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 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 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/individually)

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

PCF-levels of an ALS-patient before and after using ambu

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!