Need For Definitive Care

[CAOX3]

I'll throw a monkey wrench into it. How about a Venturi mask? I am sure most were never shown or taught these as well. Personally, I found them much tolerable for COPD patients as well as having the ability to know what percentage I am administering. R/r 911

Yeah we used to carry them, they came in very handy. They have gone away. Could it be a cost issue?

 

[medic417]

I'll throw a monkey wrench into it. How about a Venturi mask? I am sure most were never shown or taught these as well. Personally, I found them much tolerable for COPD patients as well as having the ability to know what percentage I am administering.

Vent I have not seen them used in years in both settings. Was there a problem with them, that I was not aware of or they fell out of favor due to newer devices?

In regards to not being taught "15 lpm NRBM"; I don't think its about being lazy. Rather the emphasis is if you want your student to pass the written/practical they better answer such. Again, the reason is because the lack of education the EMT recieves and is perceived it is much better to see the patient with oxygen than without. As I had seen many patients arrive with oxygen per NRBM re-breathing their own Co2.

The other reason is much more simpler. It is doubtful many of the EMT instructors know much better themselves. As it does not require much to become one; other than an 39 hour instructor course and maybe experience requirements.

R/r 911

Still around. For those that have not seen them or used them here is a picture. http://img1.tradeget.com/sudarsurgicals\CM8Q0D6M1product3.jpg

I agree as EMS has been dumbed down and is being dumbed down further by some organizations many procedures that could benefit patients are being ignored.

 

[medic417]

Here is a description from that unreliable wiki.

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

 

[CAOX3]

When I finally learned the color correlation to the percentage of O2 they were gone.

 

[medic417]

When I finally learned the color correlation to the percentage of O2 they were gone.

Why gone? They are still out there. Used one a couple of weeks ago.

http://www.sudarsurgicals.com/F18971/venturi_mask_kit.html

http://www.resto-medical.com/Venturi-mask-97.html

 

[Sasha]

My old service still carried them for trache patients.

 

[CAOX3]

Why gone? They are still out there. Used one a couple of weeks ago.QUOTE]

I dont know why we dont carry them any longer. They were great.

Lets see if I remember the colors

Blue=24%
yellow=28%
white=31%
green=35%
orange=45%
pink=50%

 

[ffemt8978]

Wow surely you joke. Even as a first responder many many years ago I could place on O2 based on need rather than a set amount.

Nope, it was written in our protocols that basics could only give 15lpm O2 via NRB. Intermediates and above could titrate O2 to maintain pulse ox greater than 90%.

 

[medic417]

Nope, it was written in our protocols that basics could only give 15lpm O2 via NRB. Intermediates and above could titrate O2 to maintain pulse ox greater than 90%.

That is scary that the medical director would not be willing to require that the basics be educated to a point that they felt they could allow better use of O2 therapy.

Hopefully that will not be an issue in the near future as education reform takes place nationwide.

 

[VentMedic]

i have a question. it seems like regardless what i do, it seems wrong. i've came across a COPD pt with diff breathing(according to the NH). They are on 2LPM O2 via NC with sat's at 86 and RR at about 26/min. now here is where i have a problem. do you leave them on the canula at 2LPM, or do you put them on a NRB and up the flow. i've txp with the canula and when we got to the er they put them on NRB and i've txp after putting them on NRB and got to the er where they put them back on canula. granted i do know that high flow O2 is bad for COPDer's but my understanding was that if it was bad only if you had them on high flow for an extended period of time.

As stated, do not withhold oxygen.

There are many types of COPD patients and less than 5% within this classification are CO2 retainers. Long term COPD patients will almost always have some type of cardiovascular problems which must also be treated by O2 because their potential is more deadly than a person becoming somnolent. You are trained in the use of a BVM for those that do become somnolent or have depressed respirations and it may not be because of the FiO2 you are giving.

That NC can also go up to 6 L/m.

If your instructors would take time to explain how minute volume influences FiO2, it would make things clearer.

If a patient is accustomed to breathing at a minute volume of 6 L/m on a NC at 2 L/m and then their minute volume become 12 L/m, the NC may have to be increased to maintain the same FiO2. The textbook values for FiO2 at the different liter flows are for a normal patient breathing a textbook normal minute ventilation at rest without distress. The patient may not need that much more O2 but just enough to keep their inspired FiO2 within a good range.

For a person with a greatly increased minute volume or each tidal volume, that 2 L of O2 with be diluted to almost 21% or room air.

If you put that same 2 liters or even 1 liter on a baby by NC, you may be meeting their entire minute volume and are delivering almost 100% O2. That is why blenders mixing air and O2 are used for them when they way NCs. If the blender is set at 28%, a 1 liter NC can give a small baby close to 28% with little dilution from the room air.

A litte side note, for a patient to qualify for home O2 by insurance standards, including Medicare, we have to document an SpO2 of less than 86% or a PaO2 of 55 mmHg. However, that does not mean they should stay at that level which is the reason for the home O2. Many complications occur if their body stays at a very low PaO2 for any length of time. Some are sensitive very quickly if their PaO2 drops for any length of time if they also have cardiovascular problems.

If you get involved in IFTs of almost any type, you should become familiar with the different classifications of O2 equipment. A "true" high flow device may not always deliver a high FiO2.
A venturi mask is a high flow device even if it is running at what EMS providers believe to be low flow. This is because venturi masks are able to provide total inspiratory flow at a specified FIO2. A NRBM cannot always do that and is considered a low flow mask.

The amount of oxygen going into the O2 device does not necessarily mean it is a high flow or even low flow device. The device must be able to provide the total inspiratory flow. Thus, devices are classified whether they meet the true definition of flow and by their FiO2 delivery. However, air entrainment systems may have their limitations at some point.

Study how you O2 device works and you won't have to rely on memorizing a recipe for each situation. Learn gas laws, oxyhemoglobin dissociation curve, venturi effect and bernoulli's principle.

Here's some good reading:
http://www.dmacc.cc.ia.us/instructors/kegeorge/prac5/Oxygen.htm

http://www.salisbury.edu/healthsci/resp/classes/lrjoyner/fall/RESP301/O2Tx.htm
This is the explanation the medicine world is leaning toward for an explaination for increased PaCO2 in a COPD patient.

High levels of O2 may disrupt the normal V/Q balance, causing an increase in the VD/VT ratio and a rise in paco2.

AARC O2 guidelines for Peds and infants
http://www.rcjournal.com/cpgs/soddnppcpg-update.html

AARC - adults
http://www.rcjournal.com/cpgs/otachcpg-update.html

AARC - Homecare or Nursing homes and LTC facilities
http://www.rcjournal.com/cpgs/pdf/08.07.1063.pdf

Hypoxic Drive theory disputed for other causes
http://www.rcsw.org/Download/2004_RCSW_conf/The death of the hypoxic drive.ppt

Hypoxic drive references for those that might want more reading on the subject.
http://www.rcsw.org/Download/2004_RCSW_conf/The death of the hypoxic drive studies cited in.doc

One also must understand the relationship between ventilation and perfusion to provide effective O2 therapy.

Good Basic powerpoint:
http://www.clt.astate.edu/agrippo/RESPIRATORY DISEASESf03.ppt


http://www.cardionursing.com/pdfs/Ventilation-Perfusion-Diffussion-and-More.pdf

http://www.uams.edu/m2008/notes/phys/pdf/March 22 Ventilation Perfusion Relations.pdf


For those of you who want a more advanced approach to ABGs or acid base analysis:
http://www.rcsw.org/Download/2006_RCSW_conf/Presentation 2006 RCSW Acid Base Analysis.ppt

Medicine is constantly evolving with new research published everyday. There may be not just one correct answer for every problem. However, if you don't understand the basic fundamentals or principles for any device or therapy, you will just be following a recipe.

 

[VentMedic]

My old service still carried them for trache patients.

Venturi Masks are considered high flow devices. That little colored piece of plastic mask is the same device used on their hospital aerosol bottle which uses the venturi principle for air entrainment as well as providing a high flow. If you were to just put a NRBM or Simple mask over the trach, you would be restricting their inspiratory flow since these devices can not provide a high flow to meet the patient's demands.

The same principle used with all those pretty little colored venturi devices is found in many devices used for respiratory therapy.

 

[VentMedic]

How often do you have a patient that actually requires high flow oxygen as oppose to a cannula at 2lpm? Is that something they'd continue after discharge from the hospital?

High Flow Nasal cannulas are now used very frequently. The work great in neonatal with flows up to 8 liters and can be better tolerated than some other devices.

For adults, we prefer them to masks since the patient can feel less confined and with the HiFlow NC it is easier to achieve an adequate FiO2 and still meet the patient's total inspiratory requirement.

The pt can also drink and eat with these HiFlow NC. Some patients' lungs have deteriorated to the point where their FiO2 requirements are very high.

We may also use these devices in comfort care for the patient who is alert and still wants some quality time talking with their family.

 

[medic417]

High Flow Nasal cannulas are now used very frequently. The work great in neonatal with flows up to 8 liters and can be better tolerated than some other devices.

For adults, we prefer them to masks since the patient can feel less confined and with the HiFlow NC it is easier to achieve an adequate FiO2 and still meet the patient's total inspiratory requirement.

The pt can also drink and eat with these HiFlow NC. Some patients' lungs have deteriorated to the point where their FiO2 requirements are very high.

We may also use these devices in comfort care for the patient who is alert and still wants some quality time talking with their family.

So in the field would it be easy to identify that the patient is on HiFlow NC rather than the 2LPM or less that many are on? I have seen what you describe at the hospital but am not aware of seeing one in the home before.

 

[VentMedic]

So in the field would it be easy to identify that the patient is on HiFlow NC rather than the 2LPM or less that many are on? I have seen what you describe at the hospital but am not aware of seeing one in the home before.

At this time HiFlow NC are not common yet in homecare since they have a high O2 consumption and require a 50 psi outlet. However, some LTC facilities may use them. It may look like an IV pump attached to a nasal cannula. Some models may look like a large heated humidifier on an IV pole. Some have blenders either internal or external to adjust the FiO2.

Vapotherm is one example.
http://www.vtherm.com/products/precision/default.asp

Good article on high flow O2 therapy and cost effective concerns.

For hurricane season we also make sure a supply of oxgen conserving nasal cannulas are available.

Example:
Oxymizer
http://www.mhoxygen.com/images/Oxymizer.pdf