Humidified oxygen

[WolfmanHarris]

So I've got a little dilemma that I'd appreciate some input on. In Ontario they no longer carry bubblers for humidifying oxygen on the Ambulance, meaning that the only way to provide it is by a nebulizer mask with normal saline.

So here's the problem I have. The burn management standard calls for high concentration, humidifed oxygen for burn patients. This leaves me with an option of high concentration via NRB or humidified via neb. In the balance of things, which do you think is the better way to go, 60% concentration and humidified or 100% concentration and non-humidified.

My personal thinking on this is NRB as I'd be more concerned about hypoxia from burnt airways, but I'm concerned that I might be missing something.

- Matt

[CBEMT]

I would think that pre-hospital, there's bigger things to worry about in general t than whether or not the O2 has some water vapor in it.

[Dustdevil]

Agreed. O[sub:7508715754]2[/sub:7508715754] humidifiers are a total waste of money for EMS. Even the ultra expensive, top of the line, non-disposable models provide only negligible humidification. If you can provide aerosolised O[sub:7508715754]2[/sub:7508715754] via aerosol mask and tubing, that's great. But via a normally tubed mask, like those carried by EMS, don't even bother. Yes, we want to do everything we can to prevent fluid loss in the burn patient, but trying to make a difference with an O[sub:7508715754]2[/sub:7508715754] humidifier is like pissing in the ocean.

[WolfmanHarris]

Thanks that's what I thought. I'll just go ahead and ignore that part of the protocol from here on in.

[defib_wizard]

If you feel like improvising you can do both. All it takes is a NRM and a SVN.

1. Set up your SVN with the saline or meds you want to give.

2.Here comes the creative part-

Option A- Cut a slit in the NRM bag put the svn in it ( in such a way it wont spill ) tape the slit closed with the svn O2 line coming out. Hook up your NRM to O2 at 10 lpm and the SVN at 5-8 lpm.

Option B-put the NRM on the pt as normal. put the SVN together with the T and extension tubing take the bag the SVN came in and seal the end of the T by putting the plastic bag on the mouthpiece and attach it to the T. Put the spacer tubing under the mask and start the SVN. If you need too, trim a notch in the mask for the tubing.

( This way of blocking off an SVN also works for giving SVN's with blow-by to a pediatric pt.)

Hopefully this keeps you from getting called into a MDs office for not following protocol.

[VentMedic]

You can not provide humidification through a standard NRB. The port is too small and the bleed out through the pop off will actually decrease your ability to maintain adequate flow. The patient will be forced to attempt to breathe around the mask somehow since a NRB mask is NOT a high flow device. Dramatically altering a medical device as you have suggested for the NRBM is not adviced and further decreases the effectiveness of the mask.

Also, if you notice in hospitals, we do not use nebulized saline for long term humidification in any device.

If a patient needs humidification and high FiO2, they need intubated. The high FiO2 may be for the high CO levels if there is smoke inhalation. Humidification in short term does very little and definitely is not effective if not done properly with the proper devices.

Other than that, the additional time setting up the correct equipment may delay transport or other care. If you keep a set up open and ready in your truck at all times for humidification, you may just introduce serious contaminants into the airway.

I suggest you find an Intro to RT book and read the basics of relative and absolute humidity, what a high flow vs high FiO2 device is and why certain nebulized liquids work better than others.

Some of the things suggested can do more harm than good. Make sure you thoroughly understand the working principlesof O2 and humidity before screwing around too much.

[tniuqs]

"VentMedic"

You can not provide humidification through a standard NRB.

Just how many times do qualified experianced RTs have to post this to get it to go through thick EMS skulls ? No offence to the OP intended at all .... In fact in studies that I have personally been involved with the bubble or wash bottle in 50% of the time "in hospital" the set O2 flow rate (@ the thorpe tube) and (delivered O2 flow at mask or nasal cannula) were lower due improper threading, humidifier bottle to the top, threads on wash bottle to thorpe tube, and blow off pop off valves. Besides the possibilty of the tap water (yes !) or N/S or distilled H2O carryng bacteria .

NRB mask is NOT a high flow device.

zactly ... do you need Higher FiO2 ... use the BVM... ps the reservoir should not completely empty upon Ti.

Do you need Humidity ... use an DAR type filter between the mask and the BVM, should be using these types on all patients btw, for your own protection, you guys do work in Ontario dont you ? ... remember the SARS thing funny that the HERT team never amounted to jack shit ...OMG.

And Caution using any "field" modified device your just asking for Medical Control issues ... best be very knowlegable before even attempting, that said sometimes one does have to improvise in a pinch.

There are Hi Flow Masks on the market now ... but I doubt that too many services are going to fork out the cash for them ... plus more ER staff will just chuck em out when they get to ER (protocol You Know) ... ie education issues, moreover.

Also, if you notice in hospitals, we do not use nebulized saline for long term humidification in any device.

In fact N/S nebulised can cause broncospasm, fact is anything nebulized can cause this and the last thing one needs with upper airway burns.

If a patient needs humidification and high FiO2, they need intubated.

Agreed, hands down the criticality of burns jumps up markedly, and increased mortality/morbidity takes a huge jump too.

Humidification in short term does very little and definitely is not effective if not done properly with the proper devices

.

On the same page Ventmedic, studies with a wash bottle and on less than 6 lpm N/C this OPTIMALLY adds 4 % realitive humidity, with high flows even lower relative humidity contact time issues.

[tniuqs]

If you feel like improvising you can do both.

<snip>

Hopefully this keeps you from getting called into a MDs office for not following protocol.

Nope this will guarantee that improvised practice should be reviewed.

[fiznat]

I hope you guys don't mind the quick change of subject from the OT, but this discussion about "street modified" equipment is particularly interesting to me.

RT guys- what do you think about an apparatus constructed out of a BVM to deliver nebulized bronchidilators to an asthmatic patient who has "tired" and no longer adequately ventilating? I understand that there are more important things to be done at this point (epinephrine namely, possibly intubation), but I have a medic friend at work who swears by this contraption he's created out of a BVM and a nebulizer chamber. He demonstrated it for me and it seems to work fairly well, but still I'm wary about this "McGiver Medicine" and how it might play out with medical control. Is there a commercially available device that does the same thing?

What do you guys think?

[Arctickat]

You mean an MDI port?

http://www.allmed.net/catalog/item/79/938

http://www.lifemedicalsupplier.com/disposa...000-p-1148.html

http://www.hrsrh.on.ca/portal/uploads/07-0...%20Ventolin.pdf