Episode #2: The Nebulizer’s Guide to the Galaxy… Part Two

During our last episode, we started to talk about when and how to use a nebulizer in conjunction with CPAP. Today’s episode is slightly more complicated, simply because I genuinely believe that most prehospital providers are gun-shy enough about aiding a patient with mechanical ventilation via BVM.

Who do we ventilate?

  • This is oversimplified, but here are my two categories of patients:
    • Obtunded adult OR pediatric respiratory failure OR respiratory distress
    • Pediatric patients that we cannot fit a CPAP mask on

Hypoxia or Hypercapnia?

  • Determine the difference of hypoxia, hypercapnia, or a mix of both
    • Hypoxia = aggression, combativeness, and brief paranoia
      • Straight hypoxia will most likely indicate CHF/Pneumonia
    • Hypercapnia = lethargy, narcosis, and often hypoventilation
      • Hypercapnia will most likely point you in the direction of a CNS depressant overdose or COPD/asthma.

Who is a candidate for an inline nebulizer with a BVM?

  • Obtunded adult OR pediatric respiratory failure OR distress with asthma, COPD, or possibly pneumonia
    • Remember that CHF can present with wheezing; use capnography to differentiate between COPD/asthma/CHF…
  • Cardiac arrest due to hypoxia from one of the three etiologies as mentioned above

Four Key Points to Remember

  • Non-invasive ventilation saves the day
  • Advanced airway placement should not feel like a “win”.
  • Prepare for respiratory distress patients to deteriorate quickly
    • Think three steps ahead of where you are
  • Mama says, “clutter is the devil”.
    • Know your essential equipment, and get rid of the rest!

What kind of mask should I use?

Obviously, BVMs come with their own mask. When you are strapped for resources and have a crashing patient, do you really want to have to use two people to effectively manage your patient’s airway? So, why does a BVM require two providers to provide effective ventilations? The answer is the seal. What if, when you don’t have enough hands, we used a CPAP mask to provide a good seal, and then just had that practitioner worry about good positioning, rate, and depth of ventilation?


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