IngMar Medical, Ltd. P.O. Box 10106 Pittsburgh, PA 15232 Tel: (412) 683-8228 Toll free: (800) 583-9910 Fax: (412) 683-8404 www.ingmarmed.com Technical White Paper Life Threatening Risks in Manual Ventilation: Training to Improve Technique and Patient Outcomes By Jennifer Bacior Correct manual ventilation technique is critical for the survival of patients in respiratory arrest. Unfortunately, multiple studies have shown that ventilation technique in the field is widely varied and inconsistent. Current efforts at ventilating prehospital patients often result in dangerous performance and application of both manual and bag-valve mask (BVM) ventilation, which, in turn, results in life-threatening consequences for patients. In order to amend these potentially life-threatening conditions, simulation training must be brought to the next level to ensure proper patient care in a wide range of real-life scenarios. Executive Summary This paper discusses manual and bag-valve mask ventilation, specifically harmful complications during use, and introduces a new approach to training that will aid in resolving these problems in the clinical setting. Overview In life-threatening situations, initial ventilation is commonly provided to patients who cannot breathe by themselves via a self-inflating bagvalve mask (BVM). This technique is widely considered to be a critical aspect of managing out-of-hospital medical emergencies.1 However, when this technique is performed improperly, lungs may experience barotraumas from high pressures and cardiac perfusion may suffer due to increased intrathoracic pressure. Another risk of incorrectly performed BVM ventilation is increased airway pressure allowing air to enter the stomach. This gastric inflation can cause gastric regurgitation, aspiration of stomach contents, and reduced tidal volume delivery into © 2006 IngMar Medical www.ingmarmed.com the lungs (because part of the volume introduced into the patient goes into the stomach.) The Mechanics of Ventilation When lungs are ventilated using manual or BVM ventilation techniques, the total volume of air that reaches the lungs depends on several factors; of these, airway resistance and respiratory system compliance may be two of the most commonly acknowledged. As resistance increases or compliance decreases, it becomes progressively harder for a first responder to inflate the lungs. Another factor is, of course, the technique of the patient care provider, specifically: head position, tidal volume, and inflation flow rate and duration, (which aid in establishing peak airway pressure,) are crucial when ventilation is administered.2 The unique interaction of these variables combines to determine the gas distribution of the air introduced into the body via manual or BVM ventilation. Life Threatening Risks in Manual Ventilation Page 1 of 5

Minor Changes Yield Major Impacts Since the balance of gas distribution weighs not only on the patient parameters of a given patient, but also on the person providing ventilation to the patient, even minor differences in technique can lead to major complications in ventilation. Studies have found that even among highly trained and experienced medical personnel, the quality of manual and BVM ventilation is inconsistent and does not meet published guidelines.3-8 In a clinical observation study, it was found that ventilation rates during the field application of CPR in a city with well-trained EMS...

The Ideal Ventilation Trainer So what characteristics would make up an ideal ventilation simulator? The two most important characteristics of this simulator would be realism and feedback. This unique tool provides real-time feedback via a wireless connection to a PDA (included) It allows you to observe and practice ventilation patterns, as well as vary delivered volume, flow, and pressure. The real-time response of the system shows the user several factors, including: The simulator should not only to look and feel like a patient, but it should also simulate several different combinations of patient...

shows, training workshops, or room-to-room within the same facility. Summary Given the importance of correct ventilation technique in proper patient care, simulation training is an imperative part of any life-support training regimen. Current efforts have been shown to result in inconsistent and often dangerous performance and application of both manual and bag-valve mask (BVM) ventilation. Simulation training must be brought to the next level to ensure proper patient care in a wide range of reallife scenarios, utilizing feedback apparatuses that allow the user to practice correct manual ventilation...

13. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: An ethical imperative. Acad Med. 2003; 78: 783788. 14. Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical education. Med Teach. 2000; 22(5): 489-495. 15. BLS Guidelines, Part 4: Adult Basic Life Support. AHA. 2005; IV-23. 16. Ricard JD. Manual ventilation and risk of barotraumas: Primum non nocere. Respir Care. 2005; 50(3): 338-339. © 2006 IngMar Medical www.ingmarmed.com Life Threatening Risks in Manual Ventilation Page 5 of 5