1. Use of ambu with ALS-patients
Kristiina Jokinen
Physiotherapist
The FNDA

2. Hand ventilation with ambu means
Assisting in labored breathing with ambu

3. 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

4. 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

5. When to use hand ventilation?
To remove secretions from the lungs
To assist coughing
After using suction

6. The aims of hand ventilation
Improved ventilation
Preventing and removing of atelectasis
Relaxation of respiratory muscles
Cough assistance

7. 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

8. 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

9. 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 !

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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

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

22. 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

23. 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!