o2 flowrate for Albuterol
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Shishkabob
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4-8lpm, with caution to the specific device you're using as some nebulizers simply will not stay connected at anything over 8lpm.
Smash
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Who cares how long it takes?
Use the flow rate for the device that optimises the production of particles of 5micrometer size. Low flow rates will produce droplets that are larger and they will be deposited in the upper airways. High flow rates will produce smaller particles that will be exhaled or hang around in the conducting airways without being deposited. Most commercial nebulisers that I am aware of are designed to work optimally with flow rates between 6-8l/m.
Better yet, unless there is a reason not to, use a metered dose inhaler.
Maybe one of the RTs on the board could explain it better or further.
Use the flow rate for the device that optimises the production of particles of 5micrometer size. Low flow rates will produce droplets that are larger and they will be deposited in the upper airways. High flow rates will produce smaller particles that will be exhaled or hang around in the conducting airways without being deposited. Most commercial nebulisers that I am aware of are designed to work optimally with flow rates between 6-8l/m.
Better yet, unless there is a reason not to, use a metered dose inhaler.
Maybe one of the RTs on the board could explain it better or further.
mycrofft
Still crazy but elsewhere
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True that,
mycrofft
Still crazy but elsewhere
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Sometimes the MD has a written order of duration and dose. Sometimes it will even work with the devices at hand.
ThadeusJ
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I'm an RT...the flow rate depends on the delivery device and most of the nebulizers suggest 6-8 Lpm. Note that there is a general limit to the volume to be administered as well. I have seen (far too many times) people giving a premixed vial of medication (i.e. saline is already in there), adding a second premixed medication with its saline and then adding yet more saline to create one whopping dose that will not only last forever but spill all over the place. As mentioned above, the key is to
generate the right particle size. If you overload the nebulizer, cranking it up isn't going to help the patient any.
My suggestion is to review the medication(s) you are giving (dose and packaging), read the P&P to make sure it doesn't conflict by suggesting that you add additional saline (written from the days of yore when you had multi-use bottles) and then see how it matches up with the equipment you are given to administer it/them. Then go with a MDI method...
generate the right particle size. If you overload the nebulizer, cranking it up isn't going to help the patient any.
My suggestion is to review the medication(s) you are giving (dose and packaging), read the P&P to make sure it doesn't conflict by suggesting that you add additional saline (written from the days of yore when you had multi-use bottles) and then see how it matches up with the equipment you are given to administer it/them. Then go with a MDI method...
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Our nebulizers are designed to run at 6 lpm with no more than 3.5cc of fluid in them.
6-8 LPM is what I've always been told, depending on the manufacturer's reccomendation for that specific device, like others have already said. If you're dead set on further increasing the FiO2 beyond what's being provided by the nebulizer you can always place a nasal cannula as well.
Always makes me giggle when we walk in and the FD has a neb setup and is flowing 15 LPM through it.
6-8 LPM is what I've always been told, depending on the manufacturer's reccomendation for that specific device, like others have already said. If you're dead set on further increasing the FiO2 beyond what's being provided by the nebulizer you can always place a nasal cannula as well.
Always makes me giggle when we walk in and the FD has a neb setup and is flowing 15 LPM through it.
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I'm not sure they'd continually be prescribed if they were inefficient at medication delivery.
I agree though about how they're used incorrectly the majority of the time. Often by patients who've been using them for years!
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I much prefer an mdi over nebs. With a chamber they are very effective. Most pts i have seen prefer them as they only have to take a few deep breaths and hold it ,vs having a neb on for a while that may not be effective if they are breathing shallow or sob.
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Anyone have a preference on hand held nebs vs nebs on a mask?
I tend to try and push my patients to let me put it on a mask for them since the majority of the time all they do is hold the neb and wave it around, spilling all the medication out of it, rather than breathing through it.
Obviously don't force them but unless they directly ask for the handheld nebulizer I just set it up on a mask and don't give them the option.
I tend to try and push my patients to let me put it on a mask for them since the majority of the time all they do is hold the neb and wave it around, spilling all the medication out of it, rather than breathing through it.
Obviously don't force them but unless they directly ask for the handheld nebulizer I just set it up on a mask and don't give them the option.
Christopher
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As an asthmatic of 23 years, I'll second the use of a Spacer if you're going to do an MDI. Using an MDI without a spacer takes literally years of practice, and even then...when you're hurting for O2 this is difficult to do.
Christopher
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I like the mask so I can put nasal EtCO2 under it (with 3-4 L/min of flow as well).
Also as an asthmatic I feel like I'm doing less work when I have a mask on.
ThadeusJ
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I'm a big supporter of MDI's over nebulizers and here's my reasoning behind it:
1) the medications are essentially "topical" in the sense that they have to reach the affected area in order to relieve symptoms and absorption into the bloodstream will bypass any therapeutic effect (although the patient will "feel" them working via increased heart rate, muscle twitching, etc);
2) in order to reach the affected airways, the particles must be as small as possible (but not too small that they will be exhaled);
3) the airways are designed to physically trap small particles such as airborne dust and bacteria that are traveling through the air (things we can't see with the naked eye);
4) the majority of the particles that are generated by a nebulizer are filtered out in the upper airway, absorbed by the mucosa and are not therapeutic and we can see them with the naked eye;
5) if you breathe them in at a fast rate, turbulent airflow increases the natural filtration of the airway and the inertia of the particles will not allow them to make all the bends in the airway (remember, there's no filter paper in the airways-think of a tornado and the centrifugal forces involved);
6) therefore, slow, deep breaths of small particles are the best way to administer inhaled particles in an efficacious manner;
7) MDI's are designed to administer small does of smaller particles only on inhalation;
8) spacers are used to capture the medication "like a cloud", to be inhaled like the only $100 cigar you are ever going to experience (slow, deep and held at end inspiration to let it marinate);
9) look at the doses you are administering: one puff of albuterol is a few um and you give, what, 2-4 puffs. The comparable dose of nebulized is 5-10 times that. Why is that?
10) yes, MDI's are misunderstood and people have died from not following orders. Most people don't take them properly. Always use a spacer (some brands even have a whistle that tells you that you have exceeded peak inspiratory flow and medication administration is becoming inefficient). Slow it down, take your time and concentrate on getting the dose to where it should be; to the bottom of the lungs. If you feel it hit the back of the throat, guess what, it ain't throat medication;
11) people often think that nebs are better because they feel relief at the end of the treatment. 20 minutes. It still takes 20 minutes to reach the peak effect for puffers since its the same medication. You just gave it all at once;
12) finally, some comic relief:
http://www.youtube.com/watch?v=dMAS2S51bM8
1) the medications are essentially "topical" in the sense that they have to reach the affected area in order to relieve symptoms and absorption into the bloodstream will bypass any therapeutic effect (although the patient will "feel" them working via increased heart rate, muscle twitching, etc);
2) in order to reach the affected airways, the particles must be as small as possible (but not too small that they will be exhaled);
3) the airways are designed to physically trap small particles such as airborne dust and bacteria that are traveling through the air (things we can't see with the naked eye);
4) the majority of the particles that are generated by a nebulizer are filtered out in the upper airway, absorbed by the mucosa and are not therapeutic and we can see them with the naked eye;
5) if you breathe them in at a fast rate, turbulent airflow increases the natural filtration of the airway and the inertia of the particles will not allow them to make all the bends in the airway (remember, there's no filter paper in the airways-think of a tornado and the centrifugal forces involved);
6) therefore, slow, deep breaths of small particles are the best way to administer inhaled particles in an efficacious manner;
7) MDI's are designed to administer small does of smaller particles only on inhalation;
8) spacers are used to capture the medication "like a cloud", to be inhaled like the only $100 cigar you are ever going to experience (slow, deep and held at end inspiration to let it marinate);
9) look at the doses you are administering: one puff of albuterol is a few um and you give, what, 2-4 puffs. The comparable dose of nebulized is 5-10 times that. Why is that?
10) yes, MDI's are misunderstood and people have died from not following orders. Most people don't take them properly. Always use a spacer (some brands even have a whistle that tells you that you have exceeded peak inspiratory flow and medication administration is becoming inefficient). Slow it down, take your time and concentrate on getting the dose to where it should be; to the bottom of the lungs. If you feel it hit the back of the throat, guess what, it ain't throat medication;
11) people often think that nebs are better because they feel relief at the end of the treatment. 20 minutes. It still takes 20 minutes to reach the peak effect for puffers since its the same medication. You just gave it all at once;
12) finally, some comic relief:
http://www.youtube.com/watch?v=dMAS2S51bM8
NomadicMedic
I know a guy who knows a guy.
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I always run a neb on a mask with an ETCO2 cannula underneath. I don't flow O2 to the cannula, I just use it to measure ETCO2. The only time I run nebs on a handheld T pipe is when they absolutely can't, will not, no freakin' way keep a mask on their face.
And I run 'em at 8. Way more than that if its inline with CPAP.
A good way to tell if they're working is to watch the expiratory plateau of the end tidal wave form. It's very nice to see the sharkfin of air trapping turn to an even co2 release.
And I run 'em at 8. Way more than that if its inline with CPAP.
A good way to tell if they're working is to watch the expiratory plateau of the end tidal wave form. It's very nice to see the sharkfin of air trapping turn to an even co2 release.
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ThadeusJ
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That is one excellent piece of advice, right there!
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We, unfortunately do not have sidestream ETCO2 :-/ Our FTOs and a few others are doing a trial of them. Haven't heard anything about them making their way onto all the trucks though... I heard there were a few problems with the brand they chose. Something about them reading too high at baseline. Not sure if they sorted it out, haven't heard much more about them.
Random excited green medic comment. I used CPAP for the first time with an inline neb for a COPDer. Worked like a charm! Probably one of the cooler things I've seen in the long time. People always said it was like a "light switch" and now I see what they were talking about!
NomadicMedic
I know a guy who knows a guy.
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I'd be checking up on the status of getting it on the trucks. It's the best indicator of effective ventilatory status we have in ems. In fact, our system has made the use of nasal prong end tidal measurement a requirement in several protocols. Any patient who receives pain management, respiratory, chest pain, any priority 1 (circling the drain), CPAP and any pre-RSI.
Of course we use it on every intubated patient as well.
If we get in the habit of using it, we don't have to think about getting the filter line set out. It becomes automatic.
We use the Oridian sets and have had no issues.
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It has been my experience that those really hurting struggle to use an MDI even with a spacer. Most of my athletes (I can do breathing treatments for sports medicine work but not on the ambulance) I work with know when they are not going to be able effectively use an MDI, so then we go ahead and give them a neb.
Usually it's handheld since we don't really stock masks and I usually either have to make one or use one "borrowed" from a standby unit.
ThadeusJ
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I would suggest that you try to use a spacer that has an attached mask or place a silicone connector onto the mouthpiece of a spacer so you can attach a cushion style BVM mask. People often say that they can't use a puffer because they can't inhale...which makes me wonder how the nebulized meds make it down...
By the way, they make spacers for horses since they are prone to exercise induced asthma.
By the way, they make spacers for horses since they are prone to exercise induced asthma.