The most common device used to generate bland aerosols.
large volume jet nebulizers
large volume jet nebulizers are usually used to treat:
1.Laryngothracheobronchitis
2.Subglottic edema
3.Post-extubation edema
4.Post-operative management of the upper airway
5.When the upper airway is bypassed
6.The need for sputum induction or to mobilize secretions.
large volume jet nebulizers' contraindications:
1.Bronchoconstriction.
2.History of airway hyperresponsiveness. (hypersensitivity)
Hazards and complications of large volume jet nebulizers:
1.Wheezing or bronchospasm
2.Bronchoconstriction with artificial airway is used
3.Infection
4.Overhydration
5.Patient discomfort
6.Caregiver exposure to pathogens. (Airborne)
7.Edema of the airway wall
8.Edema associated with decreased compliance and gas
List the assessment of need for Large volume jet nebs.
Stridor
Brassy, croup-like cough
Hoarseness following extubation
Diagnosis croup
History of upper airway irritation and increased work or breathing.
Patient discomfort associated with airway instrumentation or insult.
Bypassed upper airway.
Need for sputu
List the assessment of outcome for LVJN:
1.Decreased work of breathing
2.Improved vital signs
3.Decreased stridor
4.Decreased dyspnea
5.Improved ABG results
6.Improved oxygen saturation as indicated via pulse ox.
7.When sputum sample is achieved
What 2 things should the extent of monitoring for LVJNs be based on?
The extent of monitoring should be based on the stability and severity of the patient's condition.
List the monitoring factors for LVJNs.
1.Patient subjective response - pain, discomfort, dyspnea, restlessness.
2.Heart rate and rhythm; blood pressure.
3.Respiratory rate, pattern, accessory muscle use.
4.Sputum production - quantity, color, consistency, odor.
5.Skin color
6.Breath sounds
In what case would you want to monitor pulse oximetry when using a LVJN?
if hypoxemia is suspected.
While using a LVJN, in what situation would you monitor Spirometry equipment?
If the adverse reaction is a concern.
Air-entrainment systems direct a ___-pressure oxygen source through a _____ nozzle or jet surrounded by air-entrainment ports.
high; small
The amount of air entrained at these ports varies with directly with the:
1.Size of the port
2.Velocity of oxygen at the jet.
*The larger the intake port and the higher the gas velocity at the jet, the more air is entrained.
*The more air that is entrained, the higher is the total output flow, but the lower the delivered FIO2.
The FIO2 provided by air-entrainment devices depends on:
1. The air-to-oxygen ratio
2. The amount of flow resistance downstream from the mixing site.
Changing the _____ flow of an air-entrainment device alters the _____ flow but has little effect on the delivered ____.
input; total; FIO2
The size of the ___ and __________ ____ of a device determines the air-to-oxygen ratio and the delivered FIO2.
jet; entrainment ports
You have a patient who is experiencing tachypnea and is extremely "air hungry". His respiratory rate is 30 breaths per minute and is also experiencing slight hypoxemia. You estimate the patient's inspiratory flow rate to be approximately 40 liters per min
Equation:
Liters air = (100 - %O2)
Liters O2 (%O2 - 21)
Liters air = (100 - 40)
Liters O2 (40 -21)
Liters air = 60
Liters O2 19
Liters air = 3
Liter O2 1
The air to oxygen ratio for 0.40 is 1 part oxygen to 3 parts air. (3:1)
TOTAL FLOW = 3 + 1 = 4 (10 L/
You have a patient on a 0.50 venturi mask being run with 12 liters per minute of oxygen. Using the "magic box", determine the approximate air-to-oxygen ratio and total flow of this device:
(1.7:1) (Ratio)
TOTAL FLOW = 1.7 + 1 = 2.7 x 12 = 32.4 L/min
Major factors determining the oxygen concentration provided by an air-entrainment device is ____-______ ____ _________.
down-stream flow resistance.
In the presence of flow resistance distal to the jet, the volume of air entrained always _________.
decreases.
With less air entrained, total flow output _________, and the delivered oxygen concentration (FIO2).
decreases; increases
The two most common air-entrainment systems are:
The two most common air-entrainment systems are the Air-entrainment mask and air-entrainment nebulizer.
To compute the patients minimum flow needs, what must you first estimate?
To compute the patients minimum flow needs, you must first estimate the patient inspiratory flow.
How do you determine minute volume?
Minute volume can be determined by multiplying the patients respiratory rate (18 bpm) by tidal volume 0.6L (Example):18 bpm x 0.6L (VT) = 10.8 (VE).
A patient's peak inspiratory flow is approximately 3 times the minute volume (VE)
So... (0.6 X 18) X 3 = (
You have been asked to set up a high volume, high output entrainment nebulizer with an FIO2 of 0.50. The oxygen flow will be set to 10 L/min. Your patient has a respiratory rate of 14 bpm and a VT of 0.6 L.
Calculate the patients peak inspiratory flow dem
FIO2 = 0.50
Oxygen flow = 10 L/min
Patient's VT = 0.6 L
Patients RR = 14
VE = 8.4 L
Peak inspiratory flow = 8.4 x 3 = 25.2 L/min
Sum of ratio parts (1.7:1) or 2.7 x 10 = 27 L/min
Answer: Yes, the entrainment device will meet the patient's inspiratory dema
If the patient's inspiratory demand or inspiratory flow exceeded the total output flow of the device, would the patient still receive 0.50?
It would be lower because the patient will exceed the flow of the device.
How can you increase the flow to meet the patient's needs?
Turn up the oxygen flowrate. (the ratio or FIO2 will not change, but total flow will... it will increase.
Simple observation of mist output during patient inspiration while using a _________ system can be a fast way of determining adequate flow from a LVJN with an entrainment device.
If the mist retracts completely on ispiration, the total flow is (not meetin
T-piece
What will happen If the patient's inspiratory demands exceed the total flow of the device?
The patient will receive less oxygen.
How do you know if the total flow of an LVJB is meeting the patient's inspiratory flow demands or not?
If the mist retracts completely on inspiration, the total flow is not meeting the patient's inspiratory flow demands.
*The flow will need to be increased to the patient or adding reservoir tubing to the expiratory side.
What will adding a second nebulizer do to the total flow output?
The addition of a second nebulizer will double the total flow output.
In this example: You have a single nebulizer that can only provide a maximum flow of 40 L/min.
By combining two nebulizers together you have now the potential for 80 L/min.
Will the FIO2 be affected?
The FIO2 will not be affected as long as both systems are set to the same FIO2.
What should be considered when air entrainment systems cannot provide a high enough oxygen concentration or flow?
The use of a gas blending should be considered.
How are gases mixed within a blending system?
A blending system or "blender" uses a separate pressurized air and oxygen source, and the gases are mixed with a precision valve.
What system allows control over both FIO2 and total flow output?
A blending system.
Most blending systems can provide flow well in excess of __L/min.
60L/min.
What is an example of a precise blending system and is used for adult, pediatric, and newborn oxygen delivery?
The "Bird Blender.
Large volume nebulizers can be utilized to deliver what 2 things?
1. Bland aerosol for humidification to the lower airway.
2. Medication delivery.
When a patient with airway obstruction does not respond to a standard dosage of bronchodilator, what is it common practice to do?
It's common practice to repeat the treatment as often as every 15 minutes.
To avoid giving separate SVN treatments, what are the two ways to provide large dose applications of the drug?
1. Infusion or IV method
2. The use of a large volume SVN for medication. (Heart Neb)
What 3 nebulizers have a greater than 200 mL reservoir that produces an aerosol with a MMAD (particle size) between 2.2 and 3.5 microns?
1.The HEART
2.Westmed
3. The HOPE
What does SPAG stand for?
Small-Particle Aerosol Generator.
For what reason was the SPAG invented by ICN Pharmaceuticals?
The administration of ribavirin (Virazole) to infants with respiratory syncytial virus (RSV) infection.
What is unique about the SPAG device?
The device is unique in that it incorporates a drying chamber with it's own flow control to produce a stable aerosol.
The SPAG produces a MMAD (particle size) of __-___ microns.
1.2 - 1.4
The nebulizer should be maintained at approximately _L/m with a total flow from both flowmeters no lower than __L/m.
7L/m; 15L/m
What is the air-to-oxygen ratio for an FIO2 of 0.30?
8:1
What is the air-to-oxygen ratio for an FIO2 of 0.50?
1.7:1
What is the air-to-oxygen ratio for an FIO2 of 0.24?
25:1
You have a patient with a VT of 0.5L and respiratory rate (RR) of 12 bpm. What is the patient's estimated inspiratory flow rate?
(0.5 x 12) x 3 = 18 L/min ** (VE x 3)
You have a patient with a VT of 0.8L and a respiratory rate of 14 bpm. What is the patient's estimated inspiratory flow rate?
(0.8 x 14) x3 = 33.6 L/min
You have a 0.40 venturi mask running at 10 liters per minute of oxygen. What is the total flow of this device?
Ratio of 0.40 is: 3:1
3 + 1 = 4 x 10 L/min = 40 L/ min
You have a 0.45 venturi mask being powered by 8 L/min oxygen. What is the total flow of the device?
Ratio= 2:1 2 + 1 = 3 x 8 L/min = 24 L/min
You have a 0.50 venturi mask being powered by 10 L/min of wall air. What is the patients FIO2?What is the total flow?
0.21; Ratio: 1.7:1 1.7 + 1 = 2.7 x 10 = 27 L/min of air.
The FIO2 provided by air-entrainment devices depends on two primary factors... what are they?
1. The air-to-oxygen ratio
2. The amount of flow resistance downstream from the mixing site.
What two factors determine the FIO2 delivered by an entrainment device?
Size of the jet and entrainment ports.
Name two advantages of using an MDI:
Convenient, Inexpensive, Portable, No drug prep.
Name two disadvantages of using an MDI:
Pt. coordination required (unless using with a spacer), patient activation, risk of abuse.
What is a SPAG used for?
The delivery of Ribavirin (Virazole)
What does Virazole treat?
RSV