It's so generous of people like George, to go through the bother of setting up a camera and lighting, all for the purpose of helping others to understand what they wish to know. My hat is off to George!
Great video, thanks! Question: When deciding on weaning a patient off the high flow systems, what metric do you change first (Fio2 or flow rate) and what's the rationale? Does the need for high flow automatically suggest high Fio2 needs? or do these both go independently?
Great visual illustration of the difference. I'm teaching O2 admin devices and looking for additional resources. Great presentation @George O. RRT! Thanks!
Excellent presentation George thank you . PIFR is it 20 L/sec or /min. and how can we estimate the PIFR in a sick child are there age appropriate normal values?
Hi, thanks so much for this video, genuinely the best explanation on this topic! I have a question about the titrating of oxygen therapy e.g for a patient on airvo. Say the patient is on AIRVO 30L with 30% FiO2… but their saturations are still low…. Which of the parameters should you increase first? Flow rate, or Fi02? Thanks!
Thank you for the informative video, I am a patient and trying to figure out which device to get I am about 58 yr old and my weight is about 81kg, can you help figure out what kind of machine should I get?
Thanks George. How does an HFNC device adjust the FiO2 delivered to the patient at a given flow rate, for instance 40 lpm ? I mean at a single flow rate of 40 lpm, how can it vary the FiO2 according to our settings, say 60% and 40% !
Hi: That depends on what device your using. With an Airvo for example, you would program the flow rate and FiO2 into the device, then increase the titrated flow of O2 (from the flowmeter) into the device till the required FiO2 was attained. There are certain limitations or max values to the Airvo with flows and FiO2's deliverable to the patient. With HIgh Flow Blender setup, you would simply set the required O2 concentration on the blender then adjust your flow with the flowmeters on the blender till the required flow was attained. Always verify concentration with an O2 analyzer with the blender setup. The Airvo has a built in analyzer. Hope this helps.
For an ET tube, or a trach, if you want to do some high flow, the simplest way would be to set the ventilator in CPAP/PS, with a PEEP of 5, and a Pressure Support of 5-7, and there you go. You have high flow, Glorified that is, and you have the FiO2 you want, and not only that, you have yourself the ventilatory monitors. Now it's not as fancy as per say the High Flow I was on a few weeks ago, with the Hamilton ventilator, but it's something. And just as you said in your extubation video, It's a glorified High Flow System.
Wife here - studying midwifery - so looked for this and found your video - makes sense - probably most likely only use low flow in a home birth setting. Thanks.
I'm not a nurse and I loved this. I have a family member in the ICU with COVID on a High Flow. She was talking about being on 15 L with a 91 sats. Last year I was on 2L when I was a 84% bringing me to 91 or 92 and had to learn what I was on was different from what she is on. Not looking to take your job :) just needing some info. Thanks
Thanks for your clear explanation. Why T-piece and Venturi mask are considered high-flow delivery systems though their flow rates are usually 4-10 L/m?
Hi: When you set an oxygen flow to a certain value on the flowmeter, air is going to be entrained through the venturi device increasing the total flow the patient gets.....as long as it exceeds the patients inspiratory flow. For example; the ratio for oxygen and air for a delivered O2 concentration of 40% is 1:3. If you run an O2 flowmeter at 5 LPM, the entrainment system will draw in 15 LPM of roomair. The two gases will mix and deliver to the patient 20 LPM (total flow) with an oxygen concentration of 40%. If the patients inspiratory flow rate is less than 20 LPM, this would be a properly set up high flow system. Hope this helps.
Neonates have a much lower inspiratory flow rate than an adult and so what would be a low flow system for an adult can be an effective high flow system for a neonate. That is the context in which T pieces are typically used.
U said bigger the oxygen device is (in low flow) that much fio2 it can give. If we take a simple oxygen mask though it has big surface area it accumulates co2. So how could we make it useful.
Hi: If I understand your question correctly, Your asking how you could make a simple mask (low flow O2 therapy effective). O2 masks are effective when used properly but have their own limitations. If you are using a simple mask for example, the effective range of flow is usually between 5-10 LPM. Sometimes higher than 10 but never lower than 5 LPM (adults). When used this way, there is sufficient O2 flow coming into the system to wash out any exhaled CO2. Using flows lower than 5 greatly increase the chances of rebreathed exhaled CO2. When using masks with bags on them like the PRB mask and NRB mask (partial and non rebreathing masks respectively), maintain the rule of thumb that says when the patient inhales, ensure that those reservoir bags remain inflated.....so use enough O2 flow to keep the res bag inflated as that is where the gas comes from for the next breath, plus the flow helps to wash out any potential CO2. The design of the mask and bag and valves (NRB mask) reduce the chances of rebreathing of CO2 when used properly. Hope this helps. George
Excellent. Very relevant in 2020 A practical aspect is the management of oxygen supply which is very high when large number of patients are connected in a Covid-19 hospital. One can refer to a video " HFOT Calculator" on RUclips as a supplement to this nice video.
Generally speaking yes, the lower the percentage the better. The percent indicates Fraction of Inspired Oxygen. So if they are breathing the same with 60% vs 70% then their lungs are likely doing better. We can use their Fi02 and put it into the P/F ratio. The P is going to be their Pa02 (obtained via arterial blood gas) and the F is their Fi02. We divide their arterial o2 by the Fi02 percentage. A Pa02 of 100mmHg (perfect score)/0.21% Fi02 (room air) gives a top score of 476mmHg on the P/F ratio. The lower the number, the worse the lungs are. Below 300 is indication of ARDS, below 200 is really bad, below 100 is GREAT BADNESS. A patient with severe ARDS might only have a Pa02 of 45 (this is pushing into the severe hypoxia range) and might be getting 100% oxygen. Their P/F ratio would be 65. A P/F ratio this low is associated with a 45% mortality rate. Long answer short, the Fi02 in your example is kind of an arbitrary number to indicate their lungs working better or not by themselves. If we add a little context to it then it becomes a much more important number.
oxygen (fio2) should be at 100% starting and flow should be placed at around 35 lpm cuz normal human lpm is 20-30 lpm so u want to exceed that. once patients sats are normal, start titrating fio2 down until patients sats at around 92-96%
Hi My mom is on the high flow oxygen because of Covid pneumonia. I am concerned that her spO2 is fluctuating a lot on high flow ( 79%-99%). She is in India currently in ICU. Please advice 🙏
Sorry to hear of your moms situation. Although lower SPO2's are not the best situation, hopefully they are somewhere between 90-99%. That would be best. Its hard to advise without knowing what interventions have been taken and what equipment they have. I hope she recovers quickly.
Hi. This sounds like the exact condition that my Dad is now. He has pneumonia covid as well. Just recently taken off the bipap machine after 2 weeks, and now on an airvo machine. He's currently at 60lpm and o2 level at 90% Hope you're Mom is OK 🙏
@@malena7362 He was taken out of ICU and into a regular room after 4 long weeks thank God. He has a long road to recovery but all signs are starting to point in the right direction. Thanks for asking
When the O2 system (high flow) is set to 100% and you run the O2 to the patient at a flow that exceeds their inspiratory flow rate, the delivered O2 concentration will be what you have set it to on the high flow system....so in this case 100%....it will remain so until you either chance the set concentration, the patients inspiratory flow are or breathing pattern exceeds the set flow or you run out of oxygen. Let me know if this answers your questions.
@@GeorgeORRT I am not sure it's a small risk. At 40 to 60 liter/min flow, the entirety of a dyspnic patients flow comes from the cannula. He is not entraining ambient air. So oxygen is oxygen and, to me, matters not whether it's through an ET tube or high flow cannula. It's the Lorrain-Smith effect...how many CoVid patients may have had fatal oxygen toxicity by incautiously sitting at 75% for days. Pathologically, you could not distinguish it from progressing CoVid. I never let them go above 60%. I added CPAP.
its all a big $ making raciket! 1. one cannot buy a o2 machine without a prescription? why not? We have now, over 11 people a Day in North America( Canada, USA) that should be on O2 but aren't..! Then we now have companies putting O2 ( compressed Air) in a Can and selling it for $15 a Can! See what the Medical Profession has Done? Wonder why China makes Better O2 Oxygenators and at (50%) Lower cost and are also? -50% smaller and use 50% Less Electricity? Have to Feed the system! what a nice racket and con game..get everyone on the payroll! at all costs!!!! Wonder why we're Drivering Medicare OOB?
It's so generous of people like George, to go through the bother of setting up a camera and lighting, all for the purpose of helping others to understand what they wish to know. My hat is off to George!
Never understood this at university, you explain it so very well, cheers.
Thanks for the comment. Glad it makes sense
The newest and most effective therapy from Germany: vital-air-therapy.com
Thank you for great explanation. I have been trying to understand the difference. My mother is currently on high flow. Thank you
Dude... This was SO GOOD! Perfectly to the point and easy to understand. Thank you so much.
Thanks very much for your comment. I plan to do a few more videos on this kind of stuff in the near future
Thank you I really enjoyed this informative video George 👍🏻
Thank you! First time I've gotten the concept behind it explained
Very coherent and concise, I'm studying for my USMLE step 2, and this video helped a lot. Thank you doctor ❤️🙏
Glad it was of help to you.
great explanation! thanks George!
This is so helpful. Please make more videos.
To the point and very well presented
Great video, thanks! Question: When deciding on weaning a patient off the high flow systems, what metric do you change first (Fio2 or flow rate) and what's the rationale? Does the need for high flow automatically suggest high Fio2 needs? or do these both go independently?
To the point and very well presented ! Thanks a million
Thank you. I'm glad you've found value in it.
Thank you
Great visual illustration of the difference. I'm teaching O2 admin devices and looking for additional resources. Great presentation @George O. RRT! Thanks!
Finally understand this thanks to your clear explanation, thanks a lot! ps love the wink at the end
Thanks for your comment. Glad it was helpful for you
I had to rewind this about 10 times but I got it! Very informative thumps up👍🏾👍🏾
Glad that it helped.....keep going with that momentum
I got 9 more to go then........
Awesome explanation !!!
This was super helpful, thank you!
Excellent presentation George thank you .
PIFR is it 20 L/sec or /min. and how can we estimate the PIFR in a sick child are there age appropriate normal values?
Thank you so much i love your videos now i understand perfectly
Many thanks. This is very clear and useful.
Thanks George!
Thank you so much for this, sir! But I have a question, how will you actually know the inspiratory flow rate of the patient? Thank you!
How do you determine what thier inspiratory demand Is? I get the concept, but how do I determine if thier inspiratory demand Is 20lpm vs 40lpm?
so clear! thank you!!
fantastic! really helpful!
Thank you!
Hi, thanks so much for this video, genuinely the best explanation on this topic! I have a question about the titrating of oxygen therapy e.g for a patient on airvo. Say the patient is on AIRVO 30L with 30% FiO2… but their saturations are still low…. Which of the parameters should you increase first? Flow rate, or Fi02? Thanks!
It's wonderfully explained and helpful, thank you doc..
Thank you
love it! thank you!!!!!
well explained!! thank u so much
Thank you for the informative video, I am a patient and trying to figure out which device to get I am about 58 yr old and my weight is about 81kg, can you help figure out what kind of machine should I get?
You look like an NBA ref haha. This was very helpful, thanks man.
thanks... I totally understand now.. finally
awesome, thanks!
Thanks very much
Thnx bro 👍
Thx a LOT❤❤❤❤
Thanks George. How does an HFNC device adjust the FiO2 delivered to the patient at a given flow rate, for instance 40 lpm ? I mean at a single flow rate of 40 lpm, how can it vary the FiO2 according to our settings, say 60% and 40% !
Hi: That depends on what device your using. With an Airvo for example, you would program the flow rate and FiO2 into the device, then increase the titrated flow of O2 (from the flowmeter) into the device till the required FiO2 was attained. There are certain limitations or max values to the Airvo with flows and FiO2's deliverable to the patient. With HIgh Flow Blender setup, you would simply set the required O2 concentration on the blender then adjust your flow with the flowmeters on the blender till the required flow was attained. Always verify concentration with an O2 analyzer with the blender setup. The Airvo has a built in analyzer. Hope this helps.
Hi...
When Do use High flow and Bipap.
Which one would be the first option ?
Good....thumbs up up up
For an ET tube, or a trach, if you want to do some high flow, the simplest way would be to set the ventilator in CPAP/PS, with a PEEP of 5, and a Pressure Support of 5-7, and there you go. You have high flow, Glorified that is, and you have the FiO2 you want, and not only that, you have yourself the ventilatory monitors. Now it's not as fancy as per say the High Flow I was on a few weeks ago, with the Hamilton ventilator, but it's something. And just as you said in your extubation video, It's a glorified High Flow System.
Wife here - studying midwifery - so looked for this and found your video - makes sense - probably most likely only use low flow in a home birth setting. Thanks.
Should have mentioned the anatomical reservoir in the discussion of low flow oxygen therapy. Overall- thumbs up from an old RRT.
I'm not a nurse and I loved this. I have a family member in the ICU with COVID on a High Flow. She was talking about being on 15 L with a 91 sats. Last year I was on 2L when I was a 84% bringing me to 91 or 92 and had to learn what I was on was different from what she is on. Not looking to take your job :) just needing some info. Thanks
When do you switch from hfnc to nippv?
Does change in flow effect oxygen concentration
What does it mean when it sUs put a patient on room air?
What are high flow systems and which
Thanks for your clear explanation.
Why T-piece and Venturi mask are considered high-flow delivery systems though their flow rates are usually 4-10 L/m?
Hi: When you set an oxygen flow to a certain value on the flowmeter, air is going to be entrained through the venturi device increasing the total flow the patient gets.....as long as it exceeds the patients inspiratory flow. For example; the ratio for oxygen and air for a delivered O2 concentration of 40% is 1:3. If you run an O2 flowmeter at 5 LPM, the entrainment system will draw in 15 LPM of roomair. The two gases will mix and deliver to the patient 20 LPM (total flow) with an oxygen concentration of 40%. If the patients inspiratory flow rate is less than 20 LPM, this would be a properly set up high flow system. Hope this helps.
George O. RRT
sorry maybe stupid question,but where do you get 1:3 ratio from?
@@poliklolik the venturi pieces are designed to achieve a set ratio when provided the appropriate O2 flow.
Neonates have a much lower inspiratory flow rate than an adult and so what would be a low flow system for an adult can be an effective high flow system for a neonate. That is the context in which T pieces are typically used.
best!
what about for pulmonary embolism ???high flow or low flow oxygen for pulmonary embolism ???
Then what is the use of giving low flow if o2 is getting diluted any clinical condition
U said bigger the oxygen device is (in low flow) that much fio2 it can give. If we take a simple oxygen mask though it has big surface area it accumulates co2. So how could we make it useful.
Hi: If I understand your question correctly, Your asking how you could make a simple mask (low flow O2 therapy effective). O2 masks are effective when used properly but have their own limitations. If you are using a simple mask for example, the effective range of flow is usually between 5-10 LPM. Sometimes higher than 10 but never lower than 5 LPM (adults). When used this way, there is sufficient O2 flow coming into the system to wash out any exhaled CO2. Using flows lower than 5 greatly increase the chances of rebreathed exhaled CO2. When using masks with bags on them like the PRB mask and NRB mask (partial and non rebreathing masks respectively), maintain the rule of thumb that says when the patient inhales, ensure that those reservoir bags remain inflated.....so use enough O2 flow to keep the res bag inflated as that is where the gas comes from for the next breath, plus the flow helps to wash out any potential CO2. The design of the mask and bag and valves (NRB mask) reduce the chances of rebreathing of CO2 when used properly. Hope this helps. George
Excellent. Very relevant in 2020
A practical aspect is the management of oxygen supply which is very high when large number of patients are connected in a Covid-19 hospital. One can refer to a video " HFOT Calculator" on RUclips as a supplement to this nice video.
Does going from 50l/m at 70% to 50l/m at 60% indicate the patient's lungs are working better or is the % simply an arbitrary number?
Generally speaking yes, the lower the percentage the better. The percent indicates Fraction of Inspired Oxygen. So if they are breathing the same with 60% vs 70% then their lungs are likely doing better. We can use their Fi02 and put it into the P/F ratio. The P is going to be their Pa02 (obtained via arterial blood gas) and the F is their Fi02. We divide their arterial o2 by the Fi02 percentage. A Pa02 of 100mmHg (perfect score)/0.21% Fi02 (room air) gives a top score of 476mmHg on the P/F ratio. The lower the number, the worse the lungs are. Below 300 is indication of ARDS, below 200 is really bad, below 100 is GREAT BADNESS. A patient with severe ARDS might only have a Pa02 of 45 (this is pushing into the severe hypoxia range) and might be getting 100% oxygen. Their P/F ratio would be 65. A P/F ratio this low is associated with a 45% mortality rate.
Long answer short, the Fi02 in your example is kind of an arbitrary number to indicate their lungs working better or not by themselves. If we add a little context to it then it becomes a much more important number.
I dont understand how you come up with the oxygen concentration for high flow systems, what LPM and oxygen % are you supposed to choose for these?
oxygen (fio2) should be at 100% starting and flow should be placed at around 35 lpm cuz normal human lpm is 20-30 lpm so u want to exceed that. once patients sats are normal, start titrating fio2 down until patients sats at around 92-96%
@@Signatured thank you, I don’t know why they don’t make it more clear with high flows or if I was just missing it.
Hi
My mom is on the high flow oxygen because of Covid pneumonia. I am concerned that her spO2 is fluctuating a lot on high flow ( 79%-99%). She is in India currently in ICU. Please advice 🙏
Sorry to hear of your moms situation. Although lower SPO2's are not the best situation, hopefully they are somewhere between 90-99%. That would be best. Its hard to advise without knowing what interventions have been taken and what equipment they have. I hope she recovers quickly.
Hi. This sounds like the exact condition that my Dad is now. He has pneumonia covid as well. Just recently taken off the bipap machine after 2 weeks, and now on an airvo machine. He's currently at 60lpm and o2 level at 90% Hope you're Mom is OK 🙏
@@nem39980 how is your dad?
@@malena7362 He was taken out of ICU and into a regular room after 4 long weeks thank God. He has a long road to recovery but all signs are starting to point in the right direction. Thanks for asking
sorry how did you the 16 at the first time? 😭
What is the highest percentage points of hfo 1L ? @ 90min
When the O2 system (high flow) is set to 100% and you run the O2 to the patient at a flow that exceeds their inspiratory flow rate, the delivered O2 concentration will be what you have set it to on the high flow system....so in this case 100%....it will remain so until you either chance the set concentration, the patients inspiratory flow are or breathing pattern exceeds the set flow or you run out of oxygen. Let me know if this answers your questions.
Great! So hours and hours of CoVid treatment at FI02 above 60 % can cause oxygen toxicity just like the ventilator. Yes or no?
There is a chance albeit a small one.
@@GeorgeORRT I am not sure it's a small risk. At 40 to 60 liter/min flow, the entirety of a dyspnic patients flow comes from the cannula. He is not entraining ambient air. So oxygen is oxygen and, to me, matters not whether it's through an ET tube or high flow cannula. It's the Lorrain-Smith effect...how many CoVid patients may have had fatal oxygen toxicity by incautiously sitting at 75% for days. Pathologically, you could not distinguish it from progressing CoVid. I never let them go above 60%. I added CPAP.
@@davidmbeckmann did you have a lot of success with your COVID patients? I've wondered this about the high fio2 as well...
How about a pediatric they breath very fast
You mean, I didnt click on Dr Drew's video? 😥
Why do you say 20 liters for minute?
Our flow rate is 14, tidal volume about 600 ml/breath. 14x600= 8.5 liters/minute
Some acidodic pts need high respiratory compensation
@@Terminator-ck1xf yes I know but he does not specify situations of respiratory emergencies in which compensation is needed
@@Terminator-ck1xf besides in acidosis, the respiratory rate decreases
its all a big $ making raciket!
1. one cannot buy a o2 machine without a prescription? why not?
We have now, over 11 people a Day in North America( Canada, USA) that should be on O2 but aren't..!
Then we now have companies putting O2 ( compressed Air) in a Can and selling it for $15 a Can!
See what the Medical Profession has Done?
Wonder why China makes Better O2 Oxygenators and at (50%) Lower cost and are also? -50% smaller and use 50% Less Electricity?
Have to Feed the system! what a nice racket and con game..get everyone on the payroll! at all costs!!!! Wonder why we're Drivering Medicare OOB?