVM to preoxigenate children with spontaneous breathing?
same as adults!