Oxygen Delivery Devices By Dr H. El sharkawy. Administration of Oxygen Need for Oxygen Hazards...

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Oxygen Delivery Devices

By Dr H. El sharkawy

Administration of Oxygen

Need for Oxygen

Hazards

Delivery Devices

Hyperbaric Oxygen

Other Medical Gases

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5 Indications for Oxygen Therapy Suspected or Documented hypoxia Severe trauma MI Post op

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Hazards of Oxygen Therapy

Ventilatory depression Absorption atelectasis ROP(retinopathy of prematurity Oxygen toxicity Fire hazard Contamination

Delivery DevicesLow and High Flow

Getting the gas to the patient

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Low Flow Device Definition

FiO2 can vary with: Patient’s respiratory rate and pattern Flow of gas from the equipment Equipment reservoir

Does NOT fully meet patient’s inspiratory demand Needs additional mixing with room air

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Low Flow Oxygen

Low Flow Nasal cannula Simple oxygen mask Non-rebreathe mask Face tent

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Nasal Cannula

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Nasal Cannula

Delivers about 24 to 44% FiO2 Flow is set at 1 to 6 liters for adults

0.1 to 0.9 with newborns (special flowmeter) FiO2 varies with patient respiratory rate and

volumes Add moisture over 4 L/min or with pt comfort

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Simple Mask

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Simple Mask

Delivers 40 to 50% oxygen Need at least 5 L/min to flush out CO2

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Non – RebreatheMask

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A reservoir system

Delivers better oxygenation then simple mask.

The most oxygen without intubation 50 to 70% oxygen (some say 80-90-100%)

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Something New (VIASYS)

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The Hi-Ox 80

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Helps patients more ways than one Provides an FiO2 of >80% at a flow of 8

L/min Studies show that high FiO2

Reduces nausea post operatively Reduces s/p infections by 50%

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Trach Mask

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Trached?

Usually blue tubing connected to heated aerosol.

Can use transport tee

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T-piece

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Tee Piece

Must be intubated With aerosol mist setup or transport tee

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Face Tent

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Face Tent

Ideal for post anesthesia Not enclosed and claustrophobic Only for low oxygen concentrations

Delivery DevicesHigh Flow

Venturi (Entrainment) Mask

Aerosol mist setup

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Definition of High Flow

Meets or exceeds patient inspiratory demand (usually textbook of 30 LPM)

Provides precise concentrations despite patients breathing pattern

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Why 30 Liters per minute?

Based on minute volume Respiratory rate times tidal volume

The number of breaths multiplied by the size of the breaths

People inspire one-third of the time.

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Air Entrainment Mask

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Venturi Masks

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Entrainment Ratios

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Venturi – High flow device

Ideal for use with CO2 retainers Matches patient demand Usually 24 to 50% (some have up to 100%

running at flush)

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Aerosols and Nebulizers

Jet nebulizers Small volume nebs Aerosol setups

Aerosol output calculations Aerosol density calculations

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Keep the flow up!

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Monitoring Oxygen Therapy

Pulse Oximetry Arterial Blood gases Work of Breathing Tidal Volume and Respiratory Rate Pulse and Blood Pressure

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Less common used O2 delivery Head hoods Pendant or reservoir nasal cannula Bi-flow Tracheal catheters Croup tents Incubators Hyperbaric chamber

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Head Hood

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Head Hood

Newborns only Watch for cooling

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Pendant Reservoir

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Reservoir Cannula

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Tracheal Catheter

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Nasal Catheter

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Oxygen (Croup) Tent

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Croup Tent

Can supply 30 to 50% oxygen

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Incubator

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Oxygen Blender

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Functional Diagram of Blender

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Blenders

Found on all ventilators Easiest and most accurate way to deliver

oxygen at precise percentages

Even Less Commonly Used

Hyperbaric Oxygen (High Pressure Oxygen)

Monoplace Chamber

Multiplace Chamber

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Hyperbaric Oxygen

Used to increase the amount of oxygen carried in the blood.

HENRY’S LAW – the amount of gas dissolved in a liquid is directly related to the partial pressure of the gas(es) above the liquid.

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Hyperbaric Oxygen

Reduce the size of the air bubbles in the body Air Embolism Decompression sickness

Boyle’s Law – Pressure and Volume are inversely related.

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Indications for HBO

Decompression sickness(inflammation mouth) Diver with the ‘bends’

Gas Embolism Reduces the size of the bubbles

Carbon monoxide and Cyanide poisoning Decreases half life of CO bond

Severe anemia (blood loss) Wound healing

Ischemic skin grafts, flaps, burns

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Monoplace HBO Chamber

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Hyperbaric Chambers

Other Gases

Carbogen

Heliox

Nitric Oxide

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Carbogen

Usually 95% oxygen and 5% carbon dioxide Treats singulitus (hiccups) Provides a challenge to stimulate breathing in

some patients

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Heliox

Useful with ventilators and in ER Upper airway narrowing

Croup Asthma Stridor Tracheal tumors

The less dense gas is ideal for the tight passage through a narrow passage

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Nitric Oxide

Treatment of neonates with hypoxic respiratory failure associated with pulmonary hypertension

A significant improvement has been noted with premature infants

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Nitrous Oxide

Used with anesthesia Don’t get confused between NO and N2O

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That’s all folks

Respiratory Failure

Immediate Assessment & Treatment Indications For Intubation Non-Invasive Ventilatory Options Therapeutic Thoracentesis Initial Ventilator Settings

Tempo: seconds… Reflex Reaction

1 – 5 minutes.. … Emergency Assessment

20 minutes…. Additional Therapy

Goal: Stabilize the Patient within 20 minutes!

“Doctor…Your patient is in Respiratory Distress….?”

“Reflex” Reaction….. Vitals

Including pulse ox Oxygen….

50% face mask “Albuterol Neb”

0.5 cc solution mixed with 2.5 cc NS (= 2.5mg)

“Emergency” AssessmentFocused Exam / Important Labs / Differential

DOES THIS PATIENT NEED TO BE INTUBATED!!!

“The Look” vs “VOPS”

“The Look”

Speech Pattern Vital Signs Breathing Pattern

Accessory Muscles Retractions Thoraco-Abdominal

Paradox Hoover’s Sign Pulsus Paradox

Air Movement Cyanosis Patient’s Own

Assessment

Assessment and Treatment - Continued

Focused Physical Wheezing vs Crackles vs

No Breath Sounds Pulse Oximeter/ABG CXR

CHF Pneumonia Effusions Atelectasis Pneumothorax Clear

what should you think of?

Therapeutic Thoracentesis

Oxygen Bronchodilators Adequate Nursing /

Monitoring ? Non-Invasive

Ventilation “CPAP” or “BiPAP”

Focused Exam

Breath SoundsFremitus

PectoriloquyPercussion Extra Sounds

Bronchospasm

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

Bronchospasm Wheezing

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Pneumonia

(Bronchial) Dull (Crackles)

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

Pneumonia

Pneumothorax

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Breath Sounds

Fremitus

Pneumonia

Pneumothorax Hyper-resonant

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Pneumonia

Atelectasis

Pulmonary Edema

Effusion

Focused Exam

Pneumonia

Atelectasis Dull

Pulmonary Edema

Effusion

Focused Exam

Pneumonia

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion

Focused Exam

Pneumonia

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion

Focused Exam

Pneumonia

(Bronchial) Dull

Crackles, Egophony

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion Dull Egophony

Focused Exam

Pneumonia

(Bronchial) Dull

Crackles, Egophony

Atelectasis Dull

Pulmonary Edema

Crackles

Effusion Dull Egophony

Common CXR Dilemmas

White OutThree Major Causes:

How to Distinguish:

Pneumo vs Skin FoldHow to Distinguish:

Emergency Needle Decompression Prepare area (i.e., Betadine). Technique:

14 or 16-gauge IV catheter Second intercostal space Superior to the third rib Midclavicular line 1-2 cm from the sternal edge hold perpendicular to the chest wall listen for the hissing sound of air escaping remove the needle while leaving the catheter in place.

Prepare the patient for tube thoracostomy.

Therapeutic Thoracentesis

If effusion is large and symptoms are significant. Otherwise, if non-urgent, call the Pulmonary

Procedure Fellow in the morning (63893) Technique

http://content.nejm.org/misc/videos.shtml?ssource+recentVideos

Common Mistakes Preparation

Location (specific rib) Comfort

Angle Volume

Oxygen

How Much? Once Saturated is More Better? ? Blunting Drive to Breath ?

Type of Delivery Device

Nasal Cannula 24-44% FIO2

? FIO2 per liter

Nasal Cannula 24-44% FiO2

Simple Face Mask 40 –60% FiO2

Non-Rebreather Mask “resevoir” with one-way

valve 60-100% FiO2

Venturi Mask Includes a valve

allowing precise FiO2 delivery (? Advantage for COPD patients)

24-40% FiO2

Non-Rebreather Mask “resevoir” with one-way

valve 60-100% FiO2

Venturi Mask Includes a valve

allowing precise FiO2 delivery (? Advantage for COPD patients)

24-40% FiO2

Bronchodilators

Indication Any Wheezing Any “Silent” Chest ? Other

Which One(s)? Albuterol – 2.5 to 5 mg (0.5 to 1 cc of 0.5% sltn) Ipratropium – 500 mcg (one vial)

CPAP / BiPAP

CPAP Continuous Positive

Airway Pressure CPAP PEEP

Redistributes Edema Fluid Reduces Atelectasis Reduces WOB in COPD by

Counterbalancing auto-PEEP

BiPAP Bilevel Positive Airway

Pressure EPAP CPAP PEEP IPAP PS

Augments TV Reduces Atelectasis Reduces WOB

BiPAP Indications

Acute Pulmonary Edema PEEP/CPAP redistributes the alveolar edema

COPD Exacerbation reduces WOB caused by auto-PEEP

Pulmonary Infiltrates in the BMTU Post-Extubation Failures

reduces atelectasis…...buys time…maybe

Initial Settings: EPAP = 5 cm H2O

IPAP = 3 cm H2O

Titrate to Effect: Get rid of “The Look”

EPAP to improve oxygenation and counter-balance auto-PEEP (hard to assess!)

IPAP to TV & RR

Requires Close Nursing Supervision

Initial Vent Settings

Initial Goal… Get rid of “The Look” aka “Rest” the patient

A good place to start: a/c, TV = 500 cc, RR = 12 FiO2 = 100%, PEEP = 5 cm H2O

Oxygen Delivery Devices By Dr H. El sharkawy. Administration of Oxygen Need for Oxygen Hazards...

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