NC or NRB when suction is needed?

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emt58

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Hi all, new EMT here with a question that I would like input. If a patient having foamy sputum constantly coming from mouth and spitting up would you still stick with a NRB when suction was frequently required? Suction was causing a gag reflex (patient was alert) and I didn't want to risk vomiting inside the NRB or more airway complications after slapping it back on so I kept a NC at flow rate of 6. Spo2 reading at constant mid 80's.
 
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If they're alert with a gag reflex, that usually suggests they can manage their own airway without you horking about with hoses. Were they on a board or something?
 
Brandon O said:
If they're alert with a gag reflex, that usually suggests they can manage their own airway without you horking about with hoses. Were they on a board or something?
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Well the odd thing is that she didn't want to spit it up willfully or when requested, also didn't want to open mouth on occasion. Horrible lung sounds and probably needed intubaton. Only when it was too much to handle would it discharge from the mouth.
 
Was there some psych stuff? Dementia patient? Or head trauma or something?

To answer your question, a cannula is obviously preferable if there's vomiting, but you do have to consider oxygenation as well. Were spontaneous respirations adequate? If so you'll definitely want to maximize FiO2, given that droopy sat.

If we ignore the matter of protocols and such, physiologically you may be able to cheat a bit by turning the flow on a cannula up to 15 or so. Hopefully nobody would give you grief if it's legitimately the only way to manage the airway. Remember that when possible, a lateral or upright position helps keep anyone's airway clear. And that for the most part, if they have a gag reflex, they're not likely to aspirate their secretions even if it gets a bit sloppy.
 
Depending on their mental status you can set up the suction and just give it to them and they can suction themselves. With that said it doesn't sound like this one would've been too keen on that.
 
Nasal cannulas will not transfer much more flow to the pt despite being increased beyond a certain lpm.

OP, how were chest sounds, pulse and BP? WHat were you thinking, was this likely cardiac, infective, allergic, or just psych (not swallowing nor spitting out saliva)?

Oxygen, good. Suction ought to be welded to the oxygen in most cases and this is one, but if the pt seems clinically oxygenated belay that and givr her something to drool into. Sit her up!!
 
If it was me, and obviously is wasn't and I don't have all information, I would give 15lpm via nasal cannula, provide suction PRN and if possible, blow by 02 if SPO2 remains low. A NRB does no one and good if she starts aspirating.
 
I would say I need a bit more context...as stated above, was the pt strapped t a board? If yes, then I agree, its' tricky. If not, try to have the pt maneuver to a better position and stick to the NRB.
 
mycrofft said:
Nasal cannulas will not transfer much more flow to the pt despite being increased beyond a certain lpm.

OP, how were chest sounds, pulse and BP? WHat were you thinking, was this likely cardiac, infective, allergic, or just psych (not swallowing nor spitting out saliva)?

Oxygen, good. Suction ought to be welded to the oxygen in most cases and this is one, but if the pt seems clinically oxygenated belay that and givr her something to drool into. Sit her up!!
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Wikipedia "Nasal cannula"

AND I QUOTE:

"A nasal cannula is generally used wherever small amounts of supplemental oxygen are required, without rigid control of respiration, such as in oxygen therapy. Most cannulas can only provide oxygen at low flow rates—up to 5 litres per minute (L/min)—delivering an oxygen concentration of 28–44%. Rates above 5 L/min can result in discomfort to the patient, drying of the nasal passages, and possibly nose bleeds (epistaxis). Also with flow rates above 6 L/min, the laminar flow becomes turbulent and the oxygen therapy being delivered is only as effective as delivering 5-6 L/min."
 
mycrofft said:
Wikipedia "Nasal cannula"

AND I QUOTE:

"A nasal cannula is generally used wherever small amounts of supplemental oxygen are required, without rigid control of respiration, such as in oxygen therapy. Most cannulas can only provide oxygen at low flow rates—up to 5 litres per minute (L/min)—delivering an oxygen concentration of 28–44%. Rates above 5 L/min can result in discomfort to the patient, drying of the nasal passages, and possibly nose bleeds (epistaxis). Also with flow rates above 6 L/min, the laminar flow becomes turbulent and the oxygen therapy being delivered is only as effective as delivering 5-6 L/min."
Click to expand...

This is what they make high-flow cannulas for (up to 15 L/min).

I once picked up an ICU pt going to a hospice house that was on a special 60 L/min cannula. The thing had huge blue prongs and required a special air pump (we switched her to a NRB for the transport, if I recall).
 
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mycrofft said:
'Also with flow rates above 6 L/min, the laminar flow becomes turbulent and the oxygen therapy being delivered is only as effective as delivering 5-6 L/min."
Click to expand...

I'm gonna have to pass on an uncited Wikipedia quote with typos in it. Do you have an evidence-based source for this one?
 
Underoath87 said:
This is what they make high-flow cannulas for (up to 15 L/min).

I once picked up an ICU pt going to a hospice house that was on a special 60 L/min cannula. The thing had huge blue prongs and required a special air pump (we switched her to a NRB for the transport, if I recall).
Click to expand...

Does something like that actually work? And, really, for what need would any patient have more than 100% O2?
 
chriscemt said:
Does something like that actually work? And, really, for what need would any patient have more than 100% O2?
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With high enough flow, it creates positive pressure (i.e. it can't leak out as fast as you're pushing it in). Essentially it's PEEP, just like if you used a CPAP.

And nasal cannulas don't provide 100% O2, although at that flow it's probably close.
 
chriscemt said:
Does something like that actually work? And, really, for what need would any patient have more than 100% O2?
Click to expand...

Can you have more than 100% o2?
 
Underoath87 said:
This is what they make high-flow cannulas for (up to 15 L/min).

I once picked up an ICU pt going to a hospice house that was on a special 60 L/min cannula. The thing had huge blue prongs and required a special air pump (we switched her to a NRB for the transport, if I recall).
Click to expand...

I have head of these also, don't they totally occlude the nares? Wonder if the gas hisses into the oropahrynx if you open your mouth with it on? (I've seen pictures of one which also has a small prong which extends over the lips! Never seen in person though).
 
Brandon O said:
I'm gonna have to pass on an uncited Wikipedia quote with typos in it. Do you have an evidence-based source for this one?
Click to expand...

I'm emailing Hudson (Teleflex) now.

The basic info for the run of the mill cannula jibes with what we were taught in nursing college and in my basic EMT class in 1977. The wikipedia article's citations are as follows:

" Nasal cannula patent (GB618570)
Jump up ^ Roca, O (2010). "High-flow oxygen therapy in acute respiratory failure". Respiratory Care 4 (55): 408–13. PMID 20406507.
Jump up ^ Hasani, A (2008). "Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis". Chronic Respiratory Disease 2 (5): 81–6. PMID 18539721.
Jump up ^ Sim, DA; Dean, P; Kinsella, J; Black, R; Carter, R; Hughes, M (September 2008). "Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated". Anaesthesia 63 (9): 938–40. doi:10.1111/j.1365-2044.2008.05536.x. PMID 18540928.
Jump up ^ Turnbull, B (2008). "High-flow humidified oxygen therapy used to alleviate respiratory distress". British Journal of Nursing (Mark Allen) 17 (19): 1226–30. PMID 18974691.
Jump up ^ Parke RL, McGuinness SP, Eccleston, ML. (March 2011). "A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients.". Respiratory Care 56 (3): 265–70. PMID 21255498.
Jump up ^ Tiruvoipati, Ravindranath; Lewis, David; Haji, Kavi; Botha, John (September 2009). "High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients". Journal of Critical Care (World Federation of Societies of Intensive and Critical Care Medicine) 25 (3): 463–8. doi:10.1016/j.jcrc.2009.06.050. PMID 19781896. "

I'll keep looking.
 
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Considering 15lpm via NC is now advocated for during periods of apnea during procedures such as intubation I don't agree with you, sorry boss.

NRBs only deliver high FiO2 with a good seal, which is extremely rare. Espe ially when idiots take the valves off of them. Let me see if I can find these two articles that aren't on wiki for you.
 
Another citationed Wikipedia article, this one on high flow therapy

http://en.wikipedia.org/wiki/High_Flow_Therapy

AND I QUOTE:*

" Nasal cannulae used for oxygen delivery usually deliver 1–6 liters of oxygen per minute. The FiO2 the percent oxygen inhaled by the patient, usually ranges roughly from 24% to 35% as the 100% O2 delivered from the cannula is diluted by ambient air (21% oxygen). Flow rates for delivery of oxygen using typical nasal cannula are limited because medical oxygen is anhydrous, and when delivered from a pressurized source the gas cools as it expands with the drop to atmospheric pressure. Delivery of cold dry gas is irritating to the respiratory mucosa, can cause drying and bleeding of the nasal mucosa, trigger bronchospasm in asthmatics, and can increase metabolic demand by cooling the body. Thus oxygen delivery by nasal cannula is limited to less than 6 liters per minute.[2]

Even with quiet breathing, the inspiratory flow rate at the nares of an adult usually exceeds 12 liters a minute, and can exceed 30 liters a minute for someone with mild respiratory distress. The typical upper limit of oxygen delivery via nasal cannula of six liters a minute does not meet the inspiratory flow rates of the average adult and therefore the oxygen is then diluted with room air during inspiration. Prior to the advent of High Flow Therapy (HFT), when high FiO2 was required for respiratory support special face masks or intubation was required. With HFT, the goal is to deliver a respiratory gas flow volume sufficient to meet or exceed the patient's inspiratory flow rate. The gas is heated and humidified to give comfortable delivery of the respiratory support….

HFT requires the use of nasal cannulae and a system designed to deliver high flow rates and the pressure generated to do so. At the same time the nasal cannula must be small enough that they do not occlude more than 50% of the nares, as this allows flow during exhalation and flush out of end-expiratory CO2 to be removed from the nasopharyngeal cavity. If the cannula did seal, the high flow volume could prevent the removal of end-expiratory CO2 and potentially produce excessive pressure in the airway which may result in barotrauma."
ENDQUOTE

Citations:
McGinley, B.; Halbower, A.; Schwartz, A. R.; Smith, P. L.; Patil, S. P.; Schneider, H. (2009). "Effect of a High-Flow Open Nasal Cannula System on Obstructive Sleep Apnea in Children". Pediatrics 124 (1): 179–188. doi:10.1542/peds.2008-2824. PMC 2885875. PMID 19564298.

Waugh, J. B.; Granger, W. M. (2004). "An evaluation of 2 new devices for nasal high-flow gas therapy". Respiratory care 49 (8): 902–906. PMID 15271229.

Roca, O.; Riera, J.; Torres, F.; Masclans, J. R. (2010). "High-flow oxygen therapy in acute respiratory failure". Respiratory care 55 (4): 408–413. PMID 20406507.

Waugh, J. B.; Granger, W. M. (2004). "An evaluation of 2 new devices for nasal high-flow gas therapy". Respiratory care 49 (8): 902–906. PMID 15271229.

McGinley, B. M.; Patil, S. P.; Kirkness, J. P.; Smith, P. L.; Schwartz, A. R.; Schneider, H. (2007). "A Nasal Cannula Can Be Used to Treat Obstructive Sleep Apnea". American Journal of Respiratory and Critical Care Medicine 176 (2): 194–200. doi:10.1164/rccm.200609-1336OC. PMC 1994212. PMID 17363769.

Shoemaker, M. T.; Pierce, M. R.; Yoder, B. A.; Digeronimo, R. J. (2007). "High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: A retrospective study". Journal of Perinatology 27 (2): 85–91. doi:10.1038/sj.jp.7211647. PMID 17262040.

Kubicka, Z. J.; Limauro, J.; Darnall, R. A. (2008). "Heated, Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver Continuous Positive Airway Pressure?". Pediatrics 121 (1): 82–88. doi:10.1542/peds.2007-0957. PMID 18166560.


*Wonder why I try to always include "AND I QUOTE"? I was told once here that simple quotation marks weren't enough. Just toeing the line. ;)
 
Did you read either the case studies or the study, with data, that I posted?

I'm thinking not.

I hate to say it man but you're being very stuck in the old ways right now.
 
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