# In-Line Nebulizers



## paradoxicalmotion (Dec 1, 2014)

Does anyone have any thoughts (or better yet, know of any peer-reviewed studies) re: in-line nebulizers being used with a BVM?

Long story short, a previous lead within the agency I work for thought that by simply throwing the t-shaped piece on the rigs would allow for in-line nebulizers with CPAP *and* BVM's. We're part of a much larger company, and changing what goes in our supply order can be a very time consuming project.

Our guidelines include terbutaline, mag sulfate, methylprednisolone and both IM and IV epinephrine for bronchospasm. That being said, are albuterol and ipratropium nebulized during PPV going to make a difference in the patient's clinical course?

Any thoughts (anecdotal or peer-reviewed) are appreciated.


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## gotbeerz001 (Dec 1, 2014)

The tee is not enough. You can build it with a standard neb kit (tee, snorkel, chamber) but you need the universal adapter for it to all attach together. These are never able to be found when required so I keep one on my scope.


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## paradoxicalmotion (Dec 1, 2014)

Yep, I know the part. The guy previously in charge never included it in the equipment on the rigs or in the master list of what our department can order through central supply. 

My question was whether or not its worth the month (and I kid you not, it WILL take a month) of me playing e-mail and phone tag to get the correct part added to the master list, especially given what else is available to our medics.


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## MonkeyArrow (Dec 1, 2014)

Well, what else is available to your medics?


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## paradoxicalmotion (Dec 1, 2014)

paradoxicalmotion said:


> Our guidelines include terbutaline, mag sulfate, methylprednisolone and both IM and IV epinephrine for bronchospasm.


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## NomadicMedic (Dec 2, 2014)

Our disposable Pulmodyne CPAP came packaged with an inline neb, with all the parts. We used it with almost every CPAP application.


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## Jason (Dec 2, 2014)

I can not quote you any study or data right off hand about the patient clinical course.
However, I do understand the difficulty you're dealing with, with equipment.  DEmedic is lucky, I have to "rig" or piece together an in-line set for nebs.  I have only maybe used in-line with BVM maybe twice - it worked.  Now with CPAP, I have done it a lot and wish I had the set up like DEmedic speaks of.  I have to piece it together from two HHN set ups to make it work on my CPAP set.  I do find it beneficial to be able to do in-line neb with CPAP.  I also find the hosp continuing the treatment after I drop the patient off.  
Best of Luck.


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## Shishkabob (Dec 2, 2014)

Our classic T-neb fits perfectly between the CPAP mask and CPAP tubing.  If using a BVM and they're sitting upright, same story.  If they're supine, the adapter is needed.  

I'm a fan of in-line, and my pulmonologist medical director is too.  Sure, it's anecdotal for me, but albuterol and atrovent can't do anything if it doesn't get down to the lower airways, and if that means I have to bag it in, so be it.


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## Tigger (Dec 2, 2014)

We order these now after "struggling" to make our own adapter kits. I've used them with a BVM and they make it easy. I suppose it would work with CPAP too, probably should try that out tomorrow.


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## ThadeusJ (Dec 3, 2014)

I would try and avoid using that blue tubing when using it in-line as it increases the deadspace of the device.  For CPAP application, the T-pce itself should fit between the mask and CPAP generator itself.  Normally these patients would be in a Fowler's Position so there isn't as much of a concern about the neb tipping.  You may have to use the tubing with a BVM just to keep the neb in the right position, but be aware that the tubing will cause re-breathing.  To fit directly on a ETT, you need a 15mm ID connector (the picture of the connector on the stethoscope above is a 15mm ID/22mm OD, which fits on almost anything).


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## Tigger (Dec 3, 2014)

I just mean the t, I figure the blue tube will cause the neb to tip over.


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## gotbeerz001 (Dec 3, 2014)

The T, the tube and the adapter are all required when bagging the pt in a supine position.

Order: BVM/Adapter/Neb/Tube/Mask... (if I recall correctly)


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## Av8or007 (Dec 17, 2014)

Why does no one  seem to use these:






MDI adapter that goes inline with any vent/CPAP/NIPPV/BVM. Plug MDI into the cap part and use like normal. Only 1 O2 source needed, and easy to switch MDI canisters out between atrovent and salbutamol (albuterol).


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## Tigger (Dec 17, 2014)

We do not carry MDIs for starters.


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## Av8or007 (Dec 17, 2014)

Why? Seems like very few places in the USA do.


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## Tigger (Dec 17, 2014)

Well we are going to have to carry the nebulizer treatments anyway. Not to mention that is far more difficult to properly dose the patient with an MDI. It is astounding how poor many people's MDI technique is despite using one for years.


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## MSDeltaFlt (Jan 15, 2015)

Those little thingies are happen to be called "15mm/15mm straight line adapters".  And they will fit dang near every single BvM made if not every single BVM made.  They're pretty much univrsal.  They'll fit BVM, CPAP, BiPAP, and vents.


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## ThadeusJ (Jan 15, 2015)

ISO standard EN 5356-1:2004 specifies the sizes for medical respiratory devices (most devices were placed under the anaesthesia group). This explains why everything we commonly use is 15 mm or 22 mm.  Its designed to prohibit people from assembling parts incorrectly but it can still happen.  

Here is the excerpt under Scope:

_1 Scope_

_This part of ISO 5356 specifies dimensional and gauging requirements for cones and sockets intended for_
_connecting anaesthetic and respiratory equipment, e.g. in breathing systems, anaesthetic-gas scavenging_
_systems and vaporizers._

_This part of ISO 5356 gives requirements for the following conical connectors:_

_8,5 mm size intended for use in paediatric breathing systems;_

_15 mm and 22 mm sizes intended for general use in breathing systems;_

_22 mm latching connectors (including performance requirements);_

_23 mm size intended for use with vaporizers, but not for use in breathing systems;_

_30 mm size intended for the connection of a breathing system to an anaesthetic gas scavenging system._

_This part of ISO 5356 does not specify the medical devices and accessories on which these connections are_
_to be provided._


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