Abstract 13737: Enhanced Prehospital End-Tidal CO2 Monitor Data Analysis for Intubated Severe Traumatic Brain Injury: Striking Findings From the EPIC Study

Background: Studies show that EMS patients are often inadvertently hyperventilated (HV), resulting in hypocapnia. In TBI, HV markedly increases mortality. We evaluated continuous prehospital ETCO2 data in intubated TBI patients. Methods: Analysis of monitor data files (Philips MRx™) from a sample of intubated TBI cases in the EPIC Study (NIH-R01NS071049). Results: Among hundreds of cases, graphical display of continuous ETCO2 from 3 subjects dramatically exemplified commonly-occurring inadvertent HV. Fig 1 shows unrecognized HV lasting nearly 15 min. Fig 2 reveals nearly 14 min of increasing ventilatory rate and progressively worsening hypocapnia. Fig 3 shows nearly 4 min of HV that ends abruptly with clear, sudden recognition and slowing of ventilatory rate that leads to restoration of normal ETCO2 in only a few breaths. The corresponding EMS patient care records (PCR) failed to document the presence, severity, and duration of HV. Conclusions: In a study emphasizing prevention of HV, subsequent evaluation of continuous ETCO2 data revealed many cases of unintentionally rapid manual ventilation and severe hypocapnia, often occurring for long periods. These findings, even in the face of explicit guideline-based training, demonstrate a clear need for routine access to continuous monitor data among intubated patients for quality improvement and in clinical studies. Review of PCRs does not reliably identify mismanagement of ventilation. Furthermore, these findings make it likely that real-time audiovisual feedback technology would improve ventilatory management by alerting providers to unidentified HV that results from the frequent distractions occurring during EMS care.

Evolution and Characteristics of Bag-Valve-Mask Ventilation During Pandemic: A Review of the Literature

Mass casualty incidents such as those that are being experienced during the novel coronavirus disease (COVID-19) pandemic can overwhelm local healthcare systems, where the number of casualties exceeds local resources and capabilities in a short period of time. The introduction of patients with worsening lung function as a result of COVID-19 has strained traditional ventilator supplies. To bridge the gap during ventilator shortages and to help clinicians triage patients, manual resuscitator devices can be used to deliver respirations to a patient requiring breathing support. For patients who require ventilatory support, manual ventilation is a vital procedure. It has to be performed by experienced healthcare providers that are regularly trained for the use of bag-valve-mask (BVM) in emergency situations. We will present, a historical view on manual ventilation’s evolution throughout the last decades. Artificial ventilation has developed progressively and research is still going on to improve the actual devices used. Throughout the past years, a brand-new generation of ventilators was developed, but little was done for manual ventilation. Manual ventilation through BVM can be replaced by automatic ventilation which illustrates that the Tidal Volume vs. Time graph of the automated system is similar to the graph produced by manual operation of the BVM and to the graph produced by a human subject. The use of an automatic manually operated device may improve ventilation efficiency and decrease the risk of pulmonary overdistention, while decreasing the ventilation rate.

Utility of the SotairTM Device in Manual Ventilation of Different Lung Compliances

Background: During positive pressure ventilation, peak inspiratory pressure (PIP) and Tidal Volume (TV) must be kept at optimal levels to achieve appropriate ventilation without causing complications, such as trauma to the lung parenchyma or stomach insufflation. Manual ventilation using a Bag-valve-mask (BVM) results in highly variable TVs and PIPs that could increase the risk of volutrauma and barotrauma. It is unknown whether pathologic changes in lung compliance alter the TV and PIP during manual ventilation. Methods: This study used a lung simulator and volunteer medical students, medics and nurses to assess whether the pressure and flow limiting SotairTM device resulted in more appropriate TVs and PIPs during manual ventilation compared to BVM only, using a mechanical ventilator as the standard. The secondary aim was to determine whether decreased lung compliance, which simulates the physiology of lungs with Acute Respiratory Distress Syndrome (ARDS), affected the conclusion. Results: We found that the SotairTM device helped maintain PIP and TV closer to mechanical ventilator baseline levels than BVM only ventilation across lung compliance settings. The SotairTM device also helped providers maintain PIP levels below the threshold of pressures known to cause gastric insufflation and barotrauma. Conclusions: This data indicates that manual ventilation using the SotairTM device is a safer option than unmitigated BVM only ventilation in both normal and decreased lung compliance conditions.

Feasibility of manual ventilation replacing mechanical ventilation

BackgroundDuring the COVID-19 pandemic it is anticipated that there will be a shortage of mechanical ventilators available for patients in critical condition. This has sparked many discussions about rationing resources and withholding care; however, an alternative may be to implement manual ventilation in these situations instead. Manual ventilation and a safety device were assessed for efficacy of extended use, such as may be required during this pandemic.MethodsTo evaluate physical output characteristics of extended manual ventilation and efficacy of a barotrauma mitigation device, 47 medical students, nurses and medics completed two 1-hour manual ventilation sessions using the SmartLung 2000 Lung Simulator and 5300 Series Mass Flow Meter with a SPUR II resuscitator bag and endotracheal tube, mimicking a healthy adult with normal lung physiology, both with and without the Sotair device. Providers were randomised to complete their initial session either with or without the Sotair device.FindingsCollected data show wide variability in tidal volume and peak pressure in unmitigated manual breaths despite prior training and independent exploration of the resuscitation equipment prior to testing. The mean (±SD) tidal volume with bag only was 563.9±128.8 mL and with the safety device 536.1±80.9 mL (p<0.0001). The mean peak inspiratory pressure with bag only was 17.2±6.3 cm H2O and with the safety device 14.9±2.4 cm H2O (p<0.0001).InterpretationWhile extended manual ventilation cannot replace mechanical ventilation, it is feasible with a safety device, which may reduce barotrauma, underventilation and overventilation. These results also demonstrate that withholding care and rationing resources may not be necessary.

Continuous flow insufflation of oxygen compared with manual ventilation during out-of-hospital cardiac arrest: A survey of the paramedics

Introduction: In 2018, a continuous flow insufflation of oxygen (CFIO) device (b-card™, Vygon (USA)) placed on a supraglottic airway (SGA) became the standard of care to ventilate patients during adult out-of-hospital cardiac arrest (OHCA) care in Quebec–Capitale-Nationale region, Canada. This study aims to assess the paramedics’ perception as well as the disadvantages and the benefits relative to the use of CFIO during OHCA management. Methods: An invitation to complete an online survey (Survey Monkey™) was sent to all 560 paramedics who are working in our region. The survey included 22 questions of which 9 aimed to compare the traditional manual ventilation with a bag to the CFIO using a 5-point Likert-type scale. Results: A total of 244 paramedics completed the survey, of which 189 (77.5%) had used the CFIO device during an OHCA at least once. Most respondents felt that the intervention was faster (70.2%) and easier (86.5%) with the CFIO device compared with manual ventilation. CFIO was also associated with perceived increased patient safety (64.4%) as well as paramedic safety during the evacuation (88.9%) and the ambulance transport (88.9%). Paramedics reported that physical (48.1%) and cognitive (52.9%) fatigue were also improved with CFIO. The main reported barriers were the bending of the external SGA tube and the loss of capnography values. Conclusion: The use of CFIO during adult OHCA care allows a simplified approach and was perceived as safer for the patient and the paramedics compared with manual ventilation. Its impact on patient-centred outcomes needs to be assessed.