[Miriam57RN]

I was wondering where to post this question, looked at the different forums, and decided to post here with the rational that most males are mechanically savvy and will get an answer pretty quickly here.

This is regarding a home-care client on a vent. I noticed today that the blue T-piece where the neb tx's go in, is below the Y, in the expiratory circuit. The equipment company on this case sends someone out who changes the circuit weekly, and you'd think they'd be doing it right, but this doesn't make sense to me... that the neb T would be in the exp. circuit. Does it make any sense to you ? (my question).

On my other vent client where I do the circuit change myself once a week, I connect the blue T above the Y, closer to the patients's trach where I believe the neb meds have a better chance of reaching the trach. However set-ups vary, and this T does not fit the piece it would connect to, if set up above the (upside down) Y, and there were no adapters for it.

I figure this must be why they're putting it in the other way... but what bothers me about this is is that this baby is not getting her nebs this way, I'm convinced -because it's too far down the circuit and I'm not seeing the mist go into the trach. Plus it might be getting blown down the circuit with her CO2. The mother thinks it can't go into the inspiratory line because of the heating probes. ? . She is on three nebs... Xopenex, Pulmicort and now Tobi... and needs all of them.

I did tell the mother what I thought and asked her to see if the equipment co. could come through with the right adaptor. Does anyone think she could be getting anywhere near her dosing with it set up as it is? I'm off now but this is really bothering me. She is a former premie with laryngeal stenosis, now home, trached and vented, and currently being treated for tracheitis. (Not new to her as she spent her first year of life in the hospital and did have her share of pneumonias and URI's already... thankfully, at least cultures are showing less organisms now at home than they used to in the hospital).

[sirI]

Hello, Miriam57RN,

You are correct that this child is not receiving the benefit of the neb meds. Good call on all of this. Very astute of you.

The homecare company should be able to adapt the neb to the inspiratory side of the vent circuit.

Is there any way to get this company out today?

[Miriam57RN]

Originally Posted by sirI

Hello, Miriam57RN,

You are correct that this child is not receiving the benefit of the neb meds. Good call on all of this. Very astute of you.

The homecare company should be able to adapt the neb to the inspiratory side of the vent circuit.

Is there any way to get this company out today?

I'm hoping I jotted their number down in one of my notebooks... I'll look for it and will call them. The T could probably easily be put into the inspiratory side without an adapter. When I told the parent I wanted to put it there, she said she didn't want it on that side because of the heating probe... and I didn't think that was a problem, but wasn't positive. So, better there than on the other side, but wouldn't it be better above the Y (with an adapter) ? Or is it good enough on the inspiratory side, even if its below the Y.

going to check for the number.... thanks for your response!

[SteveRN21]

Good call.... I laughed when Siri was the first to step up and answer your "technically savvy" question. Heater wires never run the length of the inspiratory circuit, and should have a T-piece midway with a temp plug in it. The nebs adapter usually plugs in after this t piece. I hope you can get this resolved with the company soon, so the baby can actually get her nebs treatment.

[sirI]

Yes, the 'T' would be better suited above the 'Y' on the inspiratory side. Rationale: While the neb is running the whole inpiratory circuit acts as a reservoir for the medication.

[Miriam57RN]

I got ahold of the equipment company and waited for a call back. Meanwhile I also spoke to my home care director as I wasn't getting a prompt call back. She called the client family and spoke to the mother. (Wish she would have waited for me to hear from the vent supply company). The mother (who happens to be an RN) said "we've always had it this way" and claimed it wasn't a problem. The director told me they recently got in adaptors and would send one to her, but wasn't going to "shove it down their throat" (if the family doesn't want to change it).

Then I heard back from the RN at the equipment company who does this case... including the weekly circuit changes. (Not an RT as often is the case). She was angry with me and said she'd call the mother. Didn't offer any clinical advice.

Apparently this is how they've been setting it up, and all I did was cause a disturbance in bringing this up.

I still think the baby needs her nebs. I'm upset.

[sirI]

You've done about all you can do.

Let's hope they get the proper adaptor fitted.

You still a good job. Document.........

[Miriam57RN]

Well I cared for said client again today (my Saturday case) and yes, my concern was valid. She was not getting any of her neb meds with the neb "T" (I think this is also called a U-adapter) placed where it was - in the expiratory circuit.

It turns out it was the mother who had done a circuit change and put it in the wrong part of the circuit. The same night I posted here, the respiratory supply company called her back after I spoke to them, and told her to reposition it into the inspiratory circuit, confirming my message that the baby was not getting her treatments the way it was, so the problem was addressed that night though I didn't know until going back there today, and even though they all seemed to minimize my concern.

What a difference in the baby - no coughing spells, shortness or breath w/ anxiety, desats, and hardly needed any suctioning today.

So thanks again for well-timed advice - which was to call back the respiratory supply/ equipment company in the hopes of getting it dealt with that night. I had contacted them earlier while in the client's home and wanted to reposition it earlier but the mother didn't want this. One of the problems in home care is that you are in the client-family's domain.

[sirI]

EXCELLENT!!!! I am so glad you were on top of this. You did an excellent job of correcting a problem where there could have been an unfavorable outcome.

KUDOS TO YOU!!!!!