Non-rebreather use?

FlyingScot, RN · Jan 12, 2013

Right system wrong liter flow. A non-rebreather requires 10-15 lpm.

akulahawkRN, ADN, RN, EMT-P · Jan 12, 2013

I used a non re-breather mask with 5L O2 with a Pt who was mottled, RR 28-32, O2Sat 88. I couldn't find a regular mask and my thought was that he was mouth breathing so a canula wouldn't have done much good.
Did I use the right O2 delivery system or should I have used the canula?

With a non-rebreather mask, you should be using O2 flows >10LPM, and more like 15 LPM. The NRB requires higher flow rates because when the patient inhales, the reservoir bag deflates, and at lower flow rates, the bag will completely deflate and cut off supplemental O2 flow. Those masks aren't completely sealed, so the patient will continue to breathe room air once the reservoir bag is empty. It will partially refill (at 5LPM) during the expiratory phase and then collapse again during the next inspiratory phase. Run the mask at around 10-15 LPM, and it'll be difficult to completely collapse the bag.

To prevent reservoir bag collapse at lower flow rates, take the rubber tabs off the side of the mask and that will make it function like a simple mask, with the typical flow rates you can use with those. "Room air" will be more easily inspired and will mix with the O2 in the mask. The concentration of O2 will be lower than with a fully-functioning NRB at a high flow rate. Depending upon the patient's work of breathing, I might start off with a nasal cannula and "upgrade" the O2 delivery device & concentration based on the response.

Personally, I'd have likely started off with a cannula and titrated up from there, if the patient's status warranted starting that low.

All the above assumes that I have orders to allow me to use oxygen to maintain SpO2 by using any of the above methods of delivery.

FlyingScot, RN · Jan 12, 2013

Great explanation Akulahawk! OP Given your description of the patient I still think the NRB was a good choice had it been used correctly.

akulahawkRN, ADN, RN, EMT-P · Jan 12, 2013

Great explanation Akulahawk! OP Given your description of the patient I still think the NRB was a good choice had it been used correctly.

@FlyingScot: Thanks! If the patient was complaining of any shortness of breath, difficulty breathing, or had any increased work of breathing, I would have likely started off with the NRB and an O2 flow probably around 15 LPM and titrated from there. What's missing, of course, is the patient's history. If the patient had any history of COPD (especially if it's been a VERY long time), I might be a bit more careful about providing high concentrations of oxygen to the patient. It's possible, but not often likely, that a high concentration of oxygen will shut down the respiratory drive. This isn't something that happens really fast. Just keep a closer eye on those patients and be prepared to take over with the BVM.

I have worked with patients that presented with VS as the OP wrote... and some I've used the NC and some I've used the NRB. It all really depends upon the total clinical picture as to which modality I choose initially.

To kind of echo FlyingScot, the NRB very easily could have been appropriate, it just needs the proper O2 flowrate to be safely used.

Do_Good · Jan 12, 2013

To prevent reservoir bag collapse at lower flow rates, take the rubber tabs off the side of the mask and that will make it function like a simple mask, with the typical flow rates you can use with those. "Room air" will be more easily inspired and will mix with the O2 in the mask. The concentration of O2 will be lower than with a fully-functioning NRB at a high flow rate. Depending upon the patient's work of breathing, I might start off with a nasal cannula and "upgrade" the O2 delivery device & concentration based on the response.
Personally, I'd have likely started off with a cannula and titrated up from there, if the patient's status warranted starting that low.

Thanks for the tip about taking off the rubber tabs. I work in a facility with minimal equipment and we have to work with what we have. I had looked for a simple mask but couldn't find one.

FlyingScot, RN · Jan 12, 2013

A respiratory rate as high as reported by the OP qualifies as respiratory distress and the mottled skin is concerning for circulatory shut down. The oximetry of 88% is less of a worry for me because honestly it's not that low. In addition, the theory that giving COPD patients high flow 02!will shut down their respiratory drive is a myth that has been disproven over and over. I would certainly hope that this patient was transported immediately or a rapid response was called that would limit the possibility of the need for high flow 02 for any length of time. Despite this, I still stand by my praise of your post. You gave a lot of good information.

SionainnRN · Jan 12, 2013

Yep like the others said, you were fine with the NRB but too low on your O's. Next time take a good look at the NRB and make sure the bag is filled, it won't hurt anything by having the O's up more than the pt may need because of the equipment you have. I would assume the pt still felt like they couldn't breathe with the O's that low.

blondy2061h, MSN, RN · Jan 12, 2013

Many RTs have assured me again and again that NC's still provided oxygen even if the patient is mouth breathing. If you don't have adequate equipment you have to work with what you have.