Use of ambu with ALS-patients

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Use of ambu with ALS-patients

• Kristiina Jokinen
• Physiotherapist
• The FNDA

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Hand ventilation with ambu means

• Assisting in labored breathing with ambu

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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

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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

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When to use hand ventilation?

• To remove secretions from the lungs
• To assist coughing
• After using suction

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The aims of hand ventilation

• Improved ventilation
• Preventing and removing of atelectasis
• Relaxation of respiratory muscles
• Cough assistance

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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

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Notice

• The reservoir should not be used without
  additional oxygen
• A patient cant 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

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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 !

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When using ambu, consider

• Hygiene
• if several persons use the same ambu, its best
  to use bacterial/viral filters
• Patients condition
• additional diseases or conditions require
  consultation with patients doctor
• Independence and need of assistance

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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

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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

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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

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Decreased lung capacity silent chest- targeted
breathing

• Some positional habits can compromise breathing
• 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

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Ambu and physiotherapy

• Relaxing the patient after or during
  laborius/tiresome physiotherapy session with hand
  ventilation
• Adding power to inhaling in breath deepening
  exercises
• Patients own ambu makes cleaning and
  disinfecting easier

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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

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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

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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

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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/individually)

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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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PCF-levels of an ALS-patientbefore and after
using ambu
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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

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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!