Respiratory Rate Above 28, Ventilate?

I recently attended my required canned trauma recertification course.  One of the points that was repeated in the lectures was was that patients should be ventilated with a bag valve mask if their respiratory rate is above 28.  No matter what the cause of their fast rate, regardless of whether they are awake and speaking, even if they tell you to stop, the correct answer in the skill stations was to bag them.

I was taught in EMT class that if a respiratory rate is above a certain number, patients should be bagged because the only air exchanged is in dead space.  Shortly after I discovered that you get funny looks at the hospital when you ventilate a patient with a BVM who is speaking as you wheel them in.   I stopped doing that, and was never chided for it.

Lots of trauma patients breathe faster than 28 times a minute.  Very few of them need positive pressure ventilation, and many would be harmed by it.   It disrupts the body’s natural process of drawing air into the lungs with negative pressure.  My last post was about how difficult it is to ventilate a patient well.  My experience is that people bag way too forcefully and way to fast.  Anything more than a gentle squeeze of the bag blows air into the esophagus, which increases the risk of vomiting.  It also increases intrathoracic pressure, which decreases cardiac output.  Both of these are bad for someone in hemorrhagic shock or with a pneumothorax.

Patients with blunt chest trauma often take rapid, shallow breaths because it hurts when their rib cage expands.  As long as these patients are adequately oxygenated, pain medication will do much more to help their breathing than a bag valve mask.  Forcing their chest to expand more than their body wants it to just causes more pain, which along with untreated pain, may actually cause them to decompensate.

The most common cause of a fast respiratory rate in a trauma patient is anxiety.  Think of the 16-year old with neck pain who is hyperventilating after they destroyed their parent’s car.  Of course this is a diagnosis of exclusion, but the last thing this patient needs is to have a mask squeezed over their face and air forced down their throat.  I fear that inexperienced people may think that is a good idea, though – just in case – after taking the course.

This is why thinking EMS people hate merit badge classes.


  1. Skip Kirkwood says:


  2. I’ve noticed we get funny looks no matter WHAT we do from CERtain people, who appear to believe we’re of no use to the team.
    But a doctor told me you didn’t always have to and anyway, the one who runs our program doesn’t care for BVM period. No idea why.
    I know why he stopped Combitubes though. Our area is the one in which the three patients died from misplacement by EMT-B’s and Dr. C. decided to take them off the supply list b/c they train EMT-B’s to do it but not to fully understand what could go wrong with doing it in trauma patients – which is exactly what DID go wrong three separate times with three different patients.

  3. I agree… gotta be real careful about bagging those patients. As paramedics, we don’t like to do things ‘half-assed’… – If we’re gonna bag someone, we’re gonna BAG someone. It’s easy to be overzealous with the tidal volume and pressure at which those positive pressure ventilations are delivered. I can imagine how things would go for the medic that rolled into the ED with a trauma patient that was tachypneic secondary to a pneumo. after being overly aggressive with the BVM. We actually had a close call in this area last week in which a trauma patient was almost intubated and had such an injury; likely would have been detrimental to the patient’s outcome to have been intubated AND bagged too forcefully.

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