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filmtv2022 · 1 year

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By Your Side: Epilogue Part One

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Epilogue Part Two (Updated once posted)

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Summary: Time moves on, and physical wounds begin to heal. The day finally comes when Rhett is able to take Y/N home from the hospital to continue recovering from the relative comfort of home. But the challenges that come push the two in ways they could never have expected as they find their way back to one another.

A/N: Here's a glimpse into the time after that fateful night. I have one more part of this epilogue to write, which will make sense once you read the end of this one. Thanks to all of you who have stuck with this story, I appreciate your support more than you know.

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Hours morphed into days and days into weeks. Rhett’s entire world revolved around the hospital and your journey back to health. Thankful beyond measure for the care you were receiving, he still found himself growing impatient during the wait. A crushing desperation to hold you in his arms, to tell you how much he loved you, and see the corners of your eyes soften as a smile grew on your lips… it consumed him. And to hear your beautiful voice speak his name again as he held you close was the miracle he daydreamed about often. For better or worse, it was those thoughts and desires that kept him going in the moments when the setbacks seemed to outweigh the forward progress. Most days were nearly indistinguishable from the last, the only defining markers were the trips to and from the OR and the predictable switch of staff as the shift changes came. But sure as the sun does rise, you grew stronger each day.

……………….

It had been weeks since you’d first been admitted to the hospital, and your life continuously hung in the balance with each surgery, but now it was time to take the next step. The muted quiet of the hospital in the early morning did little to ease the anxiety Rhett felt as he sat with you. The hallways were nearly empty as a team of doctors and nurses moved in and out of your room. Staying by your side throughout all of their commotions, he only stepped away when directly asked by one of the team.

The machine that stabilized your breathing had been replaced by a nasal cannula as the sedation was tapered off. It had been nearly fifteen hours since the last of the medicine had been given, and Rhett was beginning to grow worried as he waited for you to come around. The staff did their best to reassure him that this was normal and that some people could take up to 72 hours before emerging from the fog, but their words did nothing to ease the pit in his stomach.

Even with his shoulder mostly healed, Rhett still had to be careful with how he moved. Easing himself down into the chair as soon as the doctors had cleared from their latest visit, he reached out to you. Bringing your hand between both of his, he kissed your thumb, his chapped lips lingered on your skin as he scanned over your body. Concentrating on the gentle rise and fall of your chest, he caressed the back of your hand, your skin smooth under his touch. Time continued to pass, the morning turning to early afternoon, and the sun high in the sky was slightly hidden by the fluffy clouds that hung in a haphazard pattern. His eyes drifted to the window as he gazed blankly at the world that passed by. Ignoring the ache in his muscles, Rhett stayed like this until the gentle twitch of your fingers snapped his attention back to you.

………….

Excruciatingly bright light flooded your vision as your eyes tried to open. Blinking quickly, tears flowed as your body attempted to ease the sandpaper feeling under your lids. Opening your eyes, you struggled to focus, the room spun unevenly as you looked ahead. Feeling trapped in your body you tried to break free from the haze, but there was a disconnect. Your brain screamed for your limbs to move, but nothing happened. Panic started to rise as you tried to speak, and yet again nothing happened. You could feel the tender flesh of your throat, a raw line of pain flashed as you swallowed. Parting your lips, you attempted to vocalize, the first try was totally silent, only a wisp of air was released. The second time you managed a feeble croak, your fingers curling against Rhett’s.

“Rh… Rhett.”

Hearing your voice and feeling you move, he was instantly out of the chair. Clicking the call button, he kept hold of your hand as he spoke, “Hey, baby, it’s me… I’m right here. Okay?”

A shallow nod took the place of a verbal answer, keeping your eyes open was taking all the energy you could muster right then. Fighting for focus, your eyes finally landed on Rhett’s face. Concern and relief washed over his features as he saw your attention land on him. Reaching out with his free hand, he cupped the side of your face.

“I missed you, Y/N.”

Bending down, Rhett pressed a gentle kiss to your lips. Staying close for a moment after he pulled away he relished the sensation of your breath floating over his face. Digging deep, you found the ability to speak again.

“Missed you too, cowboy.”

……………………

Even after waking from your sedation, it took several more weeks to build your strength up enough to even contemplate releasing you. Reaching that milestone had been a long and arduous journey. Many tears had been shed during the recovery process. The grueling physical therapy often left you spent and so utterly drained that all you could do was let Rhett hold you as you cried together. On top of all that, the many promised ‘going home’ dates that had come and gone due to lack of progress had left your spirits low.

But today was the day, the paperwork had been signed and in just a little while you’d finally be free of the room that had long since begun to feel like a prison. Walking was still a slow process, and something that could only be tolerated in short bouts, but it was getting easier all the time. The intensive physical therapy would need to continue, but in the long run that didn’t matter. What mattered was finally getting to start your life with Rhett. The plans to leave Wabang were somewhat stalled as you needed to stay close to the team that was helping you step through the healing process, but getting out meant that you and Rhett were one obstacle closer to making your life together, away from here, a reality.

………..

Situating you on the edge of the bed, Rhett helped you get dressed. He’d brought a pair of his sweats and one of his hoodies for you to wear home from the hospital. Not only did he want you to be comfortable, but your range of motion was still greatly impacted by the gunshot wounds. One of the bullets had shattered your shoulder forcing the surgeons to replace the joint during one of your many trips to the operating room. On top of that, you were still recovering from your latest surgery which reversed the temporary stoma the surgeon had created to give your intestines time to heal from the trauma of the bullet wound.

Kneeling down, Rhett helped you step into the pant legs, pulling them up as you gripped onto his shoulders. Your hands slid to his biceps as he rose from the floor. Rolling the waist a few times to ensure you didn’t trip on the extra fabric, he then grabbed for the hoodie. Opening the neck, he guided your head through the hole before easing your right arm through the sleeve. Seeing your chest moving rapidly, Rhett stopped for a second to let you breathe.

“You okay, sweetheart?”

“Yeah, I’m okay.”

“You tell me when you’re ready to keep going.”

“I just need a minute.”

Sitting next to you, Rhett took your right hand in his, “Take as long as you need, baby.”

You could feel the soft kiss he placed on your temple as he continued to sit and breathe with you. Resting your head on his shoulder, you concentrated on slowing your heart rate. The flash of pain that had risen faded as your lungs got back on track. Signaling to him that you were ready, Rhett delicately adjusted the sweatshirt over your sling before stooping down again to help you slip on the shoes he'd packed for you. The whole process was slow, but finally, with a fresh set of clothes on you were ready to leave.

As much as you would have liked to walk out of that hospital on your own two feet, you knew that simply was not within your capabilities yet. Sucking up your pride, you allowed Rhett to help you into the wheelchair the nurse had brought by earlier in the day. Throwing your bag over his shoulder, he unlocked the wheels and started down the hallway. The two of you gave a quick wave to the staff you passed on your way out, thanking them for all their time and care.

Needing to pull the truck up, Rhett found you a sunny patch of sidewalk next to the entrance and headed off with his keys. Even with the vehicle as close as it could be, getting up into the truck proved to be rather difficult. But with that next hurdle out of the way, the two of you took off into the afternoon sun toward the Abbott Ranch. Going extra slow, and trying hard to avoid any large bumps in the road, Rhett’s hand settled on your thigh for the duration of the ride. Glancing over now and again, he could see you close your eyes and relax into the beams of sun pouring through the windshield. Seeing you like this, it was easy to forget for just a second how close he’d come to losing you. But that sense of peace didn’t last long as the transition back home proved to be more difficult than expected.

……………….

The time after coming home was spent trying to regain some sense of normalcy even though the entire world seemed to be turned on its head. Perry and Amy were still missing, and the search for both of them slowed down as the likelihood of finding time alive dimmed, at least in the eyes of law enforcement. There was a shared seed of anger and resentment that grew in both you and Rhett when it came to the way the situation was being handled. At first, it appeared as though everything that could be done was happening, but it didn’t take long for that to subside. It was as if those in charge had disappeared, there was just an endless stream of excuses as to why they were unavailable to speak about the situation. Each day you woke up you missed the little girl more. Your heart ached not knowing where she was or what happened to her. The fear that found a home in your soul tainted your dream most nights. Your sleeping hours were plagued by visions of the final night with James at the rodeo and the last time you’d been with Amy.

Rhett wasn't fairing much better. His sleep was fitful at best. Most nights you'd wake to find the bed next to you empty, devoid of his warmth. A shuffling trip to the living room would bring you face to face with the haunted look in your fiance's eyes. There were no words that could ease his suffering, so you did the only thing you could. You stayed by his side through the thick of it all. Pressing yourself into him, your hand found his, holding it near as you rested your weight on him.

But on the worst nights, Rhett recoiled at your touch. The brush of your skin against his seemed to burn him like a flame. You weren't sure what distinguished these nights from the others internally, but on the outside, it was easy to tell. Rhett's body was stone-like as he sat on the couch, staring off into the distance. The fear that pooled in his eyes came along with a steady stream of tears, that he did little to hide.

The worst of it all was the barrier that had crept back in between you and Rhett. There were times it seemed to fall when the two of you were able to forget for just a minute the horrors that had unfolded not too many months ago, but for every one of those moments several more existed where the opposite was true.

The brutality of what you'd experienced left you vulnerable and weak, and in constant need of assistance. And the inability to care for yourself in the way you were used to, even with the most mundane tasks, had you fuming inside. Resentment for the cards you were dealt made your fuse short, both with yourself and with Rhett. And for him, the guilt he'd tried so hard to quell was always trailing beside him, making him question every decision he made, and leaving him angry when it seemed like his choices were only making things more difficult for you.

Additionally, the dynamic within the home was unsteady as best and volatile at worst. The void that had grown between Ceci and Royal had gotten deeper. The two seemed to be ships passing in the night, they rarely spoke and when they did there was no between. It was either polite coldness or devastating fights that left the house echoing with their shouts. Rhett wanted more than anything to get you out of this space, but with your extensive medical bills coming in, the resources just didn’t exist to make that happen.

Even with all of the tumult and turmoil, the love you and Rhett felt for one another never wavered.

…………..

Coming downstairs for breakfast, Rhett found you standing at the counter getting ready to fill the coffee pot with water. Stepping into the space behind you, he wrapped his arms around your waist, being sure to avoid putting too much pressure on the tender spots that still existed. Nuzzling his face into the side of your neck, his lips grazed over your skin as he spoke.

“Mornin’”

“Mornin’, Rhett.”

“You take your meds?”

“Yes.”

“Good. I’ll go into town later and pick up your refills.”

Pressing start, you turned around to face him, his hands settling on your waist to keep you close. Reaching up with your good arm, you swept his hair back away from his face. Holding his cheek, you noticed that his stubble was starting to fill in a bit as it had been a few days since his last shave.

“Thanks for always takin’ such good care of me.”

“Darlin’, I’d do anything for you.”

Capturing his lips, you felt one of his hands slip up higher on your torso while the other threaded neatly into your hair. Cupping the back of your head, Rhett groaned into your mouth as he heard the small gasp that escaped your lips. A flush of heat burned through him as your hands ran down his chest and settled on his hips. This wasn’t the first time the two of you had shared an embrace like this since bringing you home, but something felt different about this moment together. His body was alight with your touch, the desperation to have you, all of you, after being forced to forgo that part of your relationship for months was dizzying. But the tiny voice in the back of his head was screaming at him to be careful. Not wanting to hurt you, Rhett pulled back before he lost control of his senses. Pressing his forehead to yours, your noses bumped as your lips barely touched in a light kiss.

“I’m not gonna break, Rhett.”

“I know, I just…”

Pulling back you looked up into his stunning blue eyes, the wrinkles forming at the corners gave away the depth of his concern. Giving him an understanding smile, you brought your arm around him and leaned forward, hiding your face in his chest. Responding to your touch, he enveloped you, his lips coming to rest on the crown of your head. Your words vibrated against his front as the warmth of your breath touched the skin under his shirt.

“Need a little more time… it’s okay, I understand.”

Hearing the dejection in your voice killed Rhett. He wanted to be honest and let you into his thoughts, but he was terrified of the truth. The minefield of his brain was a touchy and dangerous place, and the last thing he wanted to do was pass off his emotional burden to you, especially now when your health was still fluttering on the edge of stability. How could he possibly explain that every time he held you like this flashes of that night came crashing back, the feeling of blood under his fingers was as real as the day he knelt beside your lifeless body? The truth was… he couldn’t, at least not yet. Even while he waged his own internal war, Rhett never wanted you to doubt his love for you.

You could tell he was lost in thought, and you didn’t want to push too hard. Rhett had been a beacon of strength for you during this long recovery process, but you knew that it had put an incredible burden on him emotionally. The guilt residing in your soul was eating away at you slowly, and in moments like these, it bit down hard. There was this hesitation and distance that grew in his eyes and you could only imagine what was going on in his head when you saw it.

Resting your cheek on his pec, you uttered your wish aloud, “I want to do somethin’, go somewhere, just the two of us.”

“Y/N, come on, you still can hardly walk by the end of the day. Now’s not the time.”

“No, you come on. When’s the last time we actually got to spend more than a couple of hours together alone? Hmm? Rhett, we can't wait for everything to be perfect or we’re never going to find normal again. Please, let's do this for us.”

Studying your face, he knew you were right. It had been far too long since the two of you had been able to spend time together outside of the Abbott Ranch.

“All right. I'm listening, what did ya have in mind?”

Smiling wide, you dangled your idea out to him, “Well… we could go out to dinner… maybe... maybe then we get a room for the night at a hotel… how’s that sound?”

“Sounds good to me. But you’ve gotta do one thing for me.”

“All right, and what’s that?” Your brows pulled together in confusion at the serious look on his face.

“Marry me.”

Laughing a little you couldn’t help, but shake your head at his answer, “What are talking about, Rhett? I already said yes, or did you forget about this?”

Holding your left hand up as high as you could, you teasingly showed him the ring, but his face didn’t soften the way you expected it to. Lowering your arm, you gripped his forearm, “What’s wrong?”

“You’re not hearin’ what I’m saying. Marry me. Not six months or a year from now.... today.” Taking your left hand in his, he continued on, “I want the wedding, and to see you walkin’ down the aisle in a white dress, but I don’t want to go another day without you bein’ my wife.”

You were taken aback by his words, your heart beat fast from the rush you felt at his words. The excitement that rose inside of you told everything you needed to know, “Okay… okay. I’m done waitin’ if you are.”

“I’d have married you the day I put that ring on your finger if you would've let me.”

“Well then, I'm so sorry to have kept you waiting.”

Smirking, you tipped your head up and pulled him down for a kiss, his own smile was evident on his lips as he leaned into your touch.

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@lostinthefandoms11

@hope-love-equality2

@eugene-emt-roe

#rhett abbott fanfic #rhett abbott x female reader #rhett abbott x reader #rhett abbott #rhett abbott outer range #rhett abbott x you #outer range #lewis pullman

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lifeinkinder · 7 months

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Y'all my face is so dry. It's cracked and peeling and it hurts. I know it's because I'm stressed and I haven't been drinking enough water but man it blows.

Baby boy is doing well. We graduated from high flow to a regular nasal cannula. Hoping to be oxygen free by tomorrow, but we shall see, especially since his o2 while sleeping is tending in the low 90s and his goal is technically about 95.

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heardatmedschool · 1 year

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“High flow nasal cannulas are fucking cool, pardon my French.”

#medicine #med school #medblr #hospital #medical emergency #emergency medicine #respiratory health #respiratory illness #breathing

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mymedlife · 1 year

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The number of parents trying to mansplain my job to me has been irritatingly high lately.

Patient presents with respiratory distress and bronchiolitis, placed on high flow nasal cannula with improvement in symptoms.

Patients father: those setting are higher than the last time she was admitted, I want you to do what they did last time.

Me: she’s a little sicker this time and needs higher settings.

Father: well I read that high flow nasal cannula only works about 60% of the time, you should just intubate her.

Me:

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ampleappleamble · 2 years

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Okay, it's looking like the danger has finally passed, so maybe now I can finally start talking about it.

I was born on a Wednesday.

On Thursday, October 13, 2022, my son was born via emergency C-section. He was immediately taken to the NICU, and he stayed there for the next three weeks being treated for pulmonary hypertension. He was on CPAP at first, but his condition quickly got worse. I only got to hold him once before they had to intubate him. My husband didn't get to hold him at all. For a week or so we couldn't even touch him due to fear that overstimulation might rile him up and drive up his oxygen needs. He was fed my pumped breast milk through an NG tube. My husband and I visited him every day, watching him improve slowly but surely, eventually being put back on CPAP, then on high flow oxygen delivered via nasal cannula, and finally, low flow oxygen. We were allowed to hold him, feed him, change him. He was getting better. It was looking like he was going to be sent home soon.

Then, on October 28, his blood pressure reading was alarmingly low in his left leg compared to his right. The doctors suspected a blood clot and performed an ultrasound, but it was inconclusive. So the suggestion was made to airlift him to another, larger city so he could be examined by a hematologist and pulmonologist. My husband and I agreed.

It was the hardest thing we'd ever, ever had to endure, watching that day as the helicopter flew off into the distance, taking our sick, helpless infant son away from us.

Wednesday's child is full of woe. Thursday's child has far to go.

We'd had the option for one of us (due to weight restrictions) to accompany him on the helicopter, but neither of us was really in any condition to be alone at the time, especially in an unfamiliar city. So we stayed home, waiting until the next day for my husband's mom to arrive in our town– an arrangement that had been set up months ago, luckily coinciding with this unfortunate event (we have no idea who'd have watched our cats otherwise). The day after that, we drove two hours to the city our son had been taken to, staying in a Ronald McDonald Charity House nearby the hospital, and we visited him in their NICU. We were traumatized, terrified, and very, very tired, but everything we were told there was promising– the blood clot they had suspected was nowhere to be seen, so it had either broken up and the problem had resolved itself, or it was never there at all and the blood pressure discrepancy was due to temporarily narrowed arteries, a fairly common side effect of the umbilical IV he'd had for a while in our NICU. So finally, it was decided that we would room in with him at the hospital the next night– Happy Halloween!– and take him home with us the next day. He would be going home on oxygen, but he would be going home.

Someone came from the oxygen supply company to train us on how to use our son's new oxygen tanks and pulse oximeter and arrange for oxygen to be delivered to our home. The nurses took us to our room, hooked our son up to his pulse oximeter and to the oxygen nozzle on the wall, and left us to it.

It was the worst night we have ever suffered through in our lives.

There were, of course, the usual new parent woes– the steep learning curve, waking up every three hours around the clock to feed and change him, a lactation consultant who was very helpful but still kinda made me feel like I'd been fucking up somehow this whole time– but the absolute worst was the pulse oximeter. As per his doctor's orders, it was set by the company that had provided it to alarm loudly when my son's oxygen saturation level dipped below 90%, in order to make sure he was getting the oxygen he needed to thrive. Ideally, the alarm would only go off if, say, his cannula were to slip out of his nose, or an oxygen tube should get disconnected.

It went off constantly. It felt like every 20 seconds, although it reality it was probably only every five minutes or so. It would sound even more frequently when he sneezed or farted, or when he got fussy. But he was almost always fussy– and somewhat peaked, we noticed. It was maddening. We got no sleep, no peace, and we were terrified and frustrated. Were we doing something wrong? Was there something wrong with him? Was the pulse oximeter faulty, or the sensor? The night nurses attending us assured us that this was normal, more or less– some babies fussed more often at night and it was natural for O2 sat to dip when one was exerting oneself the way he was. But we both couldn't help but feel that this was different, this was wrong, it shouldn't be going off this often. Finally, shifts changed and our new nurse agreed with us: this was not normal. She spoke to the doctor who also agreed, and it was decided that our son would have to go back on high flow oxygen. Which meant he'd have to go back to the NICU, and he couldn't come home yet after all.

This shattered us. Because our city's NICU was a level 3 NICU and this city's was a level 4, and moving backwards or even laterally between NICU levels is not generally done, this meant that not only was our son's condition worsening again when he had been improving, but also that we would have to stay in this horrible city indefinitely until he got better, or... you know. It felt almost like a personal failure– he'd been doing so well, and then we showed up. We'd been so full of hope that our son could finally come home, home with us where he belonged, only to now have to return to Ronald Fucking McDonald House and languish in despair for who knows how much longer. We stood above his bassinet as they hooked him up to a portable oxygen tank, weeping and clinging to each other, following the nurses as they wheeled him back into the NICU.

And then we noticed that his oxygen saturation was at 100% again.

This was confusing for a number of reasons. We'd spent the whole night under the impression that his O2 readings being so low so often was "normal," or at the very least the result of a faulty pulse oximeter or sensor. Why would it be that when hooked up to a different oxygen source than the one he had been hooked up to all night, his oxygen sat suddenly corrected itself? Our new nurse had her suspicions, and asked a nurse tech to check the oxygen source in our room, the port in the wall our son had been connected to.

Turns out it wasn't working. Our son had been on room air all night.

We'd gone through that miserable ordeal of a night for no good god damn reason. We were too exhausted to even complain about it.

The tech fixed the wall oxygen while the nurse informed the doctor, and it was decided that since there was no need to put him on high flow oxygen again after all, we could try rooming in again, this time with him on working fucking low flow oxygen. We did, and it went much more smoothly. And so the next day– November 2nd, his original due date– after yet another agonizingly long wait, we were finally discharged from the hospital and we drove two hours home with our little baby boy.

And he's here with us now! He's still on home oxygen, still quite small for his age, but he's growing more and more every day just as surely as our love for him grows, and he has lots of fun doctor appointments to look forward to to make sure he's healthy. All the heartache, all the pain and misery, it was all worth it to bring him home.

And that's our birth story.

Son boy allowed!

🍼💖👶

#personal shit #son boy allowed

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kurosaki-tendo · 2 years

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This is how doctors watch medical dramas:

While watching Ghost Doctor on Netflix: Scene 1: RA: Ay, extubated na pala s'ya? Ez: Hindi ba s'ya naka-trache(ostomy)? RA: Hindi. Naka-high flow lang. O parang normal na nasal cannula nga lang yata e. Ez: Hala, e di ba GCS 3 s'ya? RA: Oo. Dapat intubated 'yan.

Scene 2: RA: What is Rastelli procedure? Ez: Uhmmm. Hala, di ko alam. RA: Ok lang 'yan. Bubu din naman ako sa IM haha. Scene 3: RA: O, bakit sila nag-defib? Ano ba rhythm? Asystole naman yata. Ez: V-fib o. Yung sa taas kasi! RA: Ay, ok ok. Sobrang well-researched naman nitong series na 'to haha. Quezon City, PH 12 Sept 2022

#ezra #medicine

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mcatmemoranda · 2 years

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35 week old febrile pt with fever of 101.2, ApO2 86%, tachypneic, wheezing, subcostal retractions, runny nose, nasal flaring. It's a viral illness.

Low oxygen level is not necessarily bad in a child. They can tolerate low oxygen. The emergency is getting the CO2 out.

Giving oxygen for comfort is a myth. Giving oxygen won't make the pt feel better. The emergency is respiratory status: work of breathing, retractions (non-compliant lungs due to mucus), respiratory rate. The red flag is the respiratory status, not so much the hypoxemia.

90-100 is an A

80-90 is a B

70-80 is a C

All of the above are still passing grades.

Below 70 is more worrisome.

No testing is really necessary because it won't necessarily change the management. In children, WBC is 50% sensitive and 50% specific for determining viral vs. bacterial illness. So a CBC in a child isn't necessarily helpful. Viruses can cause elevated WBC in kids (adenovirus can cause WBC of 24). CMP could be helpful if pt is dehydrated. Blood culture utility is low after 2 months of age because false positive rate is double the true positive rate. If baby is septic, then get blood culture.

Abx use in childhood can increase risk of type 1 DM. Obviously, you don't give abxs automatically.

CXR increases risk of giving unnecessary abxs. Procalcitonin and CRP are better than WBC for distinguishing between viral and bacterial infection.

In an infant less than 1 month old, do a full rule out sepsis with: urine, blood, and CSF.

0.4% of infants under 1 month old with fever have meningitis.

The speaker said that the national guidelines say you should use a cutoff of 90% for SpO2, but he wrote that section and wrote it because thats where the data seemed to go, but he says that the data were not based on clinical outcomes, but on the oxygen-hemoglobin dissociation curve. Oxygen doesn't really help or hurt.

There was a study where people did a respiratory score (Respiratory Distress Assessment Index [RDAI]), waited half an hour, then went back and did another respiratory score. Most pts had no change in respiratory status. Some got significantly better and others got significantly worse. There was no intervention done.

Giving alburerol vs placebo had no difference in outcome in one of these studies in the inpatient setting. In the outpt setting, there was a small reduction in severity of illness symptoms, but no difference in hospitalization. Albuterol increases HR. You should not use albuterol.

Albuterol can make you feel crappy.

Steroids are not helpful at all in children under 2 years old. Steroids can mess up children's growth.

So for treatment of bronchiolitis: oxygen is not necessary, steroids are harmful, albuterol isn't necessary.

Mortality is rare in bronchiolitis. 1 in 200,000 die of RSV bronchiolitis.

No medication will make these kids better.

High flow nasal cannula will provide some PEEP. Babies are primary nose breathers. They take shallow breaths and re-breathe CO2-> respiratory acidosis. So high flow helps them breath better.

HFNC rate varies based on hospital. Some dose high flow at 2 L/min/kg up to a max of 30. Most don't exceed 8 L/min/kg. Most use 2 L/min.

Decision to admit depends on whether the kid is in respiratory distress. Assess hydration status. Nasal suctioning can help. The device that the parent sucks works better than the blue bulb.

IV fluids.

Kids under 2 more often get bronchiolitis.

RVP = Respiratory Viral Panel

Pearls: Differential diagnosis comes later to avoid unnecessary testing and therapies.

From the post-test:

A 3-month-old infant presents with respiratory distress. He has had cough, congestion, and fever for the past 3 days. Vital signs are notable for an oxygen saturation of 92% and respiratory rate of 60. Physical exam shows an awake and alert infant with head bobbing, intercostal retractions, and diffuse wheezes. He appears well hydrated. You diagnose him with bronchiolitis and plan to admit him.

Which of the following is the most reasonable next step in management of this patient?

Answer: start high flow nasal cannula

This infant has the classic presentation of bronchiolitis, an upper respiratory illness prodrome followed by increased respiratory effort, and he is now in respiratory distress. High flow nasal cannula has been shown to decrease escalation of care in bronchiolitis. While this infant does have a fever, the most likely source of fever in an infant of this age with bronchiolitis is viral, and routine blood cultures are not indicated in this infant. The American Academy of Pediatrics (AAP) advises against routine screening for serious bacterial illness (such as with blood culture), as the most likely source of fever in an infant of this age is a viral infection. Viral polymerase chain testing (such as with a viral respiratory panel) is also not indicated, as it would not change management in this infant. In infants receiving monthly palivizumab prophylaxis, RSV testing should be performed as monthly prophylaxis would be discontinued. The AAP also recommends that steroids, such as dexamethasone, should not be administered to infants with bronchiolitis in any setting, as it does not improve outcomes.

Citation

Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121–1131.

American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

The use of chest radiography in infants with lower respiratory tract symptoms suggestive of bronchiolitis is not indicated. Chest x-ray results in more infants being diagnosed with pneumonia and treated with antibiotics without any benefit. Infants who receive a chest radiograph do not have more frequent hospitalizations, decreased need for follow-up, or faster recovery times (despite increased antibiotic usage.

Citation:

Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet. 1998;351(9100):404–408.

Few interventions have been found to decrease hospital length of stay in bronchiolitis. Fewer lapses in superficial nasal suctioning have been associated with a shorter length of stay. Deep (nasopharyngeal) suctioning has been hypothesized to cause airway edema and irritation and thus prolonged length of stay. Use of albuterol and epinephrine have not been associated with shorter lengths of stay.

Citation:

Mussman GM, Parker MW, Statile A, Sucharew H, Brady PW. Suctioning and length of stay in infants hospitalized with bronchiolitis. JAMA Pediatr. 2013;167(5):414-421. doi:10.1001/jamapediatrics.2013.36

#bronchiolitis #peds #RVP #cribsiders

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phawareglobal · 16 days

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Victoria McKinnon - phaware® interview 469

Victoria McKinnon shares her personal experience with pulmonary hypertension, specifically her son Owen’s eight week battle with the condition. Owen was diagnosed with alveolar capillary dysplasia (ACD), a genetic disease that causes pulmonary hypertension. Despite initial improvements, they ran out of treatment options and ultimately had to make the difficult decision to remove care. Victoria emphasizes the importance of communication and honesty from healthcare professionals, as well as the support and knowledge gained from joining online support groups. She also discussing her fundraising efforts to support research and find solutions for children with PH. Learn more about Victoria’s fundraising efforts: www.withlovefromowen.com

My name is Victoria McKinnon. I'm from Boulder, Colorado right now. My connection to pulmonary hypertension is my son died from pulmonary hypertension two and a half years ago after eight weeks of life-fighting pulmonary hypertension.

Owen arrived within an hour of his due date. There was no indication that anything was going to be wrong. There was nothing wrong during the pregnancy. He actually arrived seemingly healthy. He weighed a lot. He was long. He was healthy. He came out with a big scream. It was only over the course of the first 24 hours, that we realized something was wrong. He went into respiratory distress and was intubated. We got transferred to the local children's hospital in Colorado. They assumed that it was pneumonia. We progressed. We were treating it. After a week, it wasn't getting better. He all of a sudden crashed. I'll never forget him crashing on ECMO. It was when a nurse ripped off a medical tape. We now know with pulmonary hypertension, these sort of events can precipitate a pulmonary crisis. It was extremely traumatic.

At that point, after he went on ECMO, they suspected ACD, alveolar capillary dysplasia, a genetic disease that causes pulmonary hypertension due to the misalignment of the pulmonary veins. We waited for a diagnosis from the genetics, but unfortunately, we didn't get an answer. They came back positive the genetics were totally fine. Before removing care, we decided to go ahead and do another echocardiogram. The echo actually showed positive improvement. So that kind of bought us time. We thought, "Man, this is a miracle." We had our voodoo candles out. We were so excited. Then we spent weeks three through seven trying to decide what medicine to do next. We were on Riociguat, Sildenafil, all the big hitters in pulmonary hypertension for neonates. Unfortunately, we ended up running out of options.

Even though he came off ECMO, he was extubated and he was able to be on a high-flow nasal cannula. Ultimately, there wasn't any more we could do. He was definitively dependent on NO (nitrogen) and was not stable enough for a lung transplant. So without a diagnosis and without knowing what to do and what this even is, we ended up getting really good advice from our pulmonary hypertension doctor. I will forever be grateful for this, because I do think that he kind of stuck his neck out on the line and gave us his true human empathetic answer.

For us, it was removing care. I didn't want to incite any more pain on Owen that he was already in. So we did remove care and it was only after his death that we learned that Owen and myself actually lack the FOXF1 promoter that causes ACD that was found in the regulatory region postmortem that was not tested. They only tested the exome when he was two weeks old, so that's how it was missed.

We went from, "Oh my goodness, which onesie am I going to have his newborn photos taken in?" I had a bunch screen printed with his name on it. I had a newborn photographer all lined up. I was so stressed, should I get my hair done? Should I not? The silliest things in your life. It all just came crashing down where we are just like, okay, is he going to keep breathing another minute? It was a really challenging eight weeks, but you're just single-threaded on survival for him. But it was really challenging.

There were a few things that brought us enormous comfort. At along every step, we joined a Facebook group or a community. So when we were just in the NICU and it was pneumonia, I joined the NICU moms group. Then, when it was like, oh, there's pulmonary hypertension, then it's ACD, and then it's interstitial lung disease, I actually joined a Facebook group in all of those and learned what would life look like with this diagnosis? When we joined the lung transplant group, what would it look like? What are our options? All of that sort of stuff. Ultimately, the only group where we were a member of now was the ACD group, but I think having something like phaware would've been really helpful. Granted, in those eight weeks, it's hard to find all of these things, but these sorts of networks bring so much comfort and also knowledge.

My husband Daniel has a PhD in material science. I think that that carried over to him reading every single PubMed article related to this. We were reading about clinical trials. Dan on the NICU glass wall that slides and opens up to get in the room, had taped 40 different papers all highlighted, did a tree, had written the PubMed numbers on it, trying to ask questions. He would interrogate them at rounds for an hour. All of the nurses would walk away. They're like, "This is a waste of my time." But we just went into what can we do to help? Maybe they're missing something. Maybe there's something else. So to go from, should I do my hair curly to is there a clinical trial and a rat that might save my son was just really horrible.

Right now, we're at this pulmonary hypertension conference for pediatrics and neonates. I was asked to give a 10-minute talk. While I could talk for hours about Owen, I wanted to just monopolize on an opportunity to give them something to work with. So yes, this is a really sad story. Yes, there's horrible things in the world, but how can you make our horrible days less bad? So that's kind of how it came about.

As a call to action for nurses, respiratory therapists, all of the doctors and physicians that are helping us, I have five asks from parents. I've consulted other parents in compiling these asks. Through that task, I did realize the breadth of requests from parents. I will caveat this list of five asks with, I think the best practice is to just ask how a parent wants to be communicated to, but these are my takeaways and what I would ask from my personal experience.

The first ask is the hardest. We found that during the ambiguous end-of-life decisions, we were given a lot of information, but we didn't have the context surrounding it. This was my first baby and only baby, and we haven't seen what is a survivable sick kid and what is not. During those decisions, only Dr. Kinsella offered his compassionate perspective on what he would do if it was a family member. I'm asking as a human, as a mom to another doctor what they would do. I am asking specifically, because I trust them and I am curious.

I know that this may not be shared with all of the parents to want to hear a personal opinion, but when directly asked, please go ahead and share because as a mother, I couldn't possibly have made the most impossible decision you could think of without the recommendation of someone who has seen infinitely more sick kids than I have. So his opinion was the ultimate gift of freedom for me from rumination or any guilt. So that's the first ask.

The second ask is honesty. I'm going to tell a little story, and it sounds very silly, but I actually think he was really incredible. So we call him the “Pizza Tie” doctor. He's a very cheery pulmonologist. We had never met him and he shared his point of view with the most hysterical fashion. We asked if he thought Owen had ACD and he said no. We asked if he thought Owen had another interstitial lung disease and he said yes. We thought that this was good news. He said no. We asked if he thought Owen would live, and he said no. He said all of this with a smile like recommending a soup. While this sounds very unusual, I think “Pizza Tie” doctor provided us with that direct clarity that we really needed to prepare for the worst. So I think the direct answers in a way were the most compassionate and most informative. He didn't know the answers, but he gave us his opinion. I think that that was great. So second one is honesty.

The third one is very unanimous along parents. If you're listening to this, you've probably received it, you're probably in the weeds. But we want to learn the diagnostic algorithm. What this means is what is the decision tree of options. What are the options of diagnoses? What are the pieces of information we need to go through to eliminate those options? We loved knowing this. I'm sure that as a physician or a nurse or a caretaker, your options are more vast and maybe you want to give us a pared-down list so we don't have unnecessary worrying. But I think, for us, the information and the education was incredibly empowering.

The fourth one is parents network and Facebook. As you guys all know, there's NICU groups, there's interstitial lung disease groups, there's ACD groups, there's lung disease Facebook groups. There's so much activity in these Facebook groups. During our research in the hospital, we not only use these Facebook groups to learn about the disease, we learned what is the quality of life going to be with these diseases. Then, we also connected with other parents. I think that that has been the most impactful.

There's a child in Florida that's a few years old and I am friends with the mother. While we were in the hospital, she was a few months ahead of us and she gave us so much advice about NICU, questions asked, things like that. Thank heaven her son is still alive and breathing. It's such a miracle and I am still so grateful for her. Another parent, an ACD parent, ended up moving down the street. Another ACD parent ended up being the DJ at our Children's Hospital fundraiser.

Lastly, the last ask for number five is when you are escalating intervention. Let's say you're on high-flow nose cannula or you're intubated, preparing us for what would it look like for the next intervention if the worst were to happen would really help remove some of the trauma. For me, one of the darkest memories through Owen's life was the day he crashed and went on to ECMO. I will never forget when the nurse ripped off the band-aid, he wasn't breathing, he started to turn blue. I couldn't do anything. And all of a sudden, the room filled with 30 people. It was so traumatic. Whenever I'm in a doctor's office or in a hospital room, unfortunately, I've had this experience again with my dad and nurses flood in. I completely lose it and panic. I've had to do a lot of EMDR therapy for it. But I think what would really help, and my ask for physicians and doctors is to help prepare us.

If you are at intervention intubation, tell us what would happen, what are the conditions that would be required for us to go to ECMO. Or if we're on an high-flow nose cannula, what oxygen do we go to intubation or things like that. I think talking it through, maybe even getting the paperwork ready so it's not a last-minute decision with ECMO would really change it for the parent, because it is something that I've continued to have to work through to be able to go to a doctor's office or if there's a lot of people running somewhere quickly. I know that you can't stop these emergent situations, but preparing us is that.

Owen had three moments of joy. Well, hopefully, more than that, but there are three call out moments of joy and they would not be possible without the physicians and the nurses and the research that has made this all possible. Without that ECMO bridge to more time, we wouldn't have got this. So I'm just so thankful for the medical staff and doctors. So thank you to any of those listening.

The first moment of joy was actually planned by one of his nurses, and it was night staff and our on-call attending, Dr. Paul Roseanne even made an appearance at 1:00 AM for his two-week birthday party within the hour. A nurse brought hats, balloons, and one respiratory therapist was a trained clown and made blow-up balloon animals, which escalated to sword fights in the hallway. Night shift is way more fun. We spent every night at the hospital sleeping with Owen in the room. So we were able to take part in all of that fun. ECMO, albeit a bridge to nowhere, let us reclaim a traumatic departure and have these happy moments like this birthday party. The nursing staff was just absolutely incredible and thought of everything, and we're so grateful for that one.

The second moment of joy wasn't really a moment, but a series of moments. Dr. Kinsella, our attending ordered physical therapy while balancing that we're in palliative care decision-making. I think that the physical therapy brought increased connection, engagement, and positive interactions to Owen and to us. He had a little maraca, he would shake, at least I would claim that he would shake. Maybe he was accidentally shaking it. It's unclear. He was only a few weeks old, but I would say he was very advanced for his age. He also had this little light up crab and that was all gifted from physical therapy. I think when you're a little baby and all the physical touch you're having is pain, being able to introduce some positive movement let us take control back from the situation.

The last event, and I don't know if everyone is going to be able to do this at their hospital, but we might have broken some rules. It's unclear, but we were able to get Owen onto the helipad to see the son before we removed care and he passed away. Owen was so captivated by the surroundings and the sun. I remember him just turning his head looking back and forth up at the sky. He was a little cold and he did not like the wind, but the sun and the sky, he was just enamored with it. It just rejuvenated us all. The photos of us on the roof being happy, we were singing to him, it was just the most cherished memories of my entire life. I think that that is something that doctors can help enable in the future, is allowing these sort of special moments to come through, whether it's outside or whatever.

After Owen passed, we were a little lost. We knew we wanted to have kids. Man, having Owen and just experiencing that unconditional love, it got us hooked. We really wanted to have a family. We love Owen and we want to have more kids. That has not been in the cards for us yet. We were in Boulder, Colorado. We had bought this house for Owen. Within three weeks of knowing that I was pregnant, we were like, "We need to get a house." We bought a house for him. We just couldn't live in this five-bedroom house alone anymore, so we're renting it out. We're moving back to San Francisco.

But what we're doing while we're waiting as a positive is we're doing a lot of fundraising, hearing what doctors are doing and the research. If we can help fund more private investigators to write more papers or to travel to these conferences and learn more, I want to make that happen. So, we are fundraising, we're just going through our local Children's Hospital and that they're distributing it to things like this conference to get more speakers at this conference and things like that. We host an epic rager where it's in Owen's honor, but we really want it to be a fundraiser and a positive thing. We had a band, we had it catered, we had glow sticks. We're really trying to bring joy and happiness into making a change and to finding answers to finding solutions and helping the kids that haven't been born or the kids that are still here with us make their lives better.

So that is my passion. That's what I'm working for. We thought about trying to switch and become doctors or something, but we've decided we're just going to keep working and just donate money. So that's what my passion is. That's what we're doing. It's really an honor to be here and to get to hear the research that they're doing. I hope to further that.

My name is Victoria McKinnon, and I'm aware that my son was rare.

Learn more about pulmonary hypertension trials at www.phaware.global/clinicaltrials. Follow us on social @phaware Engage for a cure: www.phaware.global/donate #phaware Share your story: [email protected]

Listen and View more on the official phaware™ podcast site

#pulmonary hypertension #phaware #rare disease #lung disease #clinical trials #podcast #PH #asthma

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nareenalifesciences · 1 month

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HFNC High-Flow Nasal Cannula

Product Description

During the patients respiratory ,the oxygen therapy system provides a higher flow rate than the conventional oxygen therapy through the non-sealing nasal cannula,tracheostomy interface and mask, and inhales the mixed gas with adjustable oxygen concentrator and controllable humidity to the patient, so as to achieve better air-oxygen management and improve

Technical Specification:

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Flow Range: Adult 10 To 80lpm, Pediatrics 2 To 25lpm

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Fio2 Range: 21%~100%

Power: 50-60 Hz,100-115v 1.6a (2.2a Max ), 220-240 1.2a (3.2a Max)

Spo2 Monitor: Optional

Website - https://nareenalifesciences.com/

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oxygen123 · 2 months

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Optimising Healthcare: Comprehensive Hospital Equipment Rental Services in Pune, India.

If you are in need of hospital equipment for medical purposes in India, look no further. Our rental services offer a comprehensive range of equipment to meet various healthcare needs. From oxygen concentrators to jumbo oxygen cylinders, we have everything you require to ensure quality care for your patients.

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Oxygen concentrators work by drawing in air from the surrounding environment, removing nitrogen and other gases, and delivering purified oxygen through a nasal cannula or mask to the patient.

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Philips Oxygen Concentrators on Rent in Pune:

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#oxygen #bedroom

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medkartonline1 · 3 months

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Portable Oxygen Concentrator: Empowering Freedom and Mobility

In the realm of respiratory therapy, portable oxygen concentrators (POCs) stand as revolutionary devices, offering individuals with respiratory conditions newfound independence, mobility, and quality of life. This comprehensive guide explores the functionalities, benefits, and considerations of portable oxygen concentrators, highlighting their pivotal role in enhancing respiratory support and enabling active lifestyles for patients.

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A portable oxygen concentrator is a medical device that extracts oxygen from the surrounding air, concentrates it, and delivers it to the user via nasal cannula or mask. Unlike traditional oxygen tanks, which require refilling and cumbersome equipment, portable oxygen concentrators are lightweight, compact, and battery-powered, allowing users to receive supplemental oxygen therapy wherever they go.

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#Portable oxygen concentrators

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