97% O2 with NRM

~agape~ · Apr 19, 2015

It is an open light weight mask with a shallow cup like piece in the center directing oxygen at the patient.
OxyMaskâ„¢ Adult | Medical Supplies | Southmedic
This site provides great info. Read the FAQs section and use it as a reference if your facility is interested or finally gets the Oxymask.
It has been around for over 10 years. It is great for ER patients because you don't have a tangled mess of different masks. The patient can still be examined, NT or oral suctioned, sip water and be weaned or increased without changing equipment. I love it for broncoscopy_ where I don't have to hold a mask near the patient when the nasal cannula is not enough.
It is great for bloody and packed noses aa well as mouth breathers.
And, it can be used with a humidifier. But, that part rarely gets mentioned if the facility still has NRB and simple masks around to avoid serious mishaps.
It is also available in pedi sizes and with an ETCO2 option.

Just checked out that link you provided and that mask is great on so many levels!!

akulahawkRN, ADN, RN, EMT-P · Apr 19, 2015

It is not so much the FiO2 which can cause the harm but the rebreathing of CO2. This will not be noticed by the SpO2 value until it is too late.
I am going to be the "2 L" thing has to do with the old training of no more than 2L for COPD patients regardless of device.
Because of so much confusion in O2 devices, NRMs and Simples masks ( and even Venti masks) should be banned. The Oxymask is safer.

That was the issue that I hadn't addressed yet. If you're attentive and if the patient is responsive to increasing pCO2 levels, you should see an increased respiratory rate and depth compared to prior to application of the NRM.

The OxyMask isn't the only design out that allows for some very high FiO2 concentrations and a quick check shows this. There seems to be at least one other design out that allows for EtCO2 monitoring at an FiO2 >90%. The OxyMask's website claims that their EtCO2 mask can't deliver an FiO2 >65%. That being said, I do like the idea of being able to stock only one device to replace non-EtCO2 monitoring oxygen delivery devices.

GrannyRRT · Apr 19, 2015

That was the issue that I hadn't addressed yet. If you're attentive and if the patient is responsive to increasing pCO2 levels, you should see an increased respiratory rate and depth compared to prior to application of the NRM..

Not necessarily. That would depend upon the situation and why the patient is requiring supplemental oxygen. Drug OD and neuro patients do not always respond as others with a normal unimpaired drive would. DKA would also give an increased rate and depth.

The OxyMask isn't the only design out that allows for some very high FiO2 concentrations and a quick check shows this. There seems to be at least one other design out that allows for EtCO2 monitoring at an FiO2 >90%. The OxyMask's website claims that their EtCO2 mask can't deliver an FiO2 >65%. That being said, I do like the idea of being able to stock only one device to replace non-EtCO2 monitoring oxygen delivery devices.

Please provide links to the other devices.

Since the Oxymask has been out for well over a decade, I am sure there are several devices coming on the market. I know Canada and Europe have been using other devices and they had been awaiting approval in the US.

Per the original post, the patient is on 2 L by whatever device. The beauty of the Oxymask is that it functions at 1 L and at 15 L. The actual FiO2 of any device that still allows entrainment of air will fluctuate with patient effort and positioning.

If the patient is requiring more than an FiO2 of 0.65 and requires continuous ETCO2 monitoring, it might be time to move on to another device such as a HFNC or even CPAP/BIPAP.

I might use the ETCO2 mask for some procedure which requires moderate sedation.

Whatever the situation, a high FiO2 mask is only a temporary measure and in the hospital we hopefully can take steps to either provide more support with ventilator assistive devices while also initiating treatment for the cause.

akulahawkRN, ADN, RN, EMT-P · Apr 19, 2015

Not necessarily. That would depend upon the situation and why the patient is requiring supplemental oxygen. Drug OD and neuro patients do not always respond as others with a normal unimpaired drive would. DKA would also give an increased rate and depth.
Please provide links to the other devices.
Since the Oxymask has been out for well over a decade, I am sure there are several devices coming on the market. I know Canada and Europe have been using other devices and they had been awaiting approval in the US.
Per the original post, the patient is on 2 L by whatever device. The beauty of the Oxymask is that it functions at 1 L and at 15 L. The actual FiO2 of any device that still allows entrainment of air will fluctuate with patient effort and positioning.
If the patient is requiring more than an FiO2 of 0.65 and requires continuous ETCO2 monitoring, it might be time to move on to another device such as a HFNC or even CPAP/BIPAP.
I might use the ETCO2 mask for some procedure which requires moderate sedation.
Whatever the situation, a high FiO2 mask is only a temporary measure and in the hospital we hopefully can take steps to either provide more support with ventilator assistive devices while also initiating treatment for the cause.

Here's one: Panoramic Oxygen Mask | Endoscopy Mask

As to the patient response to increasing pCO2, note that I said "should" and not something like "will." This is because I recognize that some patients can have their normal response to increasing pCO2 blunted via various means. IOW, the normal and expected response doesn't always happen.

The device linked above apparently delivers a 97% FiO2. I doubt it works quite as well at lower flow rates. I would say that it's more of an improved NRM design. The OxyMask's ability to be used over a wide flow range definitely makes it very attractive. I noticed that regardless of flow rate above 15 LPM, the FiO2 of the OxyMask doesn't go higher than 90%.

The mask I did link to above does have an EtCO2 port built in (no separate mask for EtCO2 monitoring) and the EtCO2 OxyMask won't deliver >65% FiO2 according to the manufacturer's own FAQ. The POM mask apparently can do EtCO2 monitoring at it's max FiO2 of 97%.

From a field provider standpoint, I'd love to be able to just purchase one device for most oxygen delivery needs, but only if that one device is less expensive than the combined cost of both a NRM and NC. Since the POM mask can't do low flow as the OxyMask can, I wouldn't buy the POM mask to replace both standard NRM and NC devices.

It'll be interesting to see what competition arrives on the scene in a few years... That could very easily change what we commonly use for oxygen therapy.

GrannyRRT · Apr 19, 2015

Here's one: Panoramic Oxygen Mask | Endoscopy Mask
As to the patient response to increasing pCO2, note that I said "should" and not something like "will." This is because I recognize that some patients can have their normal response to increasing pCO2 blunted via various means. IOW, the normal and expected response doesn't always happen.
The device linked above apparently delivers a 97% FiO2. I doubt it works quite as well at lower flow rates. I would say that it's more of an improved NRM design. The OxyMask's ability to be used over a wide flow range definitely makes it very attractive. I noticed that regardless of flow rate above 15 LPM, the FiO2 of the OxyMask doesn't go higher than 90%.
The mask I did link to above does have an EtCO2 port built in (no separate mask for EtCO2 monitoring) and the EtCO2 OxyMask won't deliver >65% FiO2 according to the manufacturer's own FAQ. The POM mask apparently can do EtCO2 monitoring at it's max FiO2 of 97%.
From a field provider standpoint, I'd love to be able to just purchase one device for most oxygen delivery needs, but only if that one device is less expensive than the combined cost of both a NRM and NC. Since the POM mask can't do low flow as the OxyMask can, I wouldn't buy the POM mask to replace both standard NRM and NC devices.
It'll be interesting to see what competition arrives on the scene in a few years... That could very easily change what we commonly use for oxygen therapy.

Field provider? Okay, I didn't go into all of the many different specialty devices we use in the ORs, bronch suites and ICUs because they usually have an RT, CRNA or anesthesiologist at the bedside. We have devices to do bronchs on BIPAP and ventilator patients also. But, these devices are kept in limited access areas since they do require close observation, trained providers and are very expensive because of the specialty label. We also have special ETTs for different purposes and have had them for several decades.

I will say many of us are kicking ourselves for not patenting the modified NRM which is now the Panoramic mask. For many years some did cut holes in the NRB to accommodate for various procedures and to monitor ETCO2.

For more common use we do have the Oxymizer NC for comfort, ambulation, home care and Pulmonary Rehab where there is a need to spare the portable O2 tank. It is low flow and still expensive. Pilots also use it and aviation was where it had its start.

I doubt if an expensive specialty device would be necessary for most EMS patients. Even for CCT, the Paramedics will toss the Oxymask in the trash which we might have at 6 L and place a NRM because "it looks funny" when they do the interfacility transport. This is even after attempts at education and even giving them a case of Oxymask. Some will put a 6 L NC under a Simple Mask or NRM, even for low FiO2 requirements, for more flow instead of using a high flow entrainment device (various venture systems). Others will try to run a regular Nasal Cannula at 15 L/M and miss how a HFNC works or its intended purpose. Change is slow even if something has been around for years.

In the hospital we have had to keep the Oxymask also under lock and key because people didn't like its looks and would rip open the package and discard it even though we have been trying to provide education. It is also rare that respiratory equipment vendors are invited to share the latest and greatest with nursing staff. Purchasing and a nurse manager makes the equipment decision based on cheapest for the budget and "what has always been used". I hate moonlighting in hospitals which have O2 devices controlled by nursing in the ED and on the floors.

I will say again, in the hospital, if the patient needs an FiO2 of 1, it is time to consider using another device and getting aggressive in treatment. They also will probably have someone specialized in respiratory equipment who has the keys to the cabinet with the cool stuff or the ability to provide other interventions.

For now hopefully at least in the urban areas, EMS can get by with NRMs or maybe consider intubation if a patient requires an FiO2 of close to 1.

If you have access to a large hospital, you might be able to get an RT, CRNA or Anesthesiologist to show your their airway cart and special equipment room. Chances are a smaller hospital will have a more limited budget but may still have some interesting stuff in their carts. If RT is under nursing, chances are their department will be more limited the exception of the bronchoscopy and endoscopy cart. You might be able to attend a state or national RT conference which usually will have over 300 vendors of specialized RT and anesthesia equipment. Go in as guest nonRT or nonRN so you won't have to pay the expensive conference fees for CEs. You might be able to get in for the student price.

brandiep1982 · Apr 19, 2015

I tried to put him back on the nasal cannula, & he would desat once again. Lungs were clear, no changes in mental status. Only issue was that off of the NRM he would desat. He does have COPD, CXR ordered, already on Xanax.

Are his nasal passages blocked?

AnnieOaklyRN, BSN, RN, EMT-P · Apr 25, 2015

This post makes no sense. If you put someone on a non-rebreather they are essentially getting less oxygen then they would in the atmosphere at 2 LPM, not to mention the CO2 retention.

Treat the patient not the monitor! My guess is you were getting an inaccurate reading intermittently. Was the patient having any signs or symptoms of respiratory distress?

Annie

Donnie-RN · Apr 27, 2015

Is the pulse ox reliable? Some of the peel and stick type we use can be a bit flakey and cause a poor pleth, resulting in low sats.