Humidified oxygen

[fiznat]

You mean an MDI port?

Not really, since I don't know what that is haha? Do they have ports for MDIs on some BVMs?

[firedoc5]

For local calls we didn't bother with humidified O2. But we did have it available for our long distance inter-facility transfers.

[Arctickat]

Not really, since I don't know what that is haha? Do they have ports for MDIs on some BVMs?

Yup, I added a website to my previous post.

[VentMedic]

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?

We, RT guys, call that placing a neb "inline" and it can be with almost any apparatus. You are not "changing" the purpose of the nebulizer nor are you altering the equipment. You are merelyl placing an adapter with the nebulizer to make it fit "inline" with your equipmment. This is also done with MDIs.

We can bag a treatment in by mask or ETT. It can also be placed inline with ventilators and with some CPAP/BiPAP machine. However, one must understand forward flow and exhalation allowance or flow follows path of least resistance to ensure the lungs do not become more hyperinflated. Too many crank the BVM with the nebulizer and bag like the wind while the neb is not allowed to vent of excess flow or pressure. You will then cause the patient to decompensate cardiovascularly.

There are several commercial devices available for both the neb and the MDI. They have been on the market for about 25 years that I know of.

Caution with the MDI ports on the BVMs. The new HFA inhalers may not fit as well some inhalers may not fit the HFA inhaler port. Likewise for some of the commercially availabe MDI adapters for vents and other inline applications. Since regulations and meds in Canada and the U.S. are not the same, different info for device application with different meds in each country will be different.

When rigging O2 equipment, on must understand how and why they work. An SVN has baffles designed to deliver medication at a specific particle size. That is why if it is used as a "humidifier" and with the wrong liquid, it can cause bronchospasm. Many medicines that we deliver with it MUST also be delivered with a bronchodilator.

If we want cool mist to an irritated throat or croup, we would use a nebulizer designed to give larger particles. If we want meds (vaponephrine) delivered to the throat we may use a different nebulizer from the one we would use the same med for bronchiolitis. If you don't understand these basic principles of delivery, you can do more harm by bronchospasm or be a total waste of time and a good med by the wrong device.

Unfortunately, Paramedic training teaches very little about the fundamentals of O2 therapy. Even the ridiculous debates about whether to us 2 L or 4Ls by NC demonstrates a lack of knowledge as to how and what O2 concentration is delivered. Too many also think that a NRBM can give "high" FiO2 and "high" flow. It can give neither if the patient's demand/minute volume is high.

[mobey]

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?

I will just add a little justification to this idea.

In Ab bls can use BVM & bronchodilators. However we cannot use epi (sept for anaphylaxis) nor intubate. I could have found this type of device VERY handy in the past and have thought of making my own too.

[tniuqs]

Ok first RT Guys ? .... LOL, vast majority are females where I live ... so then they can take on the female RNs on an equal footing, again laughing.

We can bag a treatment in by mask or ETT. It can also be placed inline with ventilators and with some CPAP/BiPAP machine. However, one must understand forward flow and exhalation allowance or flow follows path of least resistance to ensure the lungs do not become more hyperinflated. Too many crank the BVM with the nebulizer and bag like the wind while the neb is not allowed to vent of excess flow or pressure. You will then cause the patient to decompensate cardiovascularly.

Just to add, oh yes have seen these devices lots most should be discussed with medical director (generally accepted) but just to be certian, if they have crapped out best to get them on a good ICU vent or NIPPV with a compensator (for lack of a better term) the cheaper CPAP machines do not have the plastic brain required to prevent auto PEEP.

They consist of 2 pieces of ventilator tubing with a SVN "T" ed in ... this CAN cause iatrogenic "PEEP" and without recognition you could be affecting right side of the heart filling (ie Preload) a "relative" hypovolemia, DHI or Dynamic Hyper Inflation has become a serious concern and issue in educational in resus courses these days.

As for Epi ... pretty old school for Asthma, selective Beta 2's and anticholinergics are the way to go ... we used to do IV ventolin but lots of "pasty looking dudes" from that, earlier nebulised Steroids are showing some positive evidence to support that practice.

Mag Sulfate (in my neck of the woods) in Respiratory in Hospital nope ... this is a phenomenon in EMS only. There is as much evidence that this is myth vs truth, in the lit studies I can not find any realistic support that said it is really inert stuff .. called epsom salts ... you can buy this in a drug store for a 5 lb bag for 5 bucks .. it does work great for soaking my feet though ... anicdotal evidence only.

cheers

[fiznat]

Mag Sulfate (in my neck of the woods) in Respiratory in Hospital nope ... this is a phenomenon in EMS only. There is as much evidence that this is myth vs truth, in the lit studies I can not find any realistic support that said it is really inert stuff ..

I'm not sure what you're saying here. Are you saying there is little evidence to support the use of MgSo4 for acute asthma?

[tniuqs]

Well if you have a current study with good controls I would love to read it ... not just a "conclusion" although.

Mag sulfate is a trace element ... the explanation of mechanism or action is not clearly understood, I give it on spec IV when ETOH abuse is a possible factor in MI, their is science behind that.

The First Study that got this trend going was success in weaning a Ventilator Dependant Asthmatic from Support .. one patient does not make for good science .. another thing I have heard from so many Paramedics say that this is valuable medication (quite anicdotal when your giving 3 different meds via S/S neb)... thing is they do not understand peak thereputic effects of Salbutamol re: TIME

Another Point being I have not seen a Human model comparing MgSuf nebulized (only) vs Salbutamol, as this is standard of care in the acute asthmatic patient, deviating from that is called experimentation.

It becomes an ethical/legal delemia just as in comparing one antiarrythmic vs another ...

cheers

[fiznat]

It sounds like you've done a little looking around yourself, so maybe you've already seen this. Meta analysis of MgSO4 trials have found that there is little improvement when you look at the entire population of asthma patients. When you limit the criteria to only "severe" patients, however, the benefit is much more pronounced. In these patients, IV MgSO4 greatly reduces hospital admission as well as improves pulmonary function (Peak Expiratory Flow Rate (PEFR), and Absolute Forced Expiratory Volume in One Second (FEV1) were tested), all without significant adverse effects.

There are a lot of little studies conducted on this subject, so it is my opinion that they are best understood via meta analysis. Here are two of them:

Rowe BH, Bretzlaff JA, Bourdon C, et al. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. Ann Emerg Med. 2000;36:181-19

Alter HJ, Koepsell TD, Hilty WM. Intravenous magnesium as an adjunct in acute bronchospasm: a meta-analysis. Ann Emerg Med. 2000;36:191-197.

One of the guys who ran the 1st analysis, Rowe, did a pretty good summary of the current state of research on the subject which can be viewed online in it's full .pdf form. Here's the link:

http://www.emnet-usa.org/articles/Rowe_CurrOpinPM_2008.pdf

[VentMedic]

]m that, earlier nebulised Steroids are showing some positive evidence to support that practice.

Mag Sulfate (in my neck of the woods) in Respiratory in Hospital nope ... this is a phenomenon in EMS only. There is as much evidence that this is myth vs truth, in the lit studies I can not find any realistic support that said it is really inert stuff .. called epsom salts ... you can buy this in a drug store for a 5 lb bag for 5 bucks .. it does work great for soaking my feet though ... anicdotal evidence only.

cheers

We do nebulize steroids but find that the MDIs are much easier.

Mag Sulfate has gotten another look fo rnebulizing and a few hospitals are still trialing it. I personally have not heard of this in EMS in my neck of the woods. IV is common in the hospital but not for ALL asthmatics. The cost of the correct nebulizer and the inability to mix with a bronchodilator makes Mag Sulfate very impractical for EMS and very short transports. As well, not all asthmatics meet criteria nor should all athmatics have Mag Sulfate as a blanket protocol.

Lasix nebulized is another that has found to have specific purposes.

Morphine and Fentanyl are popular. We have nebulized Morphine for over 30 years and fentanyl has now become the popular med of choice for some patients with specific comfort needs.

We nebulize over 100 different meds for anything from bronchospasm to pulmonary HTN and everything inbetween including many antibiotics as well as Pentamidine for the transplant patients. We have another 10 or so that we are trying to develop and fund studies for.

The other thing to consider is that many asthmatics are severe enough to warrant a Helium mix to facilitate the medication delivery. This will include while on the ventilator as well as off.

We also have several different types of nebulizers for all the many different meds. For instance, there are few meds that I would use in the standard EMS acorn nebulizer besides albuterol. The waste is too great.

Besides all of the med nebs we can use Helium, CO2, N2 and NO. All for specific purposes and disease processes.

Before considering any med that has not been well researched you much also consider where you are giving the medication. The back of the truck is not the ideal situation for exposure to the provider. We take many procautions, even with albuterol, to avoid close exposure if at all possible. We do have enough RTs to document long term side effects from some of the meds we have been exposed to over the past serveral years.