The other side of the NH coin

[becksdad]

Ooooh! That was a good one, Michael!

[akflightmedic]

NC is inappropriate for anybody who needs over .4 fIO[sub:3f6c27bb87]2[/sub:3f6c27bb87] delivered.

NC is inappropriate at 6 or more lpm, probably less according to many.

NC is not inappropriate for a mouth breather, unless the patient's nostrils are completely occluded by debris or oedema. The nose and the mouth share the same pharynx, which is where the oxygen goes, regardless of which orofice the patient is using to breathe. Mouth breathers will get nasal oxygen just fine.

Ok Dust, educate me. Yes I am well aware of the anatomy of the airway. However, it has been my personal experience on many occasions in different scenarios to increase a mouth breather's O2 saturation levels by placing a simple face mask or lowering the nasal cannula to where it blows in the mouth. From my years of working the floor in PCU, I have been around many geriatric pts that have the permanent "O" look when sleeping. When this occurs, their sats would drop into the low/mid 80's, I would let them sleep and simply adjust the nasal cannula so the stream would blow into their mouth. Immediately their sats would come up.

This is where my question lies. Applying this same logic to a CHF'er who is heavy mouth breathing, gasping, how is it possible they would recieve plenty of O2 from a nasal cannula? I ask this with all sincerity. Make it rationale for me.

[Dustdevil]

This is where my question lies. Applying this same logic to a CHF'er who is heavy mouth breathing, gasping, how is it possible they would recieve plenty of O2 from a nasal cannula? I ask this with all sincerity. Make it rationale for me.

It's the Venturi principle. With a mouth breather, the negative pressure is creating a flow of room air that is far greater than the flow of 100% O[sub:4d52aa068b]2[/sub:4d52aa068b] through the cannula. Consequently, even though they are receiving all of that O[sub:4d52aa068b]2[/sub:4d52aa068b] from the cannula, it is being diluted by the room air. That's why the old theory of "protocols" that say "Condition A gets flowrate B by device C" is so asinine. Every patient's response is going to be different, and the effectiveness of a given flowrate or device is very individual because of many factors, including the patient's breathing pattern.

This is what the old Venti Masks were good at eliminating. Because they were high flow, pretty much everything the patient breathed in was a controlled fiO[sub:4d52aa068b]2[/sub:4d52aa068b], that was not diluted by flow-by. But the percentage delivered by an NC or SFM, or even the PRB, is affected by those factors.

We use general rules to estimate the fiO[sub:4d52aa068b]2[/sub:4d52aa068b] delivered by delivery devices. Most accept 2% to 3% per lpm as the multiplication factor. Using that rule, a nasal cannula running at 6 lpm, that adds 18%. 18 + 21 (room air) = 39% fiO[sub:4d52aa068b]2[/sub:4d52aa068b] being delivered to the AVERAGE patient who is breathing with the AVERAGE V[sub:4d52aa068b]T[/sub:4d52aa068b] at the AVERAGE RR through his nose. Breathing through the mouth or breathing deeply or shallowly will definitely affect this figure. You are certainly not incorrect in that thinking. But the original point I was making is that a patient mouth-breathing does not (barring anatomical abnormalities) preclude him from receiving nasally administered oxygen altogether. It is only a factor that should be taken into consideration when deciding if the oxygen delivered by an NC is going to be sufficient for them. And, of course, that decision and process should be guided by O[sub:4d52aa068b]2[/sub:4d52aa068b] sats, or even better, by ABGs.

[akflightmedic]

Great refresher! I feel smarter now. Thanks Dusty!

[itku2er]

I'm confused. You said her sats were 69% on 10L and then w/o any intervention her sats were 88 on 10L? And who's giving oxygen at 10LPM via cannula anyway? Something with this call doesn't at add up.

And, the occassional "..." is okay, but it shouldn't replace a standard period at the end of a sentence. Something to think about.

Shane

NREMT-P

well we dont have anything higher at the NH we can only go to 10 liters on an O2 concentrator....so i used what i had...we have no NRB theres...state regulations dont require the NH to have them...we have an ambo bags but that is it.....hell we dont even have a crash cart for codes....another thing that isnt required.....i been preaching to the choir on that one since i started 3 years ago ........but state regulations dont require it so..... :roll: :roll: .....but we do what we can with what we have to substain life til ems gets there.....

[medic001918]

While I understand that you are trying to do the best you can with what you have, that doesn't really mean that you should use a device for any other means that what it was intended for. Nasal cannulas have a limit on the amount of oxygen that is supposed to be flowing through it in the first place and for a reason. It's entirely inappropriate for an educated provider to take a nasal cannula and blast 10LPM through it. That flow rate is reserved for a mask style device. As an educated healthcare professional, I would anticipate you would know the proper uses of your equipment. I won't get angry, mad or otherwise with a staff memeber that is doing the best they can with what they have assuming the supplies available are being used in a correct manner. It's when they are used incorrectly (and using them in this manner knowingly makes it worse), that I take issue with it.

Also as a thought, if you don't have a mask but you have an ambu bag and the patient is really not doing well why not hook up the bag (it has a face mask on it) and help the patients ventilations? You have other means of assisting this patient through their difficulty breathing rather than the inappropriate use of an oxygen delievery device.

And once again, "..." between every sentence makes your posts rather difficult to read and makes them seem like one long sentence.

Shane

NREMT-P

*EDIT* Also, I'm still not sure how the patient had SpO2 of 69% on 10LPM NC and then came up to 88% on 10LPM NC without intervention? Did I miss something?

[becksdad]

You know, I learn a lot about so many different things on the City. But every once in a while there's a thread that really gives me an "AHA!" moment. This is one of them. Thanks to all!!

[itku2er]

Ok guys sorry.....I just did this to stir up the post some.....but thanks dust for the good information on the CHF and FIo2 stuff....its like Micheal said we all can still learn some more.....no matter how much we think we know there is always room for more learning and more information that can be gathered...Shane of course there was holes in this whole senerio...and it didnt make much sense....i was making it up as i went along which i wont do again cause i had myself confused most of the time.....but anyway sorry guys it was a poor attempt to get everyone thinking about things....although i think that becksdad was in "AHA" of the whole post....

[Michael]

like Micheal said we all can still learn some more

Huh? Where did I say that? I would never claim the ability to learn, let alone accuse someone else of it. I deny everything.

[itku2er]

Huh? Where did I say that? I would never claim the ability to learn, let alone accuse someone else of it. I deny everything.

OH my bad Micheal.......i would never accuse you of that ...... :wink: