There are only a few devices that provide demand flow nitrous oxide analgesia: the Nitronox® line which is made in the US and the Pronox™ line which is made in Canada. We compare these 3 devices here to help our clients decide which is best for their use cases.
Nitrous oxide has been used for over 150 years* and has a longstanding safety record. When the Porter Nitronox® nitrous oxide analgesia system is used, patients are awake (conscious), responsive, and breathing on their own.
Oxygen Fail-Safe preventing flow of N2O without O2 (system will not work without O2)
Diameter indexed gas line connections (cannot cross connect gas hoses)
Pin-Indexed cylinder regulators (cannot cross connect regulators to cylinders)
Patient has control over self-administration (can stop inhaling N2O /O2 mixture at any point)
N2O regulator check valve for 2-cylinder cart (when removing N2O regulator to change cylinders, check valve prevents flow back out into the room from the hose and device)
Visual pressure gauges for real time visual confirmation of gas and mixture supply (Nitronox Plus® only) / Visual flow tubesfor real time confirmation of gas and mixture supply (Continuous Flow Systems only)
Nitronox Plus® only:
O2 enrichment feature increases oxygen% if repetitive pattern of shallow breathing
Dual seal diaphragm block reduces risk for leak or failure
Low Inlet Pressure Alarms sound when either O2 or N2O gas supply pressure drops to approximately 35 psi (2.41 bar)
Emergency Air Intake allows the patient to breathe room air in the event that the oxygen as supply is depleted or disconnected, and delivery of mixed gas is stopped
Key Lock safety feature allows the user to prevent unauthorized use of the Nitronox® Nitrous oxide analgesia system
No, neither N2O or O2 are flammable. However, they are both oxidizers which support combustion. If you have a fuel source, heat source and add an oxidizer – there is potential for hazard. If you are utilizing lasers for medical aesthetic procedures, contact the laser manufacturer for recommendations on the use of Porter Nitronox® nitrous oxide analgesia.
Nitrous oxide is a “drug” with contraindications for use. There are also occupational concerns and risks to be aware of. Contraindications are very well documented and easy to assess. Occupational risks can be monitored and managed effectively. Additional risks could include combining N2O / O2 with other drugs and medications.
No, Porter Nitronox® nitrous oxide analgesia systems provide patients with minimal conscious sedation. Patients will be awake and able to respond to commands.
The most common side effects are dizziness, nausea, and vomiting. These side effects can be quickly reversed by having the patient remove the mask/mouthpiece and breathe room air.
Typically, you will not find a specific regulation saying who can administer Nitronox® nitrous oxide and oxygen. It is the treating clinician’s responsibility to ensure that the use of N2O / O2 are within their scope of practice. You should review guidelines from your governing body or state medical board. What you would want to look for is whether it is within your scope of practice to administer pain management medications, minimal conscious sedation, anxiolysis, analgesia, etc. If the answer is yes, N2O / O2 should be no different. For the most part, use of Porter Nitronox® nitrous oxide analgesia falls under the same umbrella as administering a local anesthetic.
In most cases the answer is no – as you are already covered for pain management, minimal sedation, analgesia, etc. That said, the treating clinician may wish to notify your malpractice carrier if you have concerns.
Typically, you will not see a regulation specific to the use of Nitronox® nitrous oxide analgesia for physicians or nurses. This falls under the same umbrella as utilizing pain medications, local anesthetics, analgesia, and minimal sedation.
As with the use of any pain medication, there is risk that a patient may be unsteady, light-headed or dizzy which could be a fall risk. It is recommended that the patient remains seated or lying down for the duration of the procedure. Allow the patient to recover for 5-10 minutes following the discontinuation of Nitronox®nitrous oxide analgesia.
There are currently no CPT medical codes for the use of Nitronox®nitrous oxide analgesia. Some physicians will choose to charge an out of pocket fee - It is not uncommon to see cash fees range from $50 to $150. Conversely, physicians may also consider using Nitronox®nitrous oxide analgesia systems as a marketing tool to help assist with attracting patients and choose to offer it at no charge.
The onset of the effects of Nitronox®nitrous oxide analgesia vary from patient to patient. Effects can be felt in as little as 30 seconds or it could take several minutes. For the fastest onset, make sure the patient keeps the mask securely on their face. Once the patient stops inhaling the gas mixture, it will be completely out of their system within 5-10 minutes*. They will start feeling back to normal almost immediately.
No, Nitronox®nitrous oxide analgesia does not eliminate pain. This is important for educating patients and setting expectations. This will also not replace a local anesthetic (if required). Nitronox®nitrous oxide analgesiais intended to take the edge off, help the patient relax, make them more comfortable, distract them, and reduce anxiety. This is not something you would use for extremely painful procedures or procedures where you need the patient to not be able to move.
Most will say it makes them feel relaxed, arms and legs feel light, tingling in extremities (hands / feet), floating feeling, sinking into a chair feeling, etc.
Nitronox®nitrous oxide analgesia affects each patient differently. The majority of patients will experience the calming and relaxing effects of the nitrous oxide but there may be small set of patients that will not feel these effects. It is important to set the expectations for your patients and explain what Nitronox®nitrous oxide analgesia is able to provide - it helps to relax and reduce anxiety but does not eliminate pain. The advantage of the Nitronox Plus® 0-70% / 0-50% and the continuous flow systems is that they allow you to adjust the percentage mixture. This gives you the option to increase the N2O percentage should a patient not feel the effects of nitrous oxide or reduce the N20 percentage if a patient is feeling that the nitrous oxide effects are too strong.
The effects of Nitronox®nitrous oxide analgesia wear off very quickly, so the patient will need to utilize nitrous oxide and oxygen to maintain comfort during the procedure. If your patient is using the nitrous oxide during a laser procedure, contact the laser manufacturer for recommendations.
This is dependent on the procedure performed, other medications administered, etc. The effects of Nitronox®nitrous oxide analgesia is completely out of the patient’s system within a few minutes. It is reasonable that a patient can safely go home about 10 minutes after ceasing use of nitrous oxide and oxygen (assuming all other discharge criteria were met).
Nitrous oxide is a medical gas, and OSHA has guidelines for workplace safety. The main concern is occupational exposure during frequent and/or long term use of nitrous oxide. Depending on duration of use and frequency of use, this may or may not be an area of concern for you and your staff. You should be educated and aware of potential risks and how to manage them. You can easily monitor exposure by periodically wearing nitrous oxide dosimeter testing badges that will verify the parts per million (PPM) of exposure.
Scavenging is the term for the removal of exhaled waste gases through a vacuum system and outside of the building. Nitronox®nitrous oxide analgesia is not metabolized by the patient so amount of gas the patient breathes in is roughly the same that is exhaled out. There is no law or regulation mandating the use of scavenging systems. OSHA has standards of care with regard to use of medical gas and provides recommendation on nitrous oxide exposure limits. Aside from scavenging you can lower exposure levels by having good room air circulation, fans, open windows, not using in confined spaces, avoiding direct contact, etc. If you are unable to maintain levels of exposure below recommended levels, scavenging should be utilized.
The gas itself is available from most medical gas suppliers. There are large national suppliers like Praxair® (www.praxair.com) and Airgas® (www.airgas.com) – and smaller regional / local ones. If you have a supplier for oxygen – more than likely you will have access to nitrous oxide. You should shop around as suppliers will have various fees and charges added on. You will need to source size “E” cylinders with a “standard post valve” (not cylinders with integrated regulators). You should order enough gas so that you have 1 of each gas for use as well as a few spare cylinders of each gas on hand. You will go through more O2 vs. N2O as there is more N2O in one cylinder. O2 = 625 Liters, N2O = 1500 Liters. A good question to ask the gas supplier – how long will it take for delivery after you order? If it is a longer period of time, factor that in as you may want to hold additional reserve cylinders.
O2 is a true gas and as it is used you will see the gauge move. A full O2 cylinder is 2000 psi, half full = 1000 psi, etc. N2O is in the cylinder as a liquid, and as it is released turns into a gas. Because of this, it maintains the same amount of pressure in the cylinder right up until it is just about empty (similar to a propane cylinder for a gas grill). A full cylinder of N2O is 750 psi, a half full cylinder of N2O is 750 psi, and a quarter full cylinder of N2O is 750 psi. You can’t look at the gauge and tell how much is left. This is why you should keep an estimate / track of use and have a spare(s) reserve on hand. The only way to know how much is in an N2O cylinder is to weigh it before and after use (which is not practical). Remember that you will get about 6 hours of use – so it should last for quite a few patients. Cylinders can be swapped out quickly and takes less than 2 minutes to complete.
