The Center for Disease Control and Prevention (CDC) gives emergency responders tips for taking care of themselves:
It recommends to limit working hours to no longer than 12-hour shifts, try to work in teams, and talk to family, friends, and teammates about feelings and experiences.
Healthcare providers work under stress witnessing human suffering and risking their lives on a regular basis along with intense workloads, life-and-death decisions, and separation from family specially during the COVID-19 pandemic.
It is important to identify emotional and mental health issues like burnout and secondary traumatic stress. Coping techniques like taking breaks, eating healthy foods, exercising, and using the buddy system can help prevent and reduce emotional distress.
Mechanical ventilators offer a safe alternative to manual ventilation with controlled Vt and RR.
Even though bag-valve-mask (BVM) system is one of the most common devices used to provide ventilation during transports, manual ventilation or BVM resuscitation (with conventional devices) has shown that:
It is complicated since it requires some level of expertise and is not recommended to be performed by a single provider.
It has variable outcomes depending on the rescuer performance.
It may cause adverse clinical consequences due to hyperventilation or hypoventilation.
It makes it difficult to reach the standards in terms of tidal volume (Vt) and respiratory rate (RR).
It may expose patients to overpressure and overinflation.
It does not allow adequate patients’ monitoring.
O-Two Medical Technologies Inc. has overcome the challenges of manual ventilation with the SMART Bag® MO Bag-Valve-Mask Resuscitator; however, this BVM controls flow assisting the rescuer to deliver proper RR and Vt. It does not eliminate the variability on the squeeze method given by the operator specially under hectic environments and difficult clinical conditions that affect ventilation parameters inadvertently.
In consequence, mechanical ventilation with portable devices have become the preferred method for transporting patients in prehospital environments. Mechanical ventilators offer a safe alternative to manual ventilation and allow healthcare professionals to deliver consistent care and controlled Vt and RR.
e-Series automatic transport ventilators offered by O-Two Medical Technologies Inc. provide controlled ventilation for resuscitation and patient transport. These ventilators ensure standardization of ventilation and adherence to international guidelines as they count with all necessary and desirable features for prehospital positive-pressure treatment.
Acute respiratory failure is a common life-threatening medical emergency. Non-invasive positive pressure ventilation provides respiratory support through a tight-fitting mask usually applied around the patient’s mouth and nose. It is used in the emergency department (ED), but it is more effective if the ventilatory support is initiated by emergency medical services during transport. For more than two decades, prehospital continuous positive airway pressure (CPAP) ventilation has been evaluated around the world, these trials were small and the findings were not consistent. However, in recent years, large controlled randomized trials have shown that the use of CPAP, by appropriately trained EMS, is effective in reducing respiratory symptoms in patients with acute respiratory distress. In general, studies showed that prehospital CPAP is a cost-effective coadjutant treatment that improves physiologic parameters, and reduces endotracheal intubation and mortality rates. Implementing CPAP as a prehospital support requires additional training and equipment for paramedics, but patients’ clinical outcomes outweigh training costs, by reducing significantly hospital admissions and shortening times in the ED.
In-hospital acute pulmonary edema
Acute cardiogenic pulmonary edema is a common cause of respiratory distress in patients presenting to the emergency department (ED). Patients with less severe symptoms of acute heart failure may respond to conventional treatment with oxygen, diuretics, and vasodilators1,2. However, patients with severe respiratory compromise may require endotracheal intubation and mechanical ventilation. Invasive ventilatory support has been associated with significant morbidity, such as nosocomial pneumonia, increased need for sedation, and thus the longer duration of ventilation1,3.
Since 1998, there have been several studies comparing noninvasive positive pressure ventilation (NIPPV) in addition to standard medical therapy versus standard medical therapy alone in an attempt to clarify the role of noninvasive ventilation in cardiogenic pulmonary edema. These trials suggested a decreased rate of intubation with NIPPV compared with standard medical therapy only1,2.
It can be estimated that early application of noninvasive ventilation in the ED can decrease the relative risk of mortality by 39% and the necessity of endotracheal intubation by 57%4. Collings et al. suggest that noninvasive ventilation with standard medical therapy is advantageous over standard medical therapy alone in ED patients with acute cardiogenic pulmonary edema1.
NIPPV should be the first option for ventilatory support for patients with either a severe exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema in ED5. In-hospital noninvasive ventilation such as continuous positive airway pressure (CPAP) safely provides earlier improvement and resolution of dyspnea, respiratory distress, and metabolic abnormalities than does standard oxygen therapy1,3,6. Therefore, CPAP should be considered as adjunctive therapy in patients with acute cardiogenic pulmonary edema who have severe respiratory distress or whose condition does not improve with pharmacologic therapy3,6.
Acute pulmonary edema in prehospital settings
Complaints of respiratory distress place a significant burden on already strained health care systems. Recent estimates place the annual cost of hospitalizations due to acute decompensated heart failure2 and exacerbation of chronic obstructive pulmonary disease in excess of $18 and $20 billion, respectively. Intensive care unit admission is the basis of the majority of these costs. Within emergency medical services (EMS) systems, complaints of respiratory distress account for 13% of total EMS response calls7.
In the United States, approximately 1 million patients per year are treated by paramedics for acute congestive heart failure. The associated morbidity and mortality are significant, as is the overall cost on the health care system8,9. The most optimal prehospital management protocol of these patients remains a work in progress; historically, EMS would center the acute pulmonary edema treatment on the use of oxygen, nitrates, diuretics, and morphine. Nevertheless, patients with severe symptoms whose respiratory efforts are failing are in need of some degree of immediate ventilatory support9. The aim of prehospital care is to stabilize patients as quickly as possible without endangering them through the measures performed in this context. Patients with acute pulmonary edema usually receive positive-pressure ventilation by bag-valve-masks or tracheal intubation in the out-of-hospital setting before their arrival at the ED10. Out-of-hospital intubation attempts in non–cardiac arrest patients are less successful and have higher rates of serious complications such as aspiration of gastric contents, hypoxia, failed intubation, hypotension, or circulatory arrest9,10, than those performed in the ED. For EMS it is therefore particularly important to have strategies for circumventing these risks, if possible. In addition, patients arriving at the ED already intubated may be more likely to remain so, thus exposing them to the risk of hospital-acquired pneumonia while being mechanically ventilated in the ICU, potentially doubling their mortality risk10.
Prehospital CPAP in acute pulmonary edema
In 2001, Kosowsky et al.6 described initial experiences with the prehospital use of CPAP for patients with respiratory failure and presumed pulmonary edema. The authors reported a preliminary case series and explained that although the decision to use CPAP is dependent on a variety of factors, the presumption is that the earlier therapy is instituted, the greater the likelihood of averting endotracheal intubation. Early NIPPV before arrival at the ED does improve acute symptoms in patients with acute cardiogenic pulmonary edema predominantly in regard to decreases in patient-reported dyspnea and improvements in vital signs11,12.
Years later, in 2006, Hubble et al.13 found substantial differences in outcomes when comparing CPAP and conventional therapy in the management of prehospital acute pulmonary edema. Patients treated with CPAP had reduced mortality and a lower rate of endotracheal intubation2,8,9,12-14,16-18. Furthermore, when compared with patients treated only with standard medical therapy, CPAP patients showed a greater degree of improvement in most physiologic variables, including dyspnea score7,11,13,20. With the use of CPAP, patients improved more quickly and allowed less admissions and shorter times in the ED22. Also, prehospital CPAP appears to be a cost-effective treatment; the cost per additional life saved is minimal, while the cost savings realized through reducing the need for intubation and mechanical ventilation are substantial21.
A decade after, Brusasco et al.23 showed that NIPPV reduces the need for endotracheal intubation, the occurrence of nosocomial infections, and both morbidity and mortality associated with respiratory failure. The benefits of NIPPV are greater if started early, thus constituting the rationale for the increasing use of NIPPV in prehospital and emergency department settings. Moreover, immediate use of CPAP in out-of-hospital treatment of acute pulmonary edema and until the condition resolves after admission significantly improves early outcome compared with medical treatment alone7,16,24. Modern systems for delivering CPAP are compact, affordable and simple to operate, making the prehospital use of CPAP conceivable6,11,25.
For patients with acute respiratory failure and presumed pulmonary edema, the prehospital use of CPAP is feasible, beneficial, and may avert the need for invasive ventilation1,6,9,13,22. Most prehospital CPAP are oxygen-driven and deliver a variable concentration of supplemental inspired oxygen titrated upon patient’s SpO2. With concerns about the use of high oxygen concentration and detrimental effects of hyperoxygenation, Bledsoe et al.11 studied the effect of prehospital low-fractional oxygen delivery CPAP. The authors concluded that low-fractional oxygen is highly effective, it improves patients’ symptoms, respiratory rate and SpO26,8. It is important to highlight that current disposable CPAP open-systems use low flow and access to ambient air to achieve oxygen concentrations lower than 100%, as an example 54% at 10 cmH2O, as the O-Two Single Use CPAP26.
Even though results may vary depending on the healthcare context, EMS team and specific regional protocols27-29, paramedics can be trained to use CPAP for patients in severe respiratory failure9. There is an absolute reduction in tracheal intubation rate of 30%25 and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who receive CPAP instead of usual medical care9.
Emergency medical services systems should consider making CPAP available as part of the treatment for out-of-hospital severe respiratory distress patients9. The effectiveness of a basic affordable device on a respiratory disorder and its associated outcomes makes the use of prehospital CPAP plausible and beneficial25. All paramedic/EMS should receive appropriate training20, and several studies found no significant difference in the compliant use of prehospital CPAP between paramedics trained to primary care paramedic (PCP) level and those trained to the advanced care paramedic level20,30, these results suggest that CPAP use by PCP-level paramedics may be feasible and safe20. In 2021, Finn et al.31 conducted a large prehospital randomized controlled trial which showed that the use of CPAP by EMS paramedics was more effective than usual care in reducing dyspnea and tachypnea in patients with acute respiratory distress, with no increased risk of adverse outcomes. The authors concluded that CPAP is a safe and effective prehospital intervention for symptom management in patients with acute respiratory distress. They recommend CPAP to be included as an option for managing dyspnea in selected patients in the clinical practice guidelines of EMS.
In conclusion, implementing prehospital CPAP support ventilation in patients suffering from acute pulmonary edema will improve their clinical condition more quickly, reduce hospital admissions and shorter times in the ED. Most of the studies point towards an absolute reduction of endotracheal intubation and mortality rates as well.
References
Collins S P, Mielniczuk L M, Whittingham H A, et al. The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: A systematic review. Ann Emerg Med, 48:3, 2006.
Finn J C, Brink D, Mckenzie N, et al. Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial. Emerg Med J, 0:1–8, 2021.
Gray A, Goodacre S, Newby D E, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med, 359:142-51, 2008.
Pandor A, Thokala P, Goodacre S, et al. Pre-hospital non-invasive ventilation for acute respiratory failure: A systematic review and cost-effectiveness evaluation. Health Technol Assess, 19:42, 2015.
Keenan S P, Sinuff T, Burns K E A, et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting CMAJ, 183:3, 2011.
Kosowsky J M, Stephanides S L, Branson R D, et al. Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: A preliminary case series. Prehosp Emerg Care, 5:2, 2001.
Aguilar S A, Lee J, Castillo E, et al. Assessment of the addition of prehospital continuous positive airway pressure (CPAP) to an urban emergency medical services (EMS) system in persons with severe respiratory distress. J Emerg Med, 45:2, 2013.
Dib J E, Matin S A, Luckert A. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure. J Emerg Med, 42:5, 2012.
Thompson J, Petrie D A, Ackroyd-Stolarz S, et al. Out-of-hospital continuous positive airway pressure ventilation versus usual care in acute respiratory failure: A randomized controlled trial. Ann Emerg Med, 52:3, 2008.
Luiz T, Kumpch M, Gruttner J, et al. CPAP Therapy by emergency physicians in patients with acute respiratory failure due to acute cardiogenic pulmonary edema or acutely exacerbated COPD. in vivo 30: 133-140, 2016.
Bledsoe B E, Anderson E, Hodnick R, et al. (2012) Low–fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. Prehosp Emerg Care, 16:2, 2012.
Simpson P M, Bendall J C. Prehospital non-invasive ventilation for acute cardiogenic pulmonary oedema: An evidence-based review. Emerg Med J, 28:609e612, 2011.
Hubble M W, Richards M E, Jarvis R, et al. Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care, 10:4, 2006.
Goodacre S, Stevens J W, Pandor A, et al. Prehospital noninvasive ventilation for acute respiratory failure: Systematic review, network meta-analysis, and individual patient data meta-analysis. Acad Emerg Med, 21:9, 2014.
Dib J E, Matin S A, Luckert A. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure. J Emerg Med, 42:5, 2012.
Ducros L, Logeart D, Vicaut E, et al. CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac intensive care unit: a randomised multicentre study. Intensive Care Med, 37:1501–1509, 2011.
Frontin P, Bounes V, Houzé-Cerfon C H, et al. Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study. Am J Emerg Med, 29:7, 2011.
Hastings D, Monahan J, Gray C, et al. CPAP. A supportive adjunct for congestive heart failure in the prehospital setting. JEMS, 23:9, 1998.
Williams T A, Finn J, Perkins G D, et al. Prehospital continuous positive airway pressure for acute respiratory failure: A systematic review and meta-analysis. Prehosp Emerg Care, 17:2, 2013.
Sahu N, Matthews P, Groner K, et al. Observational study on safety of prehospital BLS CPAP in Dyspnea. Prehosp Disaster Med, 32:6, 2017.
Hubble M W, Richards M E, Wilfong D A. Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care, 12:3, 2008.
Warner G S. Evaluation of the effect of prehospital application of continuous positive airway pressure therapy in acute respiratory distress. Prehosp Disaster Med, 25:1, 2010.
Brusasco C, Corradi F, De Ferrari A, et al. Devices for emergency prehospital use: A bench study. Respir Care, 60:12, 2015.
Nielsen V M L, Madsen J, Aasen A, et al. Prehospital treatment with continuous positive airway pressure in patients with acute respiratory failure: A regional observational study. Scand J Trauma, Resusc, 24:121, 2016.
Knox N, Chinwe O, Themba N, et al. Relationship between intubation rate and continuous positive airway pressure therapy in the prehospital setting. World J Emerg Med, 6:1, 2015.
O_Two Emergency Single Use CPAP. https://otwo.com/products/immediate-care/emergency-cpap/o_two-single-use-cpap/. Accessed on August 2021.
Cheskes S, Turner L, Thomson S, et al. The impact of prehospital continuous positive airway pressure on the rate of intubation and mortality from acute out-of-hospital respiratory emergencies. Prehosp Emerg Care, 17:4, 2013.
Willmore A, Dionne R, Maloney J, et al. Effectiveness and safety of a prehospital program of continuous positive airway pressure (CPAP) in an urban setting. CJEM, 17:6, 2015.
Bakke S A, Botker M T, Riddervold E S, et al. Continuous positive airway pressure and noninvasive ventilation in prehospital treatment of patients with acute respiratory failure: a systematic review of controlled studies. Scand J Trauma, Resusc, 22:69, 2014.
Cheskes S, Thomson S, Turner L. Feasibility of continuous positive airway pressure by Primary Care Paramedics. Prehosp Emerg Care, 16:4, 2012.
Finn J C, Brink D, Mckenzie N, et al. Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: A randomised controlled trial. Emerg Med J, 0:1–8, 2021.
O-Two Medical has partnered with the Province of Ontario to manufacture 10,000 ventilators to equip doctors fighting the COVID-19 crisis. With the support of Canada’s largest automotive suppliers, we will make sure that this important life-saving equipment gets into the hands of the healthcare professionals who need it now.
The entire team at O-Two is dedicated to fulfilling this historic
undertaking around the clock. Mitigating the risk of contamination is paramount
to achieving this goal. As such will not be doing media interviews at this
time. We sincerely hope you understand, we are all in this together.
Since 1971 O-Two Medical Technologies has produced state-of-the-art products for the provision of Emergency Respiratory Care and Inhalation Analgesia.
Exporting to over 60 countries and possessing more
than 40 patents worldwide, we offer solutions in Automatic and Manual
Ventilation, Inhalation Analgesia and Oxygen Administration. Our manufacturing
and research-and-development facilities are registered to the ISO 13485 Quality
system (MDSAP) as well as Health Canada (HC), European (CE) and US (FDA)
medical device requirements.
Nitrous oxide/Oxygen N2O/O2) is a medical gas mixture that is both a sedative and an analgesic. In the pre-hospital emergency field, the gas mixture is widely used around the world by ambulances services. The gas primarily delivered in these markets in a pre-mixed, 50%/50% N2O/O2 mixture. Its efficacy and safety are well documented. Because the route of administration is by patient-controlled inhalation, the gas mixture is ideal for short duration patient rescues and transports. [read more=”Read more” less=”Read less”]
The gas is delivered to the patient via a demand valve which reacts to the patient’s inspiratory effort and provides a flow rate equivalent to that demanded. When the patient stops inhaling, the gas ceases to flow.
The gas is supplied either in a 50/50 premixed state in a single cylinder or can be supplied from individual cylinders of N2O and O2 using a blender. Regardless of the delivery method, in the pre-hospital environment, these two gasses are always provided in a 50/50 mix.
How it Works
The way that the active ingredient, N2O works is not completely understood however it does increase the activity of the principal inhibitory neurotransmitter, causes the release of endogenous opioids and causes dopamine release. Very little N2O is absorbed by the body. A person inhaling N2O breathes out most of it as it is not metabolized. The peak effect is quickly reached within 2–5 minutes and its duration of action is about the same. Side effects include light-headedness, headache, dizziness, confusion, nausea, and vomiting, as well as feelings of euphoria.
Indications
N2O/O2 Analgesic Gas is delivered, on demand, to a conscious, spontaneously breathing patient.
The gas is suitable for use in:
Pre-hospital (emergency medical) use, and
In-hospital use (ER, Labor and Delivery etc.)
Contraindications
The contraindications for this gas mixture include, but may not be limited to:
Hypersensitivity to the medication
Head injuries with impaired consciousness
Maxillofacial injuries
Artificial, traumatic or spontaneous pneumothorax
Air embolism
Middle ear occlusion, ear infection
Decompression sickness
Abdominal distension / intestinal obstruction
N2O/O2 mixtures must never be used in any condition where air is trapped in the body and expansion (up to 3x original size) would be dangerous.
NOTE: Without supplemental oxygen, inhaling nitrous oxide can cause hypoxia
Occupational Exposure
Prolonged or repeated exposure to laughing gas can lead to a vitamin B deficiency, reproductive problems in pregnant women, and numbness. Because very little nitrous oxide is absorbed by the body, a person inhaling the gas breathes out most of it. This will then contaminate the environment unless adequate ventilation or gas scavenging is employed.
Because the gas is heavier than air the vehicle should be well ventilated otherwise the gas may present risks to emergency personnel, through both short-term intoxication and long-term cumulative exposure. However, Scavenger systems exist and should be used to vent the gas outside the vehicle.
Conclusions
Nitrous oxide can be safely and effectively used in the prehospital environment. As the gas is not routinely used, the exposure to its effects by EMS personnel is both limited and of short duration. Precautions however should be taken to avoid a build-up of the exhaled gas in confined spaces (such as the back of an ambulance). These precautions can be as simple as the use of the ambulance ventilation system or the use of a dedicated scavenging system.
It’s sedative and analgesic effects are similar to that of opiates; however, nitrous oxide doesn’t require an IV and is self-administered by the patient. N2O/O2 mixtures are a safe, effective and inexpensive tool for the control of pain in the pre-hospital environment.
In this article, we will review the various types of automatic ventilators but limit the discussion to those suitable for pre-hospital use (automatic transport ventilators or ATVs).
The adoption of ATVs has been slower in North America than most other markets worldwide. This seems quite odd when a lead in technology is taken in other areas to improve patient outcomes and/or assist rescuers. We look to automate defibrillation, pulse checking and recently compressions but when it comes to the most essential chain of survival link (breathing) many EMS departments tender for the cheapest “bag”. It is also not uncommon for services that have invested in automatic ventilators/resuscitators to leave the choice of their use up to the scene personnel (automatic ventilator or bag-valve-mask) despite the documented difficulties of delivering proper ventilation with a bag-valve-mask. Can you imagine giving EMS personnel the option of chest pounding versus an AED? [read more=”Read more” less=”Read less”]
In this article we will review the various types of automatic ventilators but limit the discussion to those suitable for pre-hospital use (automatic transport ventilators or ATVs).
The adoption of ATVs has been slower in North America than most other markets worldwide. This seems quite odd when a lead in technology is taken in other areas to improve patient outcomes and/or assist rescuers. We look to automate defibrillation, pulse checking and recently compressions but when it comes to the most essential chain of survival link (breathing) many EMS departments tender for the cheapest “bag”. It is also not uncommon for services that have invested in automatic ventilators/resuscitators to leave the choice of their use up to the scene personnel (automatic ventilator or bag-valve-mask) despite the documented difficulties of delivering proper ventilation with a bag-valve-mask. Can you imagine giving EMS personnel the option of chest pounding versus an AED?
Perhaps it is a misunderstanding on what ATVs are, how they function or memories of the dangers from the original manually triggered devices from 30 years ago. A true, safer “automatic” ventilator should perform the following without manual intervention:
Deliver the proper breath frequencies
Deliver appropriate tidal volumes
Limit peak airway pressures
Provide proper inspiratory/expiratory ratios
ATVs basically do what trained EMS personnel try to do with a BVM but which is next to impossible to achieve in the field. If artificial ventilation were being provided to a 100 kilogram (200 lb.) adult, the patient should receive 10 breaths in a minute and a 600-700 ml tidal volume in 2 seconds per breath and be provided with an expiratory time of 4 seconds. The peak airway pressure should be less than 19 cmH2O to avoid gastric insufflation. How many EMS Providers would honestly be able to achieve and sustain these parameters over the period it takes to manage and transport a patient to the hospital? ATVs can.
There are two primary types of ATVs for pre-hospital resuscitation. Those that operate with micro-pneumatics (or compressed gas) and those powered electronically by batteries.
Manually triggered oxygen-powered devices: In the USA, these devices are sometimes referred to as demand valves (see true description below) and while they provide some advantages to both rescuers and patients over BVMs, they do not “automatically” deliver set tidal volumes, frequencies or I:E ratios. A manual button delivers positive pressure gas when pressed and stops the flow when released. They should deliver no more than 40 L/min in this mode and have a pressure relief valve to prevent over inflating the lungs (unlike early models).
Demand valves: A proper definition of a demand valve is a device that will provide gas flow when negative pressure (inhalation) is applied at the rate “demanded”. SCBAs and SCUBA valves are examples but are of no use to a patient who cannot breath (inhale) on their own.
CPAP Devices: CPAP is an acronym for continuous positive airway pressure. They are therapy devices for patients with difficulty breathing (COPD as an example) versus those in respiratory arrest. While an ATV may have CPAP as an option, a “CPAP-only” device should not be used for resuscitation during CPR.
NOTE: Pressure cycled devices: These devices fall into a “gray” area in terms of defining them as ATVs or not. They are sometimes positioned for use during CPR but manufacturers of such go to great lengths to point out that they are neither “vents” nor demand valves. They work by cycling oxygen (or turning on and off) based on changes in a patient’s airway pressure. Positive pressure oxygen is initiated at one preset limit and delivered until the airway pressure reaches a higher level where it shuts off. Pressure cycled devices can create varied respiratory rates as they try to provide ventilation. When being used during CPR, they cannot “time” breaths, making it difficult to achieve a 15:2 compressions to breaths rate. A second issue is in dealing with an airway obstruction or poor compliance. They can turn on and off quickly, which can lead to either inadvertently hyperventilating or hypo ventilating a patient (the problem we are trying to resolve through the use of an ATV). The CPR Guidelines state that “pressure cycled devices are obsolete and should not be used during
Perhaps it is a misunderstanding on what ATVs are, how they function or memories of the dangers from the original manually triggered devices from 30 years ago. A true, safer “automatic” ventilator should perform the following without manual intervention:
Deliver the proper breath frequencies
Deliver appropriate tidal volumes
Limit peak airway pressures
Provide proper inspiratory/expiratory ratios
ATVs basically do what trained EMS personnel try to do with a BVM but which is next to impossible to achieve in the field. If artificial ventilation were being provided to a 100 kilogram (200 lb.) adult, the patient should receive 10 breaths in a minute and a 600-700 ml tidal volume in 2 seconds per breath and be provided with an expiratory time of 4 seconds. The peak airway pressure should be less than 19 cmH2O to avoid gastric insufflation. How many EMS Providers would honestly be able to achieve and sustain these parameters over the period it takes to manage and transport a patient to the hospital? ATVs can.
There are two primary types of ATVs for pre-hospital resuscitation. Those that operate with micro-pneumatics (or compressed gas) and those powered electronically by batteries.
Manually triggered oxygen-powered devices: In the USA, these devices are sometimes referred to as demand valves (see true description below) and while they provide some advantages to both rescuers and patients over BVMs, they do not “automatically” deliver set tidal volumes, frequencies or I:E ratios. A manual button delivers positive pressure gas when pressed and stops the flow when released. They should deliver no more than 40 L/min in this mode and have a pressure relief valve to prevent over inflating the lungs (unlike early models).
Demand valves: A proper definition of a demand valve is a device that will provide gas flow when negative pressure (inhalation) is applied at the rate “demanded”. SCBAs and SCUBA valves are examples but are of no use to a patient who cannot breath (inhale) on their own.
CPAP Devices: CPAP is an acronym for continuous positive airway pressure. They are therapy devices for patients with difficulty breathing (COPD as an example) versus those in respiratory arrest. While an ATV may have CPAP as an option, a “CPAP-only” device should not be used for resuscitation during CPR.
NOTE: Pressure cycled devices: These devices fall into a “gray” area in terms of defining them as ATVs or not. They are sometimes positioned for use during CPR but manufacturers of such go to great lengths to point out that they are neither “vents” nor demand valves. They work by cycling oxygen (or turning on and off) based on changes in a patient’s airway pressure. Positive pressure oxygen is initiated at one preset limit and delivered until the airway pressure reaches a higher level where it shuts off. Pressure cycled devices can create varied respiratory rates as they try to provide ventilation. When being used during CPR, they cannot “time” breaths, making it difficult to achieve a 15:2 compressions to breaths rate. A second issue is in dealing with an airway obstruction or poor compliance. They can turn on and off quickly, which can lead to either inadvertently hyperventilating or hypo ventilating a patient (the problem we are trying to resolve through the use of an ATV). The CPR Guidelines state that “pressure cycled devices are obsolete and should not be used during CPR.
All other days over the festive season we will be open from 8 am to 4 pm EST.
May we take this opportunity to wish all our customers, clinicians, and distributors allthe best of the season and a happy, healthy and prosperous 2020
O-Two Medical will be part of the Medica Trade Fair 2019. Find us at Hall 11 / C75. The event is taking place in Düsseldorf, Germany from November 18th to 21st.
O-Two Medical is present at EMS World Expo 2019, hosted in partnership with the National Association of Emergency Medical Technicians (NAEMT). Helton Santos and Cheryl Wise are representing the company at the event, that takes place in New Orleans, from October 14th to 18th, 2019. Visit us at Booth 1237.
O-Two Medical is present at OAPC 2019 Fall Education Summit and Annual General Meeting, organized by ONTARIO ASSOCIATION OF PARAMEDIC CHIEFS. Helton Santos is representing the company at the event, that takes place at Caesars Windsor – Windsor, Ontario, from September 24th to 26th, 2018.
Charlottetown, Prince Edward Island | June 12 – 14, 2019
Our Anita Bekavac and Paul Kahale will be exhibiting at the Paramedic Chiefs Conference next week at the Delta Hotel Prince Edward in Charlottetown. They will be at booth # 33 so do drop by to see the latest in resuscitation and ventilation products.
The use of a Breathing System Filter or BSF (commonly available in all hospitals) placed
between the facemask or bite block, and the Equinox® II Demand Valve, removes the need
to disassemble and disinfect the patient valve and diaphragm. Any pathogens present in the
expired air are removed by the filter eliminating the risk of cross infection. [read more=”Read more” less=”Read less”]
After use the facemask may be disinfected or disposed of or the bite block discarded. The
outside of the demand valve body, gas supply tubing and patient valve can simply be wiped
over with a hard surface disinfect in line with standard department protocols. Not only does
the use of a BSF significantly reduce the downtime of the device between patients, it also
limits the need for replacement parts (diaphragm and Patient Valve Housing) for the device.
The use of standard respiratory disposables also removes the need to stock proprietary items
which have only one use.
NOTE: Only filters complying with ISO 23328 should be used.
Congestive Heart Failure (CHF) defined as, “excessive blood or fluid in the lungs or body tissues caused by the failure of ventricles to pump blood effectively”. The condition is termed congestive because the fluids congest, or clog the organs. It is termed heart failure because the congestion both results from and also aggravates failure of the heart to function properly. [read more=”Read more” less=”Read less”]
CHF occurs when the left ventricle cannot pump out the amount of blood entering the ventricle, or when the ventricle is damaged and cannot effectively pump enough blood to meet the body’s requirements. It may also occur due to a build up of excess fluid in the body due to kidneys being damaged or not functioning properly due to disease.
Blood begins to congest in the lungs (pulmonary edema). The work of breathing increases as the airways are obstructed by the fluids, impeding the flow of air into the lungs. The alveoli are unable to exchange gases effectively creating severe shortness of breath in patients. As the condition worsens, this congestion will eventually cause the right ventricle to fail. When this occurs, valuable blood supply (oxygen and nutrients) to the body’s cells are seriously disrupted, and the waste products of metabolism are no longer eliminated effectively causing these toxins to accumulate and ultimately causing cell death.
CPAP (Continuous Positive Airway Pressure)
EMS Providers play a large role in the emergency management of the patients suffering from Congestive Heart Failure. CPAP is a form of Non-invasive Positive Pressure Ventilation (NPPV) which is becoming increasingly popular in the field management of the patient suffering from CHF. CPAP can save precious seconds when managing a patient with CHF, avoiding intubation and its associated field and long term concerns and side effects.
For CPAP to work the patient must be able to breathe spontaneously to benefit from this patient management protocol. The patient breathes through a pressurized circuit against a set threshold resistor that keeps the airway pressure at a pre-set level, which may be monitored on an airway pressure gauge.
The inspiratory and expiratory pressures must remain positive during the full respiratory cycle for CPAP to function correctly.
If the patient moves into respiratory arrest during CPAP treatment, the rescuer will be required tr provide artificial ventilation will be required via a bag-valve-mask or automatic ventilator.
Some transport ventilators like the eSeries from O-Two Medical Technologies provide CPAP within their operating modes. They also have the additional benefit of monitoring the patient and, if the patient stops breathing, will automatically warn the rescuer and at the same time switch to Assist Control volume ventilation. This is achieved without the operator’s input.
CPAP is a great tool in the pre-hospital treatment of CHF as well as many other respiratory conditions including Pulmonary Emphysema and even Asthma!
CPAP
• Improves the ability of the alveoli to diffuse oxygen to the red blood cells, by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli.
• Increases the resistance of gas flow during exhalation providing resistance to the exiting airflow of gas from the lungs.
• Can lessen the shortness of breath experienced by the patient by improving the performance of the heart. Ventilation improves and airway secretions are removed improving oxygenation and CO2 removal.
• Also helps by increasing intrathoracic pressure, causing an increase in cardiac output. It helps to reduce the need for CHF patients to be intubated and placed on a ventilator.
• Increases the chance that the patient can avoid an ICU stay on a ventilator and reducing the associated costs
The magazine published a report about “The Perils of Peri-Intubation Hypoxia” and the issues surrounding bad airway management. The use of a BVM such as our SMART BAG® MO plays an important role to diminish negative outcomes. You can read the full article clicking on the link below.
Physiologically, pediatric patients have three significant differences from adults (at least when it comes to airway management); these differences should be the fundamental guides for your care:
First – Pediatric patients haven’t had a lifetime of french-fries, bacon, and deep-fried Snickers® to give them coronary artery disease. Instead, hypoxia is their main life threat.
Second – Their metabolism burns oxygen much faster than yours; ever try to keep up with a two year old?
Third – Kids are little vagal monsters. Almost anything will trigger their vagal tone.
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Pediatric patients go into cardiac arrest from hypoxia. Anytime you care for a pediatric patient, your assessment from the doorway should tell you whether or not to put the child on high flow oxygen. Although most anecdotal evidence and some early research suggests that most EMS calls for children could have been handled without an ambulance, nonetheless, when a child is sick, you cannot miss the diagnosis.
Any ill child must be immediately assessed for airway patency, breathing adequacy, and cardiovascular status, and you need to start oxygen without hesitation. Even if the patient does not have a primary respiratory disease process, cellular hypoxia can occur due to children’s elevated metabolism, particularly in the face of fever and dehydration. Never hesitate to administer oxygen to a pediatric patient, and never hesitate to support the patient with bag-valve-mask ventilation; even if she’s still breathing.
Remember that the 10th cranial nerve, the vagal nerve, is easily stimulated in the pediatric patient and can cause significant bradycardia, even asystole from the ridiculous vagal tone. Hypoxia and
airway manipulation (particularly laryngoscopy) are both known vagal stimulators, and so any ill, hypoxic child in shock is a set-up for a vagal disaster. For the BLS provider, the key is oxygen and respiratory support early.
For ALS providers, consider administering a dose of atropine prior to laryngoscopy for any pediatric patient (also remember that your minimum dose is 0.1 mg; otherwise, atropine can cause paradoxical bradycardia). But probably the most important thing for the ALS provider
to remember is Gaucher’s work in 2001. Using a randomized, controlled study format, she demonstrated that, at least in the urban setting, pediatric patients who received non-intubated bag-valve-mask ventilation did as well as pediatric patients who were intubated.
Although one can argue “it’s not my system,” “that’s not how we do it,” “I’m better at managing an airway than that,” at least consider the fact that it just makes sense. If children do poorly because of hypoxia and do with oxygen, then as long as you provide good non-intubated airway management, they should do well.
Anyway, as you look at your next pediatric patient, remember that although the odds are in your favor that nothing you do will help him, also consider that, for the ill pediatric patient, an aggressive and oxygen-rich approach may be the difference between life and death. Sick pediatric patients can be terrifying, but remember, they usually only have one thing wrong (as opposed to your adult patients); support their airway and cardiovascular status and their amazing bodies will usually take care of rest.
The EMS State of the Sciences Conference (dubbed by media as “A Gathering of Eagles”) has become one of the most progressive and important EMS conferences worldwide. The faculty, derived from the U.S. Metropolitan Municipalities EMS Medical Directors Consortium, the “Eagles” are the EMS Medical Directors of the top 35 to 40 U.S. cities’ ambulance services. In addition, chief medical officers for services like the FBI, U.S. Secret Service and the White House Medical Unit. Several Medical directors from places as far afield as such as London (UK) and Sydney (Australia) are also members of this illustrious group. [read more=”Read more” less=”Read less”]
The annual Eagles conference is designed to share with participants and faculty alike the most cutting-edge information and advances in EMS patient care, research and management issues. Discussions and presentations range far and wide across the spectrum of emergency care, introducing novel patient care strategies and techniques as well as new challenges and lessons learned from those challenges.
Beyond the faculty, this unique global EMS conference is famous for its 10 minute “lightning rounds”. With 40 or so plenary presentations spread over 2 days this meeting has changed nationwide medical practices almost overnight. Accordingly, “The Eagles” have become extraordinarily influential in shaping future EMS practice trends, medical aspects of disasters, homeland security, 9-1-1 responses and resuscitations worldwide.
Heat and moisture exchange is one of the most important functions of the respiratory system. The nose is responsible for warming inspired air, increasing its humidity carrying capacity. After endotracheal intubation, however, the upper airway is circumvented and the respiratory system loses its capacity to heat and moisten inhaled gas. This imposes a burden on the lower respiratory tract, which is not designed for the humidification process. Consequently, delivery of partially cold and dry medical gases brings about potential damage to the respiratory epithelium, manifested by increased work of breathing, atelectasis, thick and dehydrated secretions, and cough and/or bronchospasm. [read more=”Read more” less=”Read less”]
Used to provide warmth and humidification of respiratory gases patient circuit humidifiers come in two types:
A “WET CIRCUIT” is a breathing circuit with active humidification (Fig. 1).
A “DRY CIRCUIT” uses a Heat and Moisture Exchanger (HME) (or a Heat Moisture Exchanger Filter – HMEF) and provides passive humidification (Fig. 2).
DESCRIPTION OF THE TWO SYSTEMS
The “WET” circuit requires power for heating the water, a disposable or reusable humidification chamber that holds water +/- a reservoir that adds water as needed, a heating element to warm water and ideally, a heated (e.g. by a heated wire along the tube) and insulated inspiratory tube that transmits heated, humidified gas. If this tube is not heated, condensation (“Rain Out”) will occur and a water trap will be required. A temperature monitor (at the patient end of the circuit) adjusts the amount of heating required to maintain the correct humidity.
The “DRY” circuit is a simple breathing circuit component requiring no heat or water to operate. The HME contains a layer of foam or paper embedded with a hydroscopic salt such as calcium chloride. Expired gas cools as it crosses the membrane, resulting in condensation and heat transference onto the HME layer. On inspiration absorbed heat evaporates the condensate and warms the gas, the hygroscopic salt releases water molecules when the vapor pressure is low, warming and humidification is thus regulated by the moisture content of the expired gas and patient’s core temperature.
METHOD OF INSERTION AND/OR USE
The “WET” circuit is inserted into the inspiratory limb of the ventilator circuit and requires specialized auxiliary equipment and heated circuit tubing.
The “DRY” HME or HMEF is inserted between the circuit and the endotracheal tube.
EFFICIENCY
Both “WET” and “DRY” humidifiers provide a minimum of 30mgH2O/L delivered at an appropriate temperature.
Advantages and Disadvantages of the two types
“WET” Humidification
Disadvantages
Should not be used with a HME
Must not be placed in the expiratory limb
If a filter is used with active humidification it should be upstream to prevent clogging with water
You must ensure the heated humidifier is turned off if there is no flow through the circuit. If not, the absence of flow will cause temperature to fall at the patient end, leading to increased heat output which may cause the inspiratory tube to melt.
Condensation (“rain-out”): risks water aspiration
Potential delivery of excessively hot fluid to the airways.
May interfere with monitoring (e.g. flows and volumes)
May damage equipment (e.g. ventilator)
Microbiological colonization and growth (e.g. in reservoir or condensate)
Over hydration
Thermal injury
Increased work of breathing due to increased resistance (some cannot be used with spontaneously breathing patients)
Potential electrical hazard
Lack of transportability
Increased cost and maintenance
Not all humidifiers are compatible with all circuits
Increased work for staff (temperature control, refilling the reservoir, draining condensate, cleaning, and sterilization)
Advantages
Optimal efficiency (generally more efficient than a HME)
Reliability
Ability to warm patient
Proven track record of safety
Some can be used for spontaneously breathing and tracheotomised patients
“DRY” Humidification
Disadvantages
Inability to use with all patients (hemoptysis, tenacious secretions)
Increased airways resistance
Increased dead space
Potential for unrecognized airway obstruction if filter blocks
Less than full humidification and body temperature
Drying of secretions
Not appropriate for patients with large air leaks (e.g. bronchopleural fistulae) due extensive loss of inspired gas and inability to conserve heat and humidity
Advantages
Ease of use
Lightweight
Can retain their ability to humidify for up to 4 days with minimal change in resistance
Less cumbersome during transport
Lower staff workload
Lower costs
Decreases ventilatory acquired pneumonia
CONCLUSIONS
Airway humidification is a key adjunct in the mechanical ventilation of patients. Humidifier devices may function passively or actively, depending on the source of heat and humidity.
Incorrect humidification or the selection of the wrong device for the ventilator application (in-hospital, transport etc.) may have a negative impact on patient outcomes or may create hazards for the healthcare professional.
The selection of the right type of humidification device for the right application is therefore essential and knowledge of the advantages and disadvantages of each of the two types of device is essential to making that right choice.
The problem of Inadvertent Hyperventilation during CPR (caused when bag-valve-masks are squeezed too hard and/or too fast in an unprotected airway) is a significant problem that can lead to serious consequences for the patient. In Part I of this series on Inadvertent Hyperventilation – Resolving the Problem with Technology, we reviewed the SMART BAG® MO that addresses the hyperventilation issue by controlling the flow from the balloon based on how the rescuer squeezes it. We will now take a look at a second technical resolution for EMS Personnel – Automatic Transport Ventilators or ATVs. [read more=”Read more” less=”Read less”]
ATVs automatically provide controlled ventilation rates (breaths per minute), tidal volumes and airway pressures. It is virtually impossible to inadvertently hyperventilate a patient with an ATV. The rescuer simply sets the rate and volume based on the patients’ size, manages the airway and the ATV provides the proper ventilation.
Since 1992 the AHA has been recommending the use of ATVs as the most effective method of ventilation in the emergency pre-hospital market. According to the Resuscitation Guidelines:
ATVs are superior at maintaining constant minute ventilation and adequate arterial blood gases
ATVs provide improved lung inflation with diminished or absent gastric insufflation.
ATVs free the rescuers hands for other tasks in intubated patients and for mask & airway maintenance in un-intubated patients.
If the patient receives better ventilation and the rescuer’s job is easier, why are BVMs still the device of choice for EMS? It likely comes down to familiarity, costs and a perception of the dangers of ATVs based on experiences with very early manually triggered devices. BVMs have been used since the 1950s and virtually all ventilation training has been focused on the quality and frequency of the squeeze. Rarely are EMS Personnel trained on automatic ventilators or even introduced to them.
From a cost standpoint, to acquire ATVs does mean tapping into capital budgets (although leasing/renting may address this). On a per-patient cost basis however, ATVs can actually be the same or less expensive. If as little as two disposable BVMs are used on a vehicle per month, a basic ATV could be a more cost effective solution.
An article the Respiratory Therapy Journal, when discussing automatic ventilators, stated “their initial purchase price exceeds that of all other transport ventilation methods, but the cost per patient is similar to that of the BVM”. Most ATVs also use 1/3 less oxygen than a BVM connected to a free flowing oxygen source. They deliver oxygen on demand or only when required versus a constant 15-30 L/Min flow.
There is also misinformation out on oxygen powered resuscitators based on some of the first manually triggered devices introduced to the market over 30 years ago. One perception is that they can “blow up a patient’s lungs”. Pressure relief valves prevent this from happening and the reality is that this is more probable with a BVM. Most adult versions do not have a pressure relief mechanism and the rescuer tends to squeeze the BVM harder when lung compliance increases.
Other protective features, like a controlled flow rate, make the ATV a safer device for ventilation.
BVMs will never be completely replaced by ATVs as they can operate without oxygen or compressed air – ATVs cannot (some even require batteries). With an open mind to change however, ATVs can provide patient benefits, ease of use for rescuers (and free hands/personnel) and possible savings on a cost-per-patient basis.
A recent article in company news reviewed the causes and effects of “Inadvertent Hyperventilation” during CPR when bag-valve-masks (BVM) are squeezed too hard and/or too fast (Check post clicking here). While improved or increased frequency of training is important, there are technological solutions that provide both patient and rescuer benefits. [read more=”Read more” less=”Read less”]
The SMART BAG® MO BVM was developed to compensate for rescuers “Inadvertently Hyperventilating” patients causing gas to enter the stomach – Gastric Insufflation – (when ventilating with a face mask), reduced venous return to the heart and decreased coronary perfusion pressure. In addition, it addresses a “preference” in the pre-hospital market for using BVMs over other ventilation devices (e.g. automatic ventilators). It works by controlling the flow of gas from the balloon based both on how the rescuer squeezes and the compliance/resistance of the airway. With a proper slow squeeze, as recommended in the resuscitation guidelines, the SMART BAG® MO works like any other BVM. If too much pressure is applied on the bag, however, a Smart Valve or piston incorporated into the BVM will move forward limiting the flow of gas. A minimum flow rate of 40 L/Min will always be provided (adult). A rescuer will know if they are applying too much pressure as the balloon will become stiffer and the SmartValve will become visible in the neck of the BVM. In affect, the SMART BAG® MO is providing real-time training or instant feedback to how well the rescuer is ventilating. If a patient’s airway is poorly compliant or restrictive, the SmartValve will balance against the increased airway pressure and will not move forward. This indicates that there is a problem in the patient’s airway and under these circumstances, the rescuer can apply higher pressures.
An override switch allows the rescuer to “lock out” or override the SmartValve during intubated CPR (when a much larger flow rate is required to deliver the breath in between chest compressions) or should the rescuer feel that the patient’s condition requires it (in our studies, however, there is no situation where the override switch is necessary except during intubated CPR).
The SMART BAG® MO has undergone a number of clinical studies that have demonstrated its superiority claim over conventional BVMs. One study of 191 EMS physicians demonstrated results of lower mean inspiratory airway pressure, lower mean ventilation rates and a 75% reduction in stomach inflation volumes. With a fairly simple technology, rescuers are provided with the ventilation device they prefer (BVM), with no change to protocols but are able to provide the patient with improved ventilation and reduced gastric insufflation.
The current push for the adoption of compression only or cardio-cerebral resuscitation (CCR) for lay person rescuers has gained some momentum in the market. The American Heart Association (AHA) has made clear statements about the use of CCR by those who are unwilling or unable to provide mouth to mouth ventilations1 [read more=”Read more” less=”Read less”]
However, the studies supporting CCR do not provide adequate scientific evidence of sufficient power to make recommendations for a change in the Guidelines. Certainly there are a number of studies that point out the negative aspects of CCR for a number of patient groups – unwitnessed arrest, asphyxial arrest, drowning etc. The studies undertaken to date also do not show improved survival with CCR over standard CPR. In fact some show a slightly lower survival rate with CCR3. In a 2017 Guidelines for CPR Update published in Circulation2 it is stated that: ”patients receiving continuous chest compressions had a lower rate of return of spontaneous circulation, worse 1-month survival (odds ratio, 0.75; 95% CI, 0.73–0.78), and worse 1-month survival with good neurological outcome (odds ratio, 0.72; 95% CI, 0.69–0.76) compared with those receiving CPR using a ratio of 30 compressions to 2 breaths”.
However, if the CCR method of providing resuscitation is used by lay persons, then the importance of providing good ventilations to remove the hypoxic and hypercapnic effects of CCR (created by no ventilations being provided by the lay person responders) falls squarely on the shoulders of those with a duty to respond – Fire Fighters, Police Officers and EMS personnel.
Discussion
While old technologies for ventilation used by responders generally fail to provide adequate ventilation, the adoption of new technologies to aid ventilations has been slow. Not only does technology create new devices to provide ever more sophisticated protocols to improve patient survival, it also creates devices that assist in the way in which everyday skills are applied. And yet, often despite a lack of high level clinical evidence, the former (and some might say more glamorous) technologies are often more readily adopted by the market than the latter. This is certainly true of ventilation where there appears to be a general overconfidence amongst healthcare providers that ventilations are being well performed and that they do not require any technological assistance in ventilating their patients. This is despite strong clinical evidence to the contrary5.
Conclusions
There are many new technologies that can assist healthcare workers in providing significantly better ventilations with less deleterious effects on the patient. If these technologies are not embraced then, where response times are greater than 5 minutes and the patient is not gasping, the detrimental effects of no ventilations being provided, while hopefully improving circulation, may not provide for improved survival rates and may even reduce the success levels still further if current research provides an accurate indication.
There has been much debate over the concept of compression only CPR (CCPR) for out of hospital (OOH) cardiac arrest. CCPR is simple, easier to teach and more laypersons may be willing to undertake CCPR than the current compression/ventilation CPR (CVCPR). It has been often stated that the risk of cross infection from mouth-to-mouth (MTM) ventilation is the primary reason for lay persons not being willing to do CPR. However, in a 2006 study by Swor et al¹, fear of doing harm was the primary reason given with only 1% stating that MTM ventilation was their concern.
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While studies are showing that CCPR may be as effective as CVCPR2, 3, 4 for witnessed OOH cardiac arrest it does not provide any improvement in overall survival5, 6 which must be our fundamental goal in cardiac arrest management. There are also many patients that require ventilation, especially if the arrest is of a long duration (greater than a few minutes)5, 7 is un-witnessed, the cause of the arrest is asphyxiation or the victim is a child8, 9. The need for ventilation to be provided, or not, is therefore not as black and white as current media reports may indicate.
Perhaps the problem lies then, not in the CCPR/CVCPR argument but in the provision of the necessary tools to laypersons to provide for an overall improvement in patient outcomes.
Discussion:
The use of CPR guidance, voice prompts, telephone directed CPR and other CPR adjuncts during training and actual cardiac arrests all seek to make the CPR process simpler and more effective. A review paper by Yeung et al10 of some 28 clinically relevant papers concluded that “There is good evidence supporting the use of CPR feedback/prompt devices during CPR training to improve CPR skill retention. Their use in clinical practice as part of an overall strategy to improve CPR quality may be beneficial”. It seems to be clear that laypersons are not totally afraid of doing CPR but are concerned that by so doing they may cause harm. It is logical to assume that a device which guides them through the CPR process and assists them in the timing of CPR would assist in overcoming that fear. However, perhaps visual and audible prompts are not sufficient, especially where MTM ventilation is concerned.
While MTM ventilation appears to be low down on the scale of things as to “why I won’t do CPR”, it is clear that providing ventilations is a very necessary part of the “Chain of Survival” for a significant number of patients. Professional responders are all trained to give ventilations and are provided with the tools to do so. Lay persons are given the option of using simple barrier devices to protect themselves from contamination. Even these however do not provide an effective means of facilitating the inflation of the patient’s lungs. There is also the issue of the lower than ambient oxygen concentration provided by an expired air breath.
Professional responders utilize bag-valve-mask (BVM) resuscitators as the primary means to ventilate patients. These devices require a particular skill set and their efficacy is generally very poor, even in highly skilled hands. Automatic ventilators/resuscitators are the “gold standard” when it comes to ventilation and are widely used around the world by those with a duty to respond, yet there have been no automatic devices manufactured for those who, by their limited training and even more limited opportunity to practice their skills, are the most in need of assistance when they are called upon to undertake life saving measures, the CPR trained lay persons. AEDs have revolutionized CPR by laypersons and yet overall survival rates have changed very little during the last decade. Perhaps it is now time to automate the CPR process further by providing lay person rescuers with automatic means of providing ventilations as well as visual and audible guidance in the performance of CPR.
For many years aggressive hyperventilation of the patient suffering from Traumatic Brain Injury (TBI) has been standard practice around the world. The original concept behind the use of this technique was to reduce intracranial pressure. However, there have been no studies to show that the patient’s neurological outcome is improved by this practice. A report by the American College of Neurosurgeons (based on research of all applicable literature from the last 25 years) now casts severe doubt on the routine use of this technique in patients suffering from TBI. [read more=”Read more” less=”Read less”]
In their “Guidelines for the Management of Severe Head Injury”, clear clinical evidence presented supports their call for a discontinuance of prophylactic hyperventilation as a treatment for TBI. In 40% of patients suffering from TBI, brain swelling and an increase in intra-cranial pressure occurs. High intra-cranial pressure following traumatic brain injury is one of the main causes of death in these patients, but it has however been wrongly assumed that hyperventilation is the great panacea for all neurological ills.
Intra-cranial pressure reduction is achieved through hyperventilation by constricting the vessels in the brain and reducing cerebral blood flow. Twenty years of research clearly shows that, in the first day following injury, the cerebral blood flow is already less than half the norm and that aggressive hyperventilation potentially risks causing cerebral ischaemia. It has also been found (in some patients), that aggressive hyperventilation can actually cause an increase in intracranial pressure.
There is irrefutable scientific evidence to show that patients with TBI have low cerebral blood flow and it is strongly suggested that in the first hours after injury the cerebral blood flow approaches levels that are consistent with causing brain ischemia. Hyperventilation will further reduce cerebral blood flow values but will not consistently cause intracranial pressure levels to fall.
It has also been shown, in a randomized clinical study, that outcomes for TBI patients are worse if they are aggressively hyperventilated. The recommendations of the American College of Neurosurgeons are quite clear and are backed by a significant amount of scientific evidence. Prophylactic hyperventilation should be avoided during the first five days following severe TBI and should be especially avoided during the first 24 hours.
“So what is the answer for those who are at the frontline in the treatment of patients with TBI”?
Limiting the use of hyperventilation following severe TBI to those patients where the deterioration in their neurological condition warrants this type of intervention, may be a safe option. Also, when deemed absolutely clinically necessary, limiting the length of time that hyperventilation is employed should be considered. However, how do we decide when to hyperventilate? Monitoring the patient’s intracranial pressure and cerebral blood flow are ways of identifying the point at which cerebral ischemia may occur, but this is impossible to undertake in the field.
Regardless of the type of injury, hyperventilation is never a substitute for controlled ventilation. Based on this research, we all should re-evaluate our protocols and consider whether hyperventilation or good ventilation should be our main aim in traumatic brain injured patients.
Where manual resuscitators are the mainstay of patient ventilation then using a device where the flow is controlled (rather than simply attempting to limit pressure with a pressure relief valve) is the best way to reduce the negative effects hyperventilation in this patient group.
The SMART BAG® MO from O-Two Medica Technologies Inc., responds to the rescuer’s squeeze and release of the BVM, controlling the flow of gas into the patient’s airway, lowering the airway pressure generated to a pressure of between 12 and 14 cm H2O (in a normally compliant and resistant airway). If the bag is squeezed too hard, high flow is generated. The SMART VALVE moves forward to control the flow rate and the bag becomes stiff to squeeze. The SMART VALVE also balances against resistance and compliance changes in the airway keeping the pressure to the minimum required to achieve adequate ventilation under these changing circumstances.
By controlling the flow of gas from the balloon ventilation is improved and the negative effects of “inadvertent hyperventilation”, CO2 wash out, cerebral vasoconstriction and increased brain ischaemia are significantly reduced.
In this article we’re going to talk about opening the airway using simple manipulation. Our techniques are based on some myths that are propagated to this day; a better understanding of airway anatomy and what really happens in the unconscious patient will make you better able to manage the airway. I’ll preface this by saying that my discussion is specific to adult patients because, frankly, the study I’ll describe hasn’t been done in children. We’ll discuss differences in adult and pediatric airways later.
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If we think about the upper airway and the opening to the lower airway at the level of vocal cords, we’re talking about a fairly complex structure. The mouth and nose, while both openings to the airway, serve distinctly different functions and have distinctly different anatomy. The mouth opens into the oropharynx, a muscular structure containing in particular a large, dexterous muscle, the tongue, as well as teeth and a number of glands. The main purpose of this cavity is to bring food into the digestive tract and begin the process of breaking it down. The nares open into the nasopharynx, a specialized structure designed to filter, warm, and humidify air. The structures are, essentially, mucous membranes stretched over cartilage. The oropharynx and nasopharynx are divided by the anterior hard palate, a rigid structure, and the posterior soft palate, a floppy structure that minimizes reflux of food and fluid into the nasopharynx. These two structures empty into the pharynx.
At this point, we are looking at an area at the level of the mandible (jaw). One of the most sophisticated structural support systems in the body lurks just inferior to the mandible: the hyoid bone. The hyoid bone, a horseshoe shaped bone with the opening pointing posteriorly, is the only bone in the body that doesn’t articulate directly with another bone. Instead, though an almost continuous set of ligaments, the hyoid attaches to almost every structure in the anterior neck. The internal structures of the neck move wherever the hyoid moves. The hyoid is attached directly the mandible so, when the mandible moves anteriorly, so does the hyoid. The hyoid is also attached to the tongue and, via the hyo-epiglottic ligament (remember that term), to the epiglottis.
Looking below the pharynx (in the hypopharynx), you will see the epiglottis, an anterior, leaf shaped structure that is essentially attached to the base of the tongue. Below this are the aryepiglottic folds, the false cords, and the true vocal cords or glottis, which serves as the entrance to the lower airway. All of these structures are thin layers of tissue overlying a series of cartilage pulleys, hinges, and levers. Movement of these cartilage structures (the thyroid and cricoid cartilage) allows you to speak, cough, and protect your airway. So, if I asked you “what is the most common cause of airway obstruction in an adult?” you would probably answer “the tongue.” Although this makes some intuitive sense, in fact, a study in 1994 proved that the tongue does not obstruct the airway of the comatose adult patient1. Although the tongue falls posteriorly and probably causes significant turbulence, the epiglottis and the soft palate are the only structures that actually contact the posterior pharynx and cause airway obstruction.
Considering airway anatomy again, how should we look at opening the airway? The goal is no longer to move the tongue off the posterior pharynx; it’s not there in the first place. Instead, the goal is to move the mandible anteriorly. This maneuver pulls the hyoid anteriorly and, through the hyo-epiglottic ligament, pulls the epiglottis anteriorly, thereby opening the airway. The tongue will also be pulled anteriorly, decreasing airway resistance in the hypopharynx. If the mandible (and hyoid) is also displaced inferiorly, the oropharynx will open more, allowing more air to move through the oropharynx.
So, when one is performing the “basic” airway opening maneuvers (jaw thrust, head-tilt chin-lift), the actual goal is to move the mandible anteriorly and inferiorly, thereby opening the airway and maximizing airflow. If you watch someone open the airway using a one-person technique, you will see that he probably achieves a good anterior-inferior mandible movement. However, when that same person occupies both hands in performing one-person bag-valve mask ventilation, he no longer effectively opens the airway, and you see the “puffy cheeks” syndrome where patients have well ventilated cheeks but no air moves beyond the oropharynx.
So, how should your airway opening techniques change?
First, you need to focus on moving the jaw anteriorly and inferiorly to maximize the airway in an open and low-resistance state. Second, you need to use a two-person bag-valve-mask technique so that one person can focus on opening the airway and maintaining mask seal while the second person focuses on the ventilation itself. Third, as I discovered recently while intubating a patient who suffered neck trauma after being hit by a car, when the hyo-epiglottic ligament is severed, you can never open the airway with simple techniques; go straight to an airway adjunct (LMA®, Combi-tube®, etc.) or intubation rather than letting your patient get more hypoxic.
It is widely believed that the phrase “Physician, first do no harm” comes from the Hippocratic Oath taken by physicians when they enter medical practice. While the oath (when translated from the original Greek) does not contain this exact phrase, it does state:
“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone”.
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All clinical practice should be based on sound scientific research. While the majority of practices are undertaken on this basis, there are some that are perpetuated by a lack of a significant alternative to current practice. One such practice is manual or “Bag-Valve-Mask” (BVM) ventilation.
Developed in 1954 by Henning Ruben in Copenhagen/Denmark, the original self-inflating bag (which he had made by his bicycle mechanic by welding together four spokes from a bicycle wheel and inserting them into a black anaesthesia bag) has changed very little since that time. In 1964, the self-inflating bag was declared by the American Medical Association to be among the most significant medical advances in anaesthesia of the past 25 years.
While there are many different makes of Bag-Valve-Mask devices currently available, they do not differ much in their performance. Certainly, in the early days of CPR the “Ambu Bags” (so named after the first commercial manufacturer) or manual resuscitators as they are more appropriately called, were the only available adjuncts for the rescuer which did not require the use of an exhaled breath, or a source of compressed oxygen to ventilate the patient. As such, they were without a doubt a significant advance in emergency respiratory care. However, considering the major advances in medicine that have taken place over the last 50 years, we are still, in the most part, relying on 65 year old technology to perform the key task of oxygenating a respiratory/cardiac arrest patient.
In the majority of user’s hands, the physiological effects on the patient that manual resuscitators can have are significant and can create many problems for the patient and the rescuer, including:
Aspiration of stomach contents
Reduced venous return to the heart
A subsequent decrease in cardiac output
Reduced coronary perfusion pressure
Increased brain ischemia
These issues are caused by what is now termed –
“Inadvertent Hyperventilation”,
providing ventilations at too high a minute volume with short inspiratory times, high ventilation rates and high peak airway pressures.
There is significant evidence to show that standard manual resuscitators can be somewhat ineffective in providing good quality ventilation and may possibly be potentially dangerous. In fact, as far back as October 1992, The American Heart Association “Guidelines for CPR” published in the Journal of the American Medical Association clearly identified that these devices were generally ineffective in providing adequate ventilations to the patient. A wealth of clinical evidence to support this, and other statements by the American Heart Association, has been accumulated over the past 30 years.
Aufderheide’s paper in 2004 entitled “Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation” (Circulation 2004;109:1960-1965) stated that:
“…. any incidence of hyperventilation is likely to have detrimental hemodynamic and survival consequences during low flow states such as CPR”.
This paper clearly showed that even trained paramedics hyperventilate patients when under stress, even immediately post training, and this hyperventilation has serious deleterious effects on the patient. This led to Pitts and Kellerman’s statement in The Lancet 2004;364 that:
“Unrecognized and unintentional hyperventilation may be contributing to the currently poor survival rates from cardiac arrest”.
A further study by O’Neill and Deakin (Resuscitation 2007;73:82-5) entitled: “Do we hyperventilate cardiac arrest patients”? reiterated the points made by Aufderheide et al stating:
“Hyperventilation was common, mostly through high respiratory rates rather than excessive tidal volumes. This is the first study to document tidal volumes and airway pressures during resuscitation. The persistently high airway pressures are likely to have a detrimental effect on blood flow during CPR. Guidelines on respiratory rates are well known, but it would appear that in practice they are not being observed”.
“Hyperventilation in brain injured patient’s increases brain ischemia”.
So the issue of inadvertent hyperventilation has far reaching effects, not only on survival but also on neurological outcomes.
For many years it could be stated that manual resuscitators were the only readily available, easy to use products for providing positive pressure ventilation. However, this has not been the case for over 30 years since the first oxygen powered, time cycled, automatic transport ventilators came on the market. These devices do have limitations in that they require a source of compressed gas (medical air or oxygen) to run them, which limits the accessibility of the products to every area where they may be required, their effectiveness in providing good quality ventilations is however the “Gold Standard” in emergency ventilation.
Mouth-to-mouth barrier devices and “pocket mask” type products, while providing a degree of protection from cross infection for the rescuer, are certainly not seen as a replacement for the BVM by the healthcare profession. Indeed, their overall efficacy, including the low O2 concentration, high ventilation pressures generated and reluctance of the rescuers to actually use the devices for fear of cross infection, make them a “last resort” product for many rescuers.
While the issue of “inadvertent hyperventilation” does seem to be prevalent in the industry, there is salvation in the form of the O-Two Medical Technologies Inc. SMART BAG® MO. This technologically advanced BVM offers the rescuer the ability to provide controlled ventilations while drastically reducing the risks associated with standard BVM ventilation.
Today and in the future, this new, “controlled flow”, manual resuscitator is assisting physicians in their quest to
Patients in respiratory distress or those suffering from impaired lung function due to conditions such as Congestive Heart Failure, Pulmonary Edema, COPD, Asthma or Cystic Fibrosis may require support of their inspiratory efforts with a mechanical device.
[read more=”Read more” less=”Read less”]
One of the primary features of the SMART BAG® is its ability to balance its function based on the patient’s respiratory parameters. If the patient’s airway is less compliant or more restrictive higher airway pressures will be required to provide adequate ventilation. In responding to this increased pressure requirement in the patient’s airway, the SMART BAG® decreases the resistance to flow from the BVM, balancing the pressure on either side of the SMART valve. This allows the required pressure to be exerted by the rescuer on the patient’s airway to overcome the resistance/compliance problem and provide adequate ventilations.
In the patient with poor compliance the healthcare provider may wish to “top up” the patient’s spontaneous breath by providing an additional tidal volume to that inspired by the patient. Under these circumstances the initial part of the patients inspiratory effort will cause the compliance to increase as air is sucked into the lungs by the action of the patient’s diaphragm and intercostals muscles. As the patient nears the end of their inspiratory effort compliance will decrease back to their normal baseline level and it is at this point that the assisted ventilation will take over and provide the higher tidal volume delivery.
When using the SMART BAG® the valve will react to the rescuer’s squeeze of the bag as it would with a patient with healthy lungs during the patient’s inspiratory cycle. If the rescuer squeezes too hard the SMART valve will activate slowing down the delivered flowrate as the resistance to flow is decreased by the inspiratory effort made by the patient. It is therefore important that the rescuer provides the correct, slow, controlled squeeze of the bag as the patient breathes in ensuring that the valve remains fully open.
As the patient’s lungs near their normal capacity the flow patterns will change, the inspiratory flow will decrease as will the lung compliance. As this occurs the operators delivered volume will supplement the inspired tidal volume and provide the additional volume required. Because the compliance is decreasing the SMART valve will react to this and remain open “providing the rescuer is squeezing the bag correctly”. If the bag is over squeezed and the airway pressure generated by the increased flow exceeds that required to provide adequate ventilation then the valve will close down the flow. Remember, the valve never closes completely so continued ventilation is always possible even with the SMART valve fully activated.
NOTE: The only reason that the valve will activate is if the bag is squeezed too hard.
We have evaluated the SMART BAG® under the circumstance of assisted ventilation against a mechanical lung model that provides an inspiratory effort and have then provided assisted ventilations. When properly squeezed the SMART Valve does not activate and the desired additional tidal volumes can be provided.
Remember that the SMART BAG® will only allow you to apply higher flowrates and airway pressures when the patient’s airway condition requires them. You will “feel” this change in compliance and resistance as the SMART BAG® allows the higher flowrates and airway pressures to be generated.
O-Two Medical will be part of Medica Trade Fair 2018. Anita Bekavac, Anis Abdalla and Helton Santos will represent the company at Hall 11 / C75. The event is taking place in Düsseldorf, Germany from November 12th to 15th .
A hand-held automatic ventilator is a device designed to provide physiologically normal positive pressure ventilation to the non-breathing patient. They are compact, with all controls located in the handpiece. This allows for the adjustment of ventilation parameters without the need for the rescuer to remove their hands from the facemask, thereby maintaining a secure mask to face seal. [read more=”Read more” less=”Read less”]
Types
Hand-held automatic ventilators come in two operating types:
Time/volume cycled ventilation:
Where the ventilation volume and rate is controlled by the device. They may also be designed with the ability to respond to the patient’s inspiratory effort and provide the patient actuated, device controlled breath (Assist Control Ventilation – ACV) or can enable the patient to demand breathe at their own rate and volume while providing a mandatory minute ventilation (Synchronous Intermittent Mandatory Ventilation -SIMV).
Pressure-cycled ventilation:
Where the rate and volume of ventilation is dictated by airway pressure. These devices are not recommended for use during CPR as chest compressions may trigger early cessation of the delivered breath with a subsequent reduction in oxygenation. These devices also provide inadvertent PEEP which may impede venous return to the heart and reduced cardiac output and coronary perfusion pressure. These devices also tend to provide reduced levels of oxygenation in patients with underlying respiratory conditions where the airway may be restricted.
Functionality
Depending on the product selected, these devices may provide automatic positive pressure ventilation, manual ventilation (for mask ventilated CPR) and demand breathing for the spontaneously breathing patient. These comprehensive devices can be considered to be the equivalent of a manual resuscitator, demand valve, and transport ventilator in one.
Their simplicity of parameter selection, size and weight make them ideal for emergency pre-hospital use. They free up the rescuer to perform other tasks by taking over the ventilation function once the airway is secured.
Equipped with safety features such as a pressure relief system, these devices ensure that the patient is monitored for changes in airway pressure. These changes may be due to over-ventilation or compliance or airway resistance changes.
Efficacy
Modern, time/volume cycled ventilators provide excellent breathing parameters to meet the needs of most respiratorily compromised patients. Their main attraction for the pre-hospital environment is in freeing up the hands of the rescuer to perform other tasks in the knowledge that the resuscitator is ventilating to the patient.
Because of their consistency, they remove the risks of Inadvertent Hyperventilation associated with manual resuscitators. By providing controlled and consistent ventilation at physiologically normal rates, volumes and I:E (inspiratory : expiratory) ratios, these device are a valuable tool for pre-hospital and in-hospital staff.
O-Two Medical Technologies manufactures two types of handheld, time cycled, automatic transport ventilators:
The CAREvent® ALS – designed for use by professional emergency medical personnel
The CAREvent® CA – Chemical Agent Resuscitation Environment Ventilator designed for use by minimally trained or professional rescuers specifically for use in toxic environments.
You can find information on both these products on our CAREvent® page.
O-Two Medical is currently present at EMS World Expo 2018. Richard Lauber, Cheryl Wise and Helton Santos are representing the company at Vendor Booth 1513. The event is taking place in Nashville – TN.
The most commonly used method of ventilation during cardiac arrest, respiratory arrest or trauma is the bagvalve-mask (BVM) manual resuscitator. There have however, been numerous studies published that show the inconsistent ventilation properties and poor skill levels of the majority of users using these devices1-4. [read more=”Read more” less=”Read less”]
More recent clinical evidence has gone on to show that the use of these devices during resuscitation may be contributing to poor patient outcomes. During BVM ventilation in the “unprotected airway”, there are a number of factors that influence the distribution of gas between the lungs and the stomach. Some are
inherent in the patient’s physiology (lower esophageal sphincter pressure, airway compliance, and resistance) whilst others are created by the rescuer (inspiratory time, inspiratory flow and peak airway pressure). These factors give rise to three areas of concern:
Gastric insufflation (gas in the stomach) leading to the aspiration of stomach contents and subsequent respiratory complications – even death6,7!
Decreased Coronary Perfusion Pressure due to the high intrathoracic pressures
Increased brain ischemia in traumatic brain injured patients.
These three problems are caused by the rescuers inadvertently squeezing the bag too hard and/or too fast. What is now called “Inadvertent Hyperventilation”!
As far back as the Guidelines 2000 for CPR5, represented the world’s first international application of evidence-based science applied to cardiopulmonary resuscitation and a fundamental step forward to improve the chain of survival of CPR. These Guidelines clearly stated that – “When the airway is unsecured (as with a mask versus a tracheal tube), the possibility of hyperventilation with gastric insufflation, vomiting, and inhalation of vomit becomes a significant concern”.
The extent of “Inadvertent Hyperventilation” was clearly shown by Aufderheide et al8 in 2004. In a clinical observational study of ventilation rates by paramedics, even immediately after training, ventilation rates were twice the Guidelines recommended levels and inspiratory times were only 50% of those recommended.
This led the authors to conclude that: “any incidence of hyperventilation is likely to have detrimental hemodynamic and survival consequences during low flow states such as CPR”.
This was reiterated in an editorial by Pitts and Kellerman in the “The Lancet” in 20049 stated: “Unrecognized and unintentional hyperventilation may be contributing to the currently poor survival rates from cardiac arrest”. They also stated that “…Additional education of CPR providers is urgently needed to reduce these newly identified and deadly consequences of hyperventilation during CPR”.
In a 1995 publication from the American College of Neurosurgeons and the Brain Trauma Foundation the issue of hyperventilation for Traumatic Brain Injury, a commonly used technique for increasing oxygenation of the brain, was addressed and it was clearly stated that “Hyperventilation in brain-injured patient’s increases brain ischemia”. This is certainly a major change in thinking as hyperventilation has been the standard practice for years for brain-injured patients. However, it has now been shown that CO2 washout increases cerebral vasoconstriction and certainly links in with the issue of reduced Coronary Perfusion Pressure from Inadvertent Hyperventilation reducing blood flow to the vital organs.
So what is the answer?
Training: As these problems appear to be an issue of applied skills, we could institute improved and more frequent training although training in the class room does not take into account incident stress which is possibly the biggest cause of inadvertent hyperventilation. Back as far as 1986, Cummins et al10, published an article entitled: “Ventilation skills of emergency medical technicians: A teaching challenge for emergency medicine”. This problem was also reported in Resuscitation in 2004 in a paper entitled “Retention of Ventilation Skills by Emergency Nurses” by De Regge et al11. In this study of resuscitation skills using Bag-Valve-Mask resuscitators” the authors concluded that: “Skill retention, even immediately post training, was insufficient using current technology”.
Technology: With the current, seemingly ineffective transfer of skills from a class room setting to the field, it may be that technology, not the skill and training of the rescuer, is the way forward to improving ventilation performance.
O-Two Medical Technologies offers products that provide the answers to both these questions. Check out the Products section on our website.
Recent research has brought into question pre-hospital emergency intubation and ALS care in general. Discussing the research and theorizing the “whys” of the results should help all EMS providers to create the best possible environment of care. [read more=”Read more” less=”Read less”] Pre-hospital cardiac arrest survival rates are highest in those cities that have the lowest number of paramedics per population. At the extreme, this could be interpreted to mean that certain ALS interventions somehow worsen patients’ chances of survival. With the exception of defibrillation, very little research has been done that demonstrates improved outcomes from specific ALS interventions (e.g. intubation, IVs, IV medications). It has been, rightly or wrongly, assumed that these interventions are beneficial, but are we sure?
One sub-study of the Ontario Pre-hospital Advanced Life Support Study (OPALS) looked at pre-hospital cardiac arrest and found that patients did no better when treated by ALS providers then they did when treated by a rapid first response (non-ALS) system with AEDs. In fact, there was a trend for them doing worse. Well-performed CPR in conjunction with defibrillation is associated with a 400% increase in survival from cardiac arrest. ANYTHING that interrupts CPR (intubation, starting IV’s, pausing to
analyze a rhythm, etc.) will decrease that number. So even if the interventions improve survival by, say 50%, interrupting CPR is so bad that the improvement will never be seen.
Focusing on airway management, there are a number of studies demonstrating that pre-hospital providers CAN perform endotracheal intubation. Only recently, however, has the attention turned to the question of “does it make a difference.”
In the realm of pre-hospital airway management, the focus has been on trauma. A large “all comers” trauma study at Hopkins, patients matched for severity who were intubated pre-hospitally did worse than patients intubated on ED arrival. The same result was found by Wang et al in Pittsburgh when they looked at non-lethally head injured patients. Both the Gausche pediatric study and the San Diego rapid sequence intubation trial found a trend towards worse outcomes in patients intubated in the pre-hospital environment. So why do patients do worse?
When intubating a patient in the ED, there is a team of three to five people maximizing the chances of success. There is a bed that can be adjusted, two suction systems (both working), good lighting and you have someone watching the cardiac monitor and pulse-ox. You have maximum control of the environment.
When you intubate a patient in the field, it’s usually you and a partner, maybe a third provider if you are doing first response. The suction will always fail right when you need it, the lighting is terrible, you are sitting in mud, and it’s raining. The monitors won’t pick up and the battery will die. If the patient vomits, he will likely aspirate. You have minimum control over the environment and the patient is always crashing. In other words, while you may be great at intubating patients, the prehospital environment itself puts the patient at significant risk for a bad outcome.
What does all this mean?
Focus on good CPR. If you are oxygenating and ventilating a patient, don’t interrupt compressions for intubation. If you can place an LMA or Combitube without interrupting CPR, consider doing so. Interrupt CPR as little as possible for your rhythm interpretations.
Consider your environment Do your procedures put the patient at increased risk? Do you have enough people to do an intubation? Is your patient at risk for hypoxia and aspiration?
More and better research is needed in the pre-hospital environment. Access journals, on-line research, and meetings to find out what the current best evidence is. Participate in studies. Most of all, always question what you are doing and keep an open mind.
There is much debate over the concept of compression-only CPR (CCPR) for out of hospital (OOH) cardiac arrest. CCPR is simple, easier to teach and more laypersons may be willing to undertake CCPR than the current compression/ventilation CPR (CVCPR). It has been often stated that the risk of cross infection from mouth-to-mouth (MTM) ventilation is the primary reason for lay persons not being willing to do CPR. However, in a 2006 study by Swor et al 1, fear of doing harm was the primary reason given with only 1% stating that MTM ventilation was their concern. [read more=”Read more” less=”Read less”]
While studies are showing that CCPR may be as effective as CVCPR2,3,4 for witnessed OOH cardiac arrest it does not provide any improvement in overall survival 5,6 which must be our fundamental goal in cardiac arrest management. There are also many patients that require ventilation, especially if the arrest is of a long duration (greater than a few minutes) 5,7 is un-witnessed, the cause of the arrest is asphyxiation or the victim is a child 8,9. The need for ventilation to be provided, or not, is therefore not as black and white as current media reports may indicate.
Perhaps the problem lies then, not in the CCPR/CVCPR argument but in the provision of the necessary tools to laypersons to provide for an overall improvement in patient outcomes.
Discussion:
The use of CPR guidance, voice prompts, telephone directed CPR and other CPR adjuncts during training and actual cardiac arrests all seek to make the CPR process simpler and more effective. A review paper by Yeung et al10 of some 28 clinically relevant papers concluded that “There is good evidence supporting the use of CPR feedback/prompt devices during CPR training to improve CPR skill retention. Their use in clinical practice as part of an overall strategy to improve CPR quality may be beneficial”. It seems to be clear that laypersons are not totally afraid of doing CPR but are concerned that by so doing they may cause harm. It is logical to assume that a device which guides them through the CPR process and assists them in the timing of CPR would assist in overcoming that fear. However, perhaps visual and audible prompts are not sufficient, especially where MTM ventilation is concerned.
While MTM ventilation appears to be low down on the scale of things as to “why I won’t do CPR”, it is clear that providing ventilations is a very necessary part of the “Chain of Survival” for a significant number of patients. Professional responders are all trained to give ventilations and are provided with the tools to do so. Lay persons are given the option of using simple barrier devices to protect themselves from contamination. Even these, however, do not provide an effective means of facilitating the inflation of the patient’s lungs. There is also the issue of the lower than ambient oxygen concentration provided by an expired air breath.
Professional responders utilize bagvalve-mask (BVM) resuscitators as the primary means to ventilate patients. These devices require a particular skill set and their efficacy is generally very poor, even in highly skilled hands. Automatic ventilators/resuscitators are the “gold standard” when it comes to ventilation and are widely used around the world by those with a duty to respond, yet there have been no automatic devices manufactured for those who, by their limited training and even more limited opportunity to practice their skills, are the most in need of assistance when they are called upon to undertake life saving measures, the CPR trained lay persons. AEDs have
revolutionized CPR by laypersons and yet overall survival rates have changed very little during the last decade. Perhaps it is now time to automate the CPR process further by providing lay person rescuers with automatic means of providing ventilations as well as visual and audible guidance in the performance of CPR.
The SMART BAG® MO flow controlling manual resuscitator is supplied in only two sizes – Adult and Pediatric. This device is not supplied in the “neonatal” size common in the market place for manual resuscitators. [read more=”Read more” less=”Read less”]The rational for this is based on the recommendations of the 2005 Resuscitation Guidelines from the International Liaison Committee on Resuscitation (ILCOR) as published by the American Heart Association, European Resuscitation Council and other National resuscitation organizations. Below is the section from the 2005 Guidelines that detail this recommendation:
Bag-mask ventilation can be as effective as endotracheal intubation and safer when providing ventilation for short periods. But, bag-mask ventilation requires training and
periodic retraining in the following skills: selecting the correct mask size, opening the airway, making a tight seal between the mask and face, delivering effective ventilation, and assessing the effectiveness of that ventilation. In the out-of-hospital setting, preferentially ventilate and oxygenate infants and children with a bag and mask rather than attempt intubation if transport time is short (Class IIa; LOE 166; 367;468,69).
Ventilation Bags
Use a self-inflating bag with a volume of at least 450 to 500 mL; smaller bags may not deliver an effective tidal volume or the longer inspiratory times required by full-term neonates and infants.
A self-inflating bag delivers only room air unless supplementary oxygen is attached, but even with an oxygen inflow of 10 L/min, the concentration of delivered oxygen varies from 30% to 80% and depends on the tidal volume and peak inspiratory flow rate. To deliver a high oxygen concentration (60% to 95%), attach an oxygen reservoir to the self-inflating bag. You must maintain an oxygen flow of 10 to 15 L/min into a reservoir attached to a pediatric bag72 and a flow of at least 15 L/min into an adult bag”
To meet the requirements of these recommendations, the SMART BAG® MO pediatric bag was designed with a volume of 470 mL. This meets the guidelines recommendations for bag size while maintaining its use for all Pediatric, Infant and neonate patients.
In an emergency it has been shown that rescuers, because of the stress of an incident, do not maintain constant visualization of the ventilation process and is therefore of little value in ensuring controlled ventilation. [read more=”Read more” less=”Read less”]
The O-Two Medical Technologies’ SMART BAG® and SMART BAG® MO are the only manual resuscitation devices (Bag –Valve-Masks or BVMs) to provide rescuer and patient responsive controlled flow. Other companies have made claims that the use of a manometer and pressure relief system provides the same functionality as the SMART BAG® and SMART BAG® MO however this is simply not true.
The pressure relief system on a standard bag allows the airway pressure to reach a maximum 40 cm H2O, twice the lower esophageal sphincter opening pressure, allowing gastric insufflation to occur. The use of the Mini Ventilation Training Analyzer provides clear and indisputable evidence of this. In addition, these high pressures, because rescuers generally ventilate with very short expiratory times, will also cause reduced venous return to the heart.
While a pressure manometer may be of some assistance, it does require continuous monitoring and in and of itself does not ensure that the delivered airway pressure is not excessive. In an emergency, it has been shown that rescuers, because of the stress of an incident, do not maintain constant visualization of the ventilation process and is therefore of little value in ensuring controlled ventilation.
By responding to the rescuer’s squeeze and release of the BVM, the SMART BAG® and SMART BAG® MO limit the excessive flow of gas into the patient’s airway, lowering the airway pressure generated to a pressure of between 12 and 14 cm H2O (in a normally compliant and resistant airway) which is well below the lower esophageal sphincter opening pressure of 19 cm H2O. This significantly reduces the risks of “inadvertent hyperventilation”. If the bag is squeezed too hard the SMART VALVE moves forward to lower the flow rate and the bag becomes stiff to squeeze. The SMART VALVE also balances against resistance and compliance changes in the airway keeping the pressure to the minimum required to achieve adequate ventilation.
While competitors may claim that their pressure relief and manometer provide controlled ventilation, these devices only provide for monitoring of poor ventilation performance. The SMART BAG® and SMART BAG® MO are the only manual resuscitators (BVMs) to provide true “Controlled Ventilation”.
When the decision to use an automatic ventilator to provide better patient outcomes (and make rescuers’ jobs easier) is made, the next step is deciding what type of ventilator should be acquired. Like any important purchase, it is essential to understand the applications for the product and by whom. The needs of an EMS first responder will be different from a Respiratory Therapist in Critical Care. There may also be a compromise on the optimal solution based on a budget so it is important to know what the essential features are versus “desirable”.
[read more=”Read more” less=”Read less”]
There are many applications for automatic ventilators which will determine what features will be required including uses in land ambulance, air ambulance, pre-hospital care, inter-hospital transports, intra-hospital transports, BLS care, ALS care, transport of long-term ventilated patients and resuscitation (to name a few). With a focus on short-term EMS care, below are some questions and considerations to aid in making the best choice for patients, rescuers, and budgets:
Tidal Volume and Breathing Frequency Ranges – the size of patients to be transported will dictate the flexibility required.
Oxygen Concentrations – longer transports may benefit from less than 100% oxygen to conserve cylinders and there may be patient conditions where the use of 100% oxygen is contraindicated.
Demand Breathing – if patients spontaneously start breathing (which is the hope) can the ventilator support their efforts without “stacking” automatic ventilations?
Fixed I:E Ratio – in normal breathing, it takes half the time to inspire as expire. Does the automatic ventilator support a 1 to 2 ratio? Do you need I:E ratio adjustment?
Ability to meet current CPR Guidelines – does the automatic ventilator provide for the different recommendation for the compression: ventilation ratio for mask ventilated and intubated patients?
Therapy – CPAP can be used in treating patients with “difficulty breathing” conditions and there are “CPAP-only” devices on the market. CPAP is also available as a feature on some automatic ventilators to provide a single device solution for those patients moving from respiratory distress to full respiratory arrest.
Manual Ventilation Capability – can the ventilator provide manual ventilation or does it require the EMS personnel to use a bag-valve mask?
Number of rescuers available- how many rescuers would be required to manage the airway and ventilate, particularly in non-intubated patients? Two rescuers should provide manual ventilation with a bag-valve-mask. Does the automatic ventilator have the same requirement or can one perform the task?
Simplicity – is the device so complicated with features that EMS personnel are afraid to take it out of the bag or will they spend more time messing with the controls than looking after the patient?
Operating environments – where the device is to be used will affect its functionality (MRI departments, air ambulance, extreme environments etc.).
Fortunately for you, O-Two Medical Technologies took all these issues into consideration when we developed our eSeries Automatic Transport Ventilator range. With three, easy to use, models ranging from the e500 to the sophisticated e700 this range of products provides the healthcare provider with the features they need for their patient, the type of transport and their individual skill level.
Time should be spent understanding the needs of the patients served and the staff performing the task to prioritize the “must have” from “desirable” features. When you have made this assessment, check out the O-Two eSeries Automatic Transport Ventilators. We know we have a product that is right for you!
Continuous Positive Airway Pressure (CPAP) has become a standard treatment for congestive heart failure (CHF) and a number of other respiratory distress situations and has significantly reduced the need for endotracheal intubation (ETI) in these patient groups. [read more=”Read more” less=”Read less”] CPAP devices work by providing a constant positive airway pressure to the patient to splint open the airways during exhalation and, to reduce the patient’s work of breathing(WOB) work of breathing is the energy expended by the patient to breathe). CPAP is designed to reduce that WOB by “over delivering” a flow of air or oxygen during the inspiratory phase. Increased WOB leads to exhaustion and respiratory depression. The PEEP pressure during the expiratory phase is supplied to splint open the airways and to force accumulated fluid back into the interstitial spaces. In addition to the improvement in the patient’s condition and the reduction in the need for intubation and drug interventions, it has been shown that the use of CPAP with these patients’ (in the prehospital environment) also reduces the length of hospital stay and the need for admittance to the Intensive Care Unit (ICU).
Discussion
The efficacy of the delivery of CPAP pressures by the devices offered for the prehospital market differs significantly. To deliver a “continuous” (and this is the keyword in CPAP) positive airway pressure, during the inspiratory phase, the device must deliver a flow rate in excess of the flow rate demanded by the patient. Some devices on the market, while being very novel in their approach to delivering a PEEP pressure, do not provide a continuous positive pressure by providing the flow demanded by the patient during the inspiratory phase and therefore may be incorrectly classified as CPAP devices.
Other devices utilize a constant gas flow and a pressure balancing valve on the facemask to maintain the CPAP pressure. These tend to produce high sound levels which can be annoying to the patient. Their efficacy is considered to be good.
The last group of CPAP devices uses an internal pressure control circuit to actuate a demand valve and supply CPAP pressure. Some of these devices, however, have a significant delay in delivery of flow when the patient initiates the inspiratory cycle. This is due to the high triggering pressure of the demand valve which generates the inspiratory flow and creates a “hiccup” in flow delivery which can be disturbing for the patient. In addition, some have a high peak pressure at the commencement of the inspiratory phase. Any significant drop below the CPAP baseline during inspiration and airway
pressure spike at the beginning of expiration reduce the efficacy of the CPAP and adds to the patient’s WOB.
As can be seen from the following graph, the volume of the shaded area indicates when the pressures are above or below the baseline CPAP pressured set during one respiratory cycle. This indicates the additional work imposed on the patient
(Fig. 1).
Fig. 1. Pressure waveform showing high inspiratory and expiratory pressures of two, commonly available, pressure control/demand valve devices – CPAP pressure 7.5 cm H2O
Gas consumption is an important issue in the pre-hospital emergency Review/Update market. On a “D” size oxygen cylinder of the gas flow/pressure balancing valves ranges between 35 – 45 minutes while the internal pressure control devices last between 45 – 55 minutes. The novel PEEP devices have a significantly shorter operating time of between 15 – 20 minutes (based on a CPAP pressure of 7.5 cmH2O) (Fig. 2).
Fig. 2. Cylinder duration on a standard “D” size Oxygen Cylinder
Conclusion
Prehospital CPAP has been clinically proven to assist patients in respiratory distress from CHF and a number of other conditions. The following statements are taken from the conclusions drawn during a number of clinical studies. These comments validate the use of CPAP in the prehospital environment.
Toxic environment rescue and resuscitation is both an important an emotive subject. The death of an otherwise healthy individual in an industrial accident due to the inhalation of a toxic gas, or from anoxia due to an oxygen depleted environment, is unacceptable in today’s health and safety conscious society. No worker should enter an area that has the potential to be Immediately Dangerous to life or Health (IDLH) without the proper protective equipment and monitoring of the space. But what of the environment that is tested and found to be “clean”? There may still be pockets of toxic gas lurking in corners, or striated in the atmosphere waiting for the unsuspecting worker to disturb the gas and take a breath!
[read more=”Read more” less=”Read less”]
If there is any doubt that the space may be contaminated you should not go in unprotected. There are however, always circumstances where everything looks clean and safe but unfortunately is not. Under these circumstances, where there is even the remotest possibility that a worker could come in contact with toxic gas or oxygen depleted atmospheres within the working environment, the highest level of care must be taken. It is also essential that extrication of the worker, in the event of an emergency, is well planned, practised and executed. Although the regulations call for the worker entering a confined space to be on a tether, this is not always possible due to the nature of some spaces. Therefore the use of a rope to pull the victim from the confined space is not always practical.
Anywhere there is a risk of exposure to a harmful environment that may be Immediately Dangerous to Life and Health (IDLH) precautions must be taken to (a) minimize the risk of exposure and (b) plan for the rescue of a downed worker. In the event of a worker being overcome by a toxic substance could your rescue team arrive, assess the situation, gear up, enter the space and extricate the victim in time to save that workers life? Unless you have a skilled, highly trained rapid response team the likelihood is that they will arrive long after the worker is passed rescuing. Accepting this fact and not providing additional means of ventilatory support for the downed worker within the toxic environment while extrication is planned means that you are accepting that worker’s potential death.
The Solution
In 1990, one of Canada’s largest gas companies and two Doctors from the University of Florida developed a specification for a new industrial resuscitator designed to meet the challenges of confined space, toxic atmosphere resuscitation. By 1993 they had successfully, screened, tendered for, and had developed by O-Two Medical Technologies Inc., a new, toxic environment rescue resuscitator, designed specifically for the IDLH environment. This product, the Genesis® II IDLH Rescue Resuscitator was the predecessor of the CAREvent® CA Chemical Agent Environment Resuscitator. This is still the world’s only, specifically designed, toxic environment rescue resuscitator.
In 1994 the Canadian Standards Association added these criteria for a Confined Space Resuscitator to their CAN Z8382-94 standard on Resuscitators Intended for Use with Humans. This standard is an extension of the ISO 8382 standard on Resuscitators Intended For Use with Humans.
The gas company also implemented a training program for their staff that met the criteria for confined space and/or toxic atmosphere resuscitation. This ability to immediately provide ventilatory support within the confined space / toxic atmosphere (without risking the lives of other workers who may jeopardize their own life by attempting to help their coworker by entering the confined space unprotected) is achieved by having a “Safety Person” stationed nearby. This Safety Person must be in a position to call for help and render assistance in the event of an incident. The Safety Person does not take part in the actual work and wears suitable respiratory protection equipment with the mask at the ready but not in place. This person must also be able to communicate at all times with the workers inside the confined space and also with support personnel in the event a rescue is required. He/she must also have the knowledge, training and experience to perform the duty safely and properly.
Immediately a problem develops and it is identified that the downed worker requires ventilatory support and cannot be extricated, the safety person, having called for assistance, dons the mask, enters the space and begins artificial ventilation using the automatic resuscitator with which he/she is equipped. By providing this immediate assistance to the downed worker it gives the rescue team a larger time frame in which to arrive, evaluate the rescue, set up their equipment and effect the extrication in a safe, controlled manner.
The CAREvent® CA has “only one external control”. The chemical agent and IDLH environment is considered to be so hazardous that the less the rescuer has to do (during rescue and transport) to ventilate the patient, the quicker the patent can be resuscitated and the greater the chance for the patient’s survival. All the rescuer has to do is turn on the oxygen/air supply, apply the mask to the patient’s face and secure the airway. The CAREvent® CA will provide automatic ventilation to the non-breathing patient at a rate and volume designed to provide adequate oxygenation while reducing the risk of gastric insufflation in accordance with the current Guidelines for resuscitation. The micro-pneumatic circuitry of the CAREvent® CA requires no batteries or electrical supply to operate. Should the patient start spontaneous breathing, the “Demand Breathing” feature of the CAREvent® CA allows the patient to breathe at their own rate and volume. The patient’s inspiratory effort (if adequate) will also cause the “automatic circuit shut off” to stop the automatic cycling of the ventilator allowing the patient to breathe at their own rate and volume. If the patient stops breathing again, the automatic cycling will restart with no action required on the part of the rescuer.
A Manual Override Button is provided to allow for the provision of 2 breaths followed by 30 chest compressions during CPR in accordance with the current resuscitation guidelines. in addition it can also be used to supplement spontaneous ventilations if required. An added feature of the CAREvent® CA is the 2 L/min “MASK PURGE”, BLEED FLOW. This reduces the risk of the patient drawing in toxic ambient air into the mask should a leak in the mask-to-face seal occur.
By combining this “simplicity of operation” with technological sophistication, the CAREvent® CA provides trained individuals with a safe and effective means of maintaining artificial ventilation during respiratory arrest which may occur during confined space entry or a toxic chemical agent release.
Conclusion
By incorporating the CAREvent® CA into your toxic environment emergency planning the benefits you provide to the downed worker are immediate and one does not have to become resigned to the only possible outcome (which currently exists) if immediate extrication is not possible, which is the potential for the necessity to remove a body from the toxic environment.
Despite intensive efforts to improve cardiac arrest survival over the last 3 decades, survival rates have seen little change. The unadjusted rates of survival to hospital discharge only increased from 5.7% in 2005/2006 to 9.8% in 20121. This is despite an exponential growth in the treatments and devices used to aid the rescuers in their resuscitative attempts.
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Chest compression rate and depth has been a key focus of the resuscitation guidelines2 development over the past 15 years and have spawned a number of products designed to replace the rescuer in the provision of chest compressions. However, none of these has shown any advantage over manual chest compression when it comes to patient survival3.
Ventilation, on the other hand, has only attracted minimal attention. This is despite the fact that the effects of “Inadvertent Hyperventilation” (IH) have been shown to be a key factor in patient survival4.
While chest compressions are key in circulating oxygenated blood to the vital organs during CPR, any action that inhibits venous return to the heart will, of course, reduce the volume of blood available to be circulated. This reduction in blood flow greatly impacts oxygenation and the patient’s chance of survival.
IH has numerous effects on circulation as well creating other issues for the patient. In the mask ventilated patient, when ventilations are delivered at too fast a rate and too high a tidal volume, gastric insufflation, and aspiration of stomach contents are a major (and well documented) concern5,6. In the protected airway, these force are applied directly to the lungs creating high peak airway pressures and risking barotrauma.
The mechanisms by which IH affects survival are purely mechanical and simple to understand. Over-inflation of the lungs or not allowing sufficient expiratory time for full lung emptying before delivery of the next breath (“breath stacking”) has the effect of reducing intrathoracic space as well as increasing peak airway pressure and creating inadvertent PEEP. In the mask ventilated patient, the creation of gastric insufflation pushes the diaphragm up into the thoracic cavity further reducing the intrathoracic space and limiting lung expansion.
This reduction in intrathoracic space decreases lung compliance (making it even more difficult to ventilate) and creates compression of the great vessels, decreasing venous return to the heart. This, in turn, reduces cardiac preload and subsequent forward blood flow.
With less blood to move forward the volume of blood that can be oxygenated, is decreased. While reducing circulatory flow affects all vital organs, deoxygenating heart muscle, in particular, makes it less susceptible to the effects of defibrillation. This of course greatly affects patient survivability from a cardiac arrest.
By the action of Inadvertent Hyperventilation, we create a vicious circle of over ventilation, great vessel compression, reduced cardiac pre-load, reduced circulation, reduced oxygenation, lower coronary perfusion pressures, reduced CO2 removal and a reduction in the effectiveness of defibrillation. All of which can be eliminated by providing high-quality chest compressions along with the “controlled ventilation” that is key to increased patient survival.
Where small tidal volumes are delivered at a fast rate the issue of reduced cardiac pre-load due to compression of the great vessels may not be as serious a concern. However, the washout of CO2 that will occur does create an additional insult to the patient.
Decreased CO2 levels in the blood will create cerebral vasoconstriction, destroying brain cells and potentially risking an increase in the level of neurological deficit in cardiac arrest survivors. This effect is of course also very serious in Traumatic Brain Injury (TBI) patients where cerebral ischemia may well be exacerbated by CO2 washout caused by inadvertent hyperventilation, increasing neurological damage7.
Inadvertent Hyperventilation (IH) (which is the delivery of an excessive minute volume), during CPR or respiratory arrest, has been shown to be very common and to have severe detrimental effects on patient hemodynamics [1] as well as the associated risks of gastric insufflation and
pulmonary aspiration of stomach contents. In traumatic brain injury IH also contributes to increased brain ischemia [2].
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Current International Resuscitation Guidelines[3] clearly indicate that ventilations should be provided in a slow, controlled, manner with tidal volumes being limited to 6 – 7 ml/kg and ventilation rates to be in the 10 – 12 breaths per minute in adults. However, studies have shown ventilation rates to be 2 – 3 times this recommended rate[1] [4] with tidal volumes and airway pressures being excessive and inspiratory times being too short. While the physiological effects on these patients have been evaluated the additional cost of these negative actions on patient care in the hospital has not been clearly defined.
Pulmonary aspiration of stomach contents during CPR is, not surprisingly, very high. Felegi et al[5] in their 1996 study showed pulmonary aspiration rates as high as 33% in non-survivors of cardiac arrest. Lawes and Basket[6] reported in the Intensive Care medicine journal that “the incidence of pulmonary aspiration in a group of patients who did not respond to cardiopulmonary resuscitation (CPR) was assessed at autopsy and found to be 29%. This figure is undoubtedly an underestimate of the total problem. In survivors, any aspiration of stomach
contents will have seriously detrimental effects on morbidity and mortality.
Another issue related to inadvertent hyperventilation is barotrauma, due to excessive tidal volume delivery and breath stacking, which may require post-arrest treatment and intensive care stays. Emergency tracheal intubation is also not without significant risk.
When requiring ventilation in the ICU, patients also run the risk of ventilator associated pneumonia (VAP). Hunter, in his paper in the BMJ[7] stated: “Ventilator associated pneumonia is the most common healthcare associated infection in intensive care”. “The condition is associated with increased morbidity, mortality, length of stay, and costs”. VAP accounts for about half of all antibiotics given in the ICU. It occurs in 9-27% of mechanically ventilated patients. The condition is associated with increased ICU and hospital stay and has an estimated attributable mortality of 9%.
In the HCNA Series[8] it is stated that there are “ten conditions that use the greatest number of bed-days” in the ICU, one of which is inhalation pneumonitis (gastrointestinal contents)”. These ten conditions made up 32.8% of ICU bed days with an average length of stay 5.02
days. Nolan et al[9] stated in their article in anesthesia that, in the UK: “Mechanically ventilated survivors of cardiac arrest accounted for 24,132 (5.8%) of all admissions.”
Tan SS. et al[10] showed daily ICU costs in four European Countries to be in the range of €1168 – €2025 (£1000 – £1800) per day. In North America these average daily costs for a ventilated patient are estimated to be $5,500 per day[10]. Therefore, the per-patient cost of treating,
what is a potentially avoidable complication of cardiopulmonary resuscitation, is significant and estimated to be in the €5,800 – €10,000 (£5,000 – 9,000) range in Europe. In North America this cost is estimated to be $27,500[11].
These figures equate to an average annual cost burden (of out of hospital cardiac arrest and the issues related to Inadvertent Hyperventilation) on the various country healthcare systems of:
Review/Update
Estimated Cost of Inadvertent Hyperventilation on Intensive Care Departments O‐Two Medical Technologies Inc. 2016 Conclusions Inadvertent hyperventilation needs to be removed from the CPR equation to reduce both morbidity and mortality in cardiac arrest. The added cost of treating cardiac arrest survivors who have been respiratory compromised to the point of requiring ICU admission due to inadvertent
hyperventilation is significant. Improved methods of providing controlled ventilation (such as Automatic Transport Ventilators and flow controlling manual resuscitators need to be routinely employed during CPR. Technology-based solutions can assist in reducing this cost burden on healthcare systems (with minimal increased expenditure on devices and training) to provide controlled ventilation.
The key to the function and gas saving feature of the O-Two Single Use Open CPAP
System is the simplicity of its operating principle.
While other devices utilize complex turbulent flow to generate what has been termed
a “virtual valve” and create PEEP. We utilize the very simple “head out of the car window”
principle to create CPAP!
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When driving, if you put your head out of the window, you will experience CPAP as
the air flow assists in forcing air into the lungs and creates PEEP when breathing out. The
faster you go the greater the level of CPAP generated.
The O-Two Single Use Open CPAP System utilizes the same method by accelerating
the oxygen flow through the “vectored flow valve” in the device. The higher the flow, the
faster the air is accelerated through the nozzle and the higher the CPAP pressure generated.
The accelerated flow generates the positive pressure to assist in inspiration.
Combine this with the calculated ejection angle on the patient side of the nozzle and
the air flow is directed to completely fill the internal bore of the O-Two Single Use Open
CPAP System creating a CPAP “curtain” which generates the PEEP for expiration, thus
creating continuous positive airway pressure – CPAP.
While the use of Mechanical Chest Compression Devices do not provide any benefit versus manual compressions their use in certain circumstances may be a reasonable alternative to conventional CPR1. Because these devices deliver constant chest compressions their use in conjunction with ventilations an advanced airway is necessary.
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Fig 1. Mechanical chest Compression Devices
AHA guidelines for CPR state:
“Ventilation during CPR with an advanced airway. It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed”.
These ventilations may be provided either utilizing a BVM or an automatic transport ventilator.
Delivery of a breath between compressions.
At a rate of 100 compressions per minute the available time between compressions is the decompression phase which amounts to only 0.3 seconds. With a manual ventilator, a study by Herff et al2 that attempted to provide ventilations between chest compressions concluded that:
“Ventilation windows of 0.25, 0.3, and 0.5 sec were too short to provide adequate tidal volumes in a simulated non-intubated cardiac arrest patient. In a simulated intubated cardiac arrest patient, ventilation windows of at least 0.5 sec were necessary to provide an adequate tidal volume”.
Therefore, the only method for ventilations to be provided is over a series of chest compressions so that at least a part of the ventilation is delivered during each decompression phase. The additional negative pressure created by the chest recoil should also assist in entraining of the delivered portion of the breath.
Fig 2. Portion of breath entering the lungs.
Selecting the right ventilator mode
When using an ATV in conjunction with an automated chest compression device the ventilator must be set in a mode that does not allow for any patient triggering, which may be caused by the chest recoil during the decompression phase of the chest compression cycle. This means that the selected mode must have any patient trigger or pressure cycling mode turned off.
The primary mode on a ventilator which offers these conditions in CMV (continuous mandatory ventilation). In this mode the ventilator provides both the delivered volume and respiratory rate without any possible action on the part of the patient.
Setting the eSeries ventilators to CMV
On the eSeries ventilators this is not selectable mode but is easily set by selecting the A/C V mode.
Fig 3. eSeries Ventilator settings for CPR with a mechanical chest compression device.
The patient trigger must be set to “-“. The peak airway pressure is recommended to be set to 60 cm H2O so as to reduce the risk of barotrauma during the compression phase when the ventilation overlaps the “down stroke” of the compression. Turn the PEEP setting to “O”. Ensure the inspiratory time (Ti) is set to 2.0.
These settings will enable the chest compression device to provide continuous compressions in line with the Resuscitation Guidelines without the ventilator function being affected.
Since the late 1950’s, the Bag-Valve-Mask resuscitator, (originally developed by AMBU in Denmark), has been the mainstay of the healthcare provider for emergency ventilation of the patient in respiratory and/or cardiac arrest. These self-inflating balloons (a development from the anesthesia machine “black breathing bag”) have proliferated into an industry estimated to be worth some 60 million dollars in the U.S. alone. But what of the effectiveness of these devices?
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Certainly, in the early days of CPR (first truly defined in 1961), the “AMBU Bags” (as all BVM’s have now become known) were the only available adjuncts for the rescuer which did not require the use of exhaled breath to ventilate the patient. As such, they were a significant advance in emergency respiratory care. However, considering the major advances in medicine that have taken place over the last 64 years, we are still, in the most part, relying on old technology to perform the key task of oxygenating the respiratory/cardiac arrest patient.
The American Heart Association “Guidelines for CPR” have quite clearly identified that these devices are generally ineffective in providing adequate ventilations to the patient. A wealth of clinical evidence to support these claims has been accumulated and yet this evidence has, for the most part, been ignored as die‐hard “baggers” continue to utilize these devices. This continued use is not based on sound clinical evidence that they provide good ventilation, but seemingly because – “it has always been done this way”.
Some claim that the “feel” they get from the BVM allows them to make clinical judgements on the patient’s lung condition. In reality what they are probably feeling is the back pressure created by the high flowrates generated when squeezing the bag too hard or for too short an inspiratory time. This masks the actual compliance and resistance of the patient’sairway.
The vast array of clinical studies that have been published (including the landmark study by Aufderheide et al published in Circulation in 2004) clearly show that this original technology is ineffective in the way in which it provides ventilation (in the majority of healthcare provider’s hands) and potentially dangerous, especially in some non-protected airway situations.
The O-Two Medical Technologies SMART BAG® has been proven to be effective in controlling the ventilations by constantly training the rescuer, with every squeeze and release of the bag, to slow down and deliver controlled ventilations. Its use is now widespread however, there are still a large number of users who do not see the need for such a device or indeed accept that their BVM technique is poor, regardless of the clinical evidence to the contrary.
If patient survival is to improve then ventilation needs to be controlled. SMART BAG® provides that control without having to change the way in which you were taught to bag.
O-Two Medical will be present at OAPC 2018, organized by ONTARIO ASSOCIATION OF PARAMEDIC CHIEFS. Anita Bekavac will be representing the company at Vendor Booth 58. The event will take place at the London Convention Center – London, Ontario, from September 18th to 20th, 2018.
The Lithium Ion battery used in the e700 portable transport ventilator provides an exceptionally long operating time.
When compared to the two main competitive portable transport ventilators of its type in the market, the e700 transport ventilator operates 2.5 times longer on a single battery charge.
In this day and age we sometimes forget that convenience often comes at a cost. One such area of convenience v cost is in the area of disposable/single use CPAP devices packaged with nebulizers and even ETCO2 cannulas.
With a generally accepted average of only 28% of patients treated with disposable/single use CPAP receiving nebulized medications, either of these additional items may well be routinely discarded….at a significant cost.
On the 13th – 15th June in Edmonton – Alberta, Anita Bekavac is representing O-Two Medical at Paramedic Chiefs of Canada Leadership Summit 2018. The program can be checked here.
The Senior Communications Advisor Alberta Health Services, Francis Silvaggio and the labour and employment lawyer Mark Mason are going to participate in the event at The Westin Edmonton.
Anita Bekavac will be representing O-Two Medical at SEMSA in Mouse Jaw on the 7th – 8th May. Come by the booth ans see our transport ventilators, single use CPAP device and SMART BAG manual resuscitator.
Our Anita Bekavac will be attending this meeting next week working with our distributor Levitt Safety. Do drop by the Levitt booth to see the O-Two products on offer including our personal CPR protective devices, oxygen regualtors, pulse oximeters and the revolutionary SMART BAG.
The Ontario Association of Fire Chiefs will take place at the International Centre in Mississauga, Ontario from 4th to the 6th May. Our very own Anita Bekavac will be joining Levitt Safety on their Booth to demonstrate our range of emergency respiratory care products.
Missouri Ice Spring Break EMS Conference, Holiday Inn Executive Center, Columbia, Mo March 26 – 30, 2018
Cheryl will attending the Vendor Fair at this conference on March 27th and 28th and will be showing our eVents, CPAP and SMART BAG at the Henry Schein booth. Everyone is welcome to come by for a demonstration.
Cheryl Wise will be attending the Society of Michigan EMS Instructors & Coordinators Conference, Grand Traverse Michigan Resort, Traverse City, Michigan from the 23rd to 25th March 2018.
She will be showing our eVents, CPAP and SMART BAG on the J & B Medical booth. Make sure you drop by to see the products that are making significant waves in the market!!!
We are pleased to be exhibiting once again at the 2018 Gathering of Eagles meeting which takes place Friday, March 2nd & Saturday, March 3rd at the Sheraton Downtown Dallas (400 North Olive Street, Dallas, Texas 75201).
Cheryl, Richard and Helton will be exhibiting our range of emergency respiratory care devices including the eSeries ventilators, O-Two CPAP and SMART BAG as well as our Equinox Relieve Analgesic Gas Mixing and Delivery System. Make sure you drop by to see how we can ease your patient’s pain improve your ventilations.
East TN Region II EMS Directors Association Conference, November 9th and 10th at the Park Vista Hotel, Gatlinburg, TN. Our Richard Lauber will be in the Henry Schein booth.
Cheryl Wise and Ryan Lovelady will be exhibiting our products at the EMS World Expo, Las Vegas, NV. October 18, 19 and 20.
The show is taking place at the Las Vegas Convention Center and you can meet Cheryl and Ryan at our Booth number 1125. Make sure to come by and see the latest products from O-Two including the eSeries ventilators and O-Two CPAP.
It is with great sadness that we must inform our extended O-Two family of staff, customers and distributors of the untimely death of our International Sales and Marketing Manager Ken Thom. Ken died on Sunday 24th September in a SCUBA Diving accident while in South Africa.
All those who knew Ken during his 26 years with O-Two will fondly remember his sense of fun and unwavering commitment to improving emergency respiratory care. His input into product development helped to bring many new and innovative devices to the market, devices which are saving lives on a daily basis around the world.
Many of you will also be aware of Ken’s love of sport and especially his commitment to coaching Paralympic athletes where he coached Bermuda in the London Paralympics in 2012. Who will ever forget the sight of Ken in his pink Bermuda shorts at the opening ceremony?
Ken was a member of the Canadian Paralympic Committee and coached his son Curtis, who is a Canadian National wheelchair athlete at the 2016 games in Rio. Ken also had a great love of football, which he coached in Streetsville-Meadowvale for many years.
Ken leaves behind his wife Karen, sons Christopher and Curtis and daughter Stephanie, Son in law Nick and Daughter in law Bonnie along with his 3 grandchildren Riley, Alexis and Maleia (who were the center of Ken’s universe) and one yet to be born to Stephanie in January
Our thoughts are with his family at this sad time. Ken will be sadly missed by family, friends, athletes, colleagues and customers alike.
For those who wish to express their sympathy the family would appreciate donations to the Ontario Wheelchair Sports Association 100 Sunrise Ave. Unit 101, Toronto, ON M4A 1B3 www.owsa.ca or the Cruisers Sports for the Physically Disabled 9-6975 Meadowvale Town Centre Circle, Suite 158, Mississauga, ON L5N 2V7.
O-Two will be exhibiting at the O A P C – The Shaw Center, Ottawa – September 26-28, 2017.
Our Anita Bekavac will be at our booth # 409. On display will be our award winning O-Two Single-Use CPAP, SMART BAG controlled Flow manual Resuscitator and our eSeries Electronic Transport Ventilators. Drop by for a demonstration of these, or any, O-Two products.
Cheryl Wise will be working on the Henry Schein Booth at the Illinois Ambulance Association, Peoria, Illinois. do drop by to see our CPAP and transport ventilator solutions.
O-Two will be exhibiting at Booth #515 at the Paramedicine Across Canada Expo, 17th to 20th August at the Quebec City Convention Center. Anita Bekavac will be there to introduce you to our exciting range of emergency respiratory care roducts including the SMART BAG, O-Two Single use CPAP device and our eSeries ventilator range.
The one-day, CPECC – California Pediatric Emergency Care Conference, June 23, 2017, NorthBay Healthcare in Fairfield, California, Takes place on June 23rd. Our Western USA Sales manager, Ryan Lovelady, will be there exhibiting our range of emergency respiratory care products including our e7oo transport ventilator and the Pediatric SMART BAG MO\, “controlled flow”, manual resuscitator.
June 18 – 22 sees the ICM coming to Toronto for their Triennial International Congress. O-Two will be there (Booth# T5) displaying our range of pain relief and emergency resuscitation products for labor and delivery.
Anita Bekavac and Kevin Bowden will be attending so do look out for us.
Our Anita Bekavac will exhibiting at the Paramedic Chiefs of Canada Leadership Summit 2017 — Halifax, Nova Scotia, June 7- 9, 2017, at The Westin Nova Scotian Hotel. Come by our booth to see the range of controlled ventilation solutions offered by O-Two.
SEMSA (Saskatchewan Emergency Medical Services Association) Conference, Mosaic Place, Moose Jaw, SK, is taking place May 8 – 10, 2017. Our Anita Bekavac will be there on our booth demonstrating our range of emergency respiratory care products, single use CPAP and transport ventilators. Make sure to drop by to see the latest offerings from O-Two Medical.
O-Two will be represented at the ‘The Summit EMS Conference’ in Coeur d’ Alene Idaho located at the Coeur d’ Alene Resort, by our Ryan Lovelady. He will be working with our distributor Life-Assist in their booth. Come by to see the very best in emergency respiratory care from O-Two Medical Technologies.
Cheryl Wise will be attending the Illinois EMS Summit April 6th at the Memorial Center for Learning and Innovation
600-698 N. Rutlege St. Springfield, IL. Cheryl will be working with Henry Schein on their booth.
Cheryl Wise, Central US Sales Manager, will be exhibiting at the Minnesota – Long Hot Summer conference on Trauma & Emergency Care March 3 – 4. Drop by to say “Hi”!
O-Two will be exhibiting our range of controlled ventilation products on booth #1529 at EMS Today in Salt Lake City, Utah at the Calvin L. Rampton Salt Palace Convention Center, Feb 23rd – 25th. Ryan Lovelady will be there to answer all your questions and to show you our exciting range of eSeries electronic transport ventilators, single use CPAP devices and controlled flow manual resuscitators. Make sure to drop by to see him.
Cheryl Wise and Richard Lauber will be exhibiting at the Eagles meeting in Dallas this week. This conference brings together a faculty of the best minds in EMS Medical Direction for a fast paced meeting on the current and future course of pre-hospital emergency care.
Stop by to see how O-Two is contributing to improving controlled ventilation in the EMS environment.
Our Western US Sales Manager, Ryan Lovelady, will be attending Firehouse World in San Diego at the San Diego Convention Center, ( https://www.firehouseworld.com/ ) 7th and 8th February. Ryan will be working with our Life-Assist ( https://www.life-assist.com/ ) colleagues in their booth #1018. Do drop by to meet Ryan and see our latest controlled ventilation solutions.
Come see the transport ventilator that is captivating EMS, the e700 from O-Two Medical Technologies, at WI EMS Working Together Conference & Exposition January 25 @ 8:00 am – January 28 @ 5:00 pm.
Taking place at the Wisconsin Center, 400 W. Wisconsin Avenue, Milwaukee, WI 53203 , our Cheryl Wise will be there working with our distributors Moore Medical, Henry Schein and EMP. Do make sure you drop by to see what is so special about this amazing product. Also ask about our single use CPAP and controlled flow manual resuscitator, the SMART BAG MO!
Our Cheryl Wise will be in the Henry Schein Booth at the Arrowhead EMS Conference, Duluth Minnesota. 19th to 21st January Friday from 10:00AM to 6:00 PM and Saturday 7:00AM to 3:30PM.
Do drop by to look at the latest extension to our Single use CPAP, now packaged with our nebulizer kit! Also ask Cheryl to show you our eSeries Ventilators which are grabbing a lot of attention from the EMS market.
Our Richard Lauber (richardl@otwo.com), is exhibiting our range of controlled ventilation devices at the 37th Annual Virginia EMS Symposium, November 09 – 13, 2016, Norfolk Waterside Marriott, Norfolk, Virginia. Richard can be found on the booth distributor, BoundTree, booth number 34, 41-43.
Richard demonstrates our e700 Automatic Transport Ventilator to a conference attendee.
“O-Two has moved to new premises to allow us to continue our expansion and to serve you better”!
While our new premises are not too far from our previous location, the move has required not only a change of address but also a changein our Telephone and Fax numbers.
O-Two Medical Technologies Inc. is now located at:
While Cheryl and Richard are in New Orleans at EMS EXPO our Ryan Lovelady (ryan.l@otwo.com) will be in Reno, Nevada at Firehouse West, Reno Sparks Convention Center, Oct. 4-5
Ryan will be joining our distributor Life-Assist on their booth for the show and will be displaying our SMART BAG, Single Use CPAP and eSeries ventilators so do drop by to take a look.
Our Cheryl Wise (cheryl@otwo.com) and Richard Lauber (richardl@otwo.com) will be attending the EMS World Expo- October 3-7, 2016 Ernest Morial Convention Center, New Orleans, LA next week. They will be manning our booth #549 in the exhibition hall so do come by to see the latest in controlled ventilation technologies. They will be displaying our SMART BAG, Single Use CPAP and eSeries Ventilators so make a point of coming to booth #549 to take a test drive.
O-Two will exhibiting at the OAPC CONFERENCE in Collingwood next week. We will be represented by our Anita Bekavac (anita@otwo.com) at Booth # 50. Make sure to drop by and have Anita show you the latest in “controlled ventilation” technology from O-Two.
The conference is taking place at the Blue Mountain Village, 156 Jozo Weider Boulevard, The Blue Mountains, Collingwood.
Our Ryan Lovelady will be attending the Oregon EMS Conference, Riverhouse Convention Center, Bend, Oregon Sept. 22-24
Ryan will be in the Life-Assist booth helping to present out SMART BAGs, single use CPAP and eSeries ventilators. Do drop by to see these exciting products.
Ryan can be contacted by phone: 647-522-7637 or e-mail: ryan.l@otwo.com
Our distributor PennCare will be exhibiting at the Tri ambulance Association meeting this week. Our own Richard Lauber (richardl@otwo.com) will be assisting them with our range of ventilation products including the eSeries ventilators, SMART BAG and Single use CPAP. Do drop by to see and try these exciting products.
Curtis Thom (son of our own Ken Thom, International Sales and Marketing), has been selected to race for Canada in the 400m and 4 X 400m relay wheelchair racing events at the Rio Paralympics.
Born with Spina Bifida, Curtis, age 30, took up wheelchair racing at age 11. He is not a new comer to international sporting events having represented Canada in the Paralympics in both Athens and London as well as multiple World Championships. He is the current the Canadian record holder for the 400m , 4 x 100m relay and the 4 x 400m relay events. In 2013 he won Bronze in the Francophone Games in Nice. Here is Curtis racing in Edmonton at the Canadian championships in July 2016:
Ken is the the National Team Coach for ParaAthletics for Bermuda as well as a personal coach for one of the Canadian athletes in Rio. Ken will be attending the games from the 3rd to 18th September. For those of you who know him, watch out for those “Pink” Bermuda shorts at the opening ceremony!
We at O-Two wish Curtis every success in Rio! “GO CANADA”!!!
Ken Thom, International Sales and Marketing and Helton Santos,our South America Sales Manager will both be attending FIME 2016 (Florida International Medical Exhibition), at the Miami Trade Center, Miami, Florida 2nd to 4th August 2016. Do drop by our booth (#: D-B41) to see our range of controlled ventilation products including the eSeries ventilators, SMART BAG and Single Use CPAP as well as our Equinox Analgesic Gas Delivery Systems.
If you would like to make an appointment to meet with us at the show please contact Ken (kenthom@otwo.com) or Helton (helton@otwo.com) to set up a meeting time.
Our Central USA Sales Manager Cheryl Wise (cheryl@otwo.com) will be attending the Missouri EMS Conference at the Hilton Convention Center, Branson MO from July 26th to 28th. Cheryl will be working with one of our distribution partners, Henry Schein, in their booth.
Attendees at this conference come from all levels of EMS including Clinical Educators, Assistant EMS Chiefs and EMS Chiefs. Do drop by to speak with Cheryl and see our innovative ventilation solutions including the eSeries Ventilators, single use CPAP and SMART BAG MO.
Our Ken Thom and Helton Santos will be attending ExpoMed 2016, World Trade Center, Mexico City, 8th – 10th June. They will be exhibiting on the Ontario Pavilion. Helton is fluent n Portuguese and Spanish so we will be able to answer all your questions. Do come by the pavilion and see the latest advances that O-Two (and the rest of the medical manufacturing community in Ontario, Canada) has to offer.
Our Western US Sales Manager, Ryan Lovelady, will be attending the “Trauma 2016: yesterday, today, tomorrow” by the California EMS Authority at the Marine’s Memorial Club & Hotel, San Francisco, CA. on June 7th 2016 with our distributor Life Assist.
Make sure you visit the booth to discuss with Ryan the range of “controlled ventilation” solutions offered by O-Two.
O-Two will be exhibiting at the Paramedic Chiefs of Canada, Prairieland Park in Saskatoon, Saskatchewan, May 31st-June 2nd, 2016.
Our Canadian Sales Manager Anita Bekavac will be there at Booth #22. Please drop by to see the range of controlled ventilation solutions O-Two has to offer.
O-Two will be represented by our South American Sales Manager, Helton Santos, as a member of the Ontario Healthcare Mission to Brazil, at Hospitalar 2016. He will be at the show from the 16th until the 19th May meeting with distributors. If you are attending and would like the opportunity to see the range of controlled ventilation devices O-Two offers please contact Helton:
Click on the link below to see the first of our new Whiteboard Advertisements: “New Ideas”, providing information on O-Two Medical Technologies Inc. and its products. Please feel free to circulate this to your colleagues, customers or whomever you feel might like a lighthearted look at our “controlled ventilation” offerings.
Watch out for more of these fun and informative videos every week from your local O-Two Sales Manager.
Our Romanian distributor: SC. ALPHA MEDICAL SRL. (www.alphamedical.ro) will be exhibiting our range of controlled ventilation devices at the SRATI congress, between May, 11th and 15th in Sinaia, Romania.Make sure you drop by and say “Hi”.
O-Two will be exhibiting at the SEMSA Conference May 9th -11th Convention Trade Show at Mosaic Place in Moose Jaw, Saskatchewan. Our Canadian Sales Manager, Anita Bekavac, will be attending (anita@otwo.com). Make sure you drop by our booth to see our amazing range of controlled ventilation devices.
The Rettmobile Emergency Services Show takes place next week in Fulda, Germany. Our Hungarian distributor, Ms. Eszter Farkas of Speeding Kft., will be visiting.
On the purchase of 40 of our e700 Automatic Transport Ventilators, Chivas Guillote, BSN, RN, LP, CCRN, CFRN, CCEMTP, Vice President of Clinical Services, Harris County Emergency Corps said of the acquisition:
“O-Two and Boundtree have made our acquisition of the e700 ventilator as seamless as possible. I have nothing but fantastic things to say about the ease of the purchase, the flexibility of both companies in regards to training, and the level of responsiveness we have experienced. I have been involved in EMS equipment purchasing for a long time and I can say this implementation went flawlessly. The ventilator is an excellent piece of equipment and will serve us well for years”.
“Our staff was reluctant to change ventilators because they were concerned about having to learn more advanced features. This ventilator was so easy to teach to our team. The level of crew member confidence was high as they left the training. As you can read in the testimony below, we had several uses in the first couple of weeks after the deployment. Our staff is very comfortable with our purchase. Thanks for making this process simple and effective”.
On the first actual patient use of the e700 ventilator, Mike Reed, LP (also Mike Summers, EMT-P) said …. ” The new vent proved both easy to use and helpful when switching modes of respiration on a critical patient with an initially compromised and semi-controlled airway.”….”the controls were as simple to use as we practiced. The vents also clean up well after a call”. “I know several folks have used them now in just the first two days (including someone doing BiPAP). Our personal experience on a critical, multi-airway-strategy call was fantastic. I’d encourage everyone to think through what you’d use the different settings for, and let Clinical Practice know what works for them”. This is a very good upgrade to the vents we had before”!
Our Cheryl Wise will be attending the Missouri Education Conference at the Lake of the Ozarks, April 27th to 28th. Do drop by to see our e4xciting range of emergency respiratory care devices including our eSeries Transport Ventilators, Single use CPAP and SMART BAG Controlled Flow Manual Resuscitator.
We will be attending The Summit meeting in Coeur D’Alene, ID. with one of our US distributors, Moore Medical on the above dates. Ryan Lovelady will be there to answer any question you may have and to show you the range of “controlled ventilation” products from O-Two Medical.
Are you a professional sales person with a proven track record, or a paramedic looking to break into medical sales? Are you self-motivated and dedicated to improving patient care? Do you have what it takes to grow your sales career with an innovative, well established, Canadian manufacturer, dedicated to providing the very best in emergency respiratory care?
We are looking to expand our dynamic team of Territory Sales Managers (both Nationally and Internationally) to manage our ever growing distributor network.
O-Two is pleased to welcome our new South America Sales Manager, Helton Santos, to the O-Two team! Living in Brazil with his wife and one child, Helton comes from a background in ICU ventilation.
Cheryl Wise of O-Two will be attending the Bob Page EMS Conference in Peoria on the 22/23rd March. Drop in to say “Hi” and see the eSeries range of transport ventilators. Well worth a visit!!!
Richard Lauber, Eastern Region Sales Manager, will be attending EMS Today at the Baltimore Convention Center, Baltimore MD 24th – 27th February (https://www.emstoday.com/index.html) with Moore Medical, booth# 1225.
Richard will then be heading to Columbus OH for the ITLS Emergency with Moore Medical Feb 26 & 27th (https://www.itraumaohio.org/aws/OACEP/pt/sp/itlsconference ).
Make sure to drop by to see the eSeries range of transport Ventilators and a whole lot more “controlled ventilation” products from O-Two Medical Technologies.
Our Central Region Sales Manager, Cheryl Wise, will be representing O-Two at the 2016 Gathering of Eagles conference at the Sheraton Dallas Hotel 400 North Olive Street Dallas, Texas, February 18th – 20th (https://www.gatheringofeagles.us/2016/2016information.htm)
Visit Cheryl at our booth to see our exciting range of resuscitation and transport ventilation products.
Our 2016 North America, International and First Aid Respiratory Catalogues are now available. Visit our Resource Center/Product Literature Library to download the catalogue for your geographic area.
Our Eastern Europe Sales Manager, Anita Bekavac, reports that our Slovenian distributor Medicop d.o.o. will be attending the Airway Management in Prehospital Circumstances seminar, 4th February at the Center URSZR Pekre, Bezjakova 151, 2341 Limbuš, Slovenia. They will be exhibiting O-Two Products and we look forward to hearing some great reports from the show from them. https://www.medicop.eu/
O-Two will be exhibiting at Firehouse World, San Diego Convention Center, San Diego, CA, February 2-3, 2016 Booth # 1351.
Our very own Ryan Lovelady will be there to show you our exciting range of Controlled Ventilation devices including our ward winning O-Two Single-Use CPAP and the new eSeries Electronic Transport Ventilator Range. Make sure you come by for a look see! www.firehouseworld.com
Cheryl Wise will be attending the 30th “Working Together” Wisconsin EMS Conference at the Wisconsin Center, Milwaukee, January 29th and 30th. Cheryl will be there assisting our distributors – EMP, Henry Schein and Moore Medical with our eSeries Ventilator range, SMART BAG MO “controlled flow” manual resuscitator and O-Two Single Use CPAP products.
Drop by any of the three booths by for a demonstration. Cheryl will be more than happy to answer your questions.
You can reach Cheryl by the following methods:
Cheryl Wise – Sales Manager Central US
O-Two Medical Technologies Inc.
7575 Kimbel Street, Mississauga, Ontario, Canada, L5S 1C
T’was the night before Christmas
And all through the hall
The medics were eating
And having a ball
When out of the office
There came the chief
His eyes they were glazed
His face stricken with grief
“It seems that old Santa’s
Had a heart attack
I think that the cause
Was the weight of his sack”
The doors were flung open
And the engine was started
With lights flashing and sirens
The ambulance departed.
Oh what will we do
One medic he cried
It sounds like an arrest
And no matter how we’ve tried
We know our success rate
For ROSC is quite low
But try we must
And so on they did go
They sped through the streets
Taking corners too fast
They didn’t know how long
Poor Santa would last.
They got to his house
And then saw his plight
For Santa lay dead there
T’was a terrible sight
Try as they may
With chest compressions
And defibrillation
They had no success in
Returning circulation
Then one medic he said
Poor Santa won’t last
Get out the SMART BAG
We’re ventilating too fast!
And in a flash
The SMART BAG was applied
No Hyperventilation
Just perfect chest rise
Doing 30 to 2
And with good oxygenation
They soon got ROSC
T’was Santa’s salvation
They both cried with joy
For Christmas was saved
Santa mounted his sled
And with a wave
He turned to the crew
And without hesitation
Said “I know what saved me,
T’was ‘Controlled Ventilation’”!
Season’s Greetings and a Happy, Healthy and Prosperous New Year to All
From All the staff at O-Two Medical Technologies Inc.
At the Emergency Pediatric Interdisciplinary Care Conference in Tucson Arizona, O-Two were honored with the title of Pediatric Champions!
Ryan Lovelady, Western US Sales Manager for O-Two (ryan.l@otwo.com) said “What a great meeting with such a welcoming and supportive group of delegates and organizers. We will be definitely be back for the next one”!
Started in 2011, EPICC set out to provide high quality education in the care of the one of most vulnerable populations in Arizona: children. A non-profit group with a mission to educate emergency providers, they hope to continue to offer affordable, practical pediatric CE and CME for years to come.
The European Resuscitation Council launched the 2015 Resuscitation Guidelines in Prague. With over 3000 attendees this was one of the best attended ERC meetings ever!
O-Two was represented at the exhibition by Anita Bekavac and Kevin Bowden and the level of interest in O-Two products by the delegates (especially SMART BAG and the e700 ventilator) was phenomenal! The visitors to our booth came from 27 countries as far apart as Chile and Russia and Sweden and South Korea making this a truly international conference.
While the 2015 Guidelines did not introduce any new protocols they did solidify a number of issues and brought up some science that perhaps downgraded the benefit of certain CPR adjuncts. Of particular note was the reference to Supraglottic airways and their clinical inferiority to standard bag-valve-mask ventilation. In addition the use of automated chest compression devices was downplayed as not showing any clinical benefit over manual chest compressions.
With the guidelines now firmly set for the next 5 years we look forward to seeing an overall improvement in survival from out of hospital cardiac arrest.
O-Two will be Exhibiting at the European Resuscitation Council Guidelines Conference, Prague, Czech Republic Oct 29 – 31 2015, Booth #: E04.
Kevin Bowden and Anita Bekavac will be in attendance and we will be displaying our “e” Series ventilator range as well as our Single Use CPAP, CAREvent ventilators and SMART BAG.
Essex-Windsor EMS, the County of Essex and City of Windsor is proud to be hosting the 2015 AGM Fall Conference for the Ontario Association of Paramedic Chiefs at Caesars, Windsor from September 24 to the 25, 2015. O-Two will be exhibiting with Anita Bekavac in attendance on booth # 27. Drop by to see the latest products from O-Two.
The City of Manassas Fire-Rescue Department have become the first service in the USA to purchase the new e600 ventilators (literature) from O-Two Medical Technologies.
Chosen for its lightweight, long battery life and ease of operation, the e600 will become the front-line ventilator for this service.
Seen here is O-Two Eastern US Sales Manager Richard Lauber undertaking the initial in-service training with Manassas staff members.
Congratulations to Richard for this first sale of “e” series ventilators in the USA. Many more are on the horizon!
The John Hunter Hospital in New South Wales, Australia has taken delivery of their first 20 Equinox® Advantage units. These units offer adjustable N2O concentrations from 25 – 75% and are designed to deliver pain relief for trauma, childbirth and during painful procedures. These were sold through our distributor Gascon.
Sarella Singer & Anita Bekavac of O-Two will be exhibiting at the Paramedic Chiefs of Canada Conference. Come along to Booth #51 to see the latest ventilation technologies from O-Two.
O-Two Medical will be attending The SEMSA Convention & Trade Show, May 11 – 13 at the Sheraton Cavalier Saskatoon, Saskatchewan. Please drop by to speak with Anita Bekavac and to see the latest controlled ventilation devices from O-Two.
O-Two will be attending the Trauma Care Conference, Telford, Shropshire, UK April 18th – 24th with our UK distributor SP Services. Kevin Bowden will be presenting at the conference on Ventilation in Trauma.
Cheryl Wise will be attending the Travis City EMS Conference 23rd to the 25th April. make sure to drop by and say “Hi”. Cheryl will be showing for the first time at USA conference the new “e” Series Ventilators from O-Two! Well worth a look!!!
The 12th Dutch Reanimation Congress in Utrecht was well attended with around 1000 delegates for the one day event. Medicare Uitgeest, our Dutch distributor, sponsored the congress bags and put on a fine display with SMART BAG and the O-Two single use CPAP front and center. Two Mini Ventilation Training Analyzer workstations for the delegates to try SMART BAG attracted a lot of attention.
SMART BAG wowed the crowd with a lot of delegates asking for information and demonstrations at their hospitals. Medicare have done very well so far this year converting a number fo hospitals to SMART BAG through their representative Rob Emmens. Great Job Medicare!!
O-Two are attending this year’s Gathering of EAGLES conference in Dallas Texas.
The EMS State of the Sciences Conference (dubbed by media as “A Gathering of Eagles”) has become one of the most progressive and important EMS conferences worldwide.
The faculty, derived from the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (The “Eagles” Coalition) is comprised of most of the jurisdictional EMS Medical Directors for the nation’s 35 to 40 largest U.S. cities’ 9-1-1 systems as well as the chief medical officers for several pivotal federal agencies such as the FBI, U.S. Secret Service, White House Medical Unit and also includes several global municipalities such as London (UK) and Sydney (Australia).
In essence, this small but cohesive cadre of leading emergency medical services specialists not only oversee the medical aspects of day-to-day 9-1-1-type emergency responses and early resuscitative interventions for trauma, stroke, cardiac care and other critical emergencies in the nation’s (and some of the world’s) most populous cities, but most of them are also responsible for much of the medical aspects of homeland security and disaster management in these high-risk venues (in which nearly 100 million persons dwell and make their livelihood). Their ability to deal with these significant responsibilities is, in many ways, facilitated by the close cooperation of this unique convocation of physicians who also generally serve as the main interface between local government and the medical community at large in these metropolitan municipalities.
The purpose of the highly popular annual Eagles conference is to share with participants — and faculty alike — the most cutting-edge information and advances in EMS patient care, research and management issues — as well as trending challenges (and lessons learned from those challenges) — while also introducing novel patient care strategies and techniques.
Beyond the faculty, this unique global EMS conference is also famous for having pioneered the 10 minute bullet plenary presentation, “lightning rounds” and other innovative educational advances which have not only provided the attendees with 40 or so plenary presentations over 2 days but, according to conference evaluations, have also changed nationwide medical practices almost overnight. Accordingly, the consortium has become extraordinarily influential in shaping future EMS practice trends, medical aspects of disasters and homeland security — not to mention day-to-day 9-1-1 responses and resuscitations worldwide.
Cheryl Wise and Richard Lauber will both be there so do drop by to see them and our range of “controlled ventilation” devices that will be on display.
You can reach Cheryl by calling 1 877 782 3302 and Richard on 877 215 8869.
Following a successful trip to Croatia by Our Eastern European Sales Manager Anita Bekavac, the following customers have come on board with our “e” Series Ventilators, SMART BAG and Burn Relief: KB Sveti Duh, Zagreb, KBC Sestre milosrdnice, Zagreb, HGSS Croatian Mountain Rescue.
Sarella Singer (Cell: 514-546-5547, email: sarella@otwo.com) will be at the EXPO préhospitalier Jan 29/30. Sarella will be working with our distribution partner EMRN so do drop by to see her and take a look at the latest products from O-Two.
Elite Scientific will be representing O-Two Medical products at Arab Health, Jan 26th to 29th in Dubai. You can see our products on booth number S2E70. Please contact Anis Abdalla (cell number: +1 905 966 2912). Anis is looking forward to meeting you there.
O-Two, in the form of Sarella Singer and Anita Bekavac will be attending the Acklands Grainger 2015 Products and Services Show February 4 and 5 in Vancouver.
T’was the night before Christmas and all through the hall,
The medics were eating and having a ball.
When out of the office there came the chief,
His eyes they were glazed, his face stricken with grief.
“It seems that old Santa’s had a heart attack,
I think that the cause was the weight of his sack”
The doors were flung open, the engine was started,
With lights flashing and sirens the ambulance departed.
Oh “what will we do”? One medic he cried
“It sounds like an arrest and no matter how we’ve tried.
We know our success rate for ROSC is quite low.
But try we must” and so on they did go.
They sped through the streets taking corners too fast,
They didn’t know how long poor Santa would last.
They got to his house and then saw his plight,
For Santa lay dead there t’was a terrible sight.
Try as they may with chest compressions and defibrillation,
They had no success in returning circulation.
Then one medic he said “poor Santa won’t last.
Get out the SMART BAG we’re ventilating too fast”!
And in a flash the SMART BAG was applied.
No Hyperventilation, just perfect chest rise.
Doing 30 to 2 and with good oxygenation,
They soon got a pulse, t’was Santa’s salvation!
They both cried with joy for Christmas was saved.
Santa mounted his sled and with a wave,
He turned to the crew and without hesitation
Said “I know what saved me”, t’was Controlled Ventilation!
Our Polish distributor, Respivent, has secured a tender for 13 e700 Tranport Ventilators for ARM Poland. This follows on the back of Respivent securing business with our e700 ventilators in the new Polish Simulation Center in Northern Poland.
Bonnyville EMS has become the first EMS Service using the e700 ventilator in Alberta. Ken Hesson (Acting EMS Chief) said they are very pleased with the e700 and looking to purchase more within the next 3 years.
Kevin Bowden will be visiting the MEDICA Exhibition, Dusseldorf, Germany this week. Call or text to 001 647 309 2177 or e-mail kevinb@otwo.com to arrange a meeting.
Putnam County, TN, Hoosie Valley, NY and Northumberland County ON, are the latest services to switch to O-Two Single Use CPAP. Simplicity, size and low gas consumption cited as the reasons for the change.
Kevin Bowden will be attending the UKRC with our exclusive UK distributor SP Services on November 6th. Come by and see the latest in “controlled ventilation” technology.
O-Two will be attending the 118 congress in Genoa, Italy October 23 – 25 2014. We will be working with our exclusive Italian distributor Iredeem. Do drop by if you are attending.
Kevin Bowden will be on the booth of our Italian distributor Iredeem at the Italian Resuscitation Council Meeting. Naples, October 10/11. They will be show casing our SMART BAG, Single Use CPAP and “e” Series Ventilators. Drop by and say “Hi”!
While attending the “AmbulanseForum” in Oslo, Norway an O-Two Salesman (name withheld to protect anonymity) was arrested for “intent to supply superior product”.
O-Two will be attending the Norwegian Ambulanse Forum Sept 30 – Oct 1st in Oslo. Stop by the Ferno Norden booth to see the latest offerings from O-Two including our new “e” Series Ventilators. Kevin Bowden of O-Two will be in attendance.
Now available in North America the NEW!! O-Two Single Use CPAP Nebulizer Kit.
This enables you to run CPAP and nebulizer off one regulator utilizing the 9/16 DISS outlet to run the nebulizer and the therapy flow outlet to run the CPAP unit.Unlike other devices with built in nebulizers, running both at the same time does not affect the CPAP performance output!!!
O-Two will be exhibiting at FIME 2014 in Miami Beach on the 6th – 8th August. Ken Thom and Richard Lauber will be in attendance so do come by our booth # 2046 to see the latest exciting products from O-Two Medical.
Anita Bekavac with be attending the Congress of Intensive and Urgent Medicine, Brijuni, Croatia 16th t0 18th June. This is our first attendance at this show and the first showing major of our innovative and exciting product range in Croatia.
O-Two will be represented at the Alberta Fire Chiefs Conference (Grande Prairie, AL, 8th/9th June) and the Canadian Paramedic Chiefs Conference (Vancouver BC, 1th – 13th June) by Anita Bekavac – anita@otwo.com. Do be sure to drop by and chat with Anita about our newest products.
A new study from Belgium on the CAREvent® PAR to be published in the European Journal of Emergency Medicine, entitled:
Quality of resuscitation by first responders using the Quality of resuscitation by first responders using the public access resuscitator’: a randomized manikin study.
Concludes that:
“Compared with the face mask [pocket mask], PAR improved tidal volume, compressions per minute andhand position…”.
Even more reason to choose one of O-Two’s controlled ventilation solutions!
SMART BAG® is being included in the medical kits for the race teams belonging to the FIA (Federation Internationale de l’Automobile). This organization covers motorsport worldwide at all levels from Formula 1 through rally car to karting. All race teams must be trained in emergency medical response and the training is being undertaken by MDD Europe starting with the new Formula E electric car racing series which has it inaugural race in Beijing, September 2014.
Our Western Canada Sales Manager Anita Bekavac (anita@otwo.com) will be attending the BC FIRE EXPO and FCABC CONFERENCE June 1st and 2nd. Contact Anita to set up a meeting.
The Queensland, Australia, Ambulance Service has selected the o_two Single Use CPAP System for use by their Intensive Care Paramedics. The service has produced an excellent training video which can be found on youtube:
recently published on EMS World, shows our SMART BAG MO controlled flow manual resuscitator being used.
SMART BAG MO has been widely adopted across Arizona due to the efforts of the University of Arizona with their “EPIC Project” Traumatic Brain Injury Study.
EMS services in the following counties in Ontario have joined the Province of Manitoba in using the O-Two Disposable CPAP device to treat patients in the pre-hospital environment: County of Simcoe, Haldimand County, Norfolk County, London, Hamilton, York Region (Toronto), Essex Windsor, & Lambton County.
Cheryl will be on hand at the Appleton WI, Paramedic Conference to discuss O-Two products. Do drop by and see her or contact Cheryl to arrange a specific meeting time:
SP Services, UK, ran an excellent Ventilation Symposium at their new head offices in Telford, Shropshire. 24 people in all attended and the meeting content was very well received. Unfortunately, due to space limitations, there were a number of people who could not be accommodated. A second Ventilation Seminar is now planned for the 7th May!
Our Italian distributor, Iredeem (Bologna, Italy), ran their 2014 Sales Meeting at an unusual venue at the weekend. Choosing to hold the meeting South of Stuttgart, Germany at a “BrauHaus/Hotel” where, on Saturday evening, all 40+ delegates and presenters were treated to an evening with the “brau meister” learning all about German beer while sampling 7 different types. O-Two was represented by Kevin Bowden who presented on CPAP, SMART BAG and our new “e” Ventilator Series. An excellent venue, great conference and, no doubt, a lot of hangovers!!!
SP Services are running a one day ventilation seminar at their headquarters in Telford, Shropshire on Friday, March 21st. Registrants already exceed 25 for what promises to be an interesting and informative day on Pre-hospital CPAP, Inadvertent Hyperventilation and Automatic Transport Ventilators.
Two hospitals in Panama have switched to SMART BAG MO having realized the benefits for improved patient care of controlled manual ventilation. After a short period of orientation for the staff, SMART BAG MO has been installed throughout the hospitals.
Cheryl will be attending the Nebraska NEMSA conference. Make sure to drop by and see her or contact Cheryl to arrange a meeting: cheryl@otwo.com Tel: 1 877 782 3302
Chuck and Cheryl would like to thank everyone who took the time to visit our booth during the Gathering of Eagles meeting in Dallas. Our thanks also to the “Eagles” for yet another excellent conference. See you in 2015!
A study from the Europe reiterates the 2004 Aufderheide et al study showing that, in manually ventilated patients in cardiac arrest, 90% had ventilation rates of 20/min, twice the Guidelines recommended rate of 10/min. Even in those being mechanically ventilated, ventilation rates higher than 10/min were recorded in 92% of patients. Ventilation rates in cardiac arrest were higher than in patients without cardiac arrest for both types of ventilation.
O-Two, in the form of Chuck Doumith and Cheryl Wise, will be attending the GATHERING OF EAGLES XVI meeting (27th Feb to 1st March) at the Intercontinental Hotel, Dallas TX. Do drop by the booth if you are there.
You can contact Chuck – chuck@otwo.com Cell: 647 393 4439 or Cheryl – cheryl@otwo.com Cell: 416 988 8784 to arrange to meet.
One of our Indian distributors, JLD, has won an order from a number of coal mines for a total of 43 CAREvent® CA confined space/toxic environment rescue resuscitator kits. Along with the CAREvent®s they also ordered 11 of our Level 1 Preventive Maintenance Test Kits.
JLD has been supplying the mining industry in India for the last 10 years. Congratulations and thanks to JLD for all their hard work!
O-Two is pleased to announce the launch of its “quick reference” Product Guides for our distributor representatives. To receive your copies please contact your local O-Two representative:
Anita Bekavac, anita@otwo.comWestern Ontario, GTA, Western Canada and Eastern Europe
Cheryl Wise, cheryl@otwo.comCentral USA – OH, IN, MI, IL, WI, IA, MN, ND, SD, NE, KS, MO, OK, AR, TX, CO
Chuck Doumith, chuck@otwo.comWestern USA – WA, OR, ID, WY, NM, AZ, NV, CA, HI, AK
Ken Thom, kenthom@otwo.comAustralasia, India, Africa, South America
The o_two Single-Use Open Circuit CPAP device has been granted a US Patent. This award winning product has revolutionized the disposable CPAP market due to its low flow/high CPAP capability, reducing oxygen consumption significantly while improving both patient care and comfort.
Anita Bekavac (anita@otwo.com) is taking on the sales management of the Eastern European Countries of Lithuania, Latvia, Estonia, Ukraine, Belarus, Czech Republic, Slovakia, Slovenia, Hungary, Romania, Moldova, Croatia, Bosnia Herzegovina, Montenegro, Kosovo, Serbia, Macedonia and Albania. Anita was born in Germany, currently lives in Canada and is a fluent Croatian speaker which makes her eminently suited for this territory. These additions to her role with O-Two are on top of her already busy schedule managing Western Canada.
It is with great sadness that we must inform our extended O-Two family of staff, customers and distributors of the untimely death of our International Sales and Marketing Manager Ken Thom. Ken died on Sunday 24th September in a SCUBA Diving accident while in South Africa.
lessly. The ventilator is an excellent piece of equipment and will serve us well for years”.
his ventilator was so easy to teach to our team. The level of crew member confidence was high as they left the training. As you can read in the testimony below, we had several uses in the first couple of weeks after the deployment. Our staff is very comfortable with our purchase. Thanks for making this process simple and effective”.
Ryan Lovelady, Western US Sales Manager for O-Two (ryan.l@otwo.com) said “What a great meeting with such a welcoming and supportive group of delegates and organizers. We will be definitely be back for the next one”!
Guidelines did not introduce any new protocols they did solidify a number of issues and brought up some science that perhaps downgraded the benefit of certain CPR adjuncts. Of particular note was the reference to Supraglottic airways and their clinical inferiority to standard bag-valve-mask ventilation. In addition the use of automated chest compression devices was downplayed as not showing any clinical benefit over manual chest compressions.
This enables you to run CPAP and nebulizer off one regulator utilizing the 9/16 DISS outlet to run the nebulizer and the therapy flow outlet to run the CPAP unit.Unlike other devices with built in nebulizers, running both at the same time does not affect the CPAP performance output!!!
eSeries e700