Transcript Use of ambu with ALS

Use of ambu with ALS-patients
Kristiina Jokinen
Physiotherapist
The FNDA
Hand ventilation
with ambu means
• Assisting in labored breathing with ambu
A bag valve mask
- BMV, ambu
• Especially for patients with
symptoms of bulbarparesis
• Air stacking-method keeps
inhaled air in between the
compressions
• Beware of over-inflating
the lungs
• - pneumothorax
When to use hand ventilation?
• In failure of a mechanical ventilator
• TLC is under 2 l
• Accessory muscles of respiration are in
strong use
• Scoliosis/kyphosis: decreased lung capacity
• Respiratory frequency more than 20
breaths/minute
When to use hand ventilation?
• To remove secretions from the lungs
• To assist coughing
• After using suction
The aims of hand ventilation
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Improved ventilation
Preventing and removing of atelectasis
Relaxation of respiratory muscles
Cough assistance
Contraindications
for hand ventilation
-Absolute: pneumothorax
-Relative: bullae (big fluid-filled bulges on the
pleura), serious emphysema , hypovolemia
(state of decreased blood volume),
”ignorance" (inability to time the procedure
right in order to support the inhaling)
Arno Vuori MD, Department of Anesthesiology, Turku University Central Hospital
TYKS
Notice:
• The reservoir should not be used without
additional oxygen
• A patient can’t breath through ambu without
ventilation
• Ambu contains a one-way valve
• The mask cannot be tied onto face
• Neck support should be used in order to
relax neck and throat muscles
Notice:
• Avoid ventilation straight after meals and
before bedtime
• Avoid hyperventilation by having breaks
• Make sure the mask is tight
• The patient must feel the chest stretching
• The patient gives the rhythm !
When using ambu, consider:
• Hygiene
– if several persons use the same ambu, it’s
best to use bacterial/viral filters
• Patients condition
– additional diseases or conditions require
consultation with patient’s doctor
• Independence and need of assistance
Assisted ventilation
• Assistance in hand ventilation is needed, if
upper limbs are weak
• Assistant can also clean the ambu
• The assistant needs to be trained for the
right use of ambu/hand ventilation
• The methods and means have to be agreed
and written down by both parties
Exercises with ambu
• Exercises with different methods:
– Inhale (hold breath)– exhale with a
little pause
• series of 5-10 with pauses in between
• Cycles can be prolonged when patient
learns to take in the incoming air
– air stacking
• inflating the lungs in stages
• targeted breathing when lying by side
Air stacking
• Inflating the lungs in stages
• Holding the breath after inhaling
• 2-4 chest compressions when inhaling, the patient
takes in as much air as possible
• When the lungs are full, hold (keep the bag
”down”) for a moment without exhaling
• The patient should not experience any dizziness or
chest pain
• Monitor the patient
Decreased lung capacity
silent chest
- targeted breathing
• Some positional habits can compromise breathing
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sleeping always on one side
sitting lopsided
immobile upper limbs, hands pressing on sides
shoulders twisted forwars, collapsed chest
• Versatile use of different starting positions
– Targeting air into the silent parts of the lungs
Ambu and physiotherapy
• Relaxing the patient after or during
laborius/tiresome physiotherapy session
with hand ventilation
• Adding power to inhaling in breath
deepening exercises
• Patient’s own ambu makes cleaning and
disinfecting easier
Ambu and physiotherapy
- cooperation
Targeting air into the silent
parts of the lungs is easier
with assistance
Deepening of breathing
• Removing secretions from
the lungs is easier
• The assistant uses ambu
while psysiotherapist presses
on the body
Ambu and suction
• Removing secretions from the lungs can
lead to atellectasis
• Hand ventilation is performed always after
suction
• Listen – breath sounds should be audible
from all parts of the lungs
Cough assistance and ambu
• Weak abdominals and intercostals complicate
coughing
• Inhaling is compromised
• Ambu helps ventilation with different
methods
• Manual support on chest and/or abdomen
strenghten coughing
Strenghtening coughing
with ambu
• Assistants elbow is
kept as straight as
possible, weight
shifting is useful
• The patient inhales –
holds breath – while
exhaling the assistant
compresses chest
(along
sides/diaphragm/indi
vidually)
Strenghtening coughing
Increasing lung capacity
• Secretions in lungs reduce lung capacity
• Secretions in upper parts of the throat
complicate swallowing and spitting
• A stetoscope can help detect if there are
secretions in the lungs and if the air reaches
the lower parts of the lungs
• ”Additional air” helps in coughing and
increasing volume
– PCF-levels rise
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l/min
PCF-levels of an ALS-patient
before and after using ambu
400
350
300
250
200
PCF ennen
3xsis-ulos +ysk
air stacking +ysk
150
100
50
0
Independent use of ambu
• Independent use of ambu can
be done through
tracheostomy tube and
additional parts of ambu
– using body muscles, pressing
against chest
– using of sides, ambu between
side and upper limb
– pressing against thigh
Independent use of ambu
• While self-ventilating:
– Hands are on the sides, keeping
the air off sides
– Hands are elevated, guiding air
into the upper parts of the lungs
– A long extension tube works less
efficiently
• Assisted ventilation is more
efficient, but if that is not an
option, self-ventilation is way
better that not ventilating at all!