Does it make sense to heat gases higher than body temperature for the treatment of cold water near-drowning or hypothermia? A point of view paper.
There appears to be several areas of concern relating to the continued use of heating gases higher than body temperature for the treatment of cold water near-drowning. The use of heated gases as a primary means to rewarm a hypothermic patient does not seem to be any more effective than doing nothing at all. These low rewarming rates translate into some very long resuscitations. Even Dr. Nemiroff, who was a strong advocate of using heated humidified gases for treating cold water near-drowning, did not consider the use of warm inspired gases to be a primary rewarming technique. He referred to the use of heated humidified gases as a, "stabilization technique". However, does it make sense to use a technique that is several times slower than other methods of similar complexity? Does it make sense to use a protocol that may in fact lower a hypothermic patient's basal metabolic rate? There are some major patient safety issues raised by heating gases to high levels. However, there have not been many patients with documented airway damage. I have several hypothesis about why this is so. Few people seem to know how to significantly heat their patient's circuit. If they devise a system that gets to the therapeutic range they usually have second thoughts when the bag-valve-mask is too hot to hold, or the plastic wide bore tubing begins to melt, they will reduce the system temperature on that basis alone. Many of the hypothermic patients who are intubated simply do not have good survival rates, and so we may underestimate the degree of airway damage that occurs. Spontaneously breathing patients will tend to refuse to breathe hot gases which limits their potential for airway damage. However, is this a risk we need to run? Would it not make more sense to heat the inspired gases to close to body temperature and avoid the problem? I feel that the time has come for the Respiratory Therapy community to come together and work on this problem. The researchers have done their jobs in providing us with reasonable data on which to base a clinical decision. It would seem to me that if a Clinical Practice Guideline for cold water near-drowning or hypothermia were in place it might provide the other groups impetus for updating their guidelines. The bottom line is that patients deserve the best care that we know how to provide, and a clear set of guidelines is an essential first step.
Wallace
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D001291:Attitude of Health Personnel; D001831:Body Temperature; D005740:Gases; D006358:Hot Temperature; D006801:Humans; D007035:Hypothermia / Q000628:therapy*; D015701:Near Drowning / Q000628:therapy*; D017694:Rewarming / Q000379:methods*
D005740:Gases