VentMedic

That is the more accurate definition. Outside of the hospital setting, people rarely think about the special needs of 24 week preemies. 37 weeks is considered term. Different protocols may be used for several weeks/months until they become "infants".

You did what you could without causing further complications. Pulmonary fibrosis is an aveolar wall inflammation causing the lungs to become fibrotic. The cause can be organic or inorganic. Lung volumes and diffusing capacities are periodically checked in a pulmonary function lab if on certain meds; bleomycin, cyclophosphamide, methotrexate and amiodarone. Endstage CXRs will look like a honeycomb. Lungs will become stiff as lung compliance is lost. Overall lung volumes will decrease. The ability to diffuse oxygen is reduced thus ventilation-perfusion mismatching. Lungs may sound clear. Air will move through the airways but will be unable to diffuse into the blood stream due to the aveolar damage. This will lead to hypoxemia at rest with little relief from outside therapies eventually. If I ever reached end stage with a breathing disorder; high flow nasal cannula (Vapotherm) so I can have my martini with some vodka on the side to nebulize if pulmonary edema happens and nebulized morphine with matching IV doses. cheers

MPH is an excellent choice. However, not all MPH programs are created equal. Some are "generic" and are completed with ease but carry little weight in rewarding work. Programs like UC Berkeley are difficult to get into but offer a great foundation for future employment potential and not just letters behind your name. It's like the Harvard education for law.

CPAP would have delayed definitive treatment and could have further depressed her BP. You still had good SpO2 with relatively low FiO2 although her Hb may have been very low giving you a skewed view of oxygenation. 5 L NC is still low O2. Placing the pt on a high flow mask would have given you more Fi02. Remember when a pt is breathing rapid or moving large volumes per minute they are entraining more RA at 21% and diluting the amount of oxygen actually taken in. You think you're giving about 35% by NC when actually it might be 24% that is actually being inspired. An IV should be present in case of BP problems...more time. Also, what type pressors or fluids will be needed to maintain adequate BP. I have seen CPAP at 5 cm H2O totally bottom a BP on a compromised pt. Also, you might check with your medical director for a clarification for starting CPAP on a DNR. A pt in a nursing home may also have comfort care orders along with that DNR...different but similar to hospice. Once breathing technology is started, ER docs usually don't want to remove it. Then, it can become an ethical issue in some hospitals. A trial of higher concentration of O2 will be done in the hospital while fluids and steroids are given along with a trial of bronchodilators if they have a mixed component lung condition. Hospitals also have high flow NCs that can go up to 25 - 40 l/m to offset the dyspnea while providing a more comfortable alternative. If the patient is comfortable on that, they can express their wishes for more technology like CPAP or future therapy. If the pt goes to the med surg floors, CPAP used in hospitals may not be able to go with them. JCAHO standards require certain levels of monitoring unless it is a home CPAP machine. If the pt requires more O2 than prescribed for their home unit, they go on the hospital's machine and on to a monitored unit. Of course, DNR does not mean do not treat. If the immediate condition is reversible and warrants it, CPAP/BIPAP will be used and the pt will be placed in ICU or a monitored step-down unit. If the pt is end stage; CPAP is a hard way to go. They will have limited communication and will be NPO. The mask is hot and tight which will cause breakdown and skin tears, esp on a PF pt who has probably done a lot of steroids. In the ER or ICU they may be tied down to keep them from pulling off the mask once it is decided to keep the CPAP on. There are also about 200 known diseases including some medications that lead to Pulomonary Fibrosis.

It uusually only takes one memo or phone call from your medical director to quiet down another doctor protesting a protocol that your medical director has his name on. If this doc has a problem with this, your MD will probably tell him to petition the Medical Board of Standards (or Review) for his area to attempt to change things. Your medical director is the one backing you up. EMTs and EMT-Ps will not win in arguments with doctors. The ER doc also works with a Medical Director who establishes P&P. He should already be aware of the chain of command prior to making a statement like that. He can express his knowledge from different research being done and be open to discussion. For every paper pro you can find 2 con and vice versa depending on how you word your search. A couple papers published usually do not make great changes in the medical field. New equipment may be trialed for a min. of 5 years before going into general use. The ER doc has the advantage of more diagnostic tools and time to exam the patient. What may present straight forward as one problem may actually have another problem that caused or exacerbated the other. In the hospital setting, you'll literally have hundreds of doctors expressing their thoughts on how things should be including oxygen protocols. If it is reasonable, their request/order is followed. If they do not want to listen to why their request can not be followed or if it deviates from the P&P(which they will get a copy of) too much, they get a call from our medical director. Usually a compromise is quickly reached. Most doctors will comply to hospital P&Ps for they do not want to be the subject of review by their peers.

OzMedic, This is one that is much better at a personal sense than "read about" to be fully appreciated. You can try on yourself or someone near you. Medical interns or aspiring medics are my favorite choices. :wink: 2 nasal tubes - each should be able to pass at least a #14 fr suction catheter for adequate air flow with least resistance in an adult. After the nasal tubes are in, see if you can pass the 14 fr sx cathether through each without difficulty. No lubication. That's cheating. If you have very big nares...it may work. However many people have deviated septums or swollen turbinates. The turbinates may also need some neosynephrine to dilate the passages enough to pass the tubes without causing damage. You can also see if the PFT lab at your hospital will do a nasal resistance test on you with the 2 tubes. If your hospital does alot of rhinoplasty or facial trauma reconstruction, they may do still do the test. We did alot of NRTs in the 80s when rhinoplasty was vogue...to get insurance to pay for the nose job. The new software on our Medgraphics PFT machines is still setup for it, but it's not that popular now (and nobody can remember the CPT code). You can also simulate the lab with a tube attached to a manometer. Place the tube snugly into one nare, occlude the other nare. You can also see how much air can be passed though the nare with a device that measures volume like a Wright's spirometer. The advantage of the PFT software; it would do the resistance calculations for you. We run into the 2 different tubes up the nose in the hospital frequently. I'll get a tube in that I can easily sx through and a nurse will drop an NGT. There goes my 14 fr cathether access. I may have to go all the way down to a 10 fr which defeats the task secretion removal in an adult. Of course, it doesn't have to be a nasal trumpet. We will change a nasal ETT quickly if we meet any resistance when passing a suction catheter. Nasal ETTs are usually changed out quickly anyway in alot of hospitals with various Vent Assoc. PNA protocols. Every nare is a little different. There are some adults that I can not pass a #8 catheter through either nare no matter how much we try to dilate them. A lot of bronchoscopies have to be done orally due to limitations of the nares. Then there are some nares that could hold a bus in each side. And of course there are those that have little or no septum for various reasons. I do have my students and med interns put nasal trumpets into each other' nares. I haven't asked them to do two at the same time. Usually one is enough to get the idea. Also, I don't want to be sued if they damaged each other. What experiences 30 years of paramedicine and with a sputum specialty will give! I also think the polysomnographers/sleep medicine are big into nasal resistance when they are determining if a patient can use different naal devices for sleep. Their equipment has evolved in a big way. My OLD textbooks discussed nasal resistance in great detail. Two books come to mind, Shapiro and Burton,early editions. I may still have these around somewhere to quote for you later. But until then, give the above things a try and get back to me. Have a great evening!

Definitely agree that BLS is often forgotten even in the hospital setting. Sorry to disagree about the 2 nasal airways. This you can prove on yourself. Putting 2 nasal airways into the nares was big in the 70s and early 80s. Through pulmonary testing for nasal resistance it was found that the resistance for both tubes can increase by 4 - 8x. Thus, instead of very patent nasal airways, you had two partially occluded airways. The same can be demonstrated with a lg NG tube and nasal airway with attempts to sx through the nasal airway. Small nares may have significantly increased resistance. We do occasionally use 1 nasal and an oral to pre oxygenate/ventilate in the hospital setting for intubation. Besides the OR, your company can always see if your local Medical University will give you some cadaver time. If you can tube a stiff cadaver a few times... We will sometimes chalk the teeth of the cadaver to check technique. There are a couple programs in Florida that do this routinely just for their yearly check offs. Of course, there are the doctors that will pull the curtain and let you get a few passes after the "code is called" if you express an interest provided it is not an ME case. How involved are your medical directors? How much involvement do they have in seeing that your intubation skills are up to par? I do know a few EMT-Ps that do inter-facility transports that have not intubated in 5 years (since paramedic school) and yet they are considered ALS. It is just assumed that since they are a paramedic they'll be able to intubate if needed. The medical director of that company seems to be fine with that. The medical directors in the hospitals are not so happy wilth it.

Excellent book... Dale Dubin's past didn't hurt his book sales through the years.

Build it and they will come. Even with the 30 minute wait, our ER was swamped with people both with and without insurance that did not want to wait in a doctor's office. Instant gratification. People also thought a doctor would be there to greet them upon their entrance. The doctor usually didn't appear until much later when the labs/xrays results started to come back. Then our business office took a flood of complaints...like the pizza; 30 minutes or its free. Our hospital did offer to make the ER registration fee free...about $100- $200 dollars. The other $2000 is all yours. Now we don't advertise. But, we do have a "fast track" route for readily identifible in and out things;...the triage nurse can get labs and xrays started if needed. STAT protocols should already be in place in many ERs for the more serious issues to get things rolling.

Ridryder 911 Are your professors tenured or on track for tenure? If they are adjunct, they are probably paid at a semester or quarter hour rate which translates to hourly. That would be not much in yearly income if only teaching a couple of classes. Try Oklahoma State; non-tenured nursing prof start at $45k. I understand this is on par with what a nurse makes in the hospital working 3 -12 hr shifts/wk. In Florida, the start at $60k which is on track with was a Florida nurse would make at 3 - 12 hr shifts per wk - no OT. California; $80k - $100k easily. The only way I could match what I make now and with good benefits if I worked fulltime in EMS: I would have to work at a high paying Fire Department EMS like San Francisco and pick up every OT shift available. And I live and work in the South..... You put it nicely earlier where instructors do not know how to teach. I believe for credibility, the B.S. should be in your field with experience. The Masters should be in in your field and/or education. Again we have plenty of nursing MSN applicants for teaching positions at the university, we just don't have instructors applying. Nurses want teaching positions because; the hours are great, no night shift, not being yelled at everyday by pts, doctors, administration, burned out of pt care, politices are too much, JCAHO rules are making it difficult to perform simple tasks for the pt, paperwork (again JCAHO mandates) etc. A lot of nurses would like to get out of the hospital. Yes the money is great at the clinical level and the 3 days/week are nice...but. Explore the different tenure tracks at the University level if you really want to teach. Teaching in a university system can be a nice and comfy job with perks. Yeah, I'm pro education. Over 30 years, I've watched every allied health profession advance to a respected level recognized by State and National policy makers..... except EMS. There are always choices and a good role model can make a difference.

To teach Respiratory Therapy students (a third of them are Paramedics), I needed a minimum of a M.S. A couple of months ago (about the time I started checking out this forum) I was asked to substitute for a Paramedic instructor who was on medical leave. The administrators of that school did not know of my other educational affliliations. I was recommended by the Paramedic on leave. The only things required were my current EMT-P license and some ambulance experience. There wasn't but one space on the education part of the application. Our university actually has no shortage of BSN and MSNs applying for teaching positions. We have a shortage of qualified BSN, MSNs applying. Not everyone can teach.

In most cases, the RNs wage is dependent on the geographical region where the RN works and not necessarily the education level. The percentage of BSN degrees is relatively low on a national average. Two years will do just fine to get you a well paying job. Many jobs in the South are in the $25 range. Naples, FL http://www.nchhcs.org/default.aspx?id=547&link=navmenu However, in the Northeast and Northern Caliornia, $38 is below nursing minimum wage. New grad RN (with 2 yr degree and in some States, the "mail order" program) start at $40 benefited. PRN is $55 to $75 and that may include housing if you are a traveler. California is also one State where there is an established nurse/pt ratio. I can only speak for a couple of States in the South where the nurses have a heavy load for half the money. In CA and the Northeast, powerful nursing unions and unity..... San Francisco http://ucsfhr.ucsf.edu/careers/ go to salary ranges or http://ucsfhr.ucsf.edu/apps/tpp/searchresults.php You could also check the starting pay scale for San Francisco FD. Not too shabby. Of course housing prices in SF are untouchable by most. However, the cost of living in Florida isn't that great now with rising home prices due to material/construction costs, insurance (homeowners and car), and utilities. For EMTs and medics; In the 30 years I've been involved in EMS, very little strides have been made in entry level education in the US. Very little has been done with unity...no reliable State or National organizations to go to bat for EMTs. A few have come and gone through the years, but the egos or "lack of interest" have disrupted any chance of establishing a solid foundation in this profession. Other allied health professions have rallied for their cause. OT, PT, Radiology, RT etc. These groups keep lobbyists in Washingon DC to fight for insurance re-embursement and inclusion in any national policy that might affect them. Here's another thought; how about raising the entry level of EMT-B to the number of hours (1040) required of the EMT-P? And, model our EMT-P program after our Canadian neighbors with a couple more years of training at entry. Thus we could eliminate the "12 week medic" programs that can give the profession a black eye in the long run. Just a thought....

In regards to PFC or liquid ventilation; More than 470 adult, pediatric and neonatal patients have undergone PLV with Alliance's liquid ventilation agent, LiquiVent®, a pharmaceutical-grade PFC. Under normal conditions, LiquiVent can dissolve and carry approximately 20 times more O2 and three times more CO2 than saline, according to the company. Liquid ventilation is delivered by one of two techniques. Total liquid ventilation (TLV) fills the lungs with PFC to a volume equivalent to the functional residual capacity, approximately 30 mL/kg, according to the University of Michigan information. An experimental "liquid ventilator" then generates tidal breathing with PFC. Optimal CO2 clearance occurs when TLV is performed at a rate of four to five breaths/minute. Researchers consider TLV the extreme end of the LV spectrum and have never tried it in humans. The other technique is partial liquid ventilation (PLV), in which the clinician performs gas ventilation of the PFC-filled lungs using a standard ventilator. This was considered a breakthrough when introduced in 1991. While TLV, theoretically, may hold more promise in certain lung disorders, PLV has the edge in practicality. With TLV, its level of complexity would probably relegate it only to tertiary care centers. The advantage to partial is that it utilizes a ventilator technology every hospital not only already owns but can make work. Secondly, TLV's regulatory pathway has now doubled in complexity. You need FDA regulatory approval not only for the drug but the machines. That's a nightmare squared. Ongoing Trials More than 470 adult, pediatric and neonatal patients have undergone PLV with Alliance's liquid ventilation agent, LiquiVent®, a pharmaceutical-grade PFC. Under normal conditions, LiquiVent can dissolve and carry approximately 20 times more O2 and three times more CO2 than saline, according to the company. http://www.allp.com/LiquiVent/lv.htm http://www.allp.com/LiquiVent/LV_SUMM.HTM The above data compiled from various Respiratory Therapy Sources. My own experience with liquid ventilation was on neonates. Our adult ICU was also doing the trial on ARDs pts. Very good outcomes in both areas with neonatal leading.

You just answered your own question hyperventilation "syndrome". The actual determination of hyperventilation is confirmed by blood gases unless the pt just goes back to normal RR, mentation and emotion. You can have all of those symptoms, blowing off CO2 in an effort to maintain acid/base or oxygenation. Although rare, A leftward shift in the HbO2 dissociation curve and vasospasm related to low pCO2 may cause myocardial ischemia in patients with coronary artery disease. Arguments strong enough to provoke those symptoms have lead to serious coronary events. The blowing of of CO2 has a cause; emotional or physical. They will still get a full work up in the hospital even if it reveals nothing physically. Hyperventilation Syndrome (HVS) as in behavioral breathlessness or psychogenic dyspnea should be more accurately determined in a controlled environment because their needs are not likely going to be met in the prehospital environment. HVS can be either acute or chronic each with different physiological/psychological patterns. For pre-hospital; Physical assessment, meet their immediate needs and let M.D.s and Ph.D.s do their magic on this this type of pt. Of course, you may have to obey your preceptor now. Later, you'll get a good feel for "there could be more". Stereotyping people with those symptoms would be hard to defend in court. If you can't sleep, try this article; http://thorax.bmj.com/cgi/reprint/52/suppl_3/S30.pdf

Why are they "hyperventilating"? Hyperventilation can only be confirmed by blood gas analysis to see if the CO2 is low or lower than their norm. Pt with rapid respiratory rates can have an acidosis; respiratory or metabolic as in sepsis or DKA. Pulmonary emboli, pneumonia, bronchitis and head trauma (not always visible) may also present with tachypnea. Now, what would you do with any of the above mentioned situations? Emotional hysteria; you might be able to do something even if it is just oxygen in attempts to calm until more definitive treatment/needs can be met. You can always take oxygen off, but you can not put oxygen starved cells back.

Back at ya OzMedic. Excellent points in your post. I too agree there is a place for pulse oximetry. However, all I need is the pt to say "I am having trouble breathing." The pulse ox is nice but may not present the whole picture. I will start some type of treatment; O2, nebs, MDIs, whatever based on what the pt is saying, how they look and sound before messing around with a "sat". I will also make plans to intubate long before I see the SpO2 drops by their presentation. Also, SpO2 of 78% doesn't always mean a tube. If they are still talking in decent sentences...I'll try my best to keep them from the tube. Of course, I don't want the heart or head to take a hit either...the whole pt. People also over analyze the COPD thing. CO2 retainers make up a very small portion of that population. A little wager among the RTs and Medics in the ER is betting on the blood gas CO2. Rarely is their normal CO2 elevated enough to be classified as a retainer. For the COPD pt in exacerbation we use Winter's Formula; (1.5 x HCO3) + 8 to find the normal CO2 for the pt. This helps if we put them on a vent. We are careful not to get below their HCO3 compensated normal on the CO2. If we do take them down too low, the body dumps the HCO3 and we are stuck with a pt on a vent that should have been an easy wean. You've heard of the pt "failing" extubation? Many times their pre-extubation ABG is 7.40/40/80/22 instead of 7.35/60/60/35. The ET tube is pulled and the lungs put the CO2 back to 60 and the HCO3 is too low to compensate, thus pH 7.2. Also, I have actually had CO2 retainers tell me that they don't believe in the hypoxic drive dangers. Why? If it was that easy to knock out their drive; perfect for suicide or insurance collection by a loved one. In the hospital, the COPDer's do their own oxygen therapy when nobody is around. I scold them just because I have to chart something decent to get them discharged. 6L instead of 2L doesn't cut. But, if that's what they really need...so be it. We rework the home care plan. You also made a point about US medic programs. I agree there also. There are a lot of "diploma mills" still existing in the profession. It is still taught with a certificate design. The degree is an option but under utilized. For the medics to gain professional status and pay, the majority has to get on board and raise their entry level standards for EMT-P. College level A&P should be a requirement at the very least. I've seen State and National organizations come and go. I got my A.S. degree in EMS way back in 1979. We were encouraged to because that was the future so it be told. Luckily it prepared me for further education when my home State was slow to recognize the profession. Respiratory Therapy started getting recognized in the 80s. Now, the entry level is A.S. with B.S. preferred in many areas. The diploma mills had to go to gain credibility and pay. North Carolina licensure clearly spells out what an RRT can do outside the hospital. Of course, not to replace EMT-Ps (not enough RTs), but to make their education and experience known. http://www.ncrcb.org/Declaratory%20Ruling%...d%2010-7-04.pdf Also, back to SpO2, a good medical emergency(and deadly) situation has presented itself in Key West, Florida at a hotel. CO poisoning. All the symptoms of CO poisoning presented by the pts...but Key West? No furnaces. The boiler was later faulted. http://www.keynoter.com/articles/2007/01/05/news/news09.txt

I am very tough on my students when they try to give me numbers from technology before "What the pt looks like and what iis he/she is telling you?" COPDs that are still smoking will have a COHb of 6 - 12%. Thus if the SpO2 is 95%, O2 is not readily given even though the actual SaO2 is 83-89% and pt is short of breath. "They can't be short of breath...their SpO2 is 99%!" If they smell of smoke..yes they can, even with second hand smoke. Some signigicant others will have close to the same COHb if one is always smoking close by. Patients on nitrates carry a higher MetHb, again presenting a higher SpO2. And, the anemic pt who's SpO2 is 100% but their Hb is 6. Do you know what their O2 carrying capacity is?? I can only hope all Hb stay well saturated until definitive treatment. Yes, so one bleeding out may have an SpO2 of 100%, their Hb is laying on the ground. Would you "titrate" the oxygen on this patient? The pts with higher MetHb and COHb will also not look "blue". Their Hb is still saturated although not with O2. Even regular blood gases will not give you the accurate picture until cooximetry is done (hopefully with the blood gas but is not always ordered in the ER). Then again there are other factors determining the Hb's affinity for the oxygen. But that is a whole different matter in itself that ICUs have to worry about daily on some patients. COPD pts who are air-trapped, low on Hb and high on COHb can be very hard to "titrate by SpO2". If an EMT or Paramedic can not readily identify "shortness of breath, trauma", then ..... Even in the hospital setting we do not rely on SpO2 solely. Perfusion, medication, lighting, smoking, temperature...just to name a few can skew the readings. Do you know how much of a laugh the ER/ICU staff gets watching an EMT or EMT-P totally focused on "getting a sat" on someone who hasn't had good perfusion below the elbows in 20 years..."it was a 100% a minute ago" as they're coding the patient. Of course this doesn't just happen in EMS, hospital workers get caught in their technology and forget to "assess" the pt. The pulse ox can be the last sign to deteriorate on an air-trapped asthmatic. The trapped air will actually give a "PEEP" effect for a short time thus increasing oxygenation slightly. This is also what gives the BP some instability in asthmatics. Many asthmatics will actually desat for a period when they start to open up. Only by "looking" at the pt will you know if they've turned the corner for improvement OR have reached the "last sign to deteriorate" part. The hospital/ambulance lights, muscle tremors, bed vibration on pneumatic beds, blood, dirt, metalic flecked nail polish (good pleth but is it counting the metalic flecks?)...all could can give a false reading. I can always take the oxygen off...I can't replace oxygen starved cells in the brain. Thus, the number on the pulse ox can mean very little by itself. Goals are good EMERGENCY CARE and to to save yourself from being a topic of laughter in the ER.

Sorry for not stating that more clearly. "Selling" the med; "This is what we use I've seen it work well on others. Let's give it a shot." Or, "It's new and has gotten some rave reviews in the Pulmonary ward". (for a lighter atmosphere) As oposed to "We don't use MDIs here, nebs are better anyway". Or when instructing a pt in the ER avoid; "Although nebs work better, the doc has written you a script for an MDI". This happens alot and now the pt will always have those words somewhere in his mind when he/she has an asthma attack. Long term management; When a pt is end stage COPD, or just feels nothing is working, any encouragement that might get them back on track can get them through another day. The psycological aspect of COPD can fill text books several times over. Whatever I can say or do (without deception) until other meds can kick end to give a long term effect.... Air compressors; Small electric compressors can be plugged into the rig's electrical system. There are also battery operated ones. There are still some U.S. systems that are afraid of the hypoxic drive and don't put more than 2 L of O2 on a COPD pt. Many ERs only use compressed air on COPD pts. This is despite all the data that shows O2 good, hypoxemia bad. The SpO2 you see may not be the SaO2. But that is a Pandora's Box that should be opened carefully. I have had the displeasure of witnessing hypoxemia by with holding O2 first hand many times over the years. I also get to take care of the end results in the ICUs and Subacutes (long term vent facilities). There are alot of articles in the following journals comparing nebulizers, asthma attacks, accute exacerbations etc. Our medical directors give us articles to review. Some we try to duplicate to see if we get the same results. http://www.rcjournal.com/ http://erj.ersjournals.com/ http://ajrccm.atsjournals.org/ As a Respiratory Therapist, I have several protocols to choose from in the hospital and on the CCT units. I still keep my Paramedic certification for special events; doing coverage on sporting events. Not as exciting as working EMS, but my admission is free and my aging back doesn't complain as much. The EMT-Bs and EMT-Ps working EMS have my respect. (Although I have seen some ambulances better equiped than some of the ERs and ICUs I have worked in)

You gotta "sell" the medication's effectiveness to the pt. When Xopenex first came out, we didn't see it work faster on the any one pt more than Albuterol. But when you get a hard core COPDer depressed about their long term status, used Albuterol forever and isn't feeling good about it anymore.... Well here is the new and improved wonder drug :wink: ..... No matter what your real thoughts are...with the right psych mode, this might work. Of course, FEV1 studies are not done that often in pre-hospital. But in the PFT labs, the right attitude and med can produce results that can be seen. With an aerochamber, other familly members can be taught to assist the pt until EMS arrives. The 5 second holding chamber allows some medication to be inhaled. Don't believe me...check out the literature for albuterol administration on cats (house pets not lab rats) with a similar aerochamber product. 8) In EMS and ER we usually power the neb off of O2...nice hyperoxic state of feeling "better". Even if powered off of air from a tank or wall outlet, the extra flow will give them an "improved" feeling momentarily. If you ever watch a long time commercial compressed air neb user (serious COPDer)...they draw long and deep and do a little glottic closure movement (pursed lips or accessory muscle usage at the end. This gives a little extra "PEEP" action. The portable devices run at a fixed 5 -6L/m flow. The COPD pt learns to compensate overtime to get that same higher flow effect sub - glottic. Another pet peeve: telling a pt that a nebulizer works better than an MDI. If a nebulizer is what you first line protocol calls for, tell them you're trying different things and providing O2 with the med at the same time...if they ask, most don't. MDIs are rescue inhalers and that may be all the pt can carry to work. Planting the idea that their MDI doesn't work as good may set them up for failure during their next asthma/COPD attack.

Thank you for the welcome. I personally found the Circulaire with 5 - 10 mg Albuterol undiluted for pediatrics and some adults useful. The AeroTee got some decent reviews also. However, two of the studies were misleading and were defended by company reps in RT publications. I rarely give a treatment by mask. Mouthpiece for as long as they can cooperate it. I also get an idea for their inspiratory force and know if a tube may be in their future. Pet Peeve; people that tape the tube of the nebulizer so that it blows back toward the pt's face. These meds should not go into the eyes. Nor, should any of the bacteria that is present in the mouth, throat or lungs go toward the eyes.

There are several nebulizers on the market now to give improved delivery. AeroEclipse for non vented pt and Aerogen for vents come to mind. For MDIs, a spacer (Aerochamber) should always be used in any situation but definitely in emergencies. This has been proven in many labs to provide up to 60% better deposition of particles. Pt usually notice the difference. Using just Duoneb limits you as to the recommended dosage may easily be exceeded for Atrovent. Pharmacies in hospitals and accreditation boards are now monitoring this closely and suggesting a medication error report be filed for each occurence. If a physician wants more Duoneb than q4 hours, they must sign an exception for responsibility. Albuterol gives you more options for high doses...5 mg of the concentrated is used many times before starting a 10 - 25 mg/hour continuous.