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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.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.
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Rationale: The PEEP valve maintains PEEP during manual ventilation.
A patient requiring high levels of PEEP may not tolerate manual ventilation.
Do not silence a ventilator alarm while a patient is attached to the ventilator.
Rationale: Synchronizing manual breaths with the patient's spontaneous effort helps him or her gain control over breathing.
Ventilation at higher rates can cause hemodynamic instability.
Rationale: Relaxing promotes synchrony between the patient's breaths and the manual breaths.
Rationale: Slowing the rate reestablishes synchrony. When respiratory distress is relieved, the patient can be reconnected to the ventilator.
Rationale: Continuously monitoring ET
CO2 monitors airway placement and the adequacy of ventilations while manually ventilating the patient.
Rationale: Using a respirometer helps ensure that tidal volume delivery and PEEP approximate those provided by the ventilator.
Rationale: Continuously monitoring ET
CO2 monitors airway placement and the adequacy of ventilation during transport.
Reportable conditions: Difficulty ventilating the patient, no observable chest movement, agitation, diaphoresis, hypertension or hypotension, tachycardia or bradycardia, dyssynchronous breathing
Reportable conditions: A decrease in Sp
2 from the patient's baseline, an increase in ET
CO2 from the patient's baseline
Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier.
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