Model of Thermal Comfort in the Hyperbaric Facility
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Vocal Cord Dysfunction JAMES DECKERT, MD, Saint Louis University School of Medicine, St
Vocal Cord Dysfunction JAMES DECKERT, MD, Saint Louis University School of Medicine, St. Louis, Missouri LINDA DECKERT, MA, CCC-SLP, Special School District of St. Louis County, Town & Country, Missouri Vocal cord dysfunction involves inappropriate vocal cord motion that produces partial airway obstruction. Patients may present with respiratory distress that is often mistakenly diagnosed as asthma. Exercise, psychological conditions, airborne irritants, rhinosinusitis, gastroesophageal reflux disease, or use of certain medications may trigger vocal cord dysfunction. The differential diagnosis includes asthma, angioedema, vocal cord tumors, and vocal cord paralysis. Pulmo- nary function testing with a flow-volume loop and flexible laryngoscopy are valuable diagnostic tests for confirming vocal cord dysfunction. Treatment of acute episodes includes reassurance, breathing instruction, and use of a helium and oxygen mixture (heliox). Long-term manage- ment strategies include treatment for symptom triggers and speech therapy. (Am Fam Physician. 2010;81(2):156-159, 160. Copyright © 2010 American Academy of Family Physicians.) ▲ Patient information: ocal cord dysfunction is a syn- been previously diagnosed with asthma.8 A handout on vocal cord drome in which inappropriate Most patients with vocal cord dysfunction dysfunction, written by the authors of this article, is vocal cord motion produces par- have intermittent and relatively mild symp- provided on page 160. tial airway obstruction, leading toms, although some patients may have pro- toV subjective respiratory distress. When a per- longed and severe symptoms. son breathes normally, the vocal cords move Laryngospasm, a subtype of vocal cord away from the midline during inspiration and dysfunction, is a brief involuntary spasm of only slightly toward the midline during expi- the vocal cords that often produces aphonia ration.1 However, in patients with vocal cord and acute respiratory distress. -
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REVIEW COPD Physiological and clinical relevance of exercise ventilatory efficiency in COPD J. Alberto Neder1, Danilo C. Berton1,2, Flavio F. Arbex3, Maria Clara Alencar4, Alcides Rocha3, Priscila A. Sperandio3, Paolo Palange5 and Denis E. O’Donnell1 Affiliations: 1Respiratory Investigation Unit and Laboratory of Clinical Exercise Physiology, Queen’s University and Kingston General Hospital, Kingston, ON, Canada. 2Division of Respiratory Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. 3Pulmonary Function and Clinical Exercise Physiology, Respiratory Division, Federal University of Sao Paulo, Sao Paulo, Brazil. 4Division of Cardiology, Federal University of Minas Gerais, Belo Horizonte, Brazil. 5Dept of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy. Correspondence: J. Alberto Neder, 102 Stuart Street, Kingston, Ontario, Canada K7L 2V6. E-mail: [email protected] @ERSpublications Ventilatory efficiency is a key measurement for the interpretation of cardiopulmonary exercise testing in COPD http://ow.ly/1nsY307pbz8 Cite this article as: Neder JA, Berton DC, Arbex FF, et al. Physiological and clinical relevance of exercise ventilatory efficiency in COPD. Eur Respir J 2017; 49: 1602036 [https://doi.org/10.1183/13993003.02036- 2016]. ABSTRACT Exercise ventilation (V′E) relative to carbon dioxide output (V′CO2) is particularly relevant to patients limited by the respiratory system, e.g. those with chronic obstructive pulmonary disease (COPD). ′ − ′ High V E V CO2 (poor ventilatory efficiency) has been found to be a key physiological abnormality in symptomatic patients with largely preserved forced expiratory volume in 1 s (FEV1). Establishing an ′ − ′ association between high V E V CO2 and exertional dyspnoea in mild COPD provides evidence that exercise intolerance is not a mere consequence of detraining. -
The Use of Heliox in Treating Decompression Illness
The Diving Medical Advisory Committee DMAC, Eighth Floor, 52 Grosvenor Gardens, London SW1W 0AU, UK www.dmac-diving.org Tel: +44 (0) 20 7824 5520 [email protected] The Use of Heliox in Treating Decompression Illness DMAC 23 Rev. 1 – June 2014 Supersedes DMAC 23, which is now withdrawn There are many ways of treating decompression illness (DCI) at increased pressure. In the past 20 years, much has been published on the use of oxygen and helium/oxygen mixtures at different depths. There is, however, a paucity of carefully designed scientific studies. Most information is available from mathematical models, animal experiments and case reports. During a therapeutic compression, the use of a different inert gas from that breathed during the dive may facilitate bubble resolution. Gas diffusivity and solubility in blood and tissue is expected to play a complex role in bubble growth and shrinkage. Mathematical models, supported by some animal studies, suggest that breathing a heliox gas mixture during recompression could be beneficial for nitrogen elimination after air dives. In humans, diving to 50 msw, with air or nitrox, almost all cases of DCI can be adequately treated at 2.8 bar (18 msw), where 100% oxygen is both safe and effective. Serious neurological and vestibular DCI with only partial improvements during initial compression at 18 msw on oxygen may benefit from further recompression to 30 msw with heliox 50:50 (Comex therapeutic table 30 – CX30). There have been cases successfully treated on 50:50 heliox (CX30), on the US Navy recompression tables with 80:20 and 60:40 heliox (USN treatment table 6A) instead of air and in heliox saturation. -
Respiratory Therapy Pocket Reference
Pulmonary Physiology Volume Control Pressure Control Pressure Support Respiratory Therapy “AC” Assist Control; AC-VC, ~CMV (controlled mandatory Measure of static lung compliance. If in AC-VC, perform a.k.a. a.k.a. AC-PC; Assist Control Pressure Control; ~CMV-PC a.k.a PS (~BiPAP). Spontaneous: Pressure-present inspiratory pause (when there is no flow, there is no effect ventilation = all modes with RR and fixed Ti) PPlateau of Resistance; Pplat@Palv); or set Pause Time ~0.5s; RR, Pinsp, PEEP, FiO2, Flow Trigger, rise time, I:E (set Pocket Reference RR, Vt, PEEP, FiO2, Flow Trigger, Flow pattern, I:E (either Settings Pinsp, PEEP, FiO2, Flow Trigger, Rise time Target: < 30, Optimal: ~ 25 Settings directly or by inspiratory time Ti) Settings directly or via peak flow, Ti settings) Decreasing Ramp (potentially more physiologic) PIP: Total inspiratory work by vent; Reflects resistance & - Decreasing Ramp (potentially more physiologic) Card design by Respiratory care providers from: Square wave/constant vs Decreasing Ramp (potentially Flow Determined by: 1) PS level, 2) R, Rise Time ( rise time ® PPeak inspiratory compliance; Normal ~20 cmH20 (@8cc/kg and adult ETT); - Peak Flow determined by 1) Pinsp level, 2) R, 3)Ti (shorter Flow more physiologic) ¯ peak flow and 3.) pt effort Resp failure 30-40 (low VT use); Concern if >40. Flow = more flow), 4) pressure rise time (¯ Rise Time ® Peak v 0.9 Flow), 5) pt effort ( effort ® peak flow) Pplat-PEEP: tidal stress (lung injury & mortality risk). Target Determined by set RR, Vt, & Flow Pattern (i.e. for any set I:E Determined by patient effort & flow termination (“Esens” – PDriving peak flow, Square (¯ Ti) & Ramp ( Ti); Normal Ti: 1-1.5s; see below “Breath Termination”) < 15 cmH2O. -
Training Objectives for a Diving Medical Physician
The Diving Medical Advisory Committee Training Objectives for a Diving Medicine Physician This guidance includes all the training objectives agreed by the Diving Medical Advisory Committee, the European Diving Technology Committee and the European Committee for Hyperbaric Medicine in 2011. Rev 1 - 2013 INTRODUCTION The purpose of this document is to define more closely the training objectives in diving physiology and medicine that need to be met by doctors already fully accredited or board-certified in a clinical speciality to national standards. It is based on topic headings that were originally prepared for a working group of European Diving Technology Committee (EDTC) and the European Committee of Hyperbaric Medicine (ECHM) as a guide for diving medicine some 20 years ago by J.Desola (Spain), T.Nome (Norway) & D.H.Elliott (U.K.). The training now required for medical examiners of working divers and for specialist diving medicine physicians was based on a EDTC/ECHM standard 1999 and subsequently has been enhanced by the Diving Medical Advisory Committee (DMAC), revised and agreed in principle by DMAC, EDTC and ECHM in 2010 and then ratified by EDTC and ECHM in 2011. The requirements now relate to an assessment of competence, the need for some training in occupational medicine, the need for maintenance of those skills by individual ‘refresher training’. Formal recognition of all this includes the need to involve a national authority for medical education. These objectives have been applied internationally to doctors who provide medical support to working divers. (Most recreational instructors and dive guides are, by their employment, working divers and so the guidance includes the relevant aspects of recreational diving. -
A Review of the Use of Heliox in the Critically Ill
Special review A Review of the use of Heliox in the Critically Ill T. WIGMORE, E. STACHOWSKI Intensive Care Unit, Westmead Hospital, Westmead, NEW SOUTH WALES ABSTRACT Heliox, a mix of oxygen and helium, has a number of potential medical applications resulting from its relatively lower density. This paper reviews the physics underlying its utility and considers the evidence for its use. While there are studies that support its role, particularly in patients with exacerbations of asthma and chronic obstructive pulmonary disease (COPD), the data are inconclusive. (Critical Care and Resuscitation 2006; 8: 64-72) Key words: Heliox, helium, airway obstruction, asthma, chronic obstructive pulmonary disease Helium was discovered in 1868 by the French astro- a given pressure difference. Clinically this can be utilis- nomer Pierre-Jules-Cesar Janssen during a spectro- ed to assist patients who suffer from airway narrowing. scopic study of a total solar eclipse in India. It was named later the same year by the British astronomer Table 1. Physical properties of pure gases at RTP Joseph Norman Lockyer and chemist Sir Edward (298 degrees Kelvin and 1 atmosphere pressure) Frankland, the name derived from helios, the Greek for Density Viscosity Thermal sun. It is an inert gas present in the atmosphere (ρ) (η) conductivity (0.00052%) and was used initially in airships and Kg/m3 microPoise W/m K balloons. Today, most commercial helium is recovered from Air 1.184 184.33 0.025 natural gas using a cryogenic separation process, foll- owing which it is refined and liquefied. Liquid helium is Carbon 1.811 148.71 0.017 shipped from the production site to various storage Dioxide facilities worldwide before being distributed in the Helium 0.166 197.61 0.14 gaseous form into cylinders for on-site use. -
EMS DIVISION 23.1 Rev. 07/31/2020 PROTOCOL 23 WATER RELATED INCIDENTS
PROTOCOL 23 WATER RELATED INCIDENTS A. Introduction “Drowning is the process of experiencing respiratory impairment from submersion / immersion in liquid” The word Drowning, should be used to refer to a person who drowned (death) or to a person who was rescued (fatal drowning or non-fatal drowning.) Water Rescue is the process of removing someone from the water in which dangerous conditions are present but the victim shows no signs of respiratory impairment. General Care 1. Initial assessment/Care Protocol 1. 2. Administer 15 L/min Oxygen via NRB mask. 3. Maintain normal body temperature to protect against hypothermia. B. Drowning EMR/BLS 1. Consider concurrent trauma and manage accordingly Protocol 21. 2. Consider insertion of I-gel with NG Tube (Lifeguards only) Procedure 49 and Procedure 12. 3. Determine important history from the patient or bystanders which includes: a) Duration of submersion b) Water temperature c) Any possibility of seizure activity d) Any associated drug or alcohol use e) How the patient entered the water 4. All non-fatal drowning victims must be transported to the closest appropriate facility for evaluation, regardless of how well they may seem to have recovered. Delayed death or complications due to pulmonary edema or aspiration pneumonia are common. ALS 5. Consider insertion of an NG/OG Procedure 12. EMS DIVISION 23.1 Rev. 07/31/2020 PROTOCOL 23 WATER RELATED INCIDENTS 6. Treat dysrhythmias per specific protocols. Consider hypoxia as a primary cause of the dysrhythmias. C. Decompression Sickness/Air Embolism EMR/BLS 1. Evaluate for specific signs and symptoms: a) Pain (primarily joint pain) b) Altered level of consciousness c) Generalized numbness or confusion d) Weakness or paralysis e) External or diagnosed internal bleeding f) Extreme vertigo 2. -
Commercial Diving Physical Examination
Commercial Diving Physical Examination To the Applicant / Student: Attached are the forms and instructions for a commercial diving physical examination. One of the most important requirements for acceptance as a student in the Professional Certificate in Marine Technology at National University and to become a commercial diver is a thorough physical examination in accordance with Association of Diving Contractors International standards. As a commercial diver, it is a personal responsibility to always have a current physical exam. A current physical exam must have been completed within the last year and there must be no physical maladies which would preclude you from diving or making hyperbaric exposures. Although the commercial diving physical examination can be done by any licensed physician; it is always best to have the physical examination done by a physician who is trained in diving medicine or hyperbaric medicine. Attached is a list of physicians in Los Angeles and San Diego who are approved to conduct diving examinations. You must have the physical examination completed including the laboratory testing (which can take several weeks) prior to the beginning of the program. The cost of the examination can vary and supporting laboratory fees can range from $275 to $600 dollars or more depending on if the physician finds the need to run additional tests. You are personally required to provide the following forms completed and signed by the doctor: The attached National University Polytechnic Institute letter stating that you have passed the physical examination and are cleared for work as a diver and for hyperbaric exposures. The attached ADCI form (Medical History and Physical Examination) completed and signed by yourself and the physician. -
DEEP STOPS and DEEP HELIUM RGBM Technical Series 9 Bruce R
DEEP STOPS AND DEEP HELIUM RGBM Technical Series 9 Bruce R. Wienke and Timothy R. O’Leary NAUI Technical Diving Operations Tampa, Florida 33619 BASICS Deep stops – what are they? Actually, just what the name suggests. Deep stops are decompression stops made at deeper depths than those traditionally dictated by classical (Haldane) dive tables or algorithms. They are fairly recent (last 15 years) protocols, suggested by modern decompression theory, but backed up by extensive diver practicum with success in the mixed gas and decompression arenas - so called technical diving. Tech diving encompasses scientific, military, commercial, and exploration underwater activities. The impact of deep stops has been a revolution in diving circles. So have slower ascent rates across recreational and technical diving. In quantifiable terms, slower ascent rates are very much akin to deep stops, though not as pronounced as decompression stops. Deep stops plus slow ascent rates work together. And they work together safely and efficiently. Many regard deep stops as a most significant development in modern diving. Here’s why. Deep stops usually reduce overall decompression time (hang time) too. And when coupled to the use of helium in the breathing mixture (trimix) to reduce narcotic effects of nitrogen, technical divers report feeling much better physically today when they leave the water. The reduction in hang time ranges from 10% to as high as 50%, depending on diver, mix, depth, and exposure time. Feeling better while decompressing for shorter periods of time is certainly a win-win situation that would have been thought an impossibility not too long ago. -
Ambient Air, Oxygen and Nitrox Effects on Cognitive Performance at Altitude
APPLIED HUMAN SCIENCE Journal of Physiological Anthropology Ambient Air, Oxygen and Nitrox Effects on Cognitive Performance at Altitude John Leach and Sharon Almond Department of Psychology, Faculty of Applied Sciences, University of Lancaster Abstract. The effects on cognitive performance of this decrement can occur at altitudes above 3048 m breathing air, oxygen and nitrox gas mixtures at surface (Sharma and Malhotra, 1976; Luft, 1961). For acclimatized ambient pressures were investigated during an expedition subjects impairment in performance does not appear to to the Everest region of Nepal. A slight improvement occur until around 4706 m (McFarland, 1937) with most in grammatical reasoning at altitude was found under effects becoming noticeable between 3048–6096 m nitrox (p<0.05) and mathematical reasoning showed (Kramer et al., 1993; Tune, 1964) and are especially improvement at altitude on air (p<0.05), oxygen (p<0.01) marked above 5000 m (Nelson, 1982). and nitrox (p<0.01). There were non-significant trends To overcome severe decrement in cognition and towards decreasing mathematical ability, coupled with performance at extreme altitudes supplemental oxygen is an increase in variance on both grammatical and usually provided to the mountaineer. Other gases are mathematical test performance, with increasing pO2 available to reduce dysbaric impairment although they are (all p>0.05). The results suggest that there is a subtle used most noticeably in diving, for example, the use of interaction on cognition as indicated by a significant heliox, hydrox or trimix for deep water operations (>50 three-way interaction between subject x altitude x gas metres of sea water) (Shi, 1998; Shilling et al., 1976). -
Extreme Recreational Diving Pushing the Limits Assoc
1 | 65 National Center for Hyperbaric Medicine in Gdynia Medical University of Gdansk, Poland Extreme recreational diving Pushing the limits Assoc. Prof. Jacek Kot, MD, PhD Bühlmann Symposium Zürich Switzerland 2019 2 | 65 Disclaimer • I declare no real or potential conflict of interest. • Any views or opinions presented in this presentation are solely those of the author and do not necessarily represent those of any organization that author belongs to, including EUBS and ECHM. • All pictures are presented here either by the courtesy of their authors or taken from public websites for non-commercial use. Assoc. Prof. Jacek Kot, MD, PhD Head of National Center for Hyperbaric Medicine of Poland President of the EUBS General Secretary of the ECHM Medical Consultant of DAN Europe Extreme recreational diving Bühlmann Symposium Jacek Kot, 2018 Zürich Switzerland 2019 3 | 65 Professor A A Bühlmann → and Hans Keller → Hans Keller planted the Swiss flag at 1000 feet off California From - TAUCH MEDIZIN Springer-Verlag 1983 ▬▬▬▬ Extreme recreational diving Bühlmann Symposium Jacek Kot, 2018 Zürich Switzerland 2019 4 | 65 Deepest underwater cave in the world Krzysztof Starnawski _ National Geographic _ 2017 Courtesy of Krzysztof Starnawski (Poland) Extreme recreational diving Bühlmann Symposium Jacek Kot, 2018 Zürich Switzerland 2019 5 | 65 Types of recreational diving Safe Increased risk High risk (“technical”) • Up to 30 m • Between 30 and 50 m • Compressed air in open • With basic breathing Over 50 m (down to 300 circuit • mixtures (nitrox and -
Precision Flow® Heliox Instructions for Use | Vapotherm
Precision Flow® Heliox Instructions For Use Table of Contents Page Symbols 3 Section 1 Indications, Warnings and Cautions 4 Section 2 Overview 6 Section 3 Principles of operation 7 Section 4 Controls, displays & connections 8 Section 5 Modes of operation 11 Section 6 Initial assembly 12 Section 7 Setting up 13 Section 8 Adjustments 17 Section 9 Connecting to patient 18 Section 10 Operating guidelines 19 Section 11 Changing the disposable patient circuit 20 Section 12 Alarms 21 Section 13 Shut down 24 Section 14 Routine maintenance 24 Section 15 Cleaning and disinfection 25 Section 16 Specifications 26 Appendix: Audio Tone Characteristics 28 Software modes 29 EMC Guidance 30 Precision Flow® Heliox Packaging contains: Precision Flow® Heliox Unit Instructions For Use Quick Reference Guide Power Cord O2 Sensor cell Heliox & Oxygen Inlet Connectors US ONLY- Heliox and Oxygen Hoses Quick Set Up Sticker (English speaking countries only) Delivery Tube clip Page 2 3200003 Rev. B (EN) Symbols Vapotherm Inc. has declared that this product conforms with the European Council Directive 93/42/EEC Medical Device Directive when it is used in 0297 accordance with the instructions provided in the Instructions For Use. This symbol indicates that the waste of electrical and electronic equipment must not be disposed as an unsorted municipal waste and must be collected separately. Please contact an authorized representative of the manufacturer for information concerning the decommissioning of your equipment. Some Vapotherm accessories contain DEHP [Di-(2-Ethylhexyl) Phthalate] which is the most frequently used plasticizer to add flexibility to medical tubing. The medical tubing is intended for the transport of medical breathing gases and not for the storage of substances that have chemical extraction properties.