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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
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath Sounds
Fremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath Sounds
Fremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull (Crackles)
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull
Crackles, Egophony
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion Dull Egophony
Focused Exam
Breath SoundsFremitus
PectoriloquyPercussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
(Bronchial) Dull
Crackles, Egophony
Pneumothorax Hyper-resonant
Atelectasis Dull
Pulmonary Edema
Crackles
Effusion Dull Egophony
Common CXR Dilemmas
White OutThree Major Causes:
1.
2.
3.
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
Oxygen Delivery Devices
Nasal Cannula 24-44% FIO2
? FIO2 per liter
Oxygen Delivery Devices
Nasal Cannula 24-44% FiO2
Simple Face Mask 40 –60% FiO2
Oxygen Delivery Devices
Nasal Cannula 24-44% FiO2
Simple Face Mask 40 –60% FiO2
Non-Rebreather Mask “resevoir” with one-way
valve 60-100% FiO2
Oxygen Delivery Devices
Venturi Mask Includes a valve
allowing precise FiO2 delivery (? Advantage for COPD patients)
24-40% FiO2
Oxygen Delivery Devices
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
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
BiPAP
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