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Oxygen Delivery Devices and Strategies for H1N1 Patients

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Oxygen Delivery Devices and Strategies for H1N1 Patients Pandemic Planning Education Subcommittee October 2009 * * Optimization cont. What do I do if my patient is ... – PowerPoint PPT presentation

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Title: Oxygen Delivery Devices and Strategies for H1N1 Patients


1
Oxygen Delivery Devices and Strategies for H1N1
Patients
  • Pandemic Planning Education Subcommittee October
    2009

2
Outline
  • Introduction
  • Oxygen Delivery Devices
  • Optimization of Oxygenation

3
Introduction
  • Oxygen is a drug
  • Has a Drug Identification Number (DIN)
  • Colorless, odorless, tasteless gas
  • Makes up 21 of room air
  • Is NOT flammable but does support combustion.

4
Indications for Oxygen Therapy
  • Hypoxemia
  • Inadequate amount of oxygen in the blood
  • SPO2 lt 90
  • PaO2 lt 60 mmHg
  • Excessive work of breathing
  • Excessive myocardial workload

5
What does hypoxemia look like?
  • Tachycardia
  • Agitation
  • Diaphoresis
  • Cyanosis
  • Tachypnea
  • Dyspnea
  • Accessory muscle use

Adult response pediatric and neonatal patients
experience bradycardia
6
Hazards of Oxygen Therapy
  • Absorption atelectasis
  • Likely with high FIO2 in presence of partial or
    complete small airway obstruction
  • Oxygen toxicity
  • Retinopathy of prematurity
  • Oxygen induced hypoventilation
  • Rare condition manifesting in some COPD patients
    with chronic high plasma bicarbonate

7
Oxygen Therapy Devices 2 Types
  • Fixed
  • A device that meets all the patients inspiratory
    flow demands.
  • Designed to deliver a specific oxygen
    concentration to patient
  • Variable
  • Does not meet all inspiratory demands of the
    patient so some room air is breathed in
  • Oxygen concentration will vary with changes in
    the depth and rate of breathing
  • in general, the oxygen concentration is ? by ?
    the size of the reservoir

8
Fixed Device Cold Nebulizer
  • For adults set O2 flowmeter at maximum (flush)
  • 28-100 O2 selectable on collar - generally only
    reliable up to 50
  • H1N1 standard requires dry bottle routed through
    Fisher Paykal humidifier
  • Rapid respiratory rate may decrease delivered
    FIO2
  • Do not use for patient transport

9
Fixed Device High Flow Cold Nebulizer
  • Delivery at 60, 65, 75, 85, 96 selected by
    rotating collar
  • H1N1 standard requires dry bottle routed through
    Fisher Paykal humidifier
  • flowmeter must always be set to maximum!!
  • Do not use for patient transport

10
Fixed Device High Flow Cold Nebulizer mask with
Tusks
  • Corrugated tubing added to aerosol mask
    exhalation ports to ? reservoir volume and ?
    oxygen concentration
  • Strategy to increase FIO2 in mask when patient
    hyperventilating AND SpO2 not maintained
  • Should be employed with High Flow Nebulizer

11
Face Tent
  • Use with a cold nebulizer
  • The tent portion is directed upwards
  • Uses children and any patients who find mask
    claustrophobic or have had facial/nasal surgery
  • Not optimal for high FIO2 requirements

12
Tracheostomy Collar
  • Provides humidity oxygen for tracheostomy
    patients via cold neb
  • adults - 10-15 LPM up to flush
  • O2 adjusted on cold neb but maximum is usually
    50

13
Fixed Device Venturi Mask
  • Deliver a specific O2 concentration - 24, 28,
    31, 35, 40, 50
  • Concentration adjusted by changing the Venturi
    jet
  • minimum required O2 flow rate is stamped on the
    base of each Venturi jet
  • O2 flow determines accuracy of FIO2 delivered
  • Usually used for COPD patients with demonstrated
    oxygen induced hypoventilation

14
Variable Flow Nasal Cannula
  • 22 - 40
  • Stable is FIO2 based on
  • Respiratory rate
  • O2 flowrate
  • Reservoir capacity of nasopharynx
  • adults ? 6 LPM
  • infants/toddlers ? 2 LPM
  • children ? 3 LPM
  • FIO2 is not affected by mouth breathing

15
Variable Device High Flow Nasal Cannula
  • Flow rates from 6-15 LPM
  • For patients that require gt 6 LPM O2 but cannot
    tolerate a mask
  • Larger tubing inner diameter permits higher O2
    flow
  • Tubing is always green

16
Variable Device Simple Oxygen Mask
  • Flow rate of 5-10 LPM
  • 35 -50 O2
  • O2 flow and respiratory rate determine stability
    of delivered FIO2
  • CAUTION Set flow rate must be gt 5 LPM (adult and
    children) to flush exhaled carbon dioxide from
    mask

17
Variable Device Non-rebreathe Mask
  • Adults gt 12 LPM
  • 60 - 90 depending on mask fit
  • CAUTION Always ensure reservoir bag remains
    partially inflated during inspiration

18
Variable Device Non-rebreathe Mask with Filter
  • CAUTION Always ensure reservoir bag remains
    partially inflated during inspiration Ensure bag
    does not deflate during inspiration
  • Valving system directs exhaled gas through
    bacterial filter
  • May be used for transport of H1N1 isolation
    patients
  • Must be assembled from stock Ys, one way valves

19
Self Inflating Manual Resuscitator
  • Insert HME or bacterial filter between mask and
    bagger
  • If mask is retained following use, clean with
    disinfecting wipe
  • Cap the bagger when not in use

20
Manual Ventilation
  • For Respiratory Arrest
  • Deliver 1 breath every 5 to 6 seconds (10 to 12
    breaths per minute).
  • For cardiac arrest deliver 2 breaths after every
    30 compressions - deliver 8 to 10 breaths per
    minute without interrupting CPR once airway
    secured
  • Ensure that you have attached the EtCO2 sampling
    line to the correct port on the HME. The EtCO2
    sampling port has ridges to screw on the sampling
    line male

21
  • Avoid hyperventilation which may result in
  • Impaired hemoglobin function with reduced O2
    delivery to tissues
  • Gastric distension
  • Increased intrathoracic pressure causing
  • decreased venous return to the heart and
    diminished cardiac output.
  • Increased intracranial pressure

22
Complications
  • Gastric distension is the most common adverse
    event in manual ventilation
  • Distension may impair lung expansion
  • Palpate the abdomen at commencement of bagging
  • Watch for visual distension and recheck palpation
    - request gastric tube placement if abdominal
    rigidity is noted

23
Optimization of Oxygen Therapy
24
Hypoxemia
  • Hypoxemia is defined as
  • Low levels of oxygen in the blood
  • PaO2 of less than 60 mmHg (moderate)
  • SpO2 of less than 90

25
Manifestations of Hypoxemia
  • Hypoxemia will affect vital signs by
  • Increased heart rate
  • Increased blood pressure
  • Increased respiratory rate
  • CAUTION tachycardia is the adult response to
    hypoxemia children and neonates will react to
    hypoxemia with bradycardia that may rapidly
    deteriorate to cardiac arrest
  • Hypoxemia in neonates and children requires rapid
    intervention and correction

26
Hypoxemia and H1N1
  • Decompensation in hospitalized H1N1 Patients
    often begins with a decrease in SpO2 and
    increased oxygen demand
  • Be alert - and communicate even minor increases
    in oxygen flows or requirements for higher FIO2
    devices

27
Causes of Hypoxemia
  • Shunt
  • Hypoventilation
  • As carbon dioxide increases oxygen falls
  • V/Q mismatching (ventilation/perfusion) serious
    complications of H1N1 produce V/Q mismatch
  • Pneumonia
  • Pulmonary edema
  • ARDS
  • Increased diffusion gradient
  • asbestosis
  • Early pulmonary edema

28
Oxygen Therapy
  • Goal of therapy is an SPO2 of gt90 or for
    documented COPD patients 8892
  • As SPO2 normalizes the patients vital signs
    should improve
  • Heart rate should return to normal for patient
  • Respiratory rate should decrease to normal for
    patient
  • Blood pressure should normalize for patient

29
Optimization
  • My SpO2 is lt 90, what next?
  • Is the pulse oximeter working/accurate
  • Do I have a good signal?
  • Heart rate plus/minus 5 bpm?
  • Is there adequate perfusion at the probe site?
  • Can the probe be repositioned?
  • Do other vital signs or clinical manifestations
    give evidence of hypoxemia?

30
Optimization cont.
  • Check my source!
  • Ensure the O2 delivery device is attached to
    oxygen not medical air.
  • Follow tubing back to source and ensure patency
  • Are all connections tight?
  • Is the flow set high enough?
  • All nebs especially high flow large volume nebs
    need to be run at the highest rate.
  • Turn flow meter to maximum for large volume nebs.

31
Optimization cont.
  • Reposition patient.
  • Avoid laying patient flat on back.
  • Raise head of bed.
  • Encourage deep breathing/coughing
  • Listen to chest.
  • Wheezing?
  • Do they need a bronchodilator?
  • Crackles?
  • Encourage deep breathing/cough.
  • Are they fluid overloaded?

32
Optimization cont.
  • Can I improve the mechanics of breathing?
  • Patient position
  • Pursed lip breathing
  • Abdominal breathing.
  • Anxiety relief?

33
Optimization cont.
  • Increase the flow
  • With nasal prongs, increase the flow rate by 1 -2
    lpm increments until target SpO2 is reached.
  • High flow nasal prongs can be maximally set at 15
    lpm.
  • Call for physician assessment Medical if high
    oxygen flows are required.

34
Optimization cont.
  • What do I do if my patient is really hypoxemic
    (on low flow oxygen)?
  • Assess patient to determine cause of increasing
    oxygen requirements.
  • Best short term solution is non-rebreathe mask at
    15 lpm. (reservoir stays inflated)
  • Goal saturation is still 88 92.
  • Increase flow as required until re-assessed by
    physician

35
Optimization cont.
  • What do I do if my patient is really hypoxemic
    (on high flow oxygen)?
  • Assess patient to determine cause of increasing
    oxygen requirements.
  • Adjust FIO2 upwards in 10 increments titrating
    for target SPO2.
  • Call physician for further assessment

36
H1N1 points of emphasis
  • H1N1 decompensation requiring ICU admission
    usually begins with a systemic inflammatory
    response and pulmonary edema
  • CXR may not correlate with degree of oxygenation
    impairment
  • Gradually increasing oxygen requirement is a
    sentinel sign of impending respiratory failure

37
H1N1 points of emphasis
  • H1N1 Patients with escalating O2 needs warrant
    frequent monitoring for signs of impending
    respiratory failure
  • If a critical care triage system is operative,
    know the patients classification and prepare
    equipment accordingly endotracheal intubation
    may not be an option
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