Oxygen Administration Skills- Did I miss something (like demand valves comin' back?)

[HammerNoMore]

Oh, and something else I thought of....just something to bear in mind. Most patients (DCS and air embolism patients being the major exceptions) do NOT need 100% O2. Actually we respiratory therapists tend to try to keep people on as little O2 as possible.

One of the things I was taught in my very first O2 course, was when the paramedics arive to politely inform them that 100% O2 is recomended for diving injuries and leave it at that. In all likelyhood they will assume they know better and completly ignore you, but you've taken care of the CYA part....it's their problem now.

 

[sharpenu]

First, it isn't minute ventilation, it is minute volume, as in RMV (respiratory minute volume). Second, while it is true that 1000ml is a good rule of thumb for an adult's lung capacity, that is a theoretical capacity. By the time you count residual space, dead space, reserve capacity and the like, the average person takes 500ml breaths. But when a person is breathing 40 to 50 times a minute that is no where near the true tidal volume. You are lucky at this rate to hit 100 to 200 cc. That is why high RR are so dengerous. When you get RR in the area of 40 to 50, the RMV actually drops, as the tidal volume goes so low as to reduce the RMV. This is because there isnt enough time to move air in and out before the next breath begins. 20 breaths of 500 cc is 10 liters. 50 breaths of 100 cc is 5 liters. The RMV is actually lower. The good news is that a person in a panic who is breathing quickly either passes out due to a lower SaO2 or due to resp alkalosis from blowing off too much CO2. Then the condition fixes itself.

BTW, writing your certs in your sig and constantly mentioning your cert level makes you look like either a newly certified provider, a person pretending to be a provider or some other person who need to impress others. Try expressing your opinion without rubbing your certs in people's face. If you have something to say, say it. If it is intelligent, people will listen. We don't care how many letters you have after your name.

 

[medic_diver45]

One of the things I was taught in my very first O2 course, was when the paramedics arive to politely inform them that 100% O2 is recomended for diving injuries and leave it at that. In all likelyhood they will assume they know better and completly ignore you, but you've taken care of the CYA part....it's their problem now.

And you are correct.....those are two instances where as high an FiO2 that can be achieved should be a goal.

 

[TheAvatar]

Well If your patient/victim is hyperventilating I was under the assumption of the NREMT standards to use a BVM to assist breathing and to help control the hype. I go for my recert this year it may have changed.
-g mount

Have you ever tried to hyperventilate a conscious patient? It doesn't work ... The books say to hyperventilate, but it's usually not feasible. If they are moving adequate volumes of air....then don't mess with them, put a NRB on them and haul A--.

I don't recall "the book" saying to hyperventilate anyone except in some cases with head injuries but that the practice was no longer recomended.

The protocol gjmmotors is referring to is to BVM a patient who is breathing inadequately, whether bradypnea or tachypnea: 12/min @ 0.4-0.6L/squeeze with high flow O2 in an adult patient. Also that other methods should be employed first to slow breathing if possible (coaching etc).

You SHOULD know that.

The only people I defer medical decision making authority to are doctors and physician's assistants.

*cough*cough*cough*EMT-Ps*cough*cough*cough*

And depending where you are and what you are doing, RNs too.

Are you an I/85 or I/99?

And you are right that many just take guesses at RR. I don't know why. Can't they do simple mental math to ge the #? Sometimes it can be hard to see/hear but still its such a vital vital.

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We didn't train to use Flow-Restricted, Oxygen Powered Ventilation Devices here.

AAOS 8th Ed says "recent findings suggest that they should not be used routinely" and "Cricoid pressure must be maintained whenever flow resricted, oxygen powered ventilation devices are used to ventilate a patient." Also, "Learning how to use these devices correctly requires proper training and considerable practice."

This is not talking about the non-positive pressure demand masks that are in the other kits. I think those have merit on breathing patients unless you are doing low flow.


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I still want to know the answers about the physics and measurements of cylinders and O2 regulators... I'm trying to derive an equation and those are important. Perhaps you know who to ask or where I could look?

 

[medic_diver45]

First, it isn't minute ventilation, it is minute volume, as in RMV (respiratory minute volume).

Actually.....MV as a parameter on a pulmonary function test is minute volume, in the setting of ventilator settings it's taken to mean minute ventilation. The terms are used clinically more or less interchangably as i've heard both used in either of those two settings. Potato/Potah-toh, eh?

Second, while it is true that 1000ml is a good rule of thumb for an adult's lung capacity, that is a theoretical capacity.

AND BY THE WAY, THE CORRECT TERM IS TIDAL VOLUME- NOT LUNG CAPACITY Sorry couldn't resist, you stuck me on specific terms, I had to return the favor. :1poke:
OK, 8 mL/kg lean body weight is the correct way to estimate a tidal volume, but I was generalizing for the sake of brevity....God only knows this argument has gone on long enough. Oh and that's just a normal size breath for someone, actually the total amount the could suck in would be somewhere closer to their forced vital capacity (normal is 4.8 L for a 150 lb man); For those of you playing Respiratory Physiology: The Home Game a forced vital capacity is the maximum amount of air you can force out of your lungs after taking the deepest breath you can. It doesn't measure the air still remaining in your lungs (and their always is under normal conditions), but TOTAL LUNG CAPACITY is around 6.8 liters for an adult male.



But when a person is breathing 40 to 50 times a minute that is no where near the true tidal volume.

Ever seen a diabetic ketoacidosis patient demonstrating Kussmaul respirations? DEEP AND FAST.....I wouldn't be surprised if some of those patients (or people who are just plain hyperventilating) are pull 1000+ cc per breath.....same thing goes with some brainstem injuries or other cerebral insults (these are not technically Kussmaul's respirations (which are caused by systemic acidosis) but a similar type scenario can happen); another thing to keep in mind is that the normal person can voluntarily move around a 120 liters per minute of air as demonstrated by another pulmonary test (granted most can't sustain that for very long, but it proves that the human body can do some amazing things.

But I must admit that in many cases, as the respiratory rate goes up, the tidal volume falls both because of insufficient time to breath in and out ("breath stacking")....the use of a large tidal volume and fast RR was to demonstrate worst case scenario, which is what we should be planning for when it comes to oxygen supplies (and other first aid matters). That's the main impetus behind my starting this whole thread....I just want people to be prepared and properly educated that's all. It may be me or someone I care about (not that I don't really love all y'all) that's needs care and I want to make sure people who are there know what to do. We've got to look out for one another....no one else is going to.



BTW, writing your certs in your sig and constantly mentioning your cert level makes you look like either a newly certified provider, a person pretending to be a provider or some other person who need to impress others. Try expressing your opinion without rubbing your certs in people's face. If you have something to say, say it. If it is intelligent, people will listen. We don't care how many letters you have after your name.[/QUOTE]

To clarify i've been a first responder since 1997, an EMT since 1998, an Intermediate EMT since 1999 and a respiratory therapist since 2001. I'm not a newbie, and I don't mean to rub my certifications in anyone's face. It's just people have repeatedly questioned where I am coming from with my contentions. As for the acronyms after my name, it just happens that that's how I sign all my e-mails and other correspondence (except for really really informal stuff), I just typed it in here without thinking. If I wanted to brag, I would have come up with something better than "I'm a respiratory therapist".....most people don't even know what we do.....LOL


If it bothers anyone else, I will remove the letters from after my name on my signature on here. That's not a problem.

 

[TheAvatar]

If it bothers anyone else...

What would be nice is if you used the

function (use reply for autoquote). It would make your replies much easier to read.

 

[medic_diver45]

I don't recall "the book" saying to hyperventilate anyone except in some cases with head injuries but that the practice was no longer recomended.


The protocol gjmmotors is referring to is to BVM a patient who is breathing inadequately, whether bradypnea or tachypnea: 12/min @ 0.4-0.6L/squeeze with high flow O2 in an adult patient. Also that other methods should be employed first to slow breathing if possible (coaching etc).

You SHOULD know that.



*cough*cough*cough*EMT-Ps*cough*cough*cough*

Are you an I/85 or I/99?


And you are right that many just take guesses at RR. I don't know why. Can't they do simple mental math to ge the #? Sometimes it can be hard to see/hear but still its such a vital vital.

----------------------

We didn't train to use Flow-Restricted, Oxygen Powered Ventilation Devices here.

AAOS 8th Ed says "recent indings suggest that they should not be used routinely" and "Cricoid pressure must be maintained whenever flow resricted, oxygen powered ventilation devices are used to ventilate a patient." Also, "Learning how to use these devices correctly requires proper training and considerable practice."



This is not talking about the non-positive pressure demand masks that are in the other kits. I think those have merit on breathing patients unless you are doing low flow.


--------------
I still want to know the answers about the physics and measurements of cylinders and O2 regulators... I'm trying to derive an equation and those are important. Perhaps you know who to ask or where I could look?

SORRY FOR THE DELAY IN GETTING BACK WITH YOU ABOUT ALL THIS....I JUST GOT HOME FROM DINNER WITH MY FUTURE IN-LAWS AND HAVE BEEN SORTING THROUGH SEVERAL MESSAGES ON HERE AND IN MY E-MAIL



I didn't mean to suggest hyperventilating anyone, but when I went through EMT class, the rule we were taught was as you described...to "assist" inadequate ventilations; with the example being a patient who is tachypneic

That's what I was trying to say....If the patient is conscious, they are gonna fight like hell when you put that BVM on them, and assisting their ventilations is a last resort.


I'm I-99; as for medics, I'm assuming you mean to defer to you on scene? I will to a certain extent, but the question becomes since I am an RT and if the patient has ventilatory or airway problems where does the line for patient abandonment/negligence lie? A TOPIC FOR ANOTHER TIME AND PLACE- Preferrably involving BBQ and beer

THANK YOU....I WAS TRYING TO FIND THE AAOS BOOK (You are citing "Care and Transportation of the Sick and Injured" right?) I HAVE A COPY (THE PREVIOUS EDITION) AROUND HERE SO I COULD CITE IT (I just moved into a new apartment and haven't gotten all my books unpacked yet).


TANK VOLUME IN LITERS = TANK FACTOR (see below) x Pressure in PSI

TANK FACTORS (FOR BOTH COMPRESSED AIR AND OXYGEN TANKS)
D cylinder- 0.16
E cylinder- 0.28

As for the question posed earlier about oxygen regulators, I will have to check on that (tomorrow) and get back with you....I know the ones that plug in the wall (with the little ball that floats up to give you the reading) are compensated but I don't remember if it's for flow or for pressure. I haven't been asked that since I graduated from school (it just doesn't come up much in normal clinical practice) and I don't recall being told anything about compensation for normal regulators (the ones the attach directly to the tank). I don't want to tell you wrong so I will defer until in the morning. I know it's in one of the books I have left over from school. I'll look it up and get back with you. Is that OK?

If you need any more info, let me know and I will get it for you in the morning.....I'm heading for bed.

 

[TheAvatar]

That's what I was trying to say....If the patient is conscious, they are gonna fight like hell when you put that BVM on them, and assisting their ventilations is a last resort.

Thus the suggestion that all other methods to control their breathing be tried first if appropriate (coaching, nonrebreather, etc). I wouldn't want to BVM someone who was concious or semiconcious.

I will to a certain extent, but the question becomes since I am an RT and if the patient has ventilatory or airway problems where does the line for patient abandonment/negligence lie? A TOPIC FOR ANOTHER TIME AND PLACE- Preferrably involving BBQ and beer

I wouldn't want to be in that decision.

THANK YOU....I WAS TRYING TO FIND THE AAOS BOOK (You are citing "Care and Transportation of the Sick and Injured" right?) I HAVE A COPY (THE PREVIOUS EDITION) AROUND HERE SO I COULD CITE IT (I just moved into a new apartment and haven't gotten all my books unpacked yet).

Yes. That is the book. It's has perhaps 2 or 3 paragraphs on O2 powered positive pressure stuff... it's pretty clear on the subject and that's for EMT-Bs not lay people. Of course, it is written for urban operations. Still...

I'll look it up and get back with you. Is that OK?

Awesome. I'm trying to derive an equation so as to create a couple of temperature/altitude charts that will give operation time for various flowrates on Jumbo D tanks so we have something more quantifiable to go on than "altitude extends time, temperature decreases it." That info I asked for could drasticly affect it. I had no idea where to look it up either.

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Now THIS is a new one on me!

REMO2 - Surface O2 rebreather system. $110
Claims 8hrs off a Jumbo D (maybe at 2LPM?). Lithium hydroxide scrubbers I'd assume...

https://www.diversalertnetwork.org/...1000&mscssid=DWTKSUD58E969JULL1HH2RU6CT3QE0BB

http://www.diversalertnetwork.com/training/courses/remo/index.asp

I don't know what to make of that. It sure looks like it would have some darn good application in certain situations but I don't see a lot of details.

 

[sharpenu]

Not really trying to flame you. The problem lies with the fact that SO MANY people come here to Florida with stories about how they were emt's/paramedics/firefighters/whatever "up north" and they do things better/faster/cheaper where they are from. They are chuck full of helpful suggestions on how you should be operating your scene. Of course, after talking to them, you quickly realize that they are either wanna-be's or that they have no idea what they are talking about. It makes you sensative after awhile.

 

[Wildcard]

Thats funny, I just called this guy in another thread. He was told once so it must be true and everyone else is wrong.