Oxygen Delivery Devices

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Oxygen Delivery Devices

• By Dr H. El sharkawy

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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

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Delivery DevicesLow and High Flow

• Getting the gas to the patient

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Low Flow Device Definition

• FiO2 can vary with
• Patients respiratory rate and pattern
• Flow of gas from the equipment
• Equipment reservoir
• Does NOT fully meet patients 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 gt80 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

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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

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Even Less Commonly Used
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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.
• HENRYS 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
• Boyles 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
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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
• Dont get confused between NO and N2O

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Thats all folks
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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!
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DoctorYour 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)

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Emergency AssessmentFocused Exam / Important
Labs / Differential

• DOES THIS PATIENT NEED TO BE INTUBATED!!!
• The Look vs VOPS

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The Look

• Speech Pattern
• Vital Signs
• Breathing Pattern
• Accessory Muscles
• Retractions
• Thoraco-Abdominal Paradox
• Hoovers Sign
• Pulsus Paradox

• Air Movement
• Cyanosis
• Patients Own Assessment

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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

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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax ? ? Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax ? ? Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax ? ? Hyper-resonant
Atelectasis ? ? Dull
Pulmonary Edema
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax ? ? Hyper-resonant
Atelectasis ? ? Dull
Pulmonary Edema Crackles
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull (Crackles)
Pneumothorax ? ? Hyper-resonant
Atelectasis ? ? Dull
Pulmonary Edema Crackles
Effusion
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull Crackles, Egophony
Pneumothorax ? ? Hyper-resonant
Atelectasis ? ? Dull
Pulmonary Edema Crackles
Effusion ? ? Dull Egophony
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Focused Exam
Breath Sounds Fremitus Pectoriloquy Percussion Extra Sounds
Bronchospasm Wheezing
Pneumonia ? (Bronchial) ? Dull Crackles, Egophony
Pneumothorax ? ? Hyper-resonant
Atelectasis ? ? Dull
Pulmonary Edema Crackles
Effusion ? ? Dull Egophony
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Common CXR Dilemmas

• White Out
• Three Major Causes
• 1.
• 2.
• 3.
• How to Distinguish

• Pneumo vs Skin Fold
• How to Distinguish

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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.

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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

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Oxygen

• How Much?
• Once Saturated is More Better?
• ? Blunting Drive to Breath ?
• Type of Delivery Device

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Oxygen Delivery Devices

• Nasal Cannula
• 24-44 FIO2
• ? FIO2 per liter

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Oxygen Delivery Devices

• Nasal Cannula
• 24-44 FiO2
• Simple Face Mask
• 40 60 FiO2

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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

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Oxygen Delivery Devices

• Venturi Mask
• Includes a valve allowing precise FiO2 delivery
  (? Advantage for COPD patients)
• 24-40 FiO2

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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

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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)

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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

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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 timemaybe

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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

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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