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Emergency ventilation - an alternative to mouth-to-mouth resuscitation.

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VOL: 100, ISSUE: 36, PAGE NO: 59

Anthony Kemp, RN, formally an NHS resuscitation training officer, is now a specialist nurse practitioner in immediate care, BASICS Kent

The reasons for these serious delays were identified as:

The reasons for these serious delays were identified as:

- A strong reluctance by health care professionals to provide mouth-to-mouth resuscitation;

- The absence of a bag-valve-mask (BVM) device.

But whenever resuscitation is required, ventilatory support is an essential part of the procedure. Although resuscitation equipment should be available in all clinical areas, there are occasions when it is not and the potential for significant delays in emergency ventilation can arise. Examples include:

- Hospital corridors;

- Non-clinical areas;

- Primary care and community settings.

Patients who require emergency ventilatory support must have prompt and efficient intervention and in the professional health care setting a BVM would normally be used to provide this.

This has considerable disadvantages, particularly for the inexperienced practitioner who may fail to recognise that the patient is receiving inadequate ventilation due to poor technique.

The Resuscitation Council (UK) (2003) statement on teaching health care professionals to use a BVM notes that 'even they require considerable training and regular practice to maintain their proficiency'.

Mouth-to-mouth resuscitation
This is the cornerstone of first aid and is an alternative to using a BVM. This technique has been proven to be highly effective, but is unlikely to be provided by health care professionals. Many resuscitation officers do not teach it and would not expect it to be performed in clinical areas.

Blenkharn et al (1991) note that the risk of infection being transmitted during mouth-to-mouth resuscitation is low. However, there is a reluctance among nurses, doctors and ambulance staff to use mouth-to-mouth resuscitation as part of cardiopulmonary resuscitation (CPR) (Brenner et al, 1997; Hew et al, 1997; Brenner et al, 1996; Brenner and Kauffman, 1993). The most common reason given was the fear of contracting HIV (Hew et al, 1997; Brenner et al, 1996; Brenner and Kauffman, 1993).

Brenner et al (1997) reported that among medical students and doctors the willingness to perform mouth-to-mouth resuscitation became significantly less the more senior they became.

Sixty-nine per cent of fourth-year medical students said they would perform mouth-to-mouth resuscitation, while only 29 per cent of senior house officers and equivalent grades would do so.

Among CPR trainers (all of whom were health care professionals) affiliated to the American Heart Association, 82 per cent indicated that they had moderate or great concern about disease transmission during mouth-to-mouth resuscitation (Locke et al, 1995).

The actual risks of transmission of infection between a patient and rescuer are in fact small and where HIV is concerned it is estimated to be remote (Sun et al, 1995).

Several reports have indicated that virus levels are undetectable or low in the saliva of people with HIV infections (Piazza et al, 1989) and that saliva contains inhibitor components that reduce its infective potential (Bergey et al, 1993; Malamud and Friedman, 1993; Piazza et al, 1989; Fultz, 1986).

Further work has shown that HIV transmission can theoretically occur from patient to rescuer due to trauma, oral lesions and contact with blood. Studies of more than 1,000 episodes of exposures of people to known HIV-positive blood report an infection rate of 0.0006-0.1 per cent per exposure, equivalent to 6-100 per 100,000 (Gerberding, 1995; Ippolito et al, 1993).

Alternatives to the BVM and mouth-to-mouth resuscitation
The Resuscitation Council (UK)(2000), in its guidance for clinical practice and training, recommends the inclusion of pocket masks in resuscitation equipment (Fig 1). It recommends that hospital staff should 'undergo regular resuscitation training to a level compatible with their expected clinical responsibilities'. It also recommends that 'all doctors should have advanced resuscitation training. Nursing staff should have training to a standard compatible with their level of experience and expected duties within hospital'.

It is clear then that even within the hospital setting, outside of specialist units such as A&E and intensive care, nurses may not be taught how to use the BVM or use this skill often enough to achieve competence.

Primary care staff The Resuscitation Council (UK) (2003) makes recommendations for primary care staff. It suggests that 'expired air ventilation is the minimum standard expected and should be performed with a pocket mask incorporating a one-way valve to prevent secretions from the patient reaching the rescuer'.

Using a pocket mask It is clear that the pocket mask can be a useful addition to resuscitation equipment in all patient areas. It is also aesthetically more acceptable than mouth-to-mouth resuscitation.

The device can be wall-mounted in its case. Locations in which to place pocket masks include:

- Outside each main patient room on a ward;

- Treatment rooms;

- GP surgeries;

- Hospital corridors (alongside wall-mounted phones or emergency fire equipment).

Staff working in the community can carry them in their briefcase or bag.

Components of the pocket mask These provide a barrier between the patient and rescuer (Fig 2). They include the following:

- Pre-inflated cuff, which provides an effective seal around the mouth and nose;

- One-way valve, which ensures that airflow return from the patient is discharged into the atmosphere without contamination of the user (Fig 2);

- In-line filter, which filters the air (Fig 2);

- An oxygen inlet port, which allows high-flow oxygen to be administered to the patient during a resuscitation attempt.

The mask creates distance between the patient and rescuer and this enables the rescuer to observe chest movement during ventilation (Fig 3).

Training The training required to use the pocket mask is easier than that required for the BVM. The skill needed is similar to that utilised for mouth-to mouth resuscitation.

Conclusion
Providing timely and effective ventilatory support as part of resuscitation is crucial. However, there is evidence that health care professionals are reluctant to use mouth-to-mouth resuscitation in these situations.

In the absence of a BVM that is used by an experienced and competent user, the pocket mask removes the need for mouth-to-mouth resuscitation. It also removes the user from direct physical contact with the patient.

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