Resuscitation Bag: Manual Self-Inflating in Mechanically Ventilated Patients - CE

OVERVIEW

The self-inflating manual resuscitation bag (MRB) (Figure 1) is used to provide ventilation and oxygenation to a patient with or without an artificial airway in place. The device automatically re-expands between breaths and can be used with room air or can be connected to an oxygen source.^{undefined#ref2">2}

Manual ventilation with an MRB is an essential skill in emergency situations, such as respiratory distress and cardiopulmonary arrest. It is sometimes referred to a bagging. Manual ventilation is also indicated for transporting patients who are supported by mechanical ventilation and assessing airway patency and proper artificial airway device placement.

In the mechanically ventilated patient, manual ventilation is done using an artificial airway, such as an endotracheal or tracheostomy tube. Manual ventilation should result in the rise and fall of the chest and auscultatory evidence of bilateral air entry.

When signs and symptoms of respiratory distress are observed in a patient requiring mechanical ventilation and troubleshooting the ventilator does not solve the problem, the patient should be manually ventilation with an MRB attached to a 100% oxygen source.

When manual ventilation is required during transport, a procedure designed to provide a ventilatory pattern similar to the one provided by the ventilator should be used. Portable ventilators are highly recommended during patient transport.

When manually ventilating a patient, it's import to monitor the rate and depth of ventilations. Large manual breaths or rapid rates during manual ventilation may result in dynamic hyperinflation and resultant hypotension. Dynamic hyperinflation is most commonly associated with bronchospasm and chronic obstructive pulmonary disease. A high index of suspicion is necessary for the presence of dynamic hyperinflation if hemodynamic instability or worsening respiratory distress occurs with bagging.

Hyperinflation occurs when exhalation time is inadequate, which results in auto positive end-expiratory pressure (PEEP). Auto PEEP increases intrathoracic pressures and may decrease venous return, which may result in hypotension. It may also result in significant barotrauma and the possibility of pneumothorax or tension pneumothorax. A rapid solution to auto PEEP with hemodynamic or respiratory compromise is a brief disconnection from the bag to allow passive deflation and a decrease in intrathoracic pressures. This should result in improved hemodynamics. With resumption of bagging, providing a longer exhalation time (smaller tidal volumes with a lower respiratory rate) will help to minimize auto PEEP.

PATIENT AND FAMILY EDUCATION

• If time allows, explain the equipment and procedure to the patient and family including the reasons for manually ventilating the patient.
• Inform the patient and family that the patient requires assisted breathing and that he or she will be disconnected from the ventilator and manual ventilation will be performed.
• Explain the sensory experience associated with manual ventilation.
• Instruct the patient to communicate breathing discomfort.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient's oxygenation and ventilation status.
5. Assess the patient for signs of respiratory distress, including a sudden decrease in peripheral oxygen saturation (SpO₂), sudden increase in the end-tidal carbon dioxide (ETCO₂), sudden change in mental status, tachycardia, tachypnea, diaphoresis, and agitation.
6. Assess the patency of the artificial airway.
7. Assess the patient's ventilation status for changes in tidal volume, respiratory rate, minute ventilation, and peak inspiratory pressure.
8. Evaluate the interaction between the patient and the ventilator.

PROCEDURE

Respiratory Distress

1. Perform hand hygiene and don gloves, mask, and eye protection or a face shield.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. If time allows, explain the procedure to the patient and ensure that he or she agrees to treatment.
5. Check that the MRB is attached to an oxygen source that is turned on to 10 to 15 L/min.¹
6. If the patient is receiving PEEP, ensure that the MRB has a PEEP valve that provides the equivalent of the ventilator-delivered PEEP.

   Rationale: The PEEP valve maintains PEEP during manual ventilation.

   A patient requiring high levels of PEEP may not tolerate manual ventilation.

7. Disconnect the patient from the ventilator. Connect the MRB to the artificial airway. Activate the ventilator alarm silence.

   Do not silence a ventilator alarm while a patient is attached to the ventilator.

8. Observe the patient's breathing pattern and rate. Attempt to synchronize manual breaths with the patient's spontaneous effort. Observe the patient's chest rise and fall with inflation and deflation.

   Rationale: Synchronizing manual breaths with the patient's spontaneous effort helps him or her gain control over breathing.

   1. For assisted breathing, provide one breath every 6 seconds (10 breaths/min) delivered over 1 second.²

      Ventilation at higher rates can cause hemodynamic instability.

   2. If cardiopulmonary resuscitation (CPR) is being provided, make breath delivery asynchronous with chest compressions.²
9. Encourage the patient to relax while receiving manual breaths.

   Rationale: Relaxing promotes synchrony between the patient's breaths and the manual breaths.

10. Gradually slow the rate of manual breaths to approximate the ventilator rate or to achieve a rate that meets the patient's demand.

    Rationale: Slowing the rate reestablishes synchrony. When respiratory distress is relieved, the patient can be reconnected to the ventilator.

11. If available, connect the patient to a continuous ETCO₂ monitor.

    Rationale: Continuously monitoring ET CO₂ monitors airway placement and the adequacy of ventilations while manually ventilating the patient.

12. Determine if the patient is comfortable with the manual breaths.
13. Assess the ease or difficulty with which the MRB inflates and deflates.
14. Return the patient to the ventilator when respiratory distress is relieved. Reactivate and check ventilator alarms and settings.
15. If signs and symptoms of distress are not relieved, call for assistance to help determine the cause.
    1. Assess the ease or difficulty of manual ventilation. Assess the patient's airway resistance (how easily air moves down the airways) and lung compliance (how easily the lungs and chest wall distend).
    2. Assess the patient for bilateral breath sounds and symmetric chest expansion.
    3. Collaborate with the practitioner regarding the patient's need for a higher level of ventilator support.
    4. Evaluate the adequacy of the artificial airway cuff for maintaining a seal in the patient's airway.
    5. Assess the patient for anxiety and discomfort.
16. Observe the patient's breathing pattern, patient-ventilator synchrony, peak inspiratory pressure (volume ventilation), tidal volume, minute ventilation, and respiratory frequency (pressure ventilation).
17. Ensure that the nurse call system is within the patient's reach.
18. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene.
19. Document the procedure in the patient's record.

Transport

1. Perform hand hygiene and don gloves, mask, and eye protection or a face shield.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
5. Connect the MRB to an oxygen source and turn it on to 10 to 15 L/min.¹
6. If the patient is receiving PEEP, ensure that the MRB has a PEEP valve that provides the equivalent of the ventilator-delivered PEEP.

   Rationale: The PEEP valve maintains PEEP during manual ventilation.

   A patient requiring high levels of PEEP may not tolerate manual ventilation.

7. Attach a portable respirometer on the end of the bag.

   Rationale: Using a respirometer helps ensure that tidal volume delivery and PEEP approximate those provided by the ventilator.

8. Disconnect the patient from the ventilator. Connect the MRB to the artificial airway. Activate the ventilator alarm silence.

   Do not silence a ventilator alarm while a patient is attached to the ventilator.

9. Manually ventilate the patient at the approximate rate, depth, and pattern provided by the ventilator. Observe the patient's chest rise and fall with inflation and deflation.
10. Adjust the manual inflations as necessary to produce a tidal volume that approximates the ventilator tidal volume. Repeat adjustments until an approximate tidal volume is achieved. Remove the portable respirometer.
11. If available, connect the patient to a continuous ETCO₂ monitor.

    Rationale: Continuously monitoring ET CO₂ monitors airway placement and the adequacy of ventilation during transport.

12. Periodically check that the patient is comfortable with the manual ventilation technique. Make adjustments as needed to maintain the patient's comfort.
13. Upon arrival at the destination, reconnect the patient to the ventilator. Reactivate the ventilator alarms.
14. Observe the patient's breathing pattern, patient-ventilator synchrony, peak inspiratory pressure (volume ventilation), tidal volume, minute ventilation, and respiratory frequency (pressure ventilation).
15. Ensure that the call button is within the patient's reach, if appropriate.
16. Discard supplies, remove PPE, and perform hand hygiene.
17. Document the procedure in the patient's record.

MONITORING AND CARE

1. Evaluate trends or sudden changes in lung compliance, airway resistance, or patient's condition.

   Reportable conditions: Difficulty ventilating the patient, no observable chest movement, agitation, diaphoresis, hypertension or hypotension, tachycardia or bradycardia, dyssynchronous breathing

2. Monitor SpO₂ to determine the adequacy of oxygenation. Monitor the ETCO₂ level to determine the adequacy of ventilation.

   Reportable conditions: A decrease in Sp O ₂ from the patient's baseline, an increase in ET CO₂ from the patient's baseline

3. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• Maintenance of adequate oxygenation and ventilation
• Resolution of acute respiratory distress
• Safe and uneventful transport

UNEXPECTED OUTCOMES

• Hemodynamic instability secondary to dynamic hyperinflation
• Pulmonary barotrauma (e.g., pneumothorax)
• Inability to restore adequate ventilation and oxygenation with manual ventilation
• Inadvertent extubation or decannulation during manual ventilation
• Equipment failure and inability to ventilate patient manually

DOCUMENTATION

• Patient and family education
• Patient's tolerance of the procedure
• Reason for manual ventilation (e.g., to suction or to transport)
• Unexpected outcomes and related nursing interventions
• Pain assessment and management

REFERENCES

1. Barnes, T.A. (2017). Emergency cardiovascular life support. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan's fundamentals of respiratory care (11th ed., pp. 790-819). St. Louis: Elsevier.
2. Link, M.S. and others. (2015). Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 Suppl. 2), S444-S464. doi:10.1161/cir.0000000000000261 (Level D)

Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.

AACN Levels of Evidence

• Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
• Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
• Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
• Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
• Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
• Level M - Manufacturer's recommendations only