Oxygen therapy 1

Oxygen therapy

OxygentherapyIntervention

ICD-9-CM 93.96 [1]

MeSH D010102 [2]

Oxygen piping and regulator, for oxygen therapy,mounted on the wall of an ambulance

Oxygen Regulator for portable D-Cylinder,usually carried in an ambulance's resuscitation

kit.

Oxygen therapy is the administration of oxygen as a medicalintervention, which can be for a variety of purposes in both chronic andacute patient care. Oxygen is essential for cell metabolism, and in turn,tissue oxygenation is essential for all normal physiological functions.[3]

Room air only contains 21% oxygen, and increasing the fraction ofoxygen in the breathing gas increases the amount of oxygen in theblood. It is often only required to raise the fraction of oxygen deliveredto 30–35% and this is done by use of a nasal cannula. When 100%oxygen is needed, it may be delivered via a tight-fitting face mask, orby supplying 100% oxygen to an incubator in the case of infants.Oxygen can be administered in other ways, including specifictreatments at raised air pressure, such as hyperbaric oxygen therapy.

High blood and tissue levels of oxygen can be helpful or damaging,depending on circumstances and oxygen therapy should be used tobenefit the patient by increasing the supply of oxygen to the lungs andthereby increasing the availability of oxygen to the body tissues,especially when the patient is suffering from hypoxia and/orhypoxaemia.

Indications for use

Oxygen is used as a medical treatment in both chronic and acute cases,and can be used in hospital, pre-hospital or entirely out of hospital,dependant on the needs of the patient and the views of the medicalprofessional advising.

Use in chronic conditions

A common use of supplementary oxygen is in patients with chronicobstructive pulmonary disease (COPD), a common long term effect ofsmoking, who may require additional oxygen to breathe either during atemporary worsening of their condition, or throughout the day and night. It is indicated in COPD patients with PaO2≤ 55mmHg or SaO2 ≤ 88% and has been shown to increase lifespan.[4]

Oxygen therapy 2

Use in acute conditionsOxygen is widely used in emergency medicine, both in hospital and by emergency medical services or advanced firstaiders.In the pre-hospital environment, high flow oxygen is definitively indicated for use in resuscitation, major trauma,anaphylaxis, major haemorrhage, shock, active convulsions and hypothermia.[3] [5]

It may also be indicated for any other patient where their injury or illness has caused hypoxaemia, although in thiscase oxygen flow should be moderated to achieve target oxygen saturation levels, based on pulse oximetry (with atarget level of 94-98% in most patients, or 88-92% in COPD patients).[3]

For personal use, high concentration oxygen is used as home therapy to abort cluster headache attacks, due to itsvaso-constrictive effects.[6]

Storage and sources

Gas cylinders containing oxygen to be used athome. When in use a pipe is attached to the

cylinder's regulator and then to a mask that fitsover the patient's nose and mouth.

A home oxygen concentrator in situ in anemphysema patient's house. The model shown is

the DeVILBISS LT 4000.

Oxygen can be separated by a number of methods, including chemicalreaction and fractional distillation, and then either used immediately orstored for future use. The main types sources for oxygen therapy are:

1. Liquid storage - Liquid oxygen is stored in chilled tanks untilrequired, and then allowed to boil (at a temperature of 90.188 K(−182.96 °C)) to release oxygen as a gas. This is widely used athospitals due to their high usage requirements, but can also be usedin other settings. See Vacuum Insulated Evaporator for moreinformation on this method of storage.

2. Compressed gas storage - The oxygen gas is compressed in a gascylinder, which provides a convenient storage, without therequirement for refrigeration found with liquid storage. Large oxygencylinders hold 6500 litres (230 cu ft) and can last about two days at aflow rate of 2 litres per minute. A small portable M6 (B) cylinderholds 164 or 170 litres (5.8 or 6.0 cu ft) and weighs about 1.3 to 1.6kilograms (2.9 to 3.5 lb).[7] These tanks can last 4–6 hours whenused with a conserving regulator, which senses the patient's breathingrate and sends pulses of oxygen. Conserving regulators may not beusable by patients who breathe through their mouths.

3. Instant usage - The use of an electrically powered oxygenconcentrator[8] or a chemical reaction based unit[9] can createsufficient oxygen for a patient to use immediately, and these units(especially the electrically powered versions) are in widespreadusage for home oxygen therapy and portable personal oxygen, withthe advantage of being continuous supply without the need foradditional deliveries of bulky cylinders.

Delivery

Oxygen therapy 3

Various devices are used for administration of oxygen, from whichever source. In most cases, the oxygen will firstpass through a pressure regulator, used to control the high pressure of oxygen delivered from a cylinder (or othersource) to a lower pressure. This lower pressure is then controlled by a flowmeter, which may be preset or selectable,and this controls the flow in a measure such as litres per minute (lpm). The typical flowmeter range for medicaloxygen is between 0 and 15 lpm with some units able to obtain up to 25 liters per minute. Many wall flowmetersusing a "thorpe tube" style design are able to be dialed to "flush" which is beneficial in emergency situations.

Supplemental oxygen

A patient wearing a simple face mask.

Many patients require only a supplementary level of oxygen in theroom air they are breathing, rather than pure or near pure oxygen,[10]

and this can be delivered through a number of devices dependant onthe situation, flow required and in some instances patient preference.

A nasal cannula (NC) is a thin tube with two small nozzles thatprotrude into the patient's nostrils. It can only comfortably provideoxygen at low flow rates, 2-6 litres per minute (LPM), delivering aconcentration of 24-40%.

There are also a number of face mask options, such as the simple facemask, often used at between 6 and 12 LPM, with a concentration ofoxygen to the patient of between 28% and 50%. This is closely relatedto the more controlled air-entrainment masks, also known as Venturimasks, which can accurately deliver a predetermined oxygenconcentration to the trachea up to 40%.

In some instances, a partial rebreathing mask can be used, which isbased on a simple mask, but featuring a reservoir bag, which increasesthe provided oxygen rate to 40-70% oxygen at 5 to 15 LPM.

High flow oxygen delivery

In cases where the patient requires a flow of up to 100% oxygen, a number of devices are available, with the mostcommon being the non-rebreather mask (or reservoir mask), which is similar to the partial rebreathing mask except ithas a series of one-way valves preventing exhaled air from returning to the bag. There should be a minimum flow of10 L/min. The delivered FIO2 of this system is 60-80%, depending on the oxygen flow and breathing pattern.[11] [12]

High flows of warmed and humidified air/oxygen blends can also be delivered via a nasal cannula, allowing thepatient to continue to talk, eat and drink while still receiving the therapy.[13]

In specialist applications such as aviation, tight fitting masks can be used, and these also have applications inanaesthesia, carbon monoxide poisoning treatment and in hyperbaric oxygen therapy

Oxygen therapy 4

Positive pressure deliveryPatients who are unable to breathe on their own will require positive pressure to move oxygen in to their lungs forgaseous exchange to take place. Systems for delivering this vary in complexity (and cost), starting with a basicpocket mask adjunct which can be used by a basically trained first aider to manually deliver artificial respiration withsupplemental oxygen delivered through a port in the mask.Many emergency medical service and first aid personnel, as well as hospitals, will use a bag-valve-mask (BVM),which is a maleable bag attached to a face mask (or invasive airway such as an endotracheal tube or laryngeal maskairway), usually with a reservoir bag attached, which is manually manipulated by the healthcare professional to pushoxygen (or air) in to the lungs. This is the only procedure allowed for initial treatment of cyanide poisoning in theUK workplace.[14]

Automated versions of the BVM system, known as a resuscitator or pneupac can also deliver measured and timeddoses of oxygen direct to patient through a facemask or airway. These systems are related to the anaestheticmachines used in operations under general anaesthesia that allows a variable amount of oxygen to be delivered,along with other gases including air, nitrous oxide and inhalational anaesthetics.

As a drug delivery routeOxygen therapy can also be used as part of a strategy for delivering drugs to a patient, with the usual example of thisbeing through a nebulizer mask, which delivers nebulizable drugs such as salbutamol or epinephrine into the airwaysby creating a vapor-mist from the liquid form of the drug.

Filtered oxygen masksFiltered oxygen masks have the ability to prevent exhaled, potentially infectious particles from being released intothe surrounding environment. These masks are normally of a closed design such that leaks are minimized andbreathing of room air is controlled through a series of one-way valves. Filtration of exhaled breaths is accomplishedeither by placing a filter on the exhalation port, or through an integral filter that is part of the mask itself. Thesemasks first became popular in the Toronto (Canada) healthcare community during the 2003 SARS Crisis. SARS wasidentified as being respiratory based and it was determined that conventional oxygen therapy devices were notdesigned for the containment of exhaled particles.,,[15] [16] [17] Common practices of having suspected patients weara surgical mask was confounded by the use of standard oxygen therapy equipment. In 2003, the HiOx80 oxygenmask was released for sale. The HiOx80 mask is a closed design mask that allows a filter to be placed on theexhalation port. Several new designs have emerged in the global healthcare community for the containment andfiltration of potentially infectious particles. Other designs include the ISO-O2 oxygen mask,the Flo2Max oxygenmask, and the O-Mask. The use of oxygen masks that are capable of filtering exhaled particles is gradually becominga recommended practice for pandemic preparation in many jurisdictions.Because filtered oxygen masks use a closed design that minimizes or eliminates inadvertent exposure to room air,delivered oxygen concentrations to the patient have been found to be higher than conventional non-rebreather masks,approaching 99% using adequate oxygen flows. Because all exhaled particles are contained within the mask,nebulized medications are also prevented from being released into the surrounding atmosphere, decreasing theoccupational exposure to healthcare staff and other patients.

Oxygen therapy 5

Negative effectsMany EMS protocols indicate that oxygen should not be withheld from any patient, while other protocols are morespecific or circumspect. However, there are certain situations in which oxygen therapy is known to have a negativeimpact on a patient’s condition.[18]

Oxygen should never be given to a patient who is suffering from paraquat poisoning unless they are suffering fromsevere respiratory distress or respiratory arrest, as this can increase the toxicity. (Paraquat poisoning is rare - forexample 200 deaths globally from 1958–1978).[19] Oxygen therapy is not recommended for patients who havesuffered pulmonary fibrosis or other lung damage resulting from bleomycin treatment.[20]

High levels of oxygen given to infants causes blindness by promoting overgrowth of new blood vessels in the eyeobstructing sight. This is retinopathy of prematurity (ROP).Oxygen has vasoconstrictive effects on the circulatory system, reducing peripheral circulation and was once thoughtto potentially increase the effects of stroke. However, when additional oxygen is given to the patient, additionaloxygen is dissolved in the plasma according to Henry's Law. This allows a compensating change to occur and thedissolved oxygen in plasma supports embarrassed (oxygen-starved) neurons, reduces inflammation and post-strokecerebral edema. Since 1990, hyperbaric oxygen therapy has been used in the treatments of stroke on a worldwidebasis. In rare instances, hyperbaric oxygen therapy patients have had seizures. However, because of theaforementioned Henry's Law effect of extra available dissolved oxygen to neurons, there is usually no negativesequel to the event. Such seizures are generally a result of oxygen toxicity,[21] [22] although hypoglycemia may be acontributing factor, but the latter risk can be eradicated or reduced by carefully monitoring the patient's nutritionalintake prior to oxygen treatment.Oxygen first aid has been used as an emergency treatment for diving injuries for years.[23] Recompression in ahyperbaric chamber with the patient breathing 100% oxygen is the standard hospital and military medical responseto decompression illness.[23] [24] [25] The success of recompression therapy as well as a decrease in the number ofrecompression treatments required has been shown if first aid oxygen is given within four hours after surfacing.[26]

There are suggestions that oxygen administration may not be the most effective measure for the treatment ofdecompression illness and that heliox may be a better alternative.[27]

Chronic obstructive pulmonary diseaseCare needs to be exercised in patients with chronic obstructive pulmonary disease, such as emphysema, especially inthose known to retain carbon dioxide (type II respiratory failure). Such patients may further accumulate carbondioxide and decreased pH (hypercapnation) if administered supplemental oxygen, possibly endangering theirlives.[28] This is primarily as a result of ventilation–perfusion imbalance (see Effect of oxygen on chronic obstructivepulmonary disease).[29] In the worst case, administration of high levels of oxygen in patients with severe emphysemaand high blood carbon dioxide reduces respiratory drive to the point of precipitating respiratory failure, and eventualdeath. However the risk of the loss of respiratory drive are far outweighed by the risks of withholding emergencyoxygen, and therefore emergency administration of oxygen is never contraindicated. Transfer from field care todefinitive care, where oxygen use can be carefully calibrated, typically occurs long before significant reductions tothe respiratory drive.A recent study has shown that titrated oxygen therapy (controlled administration of oxygen) may be moreappropriate for COPD patients, and less of a danger to them.[28] The study also showed that other, non-COPDpatients, may also, in some cases, benefit more from titrated therapy. However, the results are not conclusive, andmay have no statistical relevance when adjusted for proper protocol usage.[30]

Oxygen therapy 6

Fire riskHighly concentrated sources of oxygen promote rapid combustion. Fire and explosion hazards exist whenconcentrated oxidants and fuels are brought into close proximity; however, an ignition event, such as heat or a spark,is needed to trigger combustion.[31] Oxygen itself is not the fuel, but the oxidant. Combustion hazards also apply tocompounds of oxygen with a high oxidative potential, such as peroxides, chlorates, nitrates, perchlorates, anddichromates because they can donate oxygen to a fire.Concentrated O2 will allow combustion to proceed rapidly and energetically.[31] Steel pipes and storage vessels usedto store and transmit both gaseous and liquid oxygen will act as a fuel; and therefore the design and manufacture ofO2 systems requires special training to ensure that ignition sources are minimized.[31]

Hospitals in some jurisdictions, such as the UK, now operate “no- smoking” policies, which although introduced forother reasons, supports the aim of keeping ignition sources away from medical piped oxygen. Other recorded sourcesof ignition of medically prescribed oxygen include candles, aromatherapy, medical equipment, cooking, andunfortunately, deliberate vandalism. Smoking pipes, cigars and cigarettes are of special concern. This does notentirely eliminate the risk of injury with portable oxygen systems, especially if compliance is poor.[32]

Oxygen therapy while on aircraftIn the United States, most airlines restrict the devices allowed on board aircraft. As a result passengers are restrictedin what devices they can use. Some airlines will provide cylinders for passengers with an associated fee. Otherairlines allow passengers to carry on approved portable concentrators. However the lists of approved devices variesby airline so passengers need to check with any airline they are planning to fly on. Passengers are generally notallowed to carry on their own cylinders. In all cases, passengers need to notify the airline in advance of theirequipment.Effective May 13th, 2009 the Department of Transportation and FAA ruled that a select number of portable oxygenconcentrators are approved for use on all commercial flights[33] . The list of approved portable oxygen concentratorsincludes the Respironics EverGo, the Invacare XPO2, the Invacare Solo 2 and others[34] .FAA regulations require larger airplanes to carry D-cylinders of oxygen for use in an emergency.

References[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=93. 96& Submit=Search& action=search[2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D010102[3] "Clinical Guidelines Update - Oxygen" (http:/ / www2. warwick. ac. uk/ fac/ med/ research/ hsri/ emergencycare/ prehospitalcare/

jrcalcstakeholderwebsite/ clinicalpracticeupdates/ oxygen_guideline_combined_final_published_version_22apr09sb. pdf). Joint RoyalColleges Ambulance Liaison Committee/Warwick University. April 2009. . Retrieved 2009-06-29.

[4] McDonald, Christine F; Crockett, Alan J and Young, Iven H (2005). "Adult domicilariary oxygen. Position statement of the Thoracic Societyof Australia and New Zealand" (http:/ / www. mja. com. au/ public/ issues/ 182_12_200605/ mcd10865_fm. html). The Medicine Journal ofAustralia 182 (12): 621–626. .

[5] O'Driscoll BR; Howard LS; Davison AG (October 2008). "BTS guideline for emergency oxygen use in adult patients" (http:/ / www.brit-thoracic. org. uk/ Portals/ 0/ Clinical Information/ Emergency Oxygen/ Emergency oxygen guideline/ THX-63-Suppl_6. pdf). Thorax(British Thoracic Society) 63 (Suppl 6:vi): 1–68. doi:10.1136/thx.2008.102947. PMID 18838559. .

[6] Sands, George. "Oxygen Therapy for Headaches" (http:/ / www. headaches. org/ consumer/ topicsheets/ oxygen. html). . Retrieved2007-11-26.

[7] "Luxfer Aluminum Oxygen Cylinders" (http:/ / www. cpr-savers. com/ Industrials/ oxygen supply/ luxfer-oxygen-cylinder-tanks. html). CPRSavers & First Aid Supply. . Retrieved 18 April 2010.

[8] McCoy, Robert. "Portable Oxygen Concentrators (POC) Performance Variables that Affect Therapy" (http:/ / www. inspiredrc. com/ POCAARC Dec 2006. pdf) (pdf). . Retrieved 2007-07-03.

[9] Evaluation of the System O2 Inc Portable Nonpressurized Oxygen Delivery System (http:/ / www. wemjournal. org/ wmsonline/?request=get-document& issn=1080-6032& volume=013& issue=04& page=0253)

[10] American Association for Respiratory Care. "Oxygen Therapy for Adults in the Acute Care Facility — 2002 Revision & Update" (http:/ /www. rcjournal. com/ cpgs/ otachcpg-update. html). . Retrieved 2008-08-31.

Oxygen therapy 7

[11] Garcia et al. The Oxygen Concentrations Delivered by Different Oxygen Therapy Systems. Chest. 128 (4):389S. 2005.[12] Earl, John. Delivery of High FiO2. Cardinal Health Respiratory Abstracts. (http:/ / www. cardinal. com/ mps/ focus/ respiratory/ abstracts/

abstracts/ ab2003/ OF-03-257. asp)[13] Sim, DA; Dean, P; Kinsella, J; Black, R; Carter, R; Hughes, M (September 2008). "Performance of oxygen delivery devices when the

breathing pattern of respiratory failure is simulated.". Anaesthesia 62 (9): 938–40. doi:10.1111/j.1365-2044.2008.05536.x. PMID 18540928.[14] Cyanide poisoning - New recommendations on first aid treatment (http:/ / www. hse. gov. uk/ pubns/ misc076. htm)[15] Hui et al. Exhaled air dispersion during oxygen delivery via a simple oxygen mask. Chest.132(2):540. 2007.[16] Mardimae et al. Modified N95 mask delivers high inspired oxygen concentrations while effectively filtering aerosolized microparticles.

Annals of Emergency Medicine. 48(4), 391-399. 2006.[17] Somogyi et al. Dispersal if Respiratory Droplets With Open vs Closed Oxygen Delivery Masks: Implications for the Transmission of Severe

Acute Respiratory Syndrome. Chest. 125(3):1157-7. 2004.[18] Patarinski, D (1976). "Indications and contraindications for oxygen therapy of respiratory insufficiency" (in Bulgarian with English

abstract). Vŭtreshni bolesti 15 (4): 44–50. PMID 1007238.[19] Experience with paraquat poisoning in a respiratory intensive care unit in North India (http:/ / www. sma. org. sg/ smj/ 4712/ 4712a2. pdf)[20] "EMT Medication Formulary" (http:/ / www. phecit. ie/ Documents/ Clinical Practice Guidelines/ EMT 3rd Edition CPGs/ EMT Appendix 1

Medication Formulary. pdf). PHECC Clinical Practice Guidelines. Pre-Hospital Emergency Care Council. 15 July 2009. p. 84. . Retrieved 14April 2010.

[21] Smerz, R.W. (2004). "Incidence of oxygen toxicity during the treatment of dysbarism" (http:/ / archive. rubicon-foundation. org/ 4010).Undersea and Hyperbaric Medicine 31 (2): 199–202. PMID 15485081. . Retrieved 2008-04-30.

[22] Hampson, Neal B.; Simonson, Steven G.; Kramer, C.C.; Piantadosi, Claude A. (1996). "Central nervous system oxygen toxicity duringhyperbaric treatment of patients with carbon monoxide poisoning" (http:/ / archive. rubicon-foundation. org/ 2232). Undersea and HyperbaricMedicine 23 (4): 215–9. PMID 8989851. . Retrieved 2008-04-29.

[23] Brubakk, A. O.; T. S. Neuman (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed.. United States: Saunders Ltd..pp. 800. ISBN 0702025712.

[24] Undersea and Hyperbaric Medical Society. "Decompression Sickness or Illness and Arterial Gas Embolism" (http:/ / www. uhms. org/ResourceLibrary/ Indications/ DecompressionSickness/ tabid/ 275/ Default. aspx). . Retrieved 2008-05-30.

[25] Acott, C. (1999). "A brief history of diving and decompression illness" (http:/ / archive. rubicon-foundation. org/ 6004). South PacificUnderwater Medicine Society Journal 29 (2). ISSN 0813-1988. OCLC 16986801. . Retrieved 2008-05-30.

[26] Longphre, J. M.; P. J. DeNoble; R. E. Moon; R. D. Vann; J. J. Freiberger (2007). "First aid normobaric oxygen for the treatment ofrecreational diving injuries" (http:/ / archive. rubicon-foundation. org/ 5514). Undersea Hyperb Med. 34 (1): 43–49. ISSN 1066-2936.OCLC 26915585. PMID 17393938. . Retrieved 2008-05-30.

[27] Kol S, Adir Y, Gordon CR, Melamed Y (June 1993). "Oxy-helium treatment of severe spinal decompression sickness after air diving" (http:// archive. rubicon-foundation. org/ 2133). Undersea Hyperb Med 20 (2): 147–54. PMID 8329941. . Retrieved 2008-05-30.

[28] Austin, Michael A; Wills, Karen E; Blizzard, Leigh; Walters, Eugene H; Wood-Baker, Richard (18 October 2010). "Effect of high flowoxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial" (http:/ / www. bmj.com/ content/ 341/ bmj. c5462. full). British Medical Journal 341 (oct18 2): c5462. doi:10.1136/bmj.c5462. ISSN 0959-8138. PMC 2957540.PMID 20959284. .

[29] Kim, Victor; Benditt, Joshua O; Wise, Robert A; Sharafkhaneh, Amir (2008). "Oxygen therapy in chronic obstructive pulmonary disease".Proceedings of the American Thoracic Society 5 (4): 513–8. doi:10.1513/pats.200708-124ET. PMC 2645328. PMID 18453364.

[30] "Study: Change in how medics use oxygen could reduce deaths" (http:/ / www. ems1. com/ medical-clinical/ articles/905005-Study-Change-in-how-medics-use-oxygen-could-reduce-deaths/ ). . Retrieved 2011-10-11. (see comments for study meta-analysis)

[31] Werley, Barry L. (Edtr.) (1991). "Fire Hazards in Oxygen Systems". ASTM Technical Professional training. Philadelphia: ASTMInternational Subcommittee G-4.05.

[32] "Home Oxygen Therapy and Cigarette Smoking: A Dangerous Practice" (http:/ / www. medbc. com/ annals/ review/ vol_19/ num_2/ text/vol19n2p99. asp). Annals of Burns and Fire Disasters 19 (2). June 2006. .

[33] http:/ / www. faa. gov/ about/ initiatives/ cabin_safety/ portable_oxygen/[34] http:/ / www. open-aire. com/ rentalcenter/

External links• American Association for Respiratory Care Clinical Practice Guideline: Oxygen Therapy for Adults in the Acute

Care Facility — 2002 Revision & Update (http:/ / www. rcjournal. com/ cpgs/ otachcpg-update. html)• Adult domiciliary oxygen therapy: a patient's perspective (http:/ / www. mja. com. au/ public/ issues/

183_09_071105/ cah10501_fm. html) Article contains consumer perspective

Article Sources and Contributors 8

Article Sources and ContributorsOxygen therapy  Source: http://en.wikipedia.org/w/index.php?oldid=443636621  Contributors: 224329, 2over0, Acahill-lambert, Activeforever1, Ale jrb, Alexps, Andrewjuren, Arcadian,Belovedfreak, Benwildeboer, Blouis79, BrianH123, Bryan Derksen, Captain-n00dle, Ccrazymann, Cdang, Charles Matthews, CommonsDelinker, Deathawk, Discospinster, Dovid, Drbarbiq7,Eastmed, Echofree, Erich gasboy, Euchiasmus, Gene Hobbs, GiollaUidir, Guy Harris, Gypsydoctor, Headbomb, Hebrides, Heggyhomolit, HighInAZ, Hmwith, Impherring13, JaGa, Jared999,Jfdwolff, John, JohnCD, JonHarder, Jonathansopko, Jumbo Snails, Jusjih, Kbdank71, Kennyrud, Kizor, Kyoko, Lakehealth, LilHelpa, LizardJr8, Macaddct1984, Mandarax, Marcika,Mark.murphy, Mattisse, Mausy5043, Mazarin07, Milton Stanley, Monstersincorporated, Nightstallion, Nihiltres, Nono64, Nv8200p, Otrfan, Owain.davies, Owen, Oxygentherapy, PeteLee, Pjf,Rajab, Red Director, RedWolf, RexxS, Rfnhussain, Rjwilmsi, Ronhjones, Sagaciousuk, Scottridlams, Seaphoto, Serlin, Shaggorama, Spitfire, Srice13, SteOsu, Stevenfruitsmaak, Sverdrup,Vegaswikian, Washburnmav, Wickedroo, Zhou Yu, 118 anonymous edits

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