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Can breathing in helium (from balloons for example) cause damage to the throat in the long term?

Can breathing in helium (from balloons for example) cause damage to the throat in the long term?


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Often an activity to do at a party, breath in helium and speak like one of the chipmunks. But, I am wondering, would infrequent inhalation of helium cause long term harm to the throat? in particular, the vocal cords?


When we speak, our vocal cords vibrate to the air. Helium makes them vibrate a lot faster (that's what makes the funny sound of your voice after inhaling helium), because its atoms are a lot lighter than nitrogen and oxygen atoms. Obviously, lighter atoms, can travel faster. This faster vibrations are unusual to the cords and they can cause sore throat or even strong throat ache. After you stop inhaling the gas, things should get back to normal, especially if the inhalation really is infrequent.

Breathing helium balloons at parties is a very dangerous fun activity, because it replaces the oxygen and this could lead to hypoxia - a condition when tissues can't get enough oxygen one reason or another. In some cases, this could even be fatal.

Even though inhaling of pure helium is dangerous, in submarines, divers breathe a mixture of nitrogen, oxygen and helium as helium is better under higher pressures. At these depths the low density of helium is found to considerably reduce the effort of breathing. Divers often have problems with dry throat and constant thirst due to the need of more oxygen. At least, inhaling helium, when it's mixed with oxygen, is far less harmful than breathing it directly from a balloon.


The airway can become narrowed or blocked due to many causes, including:

    in which the trachea or throat swell closed, including allergic reactions to a bee sting, peanuts, antibiotics (such as penicillin), and blood pressure medicines (such as ACE inhibitors) and reactions (infection of the structure separating the trachea from the esophagus)
  • Fire or burns from breathing in smoke
  • Foreign bodies, such as peanuts and other breathed-in foods, pieces of a balloon, buttons, coins, and small toys
  • Infections of the upper airway area
  • Injury to the upper airway area (collection of infected material near the tonsils)
  • Poisoning from certain substances, such as strychnine (collection of infected material in the back of the airway)
  • Severe asthma attack (weakness of the cartilage that supports the trachea)
  • Vocal cord problems
  • Passing out or being unconscious

People at higher risk for airway obstruction include those who have:

  • Neurologic problems such as swallowing difficulty after a stroke
  • Lost teeth
  • Certain mental health problems

Young children and older adults are also at higher risk for airway obstruction.


What is it about NOS that gets you high?

When inhaled, nitrous oxide acts in a similar way to ketamine. This explains some of its pain-relieving effects. Inhalation of nitrous oxide produces a very short lived but intense euphoria which at higher doses can evolve with psychedelic effects including feelings of dissociation and mild changes in perception of body image. It can enhance the effects of other drugs, especially when used with with alcohol, MDMA and psychedelics being most common.


Etiology

PRF may result from liberation failure (i.e., the inability to ventilate spontaneously without ventilator support) or extubation failure (i.e., the inability to tolerate removal of the endotracheal tube) or both [5]. Liberation failure may result from primary respiratory failure, congestive heart failure, or neurological impairment. Causes of extubation failure include upper airway obstruction and inadequate clearance of airway secretions [5, 6].

Endotracheal intubation causes damage to the airway in most patients, leading to LE, ulcerations, and damage to the vocal cords [1, 7𠄹]. Although these injuries are generally reversible, they may cause a decrease of the available airway lumen and lead to respiratory difficulty directly after extubation [1, 7, 9]. The decreased airway lumen results in an increase of air flow velocity, leading to postextubation stridor (PES), which is a clinical marker of relevant PLE. Although the exact quantitative relationship between lumen narrowing and clinical symptoms is unclear, the presence of respiratory distress and PES is thought to reflect a narrowing of the airway lumen of more than 50 % [10].


Can breathing in helium (from balloons for example) cause damage to the throat in the long term? - Biology

Surgical Emphysema

Mouth

  • Never put a balloon in or on your mouth after another person has done so. There is nothing like fresh saliva to transmit germs. Not only do you risk the usual flu and cold bugs, but, with kids (who have a tendency to get their hands into a lot of things and then put their fingers in their mouths) there is also a risk of Hepatitis A, Herpes Simplex I and other such nifty critters.

Cheeks

  • I've been blowing up 260's on a regular basis for the last 2 years. Now, over the last several months, I've been greeted by expressions of wonder as my clients exclaim, "WOW! Look at those cheeks!" Needless to say, that is worrying me a bit. If you blow up enough balloons, is there a risk of looking like Dizzy Gillespie? The short answer is YES. At IBAC, I saw a twister who could have been Dizzy's double. Plus another twister warned me personally, "Keep your cheeks in! See these jowls? I didn't have them 10 years ago." Note that you didn't say you have Winton Marsalis jowls or Sergio Mendez jowls. Why did you pick Dizzy Gillespie? Because he spent 50 years blowing his horn incorrectly, and admitted doing so. Trombone playing (trumpet playing, saxophone playing, etc.) balloon sculptors were taught how to send the air straight through our mouths into the instrument. Air in your cheeks is air that isn't going into the balloon.
  1. A salty taste in your mouth that tastes like blood
  2. The insides of your cheeks become A LOT rougher
  3. The insides of your cheeks peel for the next few days
  • Load a living bone in compression and NEW BONE CELLS GROW to help carry the load.
  • Lay weightless up in space for 6 months and your bones "un-grow" as your body re-absorbs them.
  • Muscles respond to stress too. The entire health-club industry owes its livelihood to that fact. There is even a sensory receptor called a "stretch receptor" that responds to the stretching of tissue.
  • Same for skin - when you get pregnant, do lots of body-building or gain a lot of weight, your skin gets stressed and more of it GROWS to cover up all your new insides. You'll even get "stretch marks" - linear marks on the skin (esp. of the stomach or thighs) when they have been distended by pregnancy or obesity.

So back to balloons - if you stress your cheeks by puffing them up, they are going to stretch. Tissues stretch, then rip, capillaries break, tissue dies and is sloughed off. Then the body tries to relieve the stress by causing more tissue to grow. This leads to Dizzy Gillespie cheeks and jowls. If your cheeks are peeling, give them a rest until they're completely healed (they will still be permanently enlarged - this happens every time you stress your cheeks this way, but it takes a couple of years for the enlargement to become noticeable). Then, practice inflating balloons with your cheeks tight. You have to concentrate on it - even now, after 25 years, I have to remind myself. What I do is I make a definite effort to keep my cheeks held in. I squeeze them shut when I blow. It hurts otherwise. It's never too late to start doing it right. The condition will only get worse, not better, if you continue with bad habits. If you simply can't learn to inflate the balloon without puffing your cheeks, use a pump. There's no reason to hurt yourself - balloons are supposed to be fun for everybody.

It seems easier to puff your cheeks when you first get started, but it's actually harder. You will inflate your balloons faster and more easily when you learn to hold your cheeks in. Try really hard not to puff out your cheeks when you inflate. All the power comes from your diaphragm. If you are using your cheeks or allowing them to puff out, you are dissipating some of the force of the inflation. This is why many people can't inflate the 260. They use cheek power instead of the diaphragm. This is also why horn players do it so well because they are used to using the diaphragm to produce the column of air.

  • I would take two approaches. The first is preventive use a pump all the time. If you are going to occasionally mouth inflate, keep in practice. If you only do it now and then, you can lose your technique. The key is to use your diaphragm and not to let your cheeks puff out as you inflate. The mucus membrane of the cheeks is delicate and easily injured. The good news is that such an injury heals quickly. But, if repeated on a regular basis, you can form some scar tissue (those who bite their cheek a lot will testify to the 'ridges' that develop in side their mouths.
  • The second is to treat the injury when it occurs. This will be mostly symptomatic because again, the lining of the mouth is a rapid turnover kind of tissue, so it heals quickly. Camphophinique or any of the over the counter teething pain treatments that include a topical anesthetic will work. If you enjoy pain, a good swish and spit with hot salt water 'hurts so good'. If you enjoy calories, popsicles or ice-cream will make you feel better but not really speed healing.

Neck, Shoulders and Back

  • I started having problems with my shoulder. The doctor told me I had to quit ballooning for a while to let my shoulder heal. The only thought I had was the restaurants and mall that I normally have scheduled. What to do with them? I could cover some of them, but not all. I took my nephew, or my wife, to help, but still found that the doctor was right. I would get home pretty sore. Then I thought of something. Why not try blowing them up by mouth? I found that by not using the pump I have been able to do the jobs I had scheduled, without the pain. (Ha) I thought the pain was from the twisting of the balloons, but it was actually the motion of the hand pump.

I am now happily twisting away again, with my shoulder not bothering me. I am so glad I learned to blow the balloons up by mouth. I still keep the pump with me, unless I am at a party, where I use Pump O. You never know when I might need it, like when I'm using one of the new metallic colors.

I guess the next step is to find an electric pump that is not so loud it drives the people nuts.

Throat

  • I have noticed that when I'm doing a large show (such as a few days of busking) that I get a very sore throat. It's from all the back pressure all day long just seems to do some minor damage to the throat.

Choking (General)

  • When balloons fragment, and a piece is aspirated into the airway, the Heimlich maneuver is generally ineffective. The balloon, when placed over the airway, acts like a diaphragm and moves up and down with air movement, and generally fails to dislodge in position. I know of a case where a doctor would give his patients a balloon at the end of the visit. until a kid aspirated the balloon and choked in the office. He died because they could not dislodge the balloon in time, even in the doctors office.
  • 1973 - 12
  • 74 - 10
  • 75 - 8
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  • 80 - 16
  • 81 - 10
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  • 86 - 16
  • 87 - 14
  • 88 - 7
  • 89 - 16
  • 90 - 14
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  • 93 - 7
  • 94 - 6

So you do the math. The numbers do fluctuate. But let's give a little perspective. My traffic school instructor said tonight that 44,000 individuals die in auto accidents every year. The Balloon council booklet ends the article by stating that the leading cause of death for children are tricycles and bicycles, numbering 288 fatalities per year. So, please, inform parents about these stats, and let's not let myth and fear surround our twisting when parents ask us about choking. Of course the #1 rule should be for twisters and parents to exert caution with balloons.
To order this brochure, call 800-233-8887.

85% of the time, the parent is grateful that, as a busker, I am more concerned with the child's well-being than with taking their money. Maybe 10% of the time the parents get angry that they don't their way and storm off. (great example for the kids, no?)

Beware of the parent who says, "Well, just make me one instead" or "Just make her sister an extra one instead." You know damn well they are going to walk five steps and hand that baby the balloon. It just makes me sick.

I have dealt with it a few ways myself: running after them and returning the tip and retrieving the balloon from the toddler's mouth, saying "Mommie, have you ever seen a child choke to death on a balloon?" No matter what her reply is I will say, "I haven't, and I don't want to see it today. So please keep the balloon out of Bobby's mouth (I AM smiling, but I am also firm.)

Paragraph 2 states, "The No. 1 risk to children at play remains the simple balloon, said Vivien Watts, director of the Illinois Public Interest Research Group". The article continues with information about common toys deemed most dangerous and near the end states, "In 1996 alone, said Watts, 13 children died playing with toys. Ten of them died from choking, and seven of those children choked on balloons".

And, in her conclusion, stated, "Choking on small toy parts, balloons and small balls continues to be the leading cause of toy-related deaths, killing about 15 children each year since 1980, according to commission statistics. "Little kids pick up the balloons, open them and inadvertently inhale a small portion of the balloon", said Dr. Steven Krug, head of emergency medicine at Children's Memorial Hospital in Chicago."

While the death of any child is clearly a horrible tragedy, we all need to consider each of the risks we face relative to the multitude of risks that are out there.

For example, what does the CDC National Center for Health Statistics say about infant mortality?

In 1995,looking at all races, both sexes, ages 1-4 (the ages most likely to be putting objects in their mouth), you'll see that 6,393 children died. Of those deaths:

  • 825 of them were due to motor vehicle accidents
  • 452 of them were due to "homicide and legal intervention"
  • 156 of them were due to pneumonia and influenza
  • 210 of them were due to HIV infection
  • 1495 of them were due to "all other accidents and adverse effects" [the remaining deaths were due to currently unpreventable causes such as malignent neoplasms, congenital defects, etc.]

Those numbers look a LOT bigger to me than the 15/year rate quoted for choking on balloons. Could it be that infants choking on balloons, while a terrible tragedy, is actually a fairly uncommon cause of infant mortality?

Yes, I think we can say this is objectively true. So what's the point of all this?

Rather than focusing a lot of attention and concern over a miniscule risk that is basically not even "on the charts", I'd suggest parents and concerned citizens.

  • work to encourage use of child car seats for each and every child on each and every trip (i.e., go after those 825 motor vehicle related infant deaths)
  • work to eliminate battering and other child abuse (go after those 425 infant homicides -- an incredibly high number to my way of thinking)
  • work on improving access to low cost medical treatment and well baby care (it is ludicrous that 156 children in one of the most developed countries in the world die of pneumonia and/or influenza)
  • work on controlling the spread of HIV (210 deaths)
  • look at all the *other* sources of misery and accidental infant deaths such as:

  • deaths or serious illnesses preventable by timely immunizations,
  • drownings preventable by proper supervision, water safety training, use of personal floatation devices in watercraft, etc.
  • life threatening burns (for example, from spilled hot liquids)
  • suffocation from carbon monoxide, use of plastic bags as toys, etc.
  • poisonings from accidental ingestion of medications or solvents,
  • severe cuts (including cuts caused by breaking plate glass),
  • falls (down stairs, off improperly designed playground equipment, etc)
  • fires (particularly in the absence of fire detectors),
  • electrical shocks (due to insertion of objects into electrical outlets, for example)

Does this mean that balloon professionals should encourage the careless use of balloons in conjunction with children, for example giving balloons to small children to play with unsupervised, or failing to pick up and dispose of the pieces of a broken balloon? No, obviously it does not. However an inspection of the numbers SHOULD help put the relatively small risk associated with choking on balloons in perspective and avoid hysterical overreaction to a risk that is manageable with a few simple rules:

  • Don't give uninflated balloons to small children to play with unattended.
  • Pick up and promptly dispose of the pieces of any balloons that break.

Choking (Journal of the AMA Article)

  • On December 13, 1995 both the Charlotte (NC) Observer and, probably more importantly, the USA Today newspapers briefly reported on a recent study in the Journal of the American Medical Association (JAMA) concerning balloons as the top cause of non-food choking deaths in children. According to the newspaper article, the study looked at 449 non-food choking deaths a twenty-year period, from 1972-1992. 29% of choking deaths were caused by balloons, 19% by balls or marbles, and 20% by "other toys."
  • A five-year study of kids who had to have a scope placed down their throat (endoscopy) to retrieve an object choking them. 165 kids. No deaths mentioned, and the endoscopy study does not mention balloons at all. The big offenders were food, 36 kids (22%), and coins, 60 kids (36%).
  • A ten-year study of the causes of death in children from choking on non-food items, as reported to the Consumer Product Safety Division. In this study, balloons caused 130 (29%) deaths overall. When broken down by ages, 78 of the kids were 3 or older, and 44 were younger than 3.
  • Objective: To characterize the types, shapes, and sizes of objects causing choking or asphyxiation in children, and to compare these characteristics to current standards.
  • Design: To evaluate morbidity, retrospective 5-year medical record survey to evaluate mortality, data re-analysis.
  • Settings: Pediatric hospital and consumer product testing laboratory.
  • Patients: All children (n=165) who underwent endoscopy for foreign body aspiration or ingestion at Children's Hospital of Pittsburgh (Pa) between 1989 and 1993, and children (n=449) whose deaths were caused by choking on man-made objects and recorded by the Consumer Product Safety Commission (CPSC) between 1972 and 1992.
  • Main Outcome Measures: Objects removed from children's aero-digestive tracts were characterized by location, procedure for removal, and type. Objects causing death were characterized by type, shape, and consistency. Three-dimensional objects that had caused asphyxiation were analyzed by computer-simulated models.
  • Results: Of the 165 children treated by endoscopy, 69% were 3 years of age or younger. Foreign bodies most often ingested or aspirated were food (in 36 children) and coins (in 60 children). Of 449 children whose deaths after aspirating foreign bodies were reported to the CPSC, 65% were younger than 3 years. Balloons caused 29% of deaths overall. Conforming objects such as balloons caused a significantly higher proportion of deaths in those aged 3 years or older (60%) vs. those younger than 3 years (33%). Of the 101 objects causing deaths that we could analyze, 14 met current standards for use by children younger than 3 years.
  • Conclusions: Balloons pose a significant risk of asphyxiation to children of any age. Changes in regulations regarding products intended for children's use might have prevented up to 14 (14%) of 101 deaths in this study.

They assert that mylar balloons would be less likely to block a child's airway and also suggest modifications to latex balloons. These modifications include: establishment of a minimum size, inclusion of a rigid plastic ring in balloons (though what happens when the balloon breaks beats me), texturing the balloons to allow a greater chance of airflow, putting something bitter on the balloons to make them taste bad, or finding a latex-like substance that dissolves on contact with saliva.

The part of their study which breaks things down by age (recall, the newspaper reported that a greater proportion of kids over 3 choked on balloons) actually looked at objects classed by shape or consistency, not specific type. In both cases, balloons fell into the "conforming" category. This category also included other objects, such as disposable diaper stuffing. I'm not sure from the article just what proportion of the "conforming" categories were balloons (the numbers are less than precise in this case). In their discussion, they tend to equate "conforming" with balloons.

CHICAGO--Researchers are urging the US government to regulate balloons and tighten restrictions on other products made for children, after finding that many choking deaths are caused by objects that meet government standards, according to an article in this week's issue of The Journal of the American Medical Association (JAMA).

Frank L. Rimell, MD., formerly of Children's Hospital of Pittsburgh, Pa., now with the University of Minnesota, Minneapolis, and colleagues conducted what is believed to be the first analysis of the shapes, consistencies and sizes of objects causing choking deaths in children.

They examined the medical records of 165 children who underwent endoscopy for foreign body aspiration or ingestion at Children's Hospital of Pittsburgh between 1989-1993. They also examined records from the Consumer Product Safety Commission (CPSC) on 449 children, aged 14 years and younger, who choked to death on nonfood objects between 1972-1992.

The researchers found that conforming objects such as balloons were responsible for the most deaths (29 percent), followed by round objects such as balls and marbles (19 percent), and toy products, parts, or characters (20 percent). The remaining 32 percent of the deaths were caused by products not intended for use by young children.

Of the 165 children treated at Children's Hospital, the items most often recovered were coins and food such as nuts, vegetable or fruit pieces, seeds and popcorn. Other items recovered included plastic pieces, hardware, and batteries.

The researchers found that in both groups, two-thirds of the children were three years of age or younger however, they found that children over the age of three were twice as likely to die from balloon asphyxiation than children younger than age three. In two cases, children died after choking on latex examining gloves given to them in physicians' offices.

The authors write: "These findings indicate a need for greater public awareness of the dangers balloons pose to children of any age and a search for solutions to the problem. Clinicians should keep examination gloves and similar supplies out of reach of children and caution others caring for, or interacting with, children about the hazards of these objects."

After conforming objects, round objects posed the greatest risk of choking death by a nonfood item. A computer analysis of 101 rigid, three-dimensional objects which had asphyxiated children found that 14 had passed the government's Small Parts Test Fixture (SPFT), which is a cylinder with a diameter of 3.17 centimeters (cm) and a depth between 2.54 and 5.71 cm. Objects that are too large to fit in the cylinder pass the SPFT and are deemed acceptable for young children.

The researchers write: "All 14 of these deaths might have been prevented if the SPFT had been 4.44 cm in diameter and 7.62 cm in length."

They add: "Others have commented that most foods causing choking death are spherical in several reports the majority of children asphyxiated by food lodged in the airway had aspirated round or cylindrical foods (hot dogs, peanuts, seeds, grapes, and hard candies)."

Designing the Death out of Balloons

In an accompanying editorial in this week's JAMA, Susan P. Baker, M.P.H., and Kopl Halperin, Ph.D., Johns Hopkins School of Hygiene and Public Health, Baltimore, Md., write: "In the new study, a finding of particular interest is the preponderance of balloons among objects causing fatal aspiration. Balloons, long exempted from regulation by the CPSC, kill more children than any other toy except for bicycles and other riding toys."

(What she doesn't say is how many deaths from balloons relative to the other toys. Given the trivial numbers from this study I'm sure its quite a large gap. Reason would suggest we should place our "protective emphasis" on these other toys that are agreater [in relative terms] danger)

They offer several solutions to make balloons safer, including making them with mylar or inflatable paper, neither of which "would be likely to block a child's airway." They also suggest a minimum size for balloons and that a plastic ring of at least 4.4 cm in diameter be placed inside each balloon.

They add: "A minority of balloon deaths involve a broken piece of balloon, but some strategies are applicable to both broken and intact balloons. For example, balloons could be designed with ridges or bumps that would allow air to flow between the surface of the airway and the aspirated latex. To prevent children from mouthing balloons or their fragments, a bittering agent could be incorporated into the balloons, exclusive to the mouthpiece. Other research might yield substances that react with saliva to separate into non-hazardous particles or to form a soluble or non-adherent material."

The editorialists conclude: "The long-standing problem of asphyxiation by balloons should have been addressed long ago. Surely changes can be made now to avert future deaths."

(I hate to say it, since I went to the Johns Hopkins Medical School, but this lady needs to come out of her ivory tower and join reality for a little while. In technical terms, she's a Wacko)

    No mention of the shape/ type of balloons that were found was made, nor was there mention of whether they were whole balloons or fragments. In fact, two of the "balloons" were not balloons at all, but latex exam gloves the kids got while at the doctors. (The authors point out to their physician readers that they should avoid doing this.)

This is the long way, but it seems the best way to respond to your comments on the JAMA article and question "do children die from ingesting balloons?" is to give you the following excerpts from our letter to Dr. Rimmel, author of the JAMA article. It describes the difficulty we have had in getting data that we feel is reliable and the steps we took to develop the numbers we now use. "

    In 1992, we requested and got computer printouts from CPSC that tallied choking deaths from balloons. The information is compiled by the National Injury Information Clearinghouse. The information comes from three sources and is tallied separately: (1) death certificates, (2) accident reports from hospitals and (3) reports from medical personnel and news reports. We culled those documents to develop totals, by year, from which we created graphs, charts, etc. These printouts are no longer in our files, probably discarded when we received a newer batch.

Because the information is often not gathered in a scientific manner, we found it necessary to make some judgment calls as to which reports to include and which to label duplicates:

First, we eliminated as duplicates those which involved the same age child, in the same city, on the same date (29 eliminated).

Second, in more arbitrary decisions, we eliminated 14 where the city was not identical, but close enough to reflect home town/hospital site, or the ages of the children differed little (e.g. 1 month vs. 7 months). Along the way, we found two deaths that were reported three/four times.

At the conclusion of these calculations, we have a total of 129 deaths from choking on a latex balloon from 1980-95. These are the numbers we will use until we get further updates. You will note that whereas when we relied on the 1994 figures supplied by the Clearinghouse we had 110 deaths from 1981-90, the new total now is 82. Repeating the calculations in Mr. Flynn's letter to JAMA, we still find the trend is in the right direction--although not as dramatic as with the old numbers. The average number of deaths the 10 years before warning labels (1981-90) was 8.2. In the four years after, the average was 6.7.

Lungs

  • Worried about the talcum? One breath. always OUTWARD, don't inhale from the balloon. This should reduce the risk.
A group of doctors from Belfast report in the British Medical Journal that blowing up balloons for Yuletide parties can damage your lungs, causing air bubbles to spread under the skin. They cited the case of a 24-year-old man hospitalized with lung problems after blowing up 20 party balloons in an hour.

Although he felt no ill effects at the time, he became sick 48 hours later. The doctors said air bubbles could be felt under the skin on his back and buttocks and there was a "crunching sound" when he breathed.

Stuart Elborn and his medical colleagues found that the air pressure involved in inflating balloons is enough to damage the alveoli, tiny sacs in the lung through which air is absorbed.

The researchers said they cleared up the problem in 10 days using antibiotics, painkillers and fluids.

Arms and Wrists

  • What do you do about the soreness in the forearms, wrists, hands, fingers that you get after long hours of twisting? Treat it like any other mild muscle strain for a sport:
  • Rest those muscles. Regular rest breaks throughout the day are also important.
  • Drink lots of water.
  • Get extra sleep if you can.
  • Regular doses of motrin for the pain.
  • Sore, stiff muscles are best helped by working out the pain gently. Practice twice a day for about 1/2 hour or so after the big day. This helps keep your muscles more flexible.
  • Put a hot pack on your arms at night when you get back from the long days.
  • If available, long soothing massages help out greatly.
  • 5 or 10 minutes of stretching exercises before and after the job really can work wonders - you can do this in the car while driving to the gig.
  • Do some stretching exercises before a long day of twisting much like a runner would stretch before a race. Gentle stretching using the same motions you would use to twist. The idea is to get some extra blood going through the muscles and get them 'warmed up' a bit before you hit the high speed stuff.
  • Frequent stretching, bending and flexing your fingers and rotating your wrists often helps.
  • I wear wrist and tennis elbow area arm supports regularly. I have done this for quite a long time, and they provide so much support! Available at Walgreens or Longs Drugs, etc. for about $4.00.

I have been doing balloon deco for about 3 years full time. The doctors are all fairly certain that the tying of balloons is what got me in this condition. that and me not being smart enough to do something sooner.

Please see a doc ASAP. Right now I am typing this with one hand as the other arm is in a full cast from my shoulder to my fingers. It appears that I am going to be out of commission for about 8 weeks with this, during one of the busiest seasons here in Phoenix. Fortunately, I have a partner (my sister) who is fully capable of handling things.

I hope that you will find that what you have going on is easy to fix and that my information got you in to see someone at the beginning stages of whatever your problem is.

    Hold your hands in front of you as you would praying. Turn one hand upside down so that the fingers are pointing to the floor and press lightly at first and then more strongly on the fingers of each hand using the heel of the other hand. Use this to stretch the tendons in the wrists and alternate hand positions to relieve both hands.

Hope this helps those in need, but again, I urge you to seek out a doctor. It took two years to figure out that what I had was CTS.

Hands and fingers

  • The only problem I've had with ballooning (I use a pump) is I sometimes get blisters on my fingers from tying the knot. T. Myers told me to let more air out of the end of the balloon for a longer section to tie, and that has helped a lot.

Dry hands and rough fingernails

  • Rub moisturizer into the cuticle and nail bed every night before sleep.
  • File nails regularly and keep a nail file close by when twisting to remedy any edges and tops of nails that may peel. Use the white side for top of nail, it is finer than the dark side.
  • Try a clear matte (no shine,sometimes called a base coat) nail polish.
  • Avon's Liquid Silk Wrap has no shine and helps to keep nails from peeling.
  • Go to a farm supply store and buy a product called Hoof Saver, made by Farnam Companies, Inc. It comes in a good size container about 2 lbs. so it will last you a lifetime. This is a product designed for horse hooves. Now wait, I'm not saying you are a horse. I'm saying that this will work if you follow the directions. Give it a try. I'm sure you will be pleased with the results.
  • Get acrylic nails. I go every two weeks for a "fill", and keep them fairly short. They are not sharp like regular nails, they're very tough, and you can even curl ribbons with them!
  • Eat Knox gelatin or Jell-O. The massive amounts of protein this stuff contains helps to strengthen your nails (and your hair as well).
  • Udder balm works very well as a conditioner. It is available at farm and vet supply stores.
  • Hydrate yourself and your hands at night. Drink lots of water. Wet your hands and leave them a bit damp - do not dry them completely. Then rub olive oil all over your hands and nails and rub it in really well. The oil seals the water into your skin and then moisturizes the skin and nail. Finally, put cotton gloves on your hands and wear them to bed.
  • Wash the powder residue from the balloons off your hands. If you don't have access to water while you are working, bring baby wipes - the lanolin in them helps too!
  • In an emergency, if a finger splits, I keep a supply of "finger cots" available. I clean the cut, then rub vitamin E (break a capsule open it's cheaper than the bottled kind) into the cut, then cover it with the cot and keep it oiled with the E and covered day and night until it is healed. (Finger cots are little rubber covers that look like tiny condoms and are available from your pharmacist. Just ask him - he'll know what it is.)

Latex Allergies

  • "Itchy palms" - I was having that problem and scratching my hands to pieces. They were driving me nuts. I attended a balloon convention (the round kind) in Las Vegas in 94 and happened to be sitting with a bunch of gals, and I asked them if they ever had the problem. A "Pro" (one of the teachers) - popped her head around and said - you are allergic to Latex - wash your hands more often when you are working with balloons. I do, and I don't have the problem anymore. I would suggest that you use something before twisting. Like Avon's silicone glove. It puts a protective coating over your hands. Washing may aggravate the problem if you do it a lot. My hands get dry and itchy (I think it's from the powder in the balloons), and I find a hand lotion helps afterwards. If it's a true allergy to latex it could get worse with more exposure. That's why you want to use something before hand. You want to keep from sensitizing yourself. Latex allergy is potentially a serious problem. Surgeons have had to quit due to symptoms from glove allergies appearing as everything from itching hands to trouble breathing. Now there are several makers of latex-free surgical gloves to avoid this problem. None of the materials I've seen lend themselves to ballooning though.
  • They smell nasty. More like something burnt than like the gases given off by PVC.
  • They don't have much stretch to them. Making them a bit odd to put on.
  • They only inflate to about 9" before breaking (making them useless for helium bouquets and arches).

ELASTIC
P.O. Box 2228
West Chester, PA 19380

You will get info on Latex Allergy News (you can subscribe), a flyer from the American college of Allergy, Asthma and Immunology with Q & A on latex allergy, and information on ELASTIC (Education for Latex Allergy Support Team & Information Coalition Inc.)

nam1/latex_allergy.html Latex Allergy Links is the most comprehensive and is most often recommended on the list for parents of children with spina bifida.

The ALERT support group site is good also. You can order a School Education Packet from them. Look under Products.

Other info can be found through the Latex Allergy Information Service (203)482-6869 E.L.A.S.T.I.C. (610)436-4801 A.L.E.R.T. (414)677-9707 G.L.A.S.S. (313)351-9788 and FDA Latex Allergy Hotline (301)594-3060.

Only few blurbs about balloons. they had one lady who said she got a rash around her mouth after blowing up a balloon. Then they showed a package of balloons when they were showing common products made with latex.

Over all, it didn't seem to point out that balloons were a major contributor to latex allergy cases but that latex gloves were.

Debilitating, Sometimes Deadly Latex Reactions Pose Medical Peril

By SUSAN DUERKSEN, Staff Writer

Augustine Carrillo is not expected ever to talk, possibly not to walk, certainly never to work. The 1-year-old is profoundly brain-damaged, his parents say, because of a rubber-tipped catheter.

His story is among the most horrific consequences to date of a mysterious epidemic of severe allergy to latex rubber. The unusually menacing allergy has sprung up within the past decade and has quickly become a major concern for health-care workers.

Ironically, the often life-threatening sensitivity to latex apparently arose from a sudden surge in the use of latex gloves to protect doctors, nurses, dentists and others from another hazard, the AIDS virus.

Besides more people having more contact with latex, many researchers--and lawyers representing the victims--believe gloves became more allergenic because manufacturers cut corners to produce more gloves faster.

Augustine's mother, Mildred Carrillo, was an intensive care nurse at San Diego's Mercy Hospital before his birth there in January I995. She had suffered rashes and wheezing on the job for five years, she said, and had finally concluded she was allergic to latex.

During her labor, all the nurses and doctors knew of her allergy and knew they should not use latex equipment. But one nurse accidentally used a latex catheter to drain her bladder, telling Carrillo it was not latex.

Carrillo immediately went into anaphylactic shock--marked by difficulty breathing and feeble blood pressure. For about 20 minutes, she struggled to breathe while the nurses tried to give her oxygen, said her husband Richard.

"I couldn't get air," Mildred Carrillo said. "I was suffocating."

Market Demands Spread the Problem, Some Say

After she was stabilized with shots of three drugs, her son was born by emergency Cesarean section. According to a lawsuit the Carrillos have filed against Mercy, his brain was severely damaged by oxygen deprivation and the drugs necessary to save his mother.

The Carrillos are suing for the lifelong costs of care for the vacant-eyed boy they call Auggie, for an amount not yet determined.

Patting her son's chest as he arched into one of his frequent seizures, the 32-year-old San Diego woman said doctors are unsure the boy ever will develop basic skills. He now is fed through a tube into his stomach because he cannot swallow adequately.

Mildred Carrillo's severe reaction to the inadvertent use of a latex catheter during the birth is not disputed, but Mercy has not agreed that her shock caused the brain damage, said Cary Miller, attorney for the hospital.

Nonetheless, Mercy embarked a year ago, just after Auggie's birth, on an aggressive effort to identify and protect latex-allergic employees and patients and to buy latex-free products where possible. Some other local hospitals are following Mercy's lead, but at many it is not a high priority.

The Word Spreads

"The word is just getting out about latex allergy now," said Mary-Michael Brown, a nurse specialist who headed Mercy's latex task force. "The medical community is really just beginning to believe it and act on it."

The U.S. Food and Drug Administration issued a medical alert five years ago, in March I991, warning all health-care professionals to identify latex-sensitive patients and be prepared for severe allergic reactions.

The alert followed reports of 15 deaths among patients who went into shock while having barium enemas with rubber-tipped catheters.

I suspect there are multiple other deaths out there that we don't know about," because they are listed as having other causes, said Dr. B. Lauren Charous, a Wisconsin allergist and chairman of the American College of Allergy Asthma and Immunology's Latex Hypersensitivity Committee.

"We have health care workers who can't work." Charous said. "We have people who are disabled, I'm very worried because I'm seeing more patients."

The few studies that have been done estimate that latex allergy affects from 5 to 20 percent of all health-care personnel who wear gloves much of the workday, including nurses, laboratory technicians, dentists and others.

An even more profoundly affected group--up to 65 percent latex allergic--are children with spina bifida. Those children commonly have multiple surgeries and catheterizations at very young ages, involving direct contact of batex with the bloodstream.

The federal Centers for Disease Control and Prevention (CDC) recommends that everyone undergoing surgery or dental procedures, as well as anyone being hired for a health-care job, should be asked if they are allergic to latex.

A Protein Problem

Latex is a natural product from rubber trees and contains many proteins that can provoke allergic reaction. It bas been prevalent in home as well as medical products for decades. Rubber bands, shoes, elastic, pacifiers, toys, balloons, bandages, band grips on rackets and bicycles, erasers, tires, condoms, diaphragms and many other items contain latex.

But some latex products are more hazardous than others, and an allergy generally develops after extensive contact. Latex gloves usually are dusted with cornstarch, which can bind to the proteins, pull them off the latex and rub them into skin. Or the powder can carry latex proteins into the air, where they can be inhaled.

Some of the same proteins are found in certain foods--primarily bananas, avocados, kiwis and chestnuts--which often cause reactions in people with latex allergy.

The amounts of the problem proteins vary drastically between brands of gloves, said Dr. John Yunginger, an allergist at the Mayo Clinic in Minnesota. Until recently there were no good ways to measure the protein levels, he said.

The demand for latex gloves-- which are stronger and allow more touch sensitivity than vinyl or the alternatives -- skyrocketed in 1987, after the CDC recommended that all health-care workers protect themselves from all patients' blood fluids to prevent transmission of the human immunodeficiency virus. To meet the demand, new manufacturers jumped into the market "who didn't know what they were doing," Said Wava Truscott, vice president of Safeskin Corp., a San Diego- based glove maker. At the same time, she said, efforts to clean up industrial discharges and boost the production at Southeast Asian rubber tree plantations inadvertently increased the amount of proteins on glove surfaces.

But Charous said many manufacturers sped up production without regard to the consequences. "One explanation would be that because of economic demands a different kind of rubber was produced that had more allergens," he said. "I think they did get sloppy."

Allergy Prevention

Prodded again by market demands, some glove-makers now are adding production steps to leach allergenic proteins from latex, Truscott said.

The FDA has encouraged manufacturers to make and market low-allergen gloves, but has not yet required any changes. A proposed regulation requiring simply that any product containing latex be so labeled has been in the works for three or four years.

Mel Stratmeyer, chief of the health sciences branch in the FDA office of science and technology said the regulation has been delayed by the office's workload and he cannot estimate when it might be implemented.

"I would say it has a high priority at this time," Stratmeyer said. "I really have no control over when it gets through."

In the Carrillos' case, the catheter package was clearly labeled as containing latex, said R. Christian Hulburt, the family's attorney.

Requiring labeling should have been done long ago and won't be enough, Charous said. His national committee has recommended that the FDA set maximum levels of the allergenic proteins in latex products, but Stratmeyer said it is faster to encourage voluntary cooperation by manufacturers.

Besides gloves and catheters, many other medical supplies contain latex, including intravenous tubing, rubber stoppers or syringes and tourniquets. Non-Latex alternatives are become more available, sometimes at lower cost, and some nurses say new powder-free latex gloves don't cause reactions.

For many heath-care workers, Latex allergy begins with rashes and itching on the hands and progresses to hives, then asthma, watering eyes and sneezing.

Finally, some people become so sensitized that even breathing the air where someone else has taken off latex gloves can cause the swollen airway and lowered blood pressure of anaphylactic shock, a reaction rarely seen in other allergies.

'Couldn't Breathe. . . Think'

Kirsten Clark, of Point Loma, knows the panic of that feeling too well. After 10 years as a nurse, she risks her life entering a doctor's office or hospital. When she takes her 4-year-old daughter to the doctor, she waits in the parking lot.

"I couldn't breathe, I couldn't think, I couldn't see," Clark, 37, said of her first episode of anaphylactic shock a year ago, "You only have to do that once to be terrified. There's never been an allergy like this."

Clark left her job at Scripps Memorial Hospital in La Jolla last year. She said she never heard of the FDA's 1991 alert until this year.

Lt. Harold Henderson, a Navy emergency nurse for eight years, also can no longer work in his profession. After several episodes of shock, Henderson said he carries a syringe of epinephrine, an adrenaline shot that counteracts the symptoms, wherever he goes.

I have to watch, for the rest of my life, every single thing I come in contact with," said Henderson, 38, of Rancho Penasquitos. He said he knows of other military nurses who are "suffering in silence," taking allergy medication and continuing to work rather than give up their careers.

At the San Diego Naval Medical Center, where Henderson worked, vinyl gloves are available for those who want them and a task force is looking into what else should be done, said Capt. Fang Lin, head of the hospital's allergy clinic.

In the Scripps Health system, a task force was formed last month and is aiming to make the system's six hospitals "latex-safe" within the next few months, said assistant administrator Paula Smith. "We will be substituting latex- free products wherever we can," she said.

In the six hospitals of the Sharp Health Care system, non- latex gloves are available but the issue is otherwise "a low priority right now," saidspokeswoman Stephanie Casenza. Dr. Ronald Simon, at Scripps Clinic in La Jolla, said he is about to begin experimenting with a treatment to desensitize people to latex. He plans to inject "incredibly small doses" of latex proteins into people who are highly allergic, just as bee venom injections lessen bee sting allergies.

The researchers took six brands of gloves, soaked them in salt water to extract the proteins and then mixed them.

Simon said he is prepared for the risk of severe reactions to the shots, but already had the 12 volunteers he needs initially.

CONCLUSIONS: The results suggest that the SB population is unique in demonstrating IgE responses to latex contact, which may be due to increased latex exposure or altered neuroimmunologic interactions.

Wildlife

  • I was twisting at a party last night and there was a puppy dog (yes, a real one. :-) who kept trying to get into the broken balloon bits (you know. the "clown droppings"). Other than pets biting the sculptures, has anyone ever had a problem with balloons and pets?
Sea Turtles are the most likely animal to ingest balloons since their diet consists mainly of jelly fish. This is according to an unpublished report (1989) Studies on the Ingestion of Plastic and Latex by Sea Turtles - Peter Lutz, Division of Biology and Living Resources, University of Miami, Rosenstiel School of Marine and Atmospheric Science.

Lutz fed small pieces (approximately one centimeter square) of latex balloon to sea turtles. He found that turtles ". will actively eat pieces of colored balloons but. they ignored colorless plastic." He reported that "the sojourn of the ingested material in the gut ranged from a few days to two months! Moreover, some of the turtles passed multiple pieces at different times. Since the gut clearance time for food is in the order of days it appears that some of the pieces are getting held up somewhere in the gut."

Lutz also conducted another study, where he fed 5-7 10cm x 10cm sheets of plastic to adult turtles and 1 10cm x 10cm sheet (about the size of 2 deflated 16" balloons cut open and laid flat) to juvenile turtles. He writes "No clear evidence of ill effects from plastic ingestion. in this set of experiments though it should be noted that the turtles were only allowed to consume small amounts of plastic."

But how many intact balloons can a sea turtle find? According to Don Burchette's "A Study Of The Effect Of Balloon Releases On The Environment". the percentage of balloons returned from "tagged" balloon releases is usually well under 5%. "Assuming that a full 10% of the balloons come down without bursting for a typical release of 500 balloons, it is conservatively calculated that the density would be no greater than one balloon in over 15 square miles."

Miscelleanous Health Problems

  • I thought I'd take a moment and caution y'all against twisting in the sun without proper protection. I got a healthy sun burn this weekend in a surprisingly short time. Don't be like me (ouch!). Protect yourselves. JJ (Yes. I look like a Lobster) The DJ

Use of Balloons in Surgical Procedures

Uterine balloon therapy (Champaign-Urbana News Gazette, Thurs Jan 25, 1996, picked up from Associated Press Writer Richard Cole, San Francisco)

Uterine balloon therapy: an in-office procedure currently undergoing testing on 250 women in 13 US hospitals, to be used as an alternative to hysterectomies. Has already been performed on over 300 women in other countries, and has been approved in some European countries.

"Uterine balloon therapy uses a catheter and balloon to heat the inside of the uterus and destroy its lining. " ". as with hysterectomies and any procedure in which the uterine lining is removed or destroyed, uterine balloon therapy results in sterility."

". test results so far show 25% to 30% of women stop menstrual bleeding altogether, and 50% or more have reduced flow" Dr. David Granger, director of the Center for Reproductive Medicine, Univ. of Kansas-Wichita.

Uterine balloon therapy: Done with local anesthetic, takes under 9 minutes, patient can leave within an hour and go back to work the following day, costs $10 to $7,000, less than half the cost of hysterectomy and required follow-up care. Dr. Robert London, Kaiser Permanente)

Hysterectomy General anesthetic, several days of hospitalization, four to six weeks of recovery, add high risk of infections, and damage to bladder and bowels. (Dr. Robert London, Kaiser Permanente)

Balloon-Related Diseases (Jokes)

This is a common childhood illness that is highly contagious. While never really eradicated from the system it can become dormant for extended periods of time. This "remission" can be long lasting. Occasionally, however, it relapses during adulthood. In this case, the disease is often in a much more severe form than the initial infection. Such relapsed adults then become the carriers and have frequently been identified as a primary source for new infections in both children and adults.

Symptoms (relapsed adults): While normal in appearance (there are numerous exceptions) they have a tendency to dress in unusual clothing (often in some way incorporating balloons). They are driven to always have rapid access to balloons and almost always have balloons either on their person or within immediate reach. Unpredictably, though often in crowded areas, victims enter into an almost frenzied seizure-like activity in which latex balloons are inflated, mangled, knotted, torn, tied and popped. This pitiful behavior often evokes such sympathy that others, in the area, feel prompted to give money to the sufferer, in hopes that they will seek professional attention for the disorder. Some chronic victims reach out to others in the form of books and video tapes, of this seizure like activity, in hopes that the wide distribution of such material might lead to an earlier diagnosis in others. There are victim support groups via the Internet (search on balloons).

    suckus helium squickis voicem: a short lived but interesting malady often confused with Imitatus Mickey Mousum.

MB 12/13/95
SKB 12/22/95
SKB 2/25/96
MB 7/30/96
LM 7/31/96
MB 9/13/96
SKB 2/22/97
MB 4/4/97
SMB 7/21/99


Epiglottitis Treatment

Immediate hospitalization is required whenever the diagnosis of epiglottitis is suspected. The person is in danger of sudden and unpredictable closing of the airway. So doctors must establish a secure way for the person to breathe. Antibiotics may be given.

Treatment of epiglottitis may start with making the person as comfortable as possible. For instance, an ill child may be placed in a dimly lit room with the parent holding the child. Then, the child may get humidified oxygen while being closely watched. If there are no signs of respiratory distress, IV fluids may be helpful. It is important to prevent anxiety, because it may lead to an acute airway obstruction, especially in children.

People with possible signs of airway obstruction require laryngoscopy in the operating room or intensive care unit with proper staff and airway intervention equipment. In very severe cases, the doctor may need to perform a cricothyrotomy (cutting the neck to insert a breathing tube directly into the windpipe).

IV antibiotics may effectively control inflammation and get rid of the infection from the body. Antibiotics are usually prescribed to treat the most common types of bacteria. Blood cultures are usually taken to show whether an organism is growing in the blood that could be causing the epiglottitis. In many cases, blood cultures may not show if this is the problem. If a patient is intubated, cultures taken directly from the epiglottis may work better.

Corticosteroids and epinephrine have been used in the past. However, many experts now doubt that these drugs are helpful in most cases of epiglottitis.

Treatment follow-up

Take all antibiotics until the full course is completed. Keep all follow-up appointments with the doctor -- and with the surgeon if a breathing tube had to be placed through the neck. The surgeon will remove the tube and make sure the site is healing well. Most people feel much better before leaving the hospital, so taking the antibiotics and returning to the hospital if there are any problems are the most important parts of follow-up.


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6 Treatment of the middle turbinate

The functional tasks of the middle turbinate comprise the heating and humidifying of the inhaled air in addition they direct air flow towards the olfactorily significant areas at the frontal base. At the same time they prevent a turbulent flow in the middle nasal meatus, and thus indirectly support mucociliary clearance. In contrast to the inferior turbinate, nasal respiratory resistance is not regulated by the middle turbinate [161].

The pathological changes in the middle turbinate are summarised in 4.2. The indications for postoperative correction of the turbinate body or of medialisation can be implied from this.

The surgical aim of interventions on the middle turbinate should be a turbinate anatomically adapted to individual patient needs, remaining functionally intact [104], [162], [163]. There are numerous publications on the treatment of the middle turbinate in the context of operations of the paranasal sinuses [164], [165], [166], [167], [168]. Measures suggested include, for example, double-sided caustic, cryotherapy, laser surgical procedures, partial or total resection.

In order to systematise the different kinds of surgical approaches, a division into 3 groups seems useful: medialisation (altering the position), reduction and resection.

6.1 Temporary medialisation by septum-turbinate-suture

The lateralisation of the middle turbinate is a negative result of functional endoscopic paranasal interventions. The risk is currently around 43% [169].

A medialisation does not guarantee a lack of recurrence however, Friedman et al. were able to demonstrate clearly that in 94% of cases with medialisation, patients remain asymptomatic [170]. A change of position of the middle turbinate was dispensed with only 60% of patients were free of symptoms.

The therapeutic aim of this technique consists of the medialisation of the middle turbinate until the wound healing process in the middle nasal meatus is completed. In the Rettinger technique, the middle turbinate is attached by deep stitching to the septum using an absorbable vicryl 3/0 mattress suture. The return stitch is made so that the suture lies in front of the head of the turbinate. The thread is cut off short in order to minimise crust formation. In a retrospective study, 85% of middle turbinates were in a medial position with no contact to the lateral nasal wall and the septum. In 15% there were selective adhesions either laterally or medially, but with no adverse results for either sense of smell or nasal breathing. The advantage is a controlled approximation of the turbinate to the septum without the necessity of a tamponade of the middle nasal meatus [171].

Hewitt und Orlandi were able to confirm these results in a retrospective study [172]. In 89.2% of 85 patients, they found a medial position of the middle turbinate, and in 10.8% adhesions.

In 99% of 31 patients, Thornton found a medially positioned middle turbinate [173].

Koch was also able to confirm the overall positive results of the septum turbinate suture [174]. He examined 55 patients 9 to 18 months postoperatively and found a small lateral synechia in only one patient. Some patients did report hyposmia, but this was spontaneously reversible after the stitches were removed and the turbinate relocated.

A suture-free technique for the permanent medialisation was presented by Friedman and Schalch in 2008 [175]. They use a shaver to produce corresponding wound surfaces and then adhere the middle turbinate to the septum with a bovine albumin tissue adhesive (Bio-Glue. Cryolife, Inc., Kennesaw, GA, USA). The adhesive reaches full holding power after only 2 minutes. This means that there is no need for a tamponade. 212 patients were operated on using this method and monitored for 6 months. In 93% of cases medially positioned turbinates were found. Serious complications did not occur, and in particular there was no olfactory dysfunction [176].

Bolger et al. applied a different philosophy by producing a controlled synechia between the medial blade of the middle turbinate and the septal mucosa [177]. For this reason, opposed incisions in the mucosa are made and the turbinate medially displaced by tamponade of the middle nasal meatus. The tamponade remains in situ for approximately 10 days. According to their statements, the suture technique appears too traumatising. Success rates are not mentioned in the study.

The surveys quoted show convincing results. Complications resulting from septal-turbinate-suture itself are not reported.

6.2 Narrowing of the middle turbinate

The concha bullosa can be individually pneumatised (see point 4.2). The degree of pneumatisation correlates with the complaints. Whilst the pneumatisation variants 1 and 2 tend to remain asymptomatic, in the case of type 3 (enlarged concha bullosa), symptoms of chronic sinusitis or dull mid-face pain are manifested. In these cases surgical treatment of the concha bullosa, in the sense of a reduction, for example, is indicated. Numerous surgical techniques, which do not really differ as far as the method is concerned, are listed in the literature. Pirsig [178] and Huizing [179] describe, for example, a narrowing of the middle turbinate where they first remove the mucosa from both sides, and then open the concha and resect the inner mucosa lining together with the middle bony lamella.

In 1996, Har-el and Slavit suggested a slight modification [180]. Out of 43 patients, three developed a synechia postoperatively between middle turbinate and lateral wall. The authors recommend the curettage of the inner mucosa for the prophylaxis of mucoceles, a rare complication when reducing the size of the concha bullosa. Har-el und Slavit’s technique was modified by Dogru in 2001 [181]. Following a vertical mucosal incision above the turbinate head, the concha is entered and the mucosa completely removed. Finally, the concha bullosa is reduced from superior to inferior and then to posterior using an especially non-traumatic Blakesly. This method (n=31) was compared with the lateral turbinoplasty (n=100). The follow-up period was between 4 and 47 months. In group I (reduction) synechia were found in 9.7%, in group II (partial lateral turbinoplasty) in 27%. The difference was significant.

A more radical procedure for reduction of the concha bullosa is the lateral partial turbinectomy, a procedure which has already been described by Messerklinger. Here, a wound surface is created which forms the foundation for lateral synechia. This wound surface can be covered by a posteriorally pedicalled mucosal flap. Sigston and Iseli suggested this method in 2004 [182]. In their retrospective, comparative study, the mucosal flap was used in 28 patients (group I), compared to 19 patients of the control group (group II). After 3 months there was a 7% incidence of synechia in group I, group II showed a synechia rate of 21%.

If the middle turbinate is either anatomically or pathologically enlarged, and symptoms result, the reduction using the technique cited would be a therapy option. Here methods which preserve the lateral and medial mucosa would seem to be best suitable from the functional standpoint of wound biology.

6.3 Resection of the middle turbinate

The question whether the middle turbinate should be preserved or resected in paranasal sinus surgery has a long history dating back to 1920. Since then it has been the subject of vehement controversy. The advocates routinely resect the middle turbinate in order to prevent the occurrence of synechia and to keep the maxillary sinus ostium free [183], [184], [185], [186].

With very few exceptions, the advocates of the Messerklinger school of thought respect the middle turbinate as an important functional organ and as an anatomical landmark [187], [188]. The evaluation of other texts also showed no clear trend so far. Swanson et al. report an increased risk of frontal sinusitis after partial resection of the middle turbinate [189]. However, the increased mucosal swelling in the frontal sinus was regarded as pathological.

Other authors found no increased incidence of frontal sinusitis after turbinate resection, but rather observed an increased patency rate of the middle nasal passage. In their study of 155 patients who had received a partial turbinate reduction, Fortune and Duncavage report a sinusitis rate of 10% [190]. Havas and Lowinger were able to confirm this figure [191].

Giacchi et al. carried out 100 ethmoidectomy procedures, in 50 patients the middle turbinate was removed, whereas in the remaining 50 patients the turbinate was preserved [192].

The follow-up period was 2 years. No differences were found between both groups with regard to an increased incidence of frontal sinusitis or a stenosis of the frontal recess.

All studies quoted were retrospective and are therefore limited in their significance. A prospective, intra-individual study of 31 patients with a 2 year follow-up period was presented by Shih and his research group [193]. He resected only the right middle turbinate, the left remained intact. 8/31 patients developed postoperative adhesions, 4 on the right-hand side, and 3 on the left, 1 bilaterally. The results were interpreted by the authors regarding that turbinate resection has no negative effect on the success of the therapy in case of functional endoscopic paranasal sinus interventions.

As there is still a lack of randomised, controlled studies with long-term results regarding the success rate of partial turbinate resection, it is difficult to make a clear recommendation. It seems apparent that partial turbinate resection is accompanied by a lower adhesion rate than with the total removal of the middle turbinate [194].

Experts agree in general that a middle turbinate with polyp-like changes, where the mucosa is extensively damaged or is strongly enlarged in terms of a concha bullosa, should be partially resected [195], [196].


Scheduling delegates' interim decisions and invitation for further comment: ACCS/ACMS, November 2017

An application was submitted by the Australian Competition and Consumer Commission (ACCC) to include helium gas in Schedules 6 and 7, and Appendices E and F in the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) – the Poisons Standard. The ACCC proposed that helium gas in pressurised gas canisters or cylinders sold or hired to consumers for household or domestic use must contain an aversive and that the supply of helium gas for commercial and industrial uses would not require an aversive, but its supply would be restricted by scheduling.

Scheduling application

This was a general application. The applicant’s proposed amendments to the Poisons Standard are:

Schedule 6 – New Entry

HELIUM GAS in pressurised gas canisters or cylinders sold or hired for household or domestic use and containing XX mg/kg, XX ppm or XX mg/m 3 XXXXXXXXXXXXXX of an aversive agent.

Schedule 7 –New Entry

HELIUM GAS, except when included in Schedule 6.

Appendix E, Part 2 – New Entry

Standard Statements A (For advice, contact a Poisons Information Centre (e.g. phone Australia 13 11 26 New Zealand 0800 764 766) or a doctor (at once)), G1 (Urgent hospital treatment is likely to be needed), R1 (If inhaled, remove from contaminated area. Apply artificial respiration if not breathing) .

Appendix F, Part 1 – New Entry

Warning Statement: 109: May be fatal if inhaled .

This is a truncated version of statement 13 with the words, 'swallowed or absorbed through skin' omitted.

110: Inhalation may cause brain damage.

Appendix F, Part 3 – New Entry

Warning Statement: 15 (Liquid will cause burns) 109 (May be fatal if inhaled) [new] 110 (Inhalation may cause brain damage) [new] .

The applicant's reasons for the request are:

  • The ACCC makes this proposal having regard to the safety risks associated with the supply of helium as a consumer good and following correspondence from the Victorian Coroner. The Victorian Coroner has requested that the ACCC investigate the supply of helium gas and recommended the restriction of the ease of access to helium gas by the Australian public.
  • Helium gas has known potential for misuse. The substance is a simple asphyxiant. Inhalation of helium gas has a high potential for causing harm (including death) at relatively low exposure and without warning of the asphyxiation effect. The substance is colourless, odourless and tasteless. Asphyxiation by this substance occurs very quickly and occurs through the displacement of oxygen by helium in the lungs. This may result in brain damage and death, with rescue being unlikely.
  • Asphyxiation by inert gases, including helium, is widely publicised as a certain, quick, simple, painless and non-disfiguring method of suicide.
    • Asphyxiation with helium gas is an increasingly popular method of suicide in Australia since 2000. There have been an estimated 400 suicides using helium gas between 2000 and 2016 (an average of about 24 each year). The number of cases gradually increased between 2000 and 2009, but more than doubled in 2009-10, increasing from 23 to 50 cases each year. The higher number of helium asphyxiation suicides per year has been relatively steady since 2010, at about 45 cases per year.
    • According to information in the national coronial database, the main sources of helium used for suicides are party goods suppliers (76 per cent) and industrial gas suppliers (14 per cent).
    • Helium is supplied to Australian householders for the purpose of inflating balloons or similar novelty items. Small non-refillable and disposable helium canisters are available for purchase in retail outlets. In addition, larger helium cylinders are available for hire for the same purpose from party supply stores and some suppliers of industrial gases.
    Current scheduling status

    Helium gas is not currently scheduled and has not been previously considered for scheduling. Therefore a scheduling history is not available.

    Australian regulatory information

    According to the Globally Harmonised System (GHS) of classification, helium is a non-flammable non-toxic gas 2.2 and requires the following label:

    International regulations
    New Zealand and United Kingdom (UK)

    The ACCC is aware of some efforts to address the misuse of helium in NZ and the UK. However, no jurisdictions appear to have been able find an appropriate solution or achieve any regulatory change.

    • Australia New Zealand Industrial Gas Association (ANZIGA) members have provided informal advice that approaches considered in NZ and the UK have included the use of 'Heliox' (79% helium + 21% oxygen) as an inflation gas for balloons and the inclusion of aversives. The NZ Ministry of Business, Innovation & Employment consulted their local gas industry about the 'Heliox' approach in March-April 2016.
    • Advice from ANZIGA is that in NZ there was concern about flammability issues with balloons inflated with 'Heliox', especially as helium is likely to leach from a balloon faster than oxygen, leaving the highly flammable oxygen in the balloon.
    United States of America (USA)

    According to Title 21: Food and Drugs:

      , helium is &ldquogenerally recognised as safe when used in accordance with good manufacturing or feeding practice&rdquo. , helium must be of purity suitable for its intended use and when used in food, helium has no limitations other than current good manufacturing practice. , a warning statement must be included on medical gas canisters containing helium indicating that the administration of the gas or gas combination may be hazardous or contraindicated and that the gas or gas combination should only be used by of under the supervision of a licenced practitioner who is experienced in the use and administration and is familiar with the indications, effects, dosages, methods, and frequency and duration of administration.
    European Union

    The hazard classification and labelling of helium is 'Warning' in the EU:

    Substance summary

    Helium gas is a simple asphyxiant that is insoluble in body tissues.

    Table 2.1.1: Chemical information of Helium
    Property Helium
    CAS number 7440-59-7
    Chemical structure He
    Chemical name Helium
    Atomic weight Ar (He) = 4.003
    Colour Colourless
    Odour Odourless
    Taste Tasteless
    Reactivity Inert (Noble) gas
    Flammability and explosivity Not combustible If heated in a sealed vessel, may expand to rupture container

    Acute toxicity

    Lethal doses or concentrations not established.

    Skin irritation

    Not an eye or skin irritant and non-corrosive.

    Sensitization
    Repeat-dose toxicity
    Carcinogenicity and genotoxicity

    Not mutagenic, carcinogenic or a teratogen.

    Reproduction and developmental toxicity

    Not a reproductive toxicant.

    Commercial and industrial uses:
    • Manufacture of various materials (e.g. semi-conducting materials, optical glass fibres)
    • Inert gas shield in gas-tungsten arc welding (GTAW)
    • In gas mixtures in Geiger counters, lasers
    • In breathing gas mixtures for commercial deep diving or technical diving e.g. in 'Heliox' or 'Trimix'
    • Creation of an inert atmosphere for growth of crystals and in supersonic wind tunnels
    • Coolant in high-temperature nuclear reactors
    • Inert gas diluent
    • Carrier gas in gas-liquid and gas-solid chromatography and
    • Lifting gas in airships or dirigible balloons.
    Medical uses:
    • Supportive treatment in patients with respiratory obstruction (in combination with other gases)
    • Liquid cryogen in MRI machines and
    • Rare use in gas mixtures for lung inflation during airway surgery or as a diluent in certain anaesthetic gas mixtures.
    Domestic uses:
    Misuses:
    • Squeaky or cartoon voice 'party trick'
    • Possible short term euphoric 'high' through deliberate inhalation ('huffing') and
    • Suicide.
    Section 52(E) criteria of the Therapeutic Goods Act 1989
    (a) Risks and benefits associated with the use of a substance
    • Helium gas in a domestic or household setting is legitimately used for inflation of balloons or similar novelty items, such as 'air swimmers'. These balloons are used as decorations, for amusement and as gifts. The balloons are generally made of light mylar or 'foil'. The balloons float in air due to the weight of the helium and the balloon being less than the air that it displaces. Normal thin rubber balloons can also be inflated with helium gas, but they are heavier and deflate much faster than mylar balloons.
    • Domestic use of helium gas in balloons as decoration or as a gift has social benefit, but could be considered non-essential. This type of benefit is difficult to quantify or value.
    • This application proposes the addition of an aversive to helium gas canisters or cylinders sold or hired for domestic use. The use of the gas by householders for balloon inflation is not affected by the addition of an aversive to the helium gas canister/cylinder, so this social benefit continues.
    • Uses of helium in the domestic or household setting other than for balloon inflation are considered misuses and are dangerous to health. These misuses involve the deliberate inhalation of helium for suicide, 'huffing' and a squeaky voice party trick.
    • As a simple asphyxiant, inhalation of helium can result in rapid hypoxia or death. Death may be deliberate (suicide) or accidental (as a result of over-inhalation) while 'huffing' or trying to achieve a squeaky voice for fun. Symptoms of hypoxia can include light-headedness or dizziness, which can also result in falls and injuries.
    • Information about the demographic of people who commit suicide using helium asphyxiation was not included in the data provided by the NCIS. The literature does not closely define the type of person that may choose to commit suicide by this method, but they are likely to include vulnerable consumers. Some researchers have suggested that mental illness is a commonality, but this is not likely to be unique to people who consider helium asphyxiation, as opposed to other methods of suicide. Some researchers have identified features of people choosing to commit suicide by helium asphyxiation. People committing suicide by helium asphyxiation were more likely to be younger (Howard et al., 2011, Gunnell et al., 2015a, Chang et al., 2016), more affluent (Gunnell et al., 2015a), have a psychiatric disorder (Howard et al., 2011), have financial problems (Chang et al., 2016) and a history of substance abuse (Howard et al., 2011). These characteristics are not inconsistent with the details of cases that the ACCC has been alerted to by the Victorian Coroner.
    • The literature indicates that helium asphyxiation suicides are often preceded by a period of research on the internet (Gunnell et al., 2015a, Chang et al., 2016). Gunnell et al., (2015b) did not find a generalised increase in internet searching for information about helium for suicide (2004-2014), but increased searching was documented following news coverage of helium suicides by celebrities. Around one third of links from Google searches for "suicide" mentioned helium (Gunnell et al., 2015b).
    • This application proposes that domestic users of helium should only be able to access helium gas that contains an aversive. This will not reduce the social utility of helium gas in the domestic or household setting, but it may reduce the misuse of the gas in this setting.
    (b) The purposes for which a substance is to be used and the extent of use of that substance
    • Helium gas is widely and properly used in a domestic or household setting for the inflation of party balloons and similar novelty items e.g. 'air swimmers'. Consumers may purchase balloons pre-inflated with helium from commercial outlets, such as party supplies stores or party hire businesses. Consumers can also purchase or hire kits that allow them to inflate the balloons themselves. It is unknown how long helium gas cylinders have been available to the public.
    • Helium balloon inflation kits can be purchased without restriction from retail stores. Helium balloon inflation kits for sale or hire to consumers always include a helium gas canister with fittings. Helium canisters are small non-refillable and disposable. Most kits also include a selection of balloons and trimmings some require a consumer to separately purchase balloons for use with the canister.
    • Helium gas has a range of commercial and industrial uses, including in gas tungsten-arc welding (GTAW), manufacturing and in certain medical/scientific equipment. Helium is used in commercial deep diving and technical diving in combination with oxygen ('Heliox') and sometimes also nitrogen ('Trimix'). It is used very rarely in medical or surgical practice, and this is generally in combination with other gases.
    • This application is intended to prevent the supply of helium without an aversive to consumers. It is not intended to affect the supply of helium gas to existing commercial or industrial users and proposes that helium for commercial or industrial use continues to be supplied without an aversive.
    • Party supplies stores and party hire outlets would continue to sell balloons inflated to order with helium from cylinders without an aversive, but would not be permitted to sell or hire helium gas cylinders or balloon inflation kits to consumers without an aversive.
    (c) Toxicity and safety of the substance

    Helium gas is non-toxic. It is a colourless, odourless and tasteless gas and is a simple asphyxiant.

    • The normal level of oxygen in fresh air is about 21 per cent. Oxygen concentrations below 16 per cent are dangerous to human health. Early signs of oxygen deprivation include dizziness and light-headedness. With continued exposure to a low-oxygen atmosphere, unconsciousness follows very quickly. Oxygen concentrations below 10 per cent cause rapid brain damage. Oxygen levels below 6 per cent cause unconsciousness in less than one minute (1-2 breaths), followed by death a few minutes later.
    • Simple asphyxiants displace oxygen in the lungs, causing reduced alveolar partial pressure of oxygen and, as a consequence, hypoxemia. Other gases classified as simple asphyxiants include argon, nitrogen, carbon dioxide, sulfur hexafluoride, hydrogen sulphide and gaseous hydrocarbons such as methane, ethane, propane and butane.
    • Because helium is a simple asphyxiant, there are no occupational exposure limits established for the gas in Australia or overseas. Essential use of helium in the workplace requires engineering controls and personal protective equipment to ensure an adequate oxygen supply to the worker. All Safety Data Sheets (SDSs) for helium gas note the potential for rapid asphyxiation from exposure to helium.
    • The Globally Harmonised System of Classification and Labelling of Chemicals (GHS) requires labelling of gases under pressure with standard pictograms and hazard statements (Pictogram GHS04 and 'Contains gas under pressure may explode if heated.').
    • A Safety Advice Bulletin [48] published by the Australia New Zealand Industrial Gas Association notes that "The 'fun' to be found in the squeaky voice helium trick is far from funny when people, often youngsters, die trying this. It does not take many breaths of helium to fall unconscious and die this way."
    (d) Dosage, formulation, labelling, packaging and presentation of a substance
    • The ACCC proposes that all helium gas canisters or cylinders sold or hired to consumers for domestic or household use i.e. for inflation of balloons, should include an aversive. This will reduce the attractiveness of the gas as a suicide agent and should also deter many people attempting suicide from completing the act.
    • It is not proposed to require an aversive to be added to helium gas sold for commercial or industrial purposes. Party supply stores (commercial use) could continue to sell pre-inflated helium balloons using helium without an aversive.
    • The inclusion of an aversive in helium sold to consumers will also reduce the likelihood of accidental deaths from inhalation of helium from canisters or cylinders and from balloons that the consumer has inflated themselves.
    • Some other gaseous products have included aversives to discourage the inhalation (or 'huffing') of the propellants in these products. Examples include gaseous cleaners for electronics, computers and photographic equipment.
    (e) Potential for misuse/abuse of the substance
    • The ACCC requested data from the National Coronial Information System (NCIS) on the frequency of use of helium gas for suicide from 1 July 2000 to 31 December 2016. Additional information was extracted from case notes in relation to state/territory location of the suicide, whether the helium canister or cylinder was purchased or hired (where known) and the source of the helium (where known). The NCIS data was expressly provided for the purpose of the ACCC making an application to the ACCS to amend the Poisons Standard.
    • Trends in suicide by helium asphyxiation
      • No suicides by helium asphyxiation were recorded in the NCIS for 2000. Actual or extrapolated [49] annual numbers of helium suicides in Australia for each year from 2000 to 2016 are shown in the figure below.
      • There have been an estimated 400 suicides using helium gas between 2000 and 2016 (an average of about 24 each year). The number of cases gradually increased between 2000 and 2009, but more than doubled in 2009-10, increasing from 23 to 50 cases each year. The higher number of helium asphyxiation suicides per year has been relatively steady since 2010, at about 45 cases per year (figure below).
      • Asphyxiation with inert gases, including helium, is widely publicised as certain, simple, quick, painless and non-disfiguring. The materials required are all familiar to everyone and freely available without any restriction, age limits or cooling off periods.
      • Information about how to commit suicide using these materials is accessible on the internet, videos and in publications. 'Right to die' advocates have promoted the right to voluntary euthanasia ("self-deliverance") in terminally ill patients and otherwise healthy elderly people. Voluntary euthanasia using various drugs, devices and asphyxiants is publicised through books, documentaries, meetings and the internet. Several books describing the use of these methods are banned in Australia.
      • Austin et al., (2011) quotes Dr Richard McDonald speaking at the 13th National Hemlock Biennial Conference in San Diego USA in 2003: '…we have had a shift to techniques using plastic bags and helium. That, remarkably, has become an acceptable method of hastening death… It is a very speedy process and has never failed in our program.'
      • Suicide by helium asphyxiation is not easily detectable through standard physical, pathological or toxicological examination after death, which is attractive to some people considering suicide. Suicide by helium asphyxiation leaves an intact corpse without disfiguration. Typically, helium suicide is detected only through the presence of equipment at the scene or, in rare cases, by ligature marks where a plastic bag fastened on the neck has been removed. If equipment is removed before an investigation of the death, the cause of death may not be classified as a suicide by helium asphyxiation. This could occur in the case of an assisted suicide or by loved ones wishing to avoid a finding of death by suicide due to social stigma or cultural concerns. This indicates that the documented frequency of suicide by helium is likely to be an underestimate. In addition, given the illegality of assisted suicide, a method that leaves little or no evidence once equipment is removed may be ideal for a pre-arranged suicide.
      • It is common for both adults and children to inhale gas from helium balloons at parties to achieve the squeaky/cartoon voice effect. Because this party trick is so common and sounds funny, helium gas has a reputation as being a 'harmless' and 'fun' gas to inhale.
      • This squeaky voice effect is due to the lower density of helium (compared to nitrogen, the main component of air). Sound travels faster through the helium in the vocal tract, altering the timbre of the voice and making it sound squeakier.
      • People inhaling deeply from a balloon of helium gas may experience dizziness or light-headedness. This may result in falls and injuries.
      • Another method of inhaling helium is directly from the cylinder or canister. This is extremely dangerous as the gas under pressure may rupture the lungs or cause an air embolism. Contact with liquid helium or helium directly from a pressurised cylinder or canister may also cause an injury similar to severe frost bite in the mouth, throat and lungs, which can be fatal.
      • In a 2012 study of at-risk adolescents, Whitt et al., (2012) reported that 11.5 per cent of the 723 study subjects had inhaled helium gas with the intention of getting 'high' – a practice known as 'huffing'. In this study, over a third of the users claimed to have experienced a 'high' from this activity. Although helium does not have any psychoactive effects, users may experience light-headedness, dizziness or euphoria caused by short-term oxygen deprivation. These symptoms can result in falls or other accidents, leading to injury.
      (f) Any other matter that may be relevant to the scheduling of a substance
      • The dominant companies in Australian gas production are made up by two companies (10.2 per cent market share), with smaller companies making up the remainder. The contribution of helium sales to the industrial bottled gas producers' profit is unknown. Australian producers are required to comply with Australian Standards relating to bottled gas.
      • There are also a large number of disposable non-refillable helium canisters or balloon inflation kits imported into Australia. These products are freely sold in party supply shops and discount department stores. These products are not required to comply with Australian Standards.
      • The bottled gas industry is subject to several regulatory frameworks. Aspects of the bottled gas industry are regulated by the dangerous goods transportation legislation, the industrial chemical framework, as chemicals used in workplaces and with links to the gas appliance safety system.
      • There are many voluntary Australian Standards that apply to bottled gas, including:
        • AS 2030.1-2009 Gas cylinders general requirement
        • AS 2473.2:2015 Valves for compressed gas cylinders. Outlet connections (threaded) and stem (inlet) threads
        • AS 4332-2004 (R2016) and AS 4332-2004/ (R2016)Amdt1-2005 The storage and handling of gases in cylinders
        • AS 3840.1-1998(R2016) Pressure regulators for use with medical gases. Pressure regulators and pressure regulators with flow-metering devices
        • AS 4484:2016 Gas cylinders for industrial, scientific, medical and refrigerant use - Labelling and colour coding
        • The ACCC is aware of some efforts to address the misuse of helium in New Zealand and the UK. However, no jurisdictions appear to have been able find an appropriate solution or achieve regulatory change.
        • ANZIGA members have provided informal advice that approaches considered in New Zealand and the UK have included the use of 'Heliox' (79% helium + 21% oxygen) as an inflation gas for balloons and the inclusion of aversives. The New Zealand Ministry of Business, Innovation & Employment consulted their local gas industry about the 'Heliox' approach in March-April 2016.
        • Advice from ANZIGA is that in New Zealand there was concern about flammability issues with balloons inflated with 'Heliox', especially as helium is likely to leach from a balloon faster than oxygen, leaving the highly flammable oxygen in the balloon.
        • The ACCC is continuing to investigate the outcomes of the New Zealand and UK proposals and consultations.
        • The ACCC has been unable to find information about the feasibility of the addition of an aversive to helium gas. Some aerosol "compressed air" products used for cleaning electronic and photographic equipment contain an aversive to prevent 'huffing' of the product. However, no information is available about the identity or concentration of the aversive in these products. The ACCC is aware that progress of this proposal will require information from the bottled gas industry and this is being sought.
        • In addition, the ACCC has not been able to find information about the extent of the aversion effect that would be required to prevent inhalation of helium when supplied containing an aversive. The bottled gas industry may have conducted but not published the relevant research.
        Consideration of Scheduling Policy Framework (SPF) criteria

        The public health policy framework includes a system for safe access to chemicals and safe use of these chemicals through the chemical scheduling arrangements, including any necessary restrictions on supply and requirement of appropriate labelling. Chemical scheduling considerations include:

        • the chemical's toxicity
        • purpose and need for access
        • potential for abuse or misuse
        • safe use practice, packaging and labelling and
        • the need for any specialist knowledge or equipment for the safe and effective use of the chemical.
        Schedule 9: Prohibited substances
        • The substance is not included in United Nations Conventions on narcotic drugs or psychotropic substances.
        • The substance does not require restriction to use in medical and scientific research. The substance has a long history of legitimate and safe use in domestic, commercial, industrial and medical situations.
        • The substance does not present a risk of dependency or abuse.
        • The substance is legitimately supplied for household/domestic use for the inflation of balloons. The substance presents some risk of misuse (suicide). The misuse is not extensive and does not warrant stringent controls on supply from Schedule 9, given the social benefit from the legitimate use of the substance for inflation of balloons.

        Schedule 9 is not suitable.

        Schedule 7: Dangerous Poison
        • Helium is non-toxic.
        • Helium is of a high health hazard and may cause death if inhaled.
        • Special precautions are required in the manufacturing, handling and use of helium. An atmosphere containing sufficient oxygen to sustain life must be maintained at all times, as helium is a simple asphyxiant. There are no workplace exposure standards for helium and the Hazardous Chemical Information System (HCIS ) notes that it is an asphyxiant.
        • Helium has a high potential for causing harm at relatively low exposure and without warning of the asphyxiation effect. The substance is colourless, odourless and tasteless. Asphyxiation by this substance occurs very quickly and rescue is unlikely.

        Suitable when the substance is used in a commercial or industrial setting and adequate safety precautions and training are in place.

        The ACCC notes that application of Appendix J to Schedule 7 may add further controls for commercial and industrial suppliers and users of helium gas. However, adoption of Appendix J varies between States and Territories and there is currently no reason to expect that supplies of helium without an aversive would be illicitly supplied to consumers.

        Schedule 6: Poison
        • The substance is non-toxic.
        • The substance is an asphyxiant.
        • The proposal is for the substance to be required to include an aversive when supplied for household or domestic use. The aversive e.g. mercaptan, will have an aversion effect.
        • Apart from the risk of asphyxiation, the substance does not present a health hazard. The inclusion of an aversive should reduce the risk of asphyxiation through deliberate inhalation.
        • Foreseeable harm to users is not likely to be reduced by distinctive packaging, strong label warnings or extensive safety directions. Inhalation of the substance causing fatalities is normally deliberate.
        • Changes to the packaging and presentation of the substance (specifically the simple nozzle/valve arrangement), with or without an aversive, may make the substance less accessible to both adults and children. This may reduce fatalities due to deliberate inhalation of the substance.
        • Without an added aversive, the substance has a high potential to cause harm at low exposure. With an added aversive the potential for causing harm is reduced (through aversion), but not eliminated.

        Suitable when the substance has an added aversive and is supplied for household or domestic use.

        Schedule 5: Caution

        The proposal is for the substance to be required to include an aversive when supplied for household or domestic use. The aversive e.g. a mercaptan, will have an aversion effect.

        • The substance is non-toxic and is not corrosive or sensitising.
        • The substance is an asphyxiant. An asphyxiant is not a low health hazard, even with the addition of an aversive. The substance with an aversive may still be inhaled in sufficient quantity to cause a fatality.
        • The substance is an asphyxiant. Adverse effects from sustained inhalation are not minor as fatality is likely. Very short term exposure is likely to have minor adverse effects, including dizziness, light-headedness and potential injuries from falls.
        • Risk of injury from normal handling, storage and use could be mitigated through labelling and appropriate packaging. Labelling and packaging will not reduce misuse or attempted misuse of the substance if an aversive is not included. Inclusion of an aversive and appropriate labelling may reduce attempted misuse of the substance.
        • Without an added aversive, the substance has a high potential to cause harm at low exposure. With an added aversive the potential for causing harm is reduced (through aversion), but not eliminated.

        Suitable when the substance has an added aversive and is supplied for household or domestic use.

        Appendix B: Exempt from scheduling

        Not suitable as helium gas meets factors for Schedule 7 (DANGEROUS POISON) for industrial and commercial uses of helium and Schedule 6 (POISON) or Schedule 5 (CAUTION) for domestic and household use when an aversive is included to prevent deliberate inhalation that results in fatalities.

        Consideration of the Scheduling Factors indicates that helium (with an aversive) for household or domestic use could be included in either Schedule 6 or Schedule 5 of the Poisons Standard. The ACCC recommends that the substance is included in Schedule 6, given the rapidity of the asphyxiation effect, even if an aversive is included.

        Aversives
        Mercaptans

        Mercaptans (thiols) are organosulfur compounds that contain a carbon-bonded sulfhydryl group:

        Figure 2.1.3: Chemical structure of mercaptans, where R can be an alkane, alkene or other carbon-containing moiety.

        Table 2.1.2: Properties of the mercaptans (Committee on Acute Exposures Guideline (2013)
        Mercaptan Descriptors Acute Exposure Guideline Levels (AEGL [50] ) for 10 minute exposure Acute Exposure Guideline Levels (AEGL ) for 10 minute exposure Odour intensity or awareness (LOA [51] ) detection thresholds and descriptors 4 hour inhalation LC50 (ppm) (rats/mice)
        methyl mercaptan CH4S Strong odour, garlic-like, rotten cabbage, bad breath AEGL-1 = no recommendation
        AEGL-2 = 40 ppm (80 mg/m 3 )
        AEGL-3 = 120 ppm (240 mg/m 3 )
        LOA = 0.0019 ppm
        Detection threshold = 0.041 ppm
        Strong intensity = 110 ppm
        675 / 1667
        ethyl mercaptan C2H6S Penetrating, persistent odour, garlic/leek-like, skunk-like, decaying cabbage AEGL-1 = 1 ppm (2.5 mg/m 3 )
        AEGL-2 = 150 ppm (380 mg/m 3 )
        AEGL-3 = 450 ppm (1100 mg/m 3 )
        LOA = 1.4 x 10- 4 ppm
        Detection threshold = 2.6-9.7 x 10- 4 ppm
        Strong = 21-97 ppm
        4420 / 2770
        phenyl mercaptan C2H6S Disagreeable, penetrating and repulsive odour, garlic-like AEGL-1 = no recommendation
        AEGL-2 = 1 ppm (4.5 mg/m 3 )
        AEGL-3 = 3 ppm (14 mg/m 3 )
        Detection threshold = 0.00025 ppm
        Strong = 38 ppm
        33 / 28
        tert-mercaptan C2H6S Disagreeable AEGL-1 = no recommendation
        AEGL-2 = 0.77 ppm (4.6 mg/m3)
        AEGL-3 = 2.3 ppm (14 mg/m3)
        - 51 / 47 (both males only)

        Many mercaptans have strong odours and are dominant contributors to repulsive smells including garlic, rotten eggs, rotten cabbage, skunk spray and certain chemical faults in wines etc. Mercaptans (generally methyl mercaptan and ethyl mercaptan) and sulfides are added to natural gas supplies and other odourless gases so that consumers can be aware of the gas.

        Inhalational toxicity levels and ability of people to detect mercaptans vary. Phenyl mercaptan and tert-octyl mercaptan are both highly toxic than the lower molecular weight mercaptans, methyl mercaptan and ethyl mercaptan. Compared to methyl mercaptan, ethyl mercaptan has lower inhalational toxicity in rats and mice as well as a lower detection threshold.

        Ethyl mercaptan appears to be the most suitable mercaptan candidate for inclusion in helium gas as an aversive.

        The ACCC requests the Scheduling Delegate commission expert advice about the suitability of the mercaptans (and potentially other aversives) as suitable candidates for inclusion in helium gas for consumer or domestic use.

        Pre-meeting public submissions

        Eight (8) public submissions were received for helium, one (1) in support and seven (7) opposed.

        Main points in support:
        • Data from the National Coronial Information System (NCIS) shows an increase in deaths with helium listed as the cause of death. All of these deaths were intentional suicides in individuals ranging in age from 16 years to 94 years.
        • Availability of helium for purchase online in large quantities makes this an attractive, easy, relatively inexpensive and very efficient method of suicide.
        • Online resources supporting euthanasia run workshops and sell adaptors to facilitate the use of helium for asphyxiation.
        • Additionally, the inclusion of an aversive in canisters of helium being sold or hired to consumers should make exposure to excessive quantities of helium more difficult and unpleasant.
        Main points opposed:
        • The occupational work health and safety of people who work with helium regularly and of the general public who might inhale the new gas mixture is of great concern. Rupture of a balloon filled with helium, or the leaching of helium and aversive through the latex membrane of a balloon would allow the undesirable release of the aversive into the work, home and event areas and may result in future medical issues.
        • There are many uses of helium that are essential for society, for example in MRI scanners.
        • Helium is only dangerous if deliberately misused.
        • The inclusion of an aversive would be impractical with positive environmental policies. These policies outline the proper disposal of helium balloons, which includes popping the balloon prior to disposal. Popping a balloon with such an aversive would be unpleasant and would therefore reduce the implementation of environmentally conscience disposal practices.
        • The use of an aversive has further been discussed by international authorities and organisations to some length but has never been implemented as the use of an aversive could potentially endanger or destroy the balloon industry.
        • The imposition of Schedule 7 requirements on helium will make small business operation very costly.
        • Helium does not meet the criteria for scheduling as outlined in the Scheduling Policy Framework.
        • The release of helium or other asphyxiant gases straight from its packaging is not the path taken to commit suicide. It is the additional intentional and conscious step by the end user to restrict their atmosphere through a piped direct application method (regulator, tubing and face mask) that is used to displace oxygen. Helium, when used as intended, either for industrial or medical uses, poses little risk to the user.
        • There is the potential for all oxygen displacing gases to be inappropriately used. Inert gases such as nitrogen, argon and carbon dioxide have similar asphyxiation hazards. The scheduling of one substance is unlikely to solve the problem, but will shift the focus to another.

        The public submissions will be made available on the TGA website.

        Summary of ACCS-ACMS advice to the delegates

        The committee recommended that helium does not require scheduling.

        Members agreed that the relevant matters under Section 52E(1) of the Therapeutic Goods Act 1989 included: (a) risks and benefits of the use of a substance (b) the purpose for which a substance is to be used and the and extent of use (c) the toxicity of a substance (e) the potential for abuse of a substance and (f) any other matters that the Secretary considers necessary to protect public health.

        The reasons for the recommendation comprised the following:

        1. the risks and benefits of the use of a substance:
          • The benefits of helium are that it has many legitimate uses, most of which are non-balloon uses, e.g. industrial, scientific and medical uses.
          • The risks for helium do not exist unless it is deliberately inhaled (resulting in oxygen deprivation, leading to asphyxiation) helium is otherwise safe.
        2. the purposes for which a substance is to be used and the extent of use of a substance:
          • Helium has a small number of therapeutic uses as part of gas mixtures.
          • Helium has commercial, industrial and medical uses.
          • A small amount of helium is also used in domestic situations, primarily for balloons and similar items.
        3. the toxicity of a substance:
          • Helium is an inert, non-toxic gas.
          • Correct and legitimate use of helium does not meet the scheduling criteria (SPF 2015).
        4. the dosage, formulation, labelling, packaging and presentation of a substance:
          • Nil.
        5. the potential for abuse of a substance:
          • Helium may be deliberately misused for the purpose of causing asphyxiation but use does not result in dependence or addiction.
        6. any other matters that the Secretary considers necessary to protect public health
          • The addition of an aversive may make the gas more dangerous and the evidence that this would lead to aversion is not there.
          • The ACCC should continue to work with the helium industry to reduce risks such as the proposal to modify valves and nozzles for cylinders that increase the difficulty of completing the suicide act. These changes will also reduce the likelihood of children being able to release helium from a canister.
        Delegate's considerations

        The delegate considered the following in regards to this proposal:

        • Scheduling proposal
        • ACMS advice
        • Public submissions received
        • Section 52E of the Therapeutic Goods Act 1989
        • Scheduling Policy Framework (SPF 2015)
        Delegate's interim decision

        The delegate’s interim decision is not to schedule helium.

        The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the delegate included: (a) the risks and benefits of the use of a substance (b) the purposes for which a substance is to be used and the extent of use of a substance (c) the toxicity of a substance (e) the potential for abuse of a substance and (f) any other matters that the Secretary considers necessary to protect public health.


        Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1

        Nearly fifty percent (50%) of the population is affected by cervical spine pain and/or headaches during their lives. 1 Headache is not only one of the most common human ailments, 2 but also accounts for the expenditures of billions of health care dollars annually and is a leading cause of lost time from work. 3

        Cervical dysfunction may be seen in up to seventy percent (70%) of the population suffering from any type of headache. 4 This suggests that the cervical spine may be either a causative or contributing factor in the pathogenesis of many headaches. 5

        The pilot study by Placzek, Pagett, et al. demonstrated and supported the theory that headache may be influenced by cervical muscle strength, and that weakness of the cervical spine musculature may lead to abnormal stress on the upper cervical facets which are related to head and neck pain. It is further speculated that stability, and thus normal function and biomechanics, is dependent on a balance of anterior and posterior cervical muscle balance. Despite advances, the pathogenesis of tension-type headache is not clearly understood. However, cervical musculoskeletal abnormalities have been linked to multiple headache types. 6-8

        In the study published by Fernandez-De-Las-Penas, Perez-De-Heredia, Molero-Sanchez, and Miangolarra, the authors presented results similar to those previously reported:

        1. impairment in deep neck flexor muscles in individuals with cervicogenic headaches, and
        2. deficits in the performance of the cranio-cervical flexion test (ie., reduced endurance or holding capacity of the deep neck flexor muscles).

        The authors concluded that patients with chronic tension-type headache showed reduced holding capacity of the deep neck flexors. Patients with chronic tension-type headache also exhibited greater forward head posture (FHP) in a standing position than healthy controls.

        The dental profession has become increasingly aware of the postural relationships between the head and neck, especially with regard to the diagnosis and treatment of head and neck pain and temporomandibular disorders. 10-12

        Clinical observation suggests that FHP and weakness of the deep cervical flexor musculature are associated with, and co-exist in, the cervical headache patient. 14,15 The study by Watson and Trott confirmed the clinical observation with respect to isometric endurance and isometric strength.16 The study also showed that cervical headache is commonly precipitated or aggravated by sustained neck posturing or neck movements.

        Yip, Chiu, and Poon performed a cross-sectional correlation study to investigate the relationship between head posture with pain and disability in patients with neck pain. 17 The study showed a significant difference in the Cranio-vertebral (CV) Angle between subjects with and without neck pain. There is a moderate negative correlation between CV Angle and neck disability. Patients with small CV Angle have a greater forward head posture and the greater the forward head posture, the greater the disability. 17

        Figure 1. PostureJac® exercise and posture-support device.

        New Research

        Preliminary data collected in the Department of Physical Therapy at the New York Institute of Technology (NYIT) in Old Westbury, New York, indicates that an exercise and posture-support device—such as the PostureJac® invented by one of the authors and illustrated in Figure 1—immediately increased the endurance capacity in the deep neck flexors by over forty percent (40%), whereas the control group showed only a six percent (6%) increase. This has implications for tension-type and cervicogenic headaches where the endurance capacity of the deep neck flexors has been shown to be deficient.18,19 In addition, poor endurance of the deep neck flexor muscles (rectus capitus anterior, rectus capitus lateralis, longus capitus, and longus colli) may lead to forward head posture which has been linked to not only chronic headaches, but also to:

        Exercise and Posture Support Device

        Individuals can perform myofascial stretching, self-mobilization, and muscle strengthening utilizing an exercise and support device such as the PostureJac.

        While such a device works on a biomechanical basis to correct forward head/ rounded shoulders posture, perhaps its most profound effects on form and function operate on a neurological level through sensorimotor learning and improved kinesthetic awareness. Patients are trained to recognize abnormal postures and movement patterns and exchange them for static and dynamic alignment that is balanced, efficient, and in a vertical relationship with gravity. 24 In addition to the therapeutic effects of posture correction, it serves as a tool for core strengthening of the local muscles of the lumbopelvic region (ie, transversus abdominis, pelvic floor, multifidi, and diaphragm) as well as the deep neck flexors (ie, rectus capitis anterior, rectus capitis lateralis, longus capitis, and longus colli)

        Two applications of the device—namely, posture correction exercises and deep neck flexor muscle training will be described below.

        Posture Correction Exercises

        The ‘Release.’ This introductory exercise involves the process of releasing excess tension in the upper half of the body. The upper trapezius and sternocleidomastoid muscles are known to generate excessive and unnecessary tension, 25 the result being a tendency towards forward head/rounded shoulders posture. Most likely this tension is driven emotionally through the limbic system, 26 but other postural influences certainly play a role. 27 Ideally, the head-neck-shoulder region should remain relaxed and fluid. However, because of habitual tensing in these muscles, the head-neck may intermittently “freeze.” The goal of this release maneuver is to recognize when “freezing” occurs and to restore the head-neck region to its fluid and relaxed state. Following is a series of steps in accomplishing the desired result:

        a. In the sitting or standing position, the patient is advised to become aware of muscle tightness in the shoulders, head, neck, face, and chest. Using a mirror for visual feedback may enhance the awareness of tightness by observing poor postural alignment, including elevation of the shoulders.
        b. Once aware of this excess tension, the patient is encouraged to release it by “letting go” and to enhance this release of tension by lightly pushing the handles down towards the floor (see Figure 2).
        c. As the shoulders drop, the patient should imagine the top of the head (towards the proverbial “bald spot”) floating up to the ceiling as if being “pulled” by a rope attached to a helium balloon.
        d. Breathing slowly in through the nose, followed by a long exhalation out through pursed lips—while gently pushing the handles down—enhances the release.
        e. This can be done from 1 to 5 minutes, several times per day. Over time, the patient will become more aware of unnecessary tension in the upper body and may suffer less from myofascial trigger points, tension-type headaches, etc. In addition, the patient will ultimately feel taller and less compressed.
        f. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

        The ‘Rocket.’ The goal of this exercise is stretching and strengthening by causing an upward rise of the central column of the thorax and is accomplished as follows:

        a. In the standing or seated position (ideally in a chair without armrests so as to avoid interference), the patient pretends to be a rocket that is “blasting off.” As the PostureJac handles are pushed down with moderate pressure, the patient’s torso is propelled upward against gravity like a rocket until “lift-off” is experienced (see Figure 3a). In fact, the rocket engine is an excellent example of Newton’s Third Law of Motion, which is crucial in grasping the mechanism by which the device improves body posture (ie, action and reaction). If the rocket illustration fails to communicate a sense of upward rise of one’s body posture, perhaps the image of a fountain, rising from the base of the spine and working its way through the vertebral column to the top of the head, may be preferred.
        b. Initially, the joints of the thorax may not allow the unhindered upward rise of the central column of the thorax (ie, spine and sternum). However, with time and practice this upward rise will free up and become second nature.
        c. To enhance this feeling of “lift-off” the patient can rise up on his/her toes, as the spine is lengthening, provided that the requisite balance is present (see Figure 3b).
        d. As a stretching exercise, the ‘Rocket’ is performed 3 times, held for up to 30 seconds, and repeated up to 6 times per day. As a strengthening exercise, it is performed 10 times, held for 5 – 10 seconds, and performed 3 times per day.
        e. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

        Deep Neck Flexor Muscle Training

        The ‘JacRetract.’ This 2-stage exercise works very well with McKenzie’s neck retraction exercises. 28 The key to successful head-neck retraction is trunk stability. Without it, the movement is only partially effective in restoring extension to the lower cervical spine. The stages are as follows:

        Stage 1
        a. In the sitting or standing position, the patient engages the handles in a downward direction until there is moderate pressure against the shoulders.
        b. In the chin-tucked position (chin to hyoid, eyes looking straight ahead, head rotation around ear axis), the patient retracts the head-neck backward for 3 seconds (see Figure 4a).
        c. Repeat this movement 10 times.
        d. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.
        Stage 2
        a. At the end of Stage 1, the patient is instructed to turn slowly to the right then slowly to the left, 10 times, maintaining the head-neck retraction throughout (see Figure 4b).
        b. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

        The ‘HeadFlex.’ By stabilizing the scapulothoracic region and lower cervical spine, one can dramatically improve function of the deep neck flexors (ie, strength and endurance). In addition, the reconditioning of this deep and local core system enables the superficial neck flexors (eg. sternocleidomastoid and scalenes) to relax, which contributes to posture correction of the head-neck region. Prior to commencing the ‘HeadFlex’ exercise, the therapist should first address flexion limitation in the upper cervical spine (eg. inhibitive occipital distraction technique and occipital extensor stretching). Otherwise, the deep neck flexors will be unable to achieve their full strength and endurance potential. 29-31 The procedure is as follows:

        a. The supine-lying patient begins by engaging both handles down towards the feet.

        b. When moderate pressure is felt under the shoulder straps, the patient performs a chin-tuck and raises the back of the head less than an inch off the surface (Figure 4). It is important that the motion be confined to the upper neck as much as possible. This ensures that the superficial neck flexors are kept from substituting for the deep neck flexors.

        c. The goal is for the patient to maintain this position for at least 10 seconds without shaking, raising, or lowering the head. As strength and endurance show signs of improving, the amount of downward pressure applied to the handles can be lessened. This exercise can be performed up to 3 times per day.

        d. If at any time the patient experiences pain, dizziness, numbness, etc., the exercise should be stopped.

        Conclusion

        The literature points to a strong relationship between cervicogenic headache, forward head posture, and weakness/poor endurance of the deep neck flexors. 18,32 In addition, the research literature establishes a similar correlation between FHP/deficient deep neck flexors and tension-type headache.19, 33-35 To assist head, neck, and facial pain sufferers in addressing poor postural alignment (eg., forward head posture) and weakness/poor endurance of the deep neck flexors, a device was developed by one of the authors. Recent unpublished data suggest that it holds promise as a tool for improving strength and endurance of the deep neck flexors and anecdotal evidence indicates its effectiveness in improving body posture.


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