No BVM?

A couple weeks ago, I heard a story about a paramedic, who in responding to a cardiac arrest, told the other responders not to use bag-valve-ventilation (BVM) to breathe for the patient.

Bag-valve mask ventilation is the manner in which we assist people’s breathing who are either not breathing or breathing inadequately. We hold a mask tight to their face, and squeeze a bag which forces air into their lungs. It is an essential life-saving skill.

The medic, who works primarily in another region of the state, told the other responders it was a new protocol in light of the COVID epidemic. Bag-valve mask ventilation can aerosolize droplets which could be dangerous to responders. (To be clear we are not taking about passive ventilation during the first eight minutes of a presumed cardiac arrest, but no BVM at all).

The recent state protocols (COVID supplement) mention the possible danger of bask-valve-mask (BVM). Here is what they say:

Aerosol generating procedures are interventions performed on patients that can generate infectious aerosols. Nebulized medications, CPAP, BVM, intubation, alternate airway placement, suctioning, CPR, etc. are all aerosol-generating procedures. When possible, please attempt to avoid these procedures unless considered essential to treat a life-threatening illness (severe asthma not responding to other interventions, BVM in a patient not ventilating adequately, CPR needed in a pulseless patient, etc).

To be clear, the state protocols say: Don’t use BVM unless considered essential to treat a life-threatening illness.

Within this past week, I read a protocol put out by a Connecticut sponsor hospital that states “Do not provide bag valve mask ventilations even to cardiac arrest patients.” It goes on to say it is okay to insert a blind airway, which could be attached to a BVM, but says if a blind airway is not available, use a non-rebreathing mask instead.

This is very radical. While I am all for getting ahead of the curve once you can see where it is going, I am not ready for this.

Think of a drowning victim, an apneic heroin overdose, or a tired young asthmatic. We should not let them die out of fear they might have COVID and we might get infected if we try to save their lives with a BVM.

The theory behind the protocol (I surmise) is that a BVM by aerosolizing a COVID patients respiratory droplets, endangers rescuers so it should not be used even when it might save a patient’s life.  I can understand that in the case where a patient has arrested due to COVID (likely irreversible) a resuscitation would be futile and should not be undertaken due to the risk to responders. Letting someone with a reversible condition die in respiratory arrest due to corona virus fears is not cool.

Instead, I would advocate responders (wearing full PPE, including goggles, face mask and gown), do their best to ensure that aerosolization is minimized. Use two person BVM with one person ensuring a solid seal around the nose and mouth to limit the escape of aerosols. And at the earliest opportunity, insert a supraglottic (blind) airway, if available.

These are difficult times.

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