Are you over-ventilating your patient

ZOLL Medical Australia
Sunday, 01 August, 2021

Bag-valve masks have been the standard of care for decades, but it’s hard to know how much air a patient is getting with each squeeze. Guidelines suggest a rate of 10 breaths per minute when ventilating a patient, but the average provider has been shown to deliver an average of 30 ventilations per minute — nearly three times the recommended rate.1

Real-time clinical feedback has been shown to improve patient outcomes. The new X Series® Advanced monitor/defibrillator from ZOLL® provides real-time clinical feedback for CPR and ventilation to help address cardiac arrest, traumatic brain injury and more.

“Science is showing us that to squeeze the bag a little bit inappropriately for one or three or 10 breaths can actually have an impact on outcomes,” said Drew Hoffman, a paramedic and a clinical support specialist on the ZOLL EMS team. “There is no set standard on BVMs, and the volume will vary with the size of hands of the provider, whether or not they’re using one or two hands and how aggressively the BVM is being squeezed.”

Without feedback, it’s easy — even likely — to deliver excessive ventilation that can cause decreased coronary perfusion and create serious secondary problems like barotrauma or ARDS from overinflation.

“There is no defined volume per squeeze, so you’re just eyeballing something that is vitally important for your patient,” said Hoffman.

But measuring the patient’s EtCO2 levels and other key metrics during ventilation can eliminate the guesswork when it comes to BVM use.


Access to real-time clinical feedback on the scene has been shown to improve patient outcomes with CPR. For years, ZOLL devices have provided real-time clinical feedback on CPR to help rescuers deliver high-quality compressions to patients in cardiac arrest.

“We know for a fact that feedback helps us do better CPR,” said Hoffman. “I honestly can’t imagine, as a provider, doing CPR on someone without feedback — it’s unthinkable.”

Now, ZOLL is applying the same approach to ventilation to help Emergency providers better manage a variety of conditions with its new X Series Advanced monitor/defibrillator. With real-time feedback for compressions, ventilation and more, emergency medical providers can better serve each patient with peace of mind that they are doing the right thing at the right time — as well as improve their skills overall.

For cardiac arrest patients, the X Series Advanced monitor/defibrillator offers both Real CPR Help® and Real BVM Help™, giving providers simultaneous real-time feedback on both compression and ventilation quality. In the Real BVM Help Dashboard, providers can view delivered tidal volume and rate on the monitor, as well as ventilation rate and depth, a ventilation quality indicator and a countdown timer.

“Unchecked BVM use can lead to hyperventilation, and that will pressurise your patient’s chest and lead to poor outcomes. Real BVM Help gives us real-time feedback, and it’s adjustable for absolutely every patient that we encounter,” said Hoffman. “You can focus in on every squeeze of the bag and objectively evaluate how did you do? Was the ventilation a problem? Did it cause an outcome that we didn’t want?”

Real BVM Help works with any standard-sized commercially available airway management device for both intubated and non-intubated patients, and the data can help providers maintain balance of key levels for a variety of patient conditions.


Traumatic brain injury patients present a unique set of challenges, and early management is critical to minimise common secondary injuries.2

Traditionally, TBI management has included efforts to control potential brain bleeding by hyperventilating patients to decrease intercranial pressure by limiting oxygen and causing blood vessels in the brain to shrink. But this literally starves the brain, warns Sean Culliney, a paramedic and a clinical support specialist on the ZOLL EMS team, leading to a potential cascade of adverse events.

“The problem is that it goes off the rails really fast. We can absolutely control intercranial pressure, but it’s at the expense of all of our neurons,” he said. “We’re clamping those vessels down and we’re actually starving the brain for blood, and that is a very bad thing for our patients.”

The TBI Dashboard on the X Series Advanced provides real-time data to help guide providers in managing this complex condition.

“The tricky part about the human body is that it is on a tightrope basically at all times, so it’s a very narrow path that we walk, and if we get off of that path a cascade begins to happen,” said Culliney. “If I hyperventilate or hypoventilate — if I go either way off that tightrope — a series of things starts happening, and it’s really difficult to get them back under control. Achieving a good pressure in the brain is useless if now my carbon dioxide level is dropping.”

Ultimately, he says, Real BVM Help and the TBI Dashboard can help providers achieve the proper balance for patients and assure providers that they are delivering the best possible care.

“It helps us stay right in the middle, where we need to be,” he said. “It’s a large puzzle, and Real BVM Help steadies our hand.”


In addition to supporting time-sensitive patient care, data from the X Series Advanced can be used to improve overall practices as well. With RescueNet® CaseReview, clinicians and medical directors can view data, including ventilation and CPR performance, after the fact for effective quality assurance.

The technology also supports telehealth and treatment in place, which continue to increase as a result the pandemic. With ZOLL’s remote viewing telehealth technology, healthcare professionals can view data from the X Series Advanced from a remote location to provide decision support for emergency rescue providers in the field.

“Real-time feedback is absolutely a critical priority in using a BVM, and the X Series Advanced provides that feedback in a way that helps everyone deliver the same care,” said Hoffman. “I think in 10 years people are going to say, ‘I can’t believe we ever did ventilations without this.’”

Visit ZOLL for more information.

*Article written and previously published in EMS1


1. Aufderheide TP, Lurie KG. Crit Care Med. 2004 Sep;32(9 Suppl):S345–51.

2. Spaite DW, et al. Acad Emerg Med. 2014;21:7:818-83

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