Presentations text content in Oxygen Devices
Slide1
Oxygen Deviceshttp://www.youtube.com/watch?v=1T7TGkQcIGI
RT 210A
Slide2Oxygen Therapy – Indications*
Documented hypoxemia (PaO2 and/or SaO2 decreased below patients baseline)An acute care situation in which hypoxemia is suspected (cardiopulmonary arrest, stroke, Pneumo…)Severe trauma
*From the AARC Clinical Practice Guideline
Slide3Oxygen Therapy – Indications*
Acute myocardial infarctionShort term therapy or surgical intervention
*From the AARC Clinical Practice Guideline
Slide4Indications
When
a patient exhibits signs, symptoms or situations that indicate oxygen therapy there are very few contradictions.
A patient may need oxygen to keep the workload of the heart and lungs at a normal level. If an asthmatic patient has an asthma attack and their airways are becoming restrictive they won't be able to bring in as much air to their lungs. In this case you want the air that they are able to bring into their lungs to have higher levels of oxygen than what room air alone can provide.
One indication for oxygen is short-term therapy. In many of these situations a patient may have normal SaO2 values but are in a situation where hypoxia may be common. Some of these may be postoperative patients, CO2 poisoning, cyanide poisoning, shock, trauma, acute MI or some premature babies. Oxygen can sometimes be better used as a preventative than a treatment.
Slide5Hypoxemia
When the a patient develops hypoxemia their breathing rate will begin to rise proportionally along with their heart rate to compensate for the demand of oxygen.
P
ulmonary vasoconstriction and hypotension develop. This in turn will increase the workload on the right side of the heart and over time can lead to heart failure.
Tachypnea, tachycardia, dyspnea, lethargy/confusion develop with severe hypoxemia
Other visual symptoms include restlessness and headaches.
Slide6Oxygen Therapy – Contraindications*
There are no specific contraindications to oxygen therapy when indications are judged to be present
*From the AARC Clinical Practice Guideline
Slide7Oxygen Therapy – Hazards and Complications*
Ventilatory depression (if you supersede a patients need)Absorption atelectasisOxygen toxicity
*From the AARC Clinical Practice Guideline
Slide8Oxygen Therapy – Hazards and Complications*
Fire hazard (combustible) Retinopathy of prematurityBacterial contamination (when using humidity or aerosol)
*From the AARC Clinical Practice Guideline
Slide9Ventilatory Depression
Patients at risk:
COPD patients with
hypercapnea
, again only if the patient receives more PaO2 than they require, the FIO2 does not necessarily matter during an exacerbation, always give them enough to support appropriate tissue oxygenation.
Slide10Ventilatory Depression
Mechanism of action
Patient has “normal” P
a
CO
2
> 60 mmHg (chronic hypercapnea)
Response of central chemoreceptors blunted
P
a
O
2
decreases to < 55 mmHg
Slide11Ventilatory Depression
Mechanism of action
Decrease in oxygen level triggers response by peripheral chemoreceptors,
if they
Rate and depth of breathing increase
Slide12Ventilatory Depression
Mechanism of action
When supplemental oxygen administered, P
a
O
2
can rise to > 55 mmHg, removing stimulus to peripheral receptors
Hypoventilation results
Slide13Absorption Atelectasis
Two contributing factorsFIO2 > 0.50Air trapping
Slide14What are the types of atelectasis?
Passive
From hypoventilation, typically post surgical pain, weakness, diaphragm weakness
Resorptive
When there is
endobronchial
obstruction, there is no more ventilation and air gets absorbed from alveoli. Alveoli collapse with significant loss of lung volume. Example: Lobar atelectasis from
endobronchial
lung cancer.
Relaxation
Normally lungs are held close to chest wall by the negative pressure in pleura. In pneumothorax or pleural effusion the negative pressure in pleura is lost. Lung relaxes to its resting position
.
Adhesive
Surfactant is necessary for keeping the alveoli open. In ARDS and Pulmonary embolism there is loss of surfactant and alveoli collapse
.
Slide15Absorption Atelectasis
Mechanism of action
At higher F
I
O
2
, nitrogen in alveolus is replaced by oxygen
With obstruction of the airway, oxygen is rapidly absorbed into the capillary without replacement in the alveolus
Slide16Absorption Atelectasis
Mechanism of action
Removal of oxygen causes decrease in volume of alveolus, resulting in alveolar collapse or atelectasis
Slide17Absorption Atelectasis
Mechanism of action
May also occur in patients with low tidal volumes as a result of sedation, pain, or CNS dysfunction
Oxygen is absorbed faster than it can be replaced
Alveoli gradually decrease in volume
May eventually lead to complete collapse
May occur even without supplemental oxygen
Slide18Oxygen Toxicity
Two contributing factors
F
I
O
2
> 0.50
Time of exposure
Slide19Oxygen Toxicity
Pathophysiological changes
Damage to capillary epithelium
Interstitial edema
Thickening of alveolar capillary membrane
Slide20Slide21Oxygen Toxicity
Pathophysiological changes
Destruction of type I alveolar cells
Proliferation of type II alveolar cells
Formation of exudate
Slide22Oxygen Toxicity
Pathophysiological changes
Decrease in ventilation/perfusion ratio
Physiologic shunting
Hypoxemia
Slide23Oxygen Toxicity
Mechanism of action
Overproduction of free radicals
Safe level: F
I
O
2
≤ 0.50
Slide24Oxygen Toxicity
Slide25Fire Hazard
Risk increases as oxygen level increases
Greatest risks include operating rooms and selected procedures
Laser bronchoscopy may cause intratracheal ignition in presence of increased F
I
O
2
Slide26Retinopathy of Prematurity (ROP)
Occurs in premature and low birth weight infants
Causative factor
Increased P
a
O
2
usually greater than 80 mmHg
Covered in neonatal section of curriculum
http://www.youtube.com/watch?v=BVYwo-RmDNE
Slide27Bacterial Contamination
Associated with equipment
Slide28Assessment of the Hypoxemic Patient
Clinical signs of hypoxemia
Tachypnea
Tachycardia
Anxiety
Slide29Assessment of the Hypoxemic Patient
Clinical signs of hypoxemia
Cyanosis
Present when there are 5 grams of desaturated hemoglobin
May not be present in instances of severe anemia
May be present in absence of hypoxemia in presence of polycythemia
Slide30Assessment of the Hypoxemic Patient
Clinical signs of hypoxemia
Confusion
Lethargy
Coma
Slide31Assessment of the Hypoxemic Patient
Laboratory data
Arterial blood gas results (P
a
O
2
)
Saturation (S
p
O
2
)
Increased levels of lactic acid may indicate hypoxia
O2 delivery in COPD patients:
http://www.youtube.com/watch?v=XFieSB3TzK4
Slide32Assessment of the Hypoxemic Patient
Specific clinical conditions
Myocardial infarction
Generally given 100% oxygen, especially in ED
Recent research may show that high F
I
O
2
may cause vasoconstriction of the coronary arteries, contributing to cardiac ischemia
Slide33Assessment of the Hypoxemic Patient
Specific clinical conditions
Trauma
Overdose
Slide34Monitoring the Physiologic Effects of Oxygen
The symptoms of hypoxia are cognitive impairment, cardiac rhythm and conduction dysfunction, and renal dysfunction.
Monitoring arterial blood gas analysis is standard for documenting oxygenation, ventilation, and acid–base balance.
Pulse
oximetry
is the most common form of continuously monitoring oxygen saturation.
Oxygen analyzers are used to measure the concentration of oxygen administered to patients.
Slide35Oxygen Devices
http://www.youtube.com/watch?v=OW-LkJv61eo&feature=related
Low flow systems
High flow systems
Positive pressure (vents, IPPB, resuscitation bags)
Hyperbaric chamber
Slide36Low Flow Oxygen Systems
Deliver flows at less than the patient’s inspiratory flow rate, diluting the inspired oxygen with room air
F
I
O
2
varies dependent upon the specific device and the patient’s inspiratory flow
Slide37Low Flow Oxygen Systems
Conditions required for low flow systems
V
T
between 300 and 700 mL
f < 25 breaths per minute
Regular breathing pattern
Slide38Nasal Cannula
Used on adults pediatrics and neonatesAdult flows: 0.5-6LInfant/neonatal flows: typically less than 1 LTypically a low flow device but may be high flow if given as a high flow nasal cannulaAdd humidity for flows over 4L or anytime a infant/neonate or pediatric is on any amount of O2
Slide39Delivery Devices – Nasal Cannula
Advantages
Economical
Comfortable – better patient compliance
Patient able to eat, speak, and cough with cannula in place
Mouth breathing not a significant factor
Slide40Estimating FiO2
Nasal Cannula flow rateFIO21 L.242 L.283 L.324 L.365 L.406 L.44
O2 mask flow rate
FIO2
5-6 L
0.4
6-7 L
0.5
7-8 L
0.6
Slide41NC
0.5 LPM = 22%
1 LPM = 24%
2 LPM = 28%
3 LPM = 32%
4 LPM = 36% starting at 4 LPM a bubble humidifier is required to prevent
5 LPM = 40% irritating the nasal mucosa which can cause nose bleeds or
6 LPM = 44% drying of mucus.
Slide42Delivery Devices – Nasal Cannula
DisadvantagesImprecise concentration of oxygen delivered May fluctuate according to patient’s breathing patternMay cause irritation to nares, nasal airway, or ears (around ear), may use cushion around earEasily dislodged
Slide43Delivery Devices – Nasal Cannula
Flows generally not greater than 6 L/minMay use with very low flows, less than ¼ L/minFlows ≤ 4 L/min do not require use of humidifier
Slide44Figure 16-9A: Nasal cannula with elastic strap.
(A) Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999.
Slide45Figure 16-9B: Over-the-ear style nasal cannula.
Slide46Figure 16-9C: Various styles of nasal prongs.
Courtesy of Teleflex Incorporated. Unauthorized use prohibited
Slide47Nasal Cannula
Keep flange against upper lip
NC should be adjusted below chin, do not place behind head, choking risk; unless applying to neonates/small
peds
. On infants, tape to face
Slide48Nasal Cannula
Insert the nasal cannula into your nose and breathe through your nose normally.If you’re not sure whether oxygen is flowing, place the cannula in a glass of water. Bubbles mean that oxygen is flowing.Patients may use extension tubing for increased mobility
Slide49Simple Mask/O2 mask
Slide50Figure 16-10B: Simple O
2 mask.
© Corbis/age fotostock
Slide51Simple Oxygen Mask
Typically given for short term use, during deliveries, in the ER
Flows begin at 5-6L at least to prevent rebreathing exhaled CO2
Max flow is around 10-12L
DO not add a bubble humidifier
Not used regularly by RT’s
Slide52Simple Mask
Used for patients in need of oxygen in the range of 35% to 50%.
Again
this is a estimation since it is a low flow device. This mask is used on children through adults but not neonates. The mask can be uncomfortable and needs to be removed to eat. Used for short term or emergency use requiring moderate O2 use such as CHF, Pulmonary Emboli, Pulmonary Fibrosis, Labor, Surgery, Heart attack, and a multitude of other diseases. Not for CO2 retainers.
Slide53Delivery Devices – Simple Oxygen Mask
Advantages
Can deliver moderate concentrations (F
I
O
2
between 0.35 and 0.55 at flows of 5 to 10 L/min)
Economical
Mouth breathing not a factor
Slide54Delivery Devices – Simple Oxygen Mask
Disadvantages
Uncomfortable for most patients
Must be removed for eating, speaking, expectorating
May allow vomitus to be aspirated
Slide55Delivery Devices – Simple Oxygen Mask
Disadvantages
May allow accumulation of CO
2
and rebreathing if flow is inadequate
Can irritate skin and cause pressure sores
http://www.youtube.com/watch?v=tBUjR5HDqNs&feature=related
Slide56Aerosol Mask
Used for the delivery of aerosol. Either by:Small volume nebulizer or Large volume nebulizerCan be a face or trach maskFIO2 dependent on device in it is used
Slide57Partial Rebreathing Mask
No one way valvesOtherwise looks identical to a non rebreathing mask
Slide58Partial Rebreathing Mask
Originally used in anesthesia; currently used for short-term therapy requiring moderate to high F
I
O
2
, Not a commonly used mask
Has a reservoir bag that fills with oxygen but also exhaled CO2. Delivers up to 60% O2 with flows of 10-15 LPM. The bag should not deflate on inspiration, if it does INCREASE THE FLOW. Used for the delivery of moderately high FIO2’s and is given for the same reasons a simple mask is given. Usually seen in emergency rooms. Not for CO2 retainers. This is a low flow oxygen device, the patient should be breathing adequately and simply need an increased FIO2.
Slide59Partial Rebreathing Mask
Advantages
Able to deliver moderate concentrations of oxygen (F
I
O
2
between 0.40 And 0.70)
Economical
Mouth breathing not a factor
Slide60Partial Rebreathing Mask
Disadvantages
Uncomfortable for many patients
Must be removed for eating, speaking, expectorating
Slide61Partial Rebreathing Mask
Disadvantages
May allow vomitus to be aspirated
Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails
Slide62Non Rebreathing mask (NRB)
Looks similar to the partial rebreathing mask except this one has 3 one way valves that prevents the patient from exhaling CO2 into the reservoir bag.
Instead
the bag is filled with 100% O2 that the patient inhales. This device is set at flows of 10-15 LPM and is similar to the partial rebreathing mask in that the bag should not deflate on inspiration.
This
device can deliver 55% to 95% oxygen depending on how many one way valves are present. This mask is given in all emergencies, for nitrogen washout, ARDS, heart attack, pulmonary embolism, CHF,
pnemothorax
, pneumonia, and a multitude of other diseases in which the patient is spontaneously breathing but requires high FIO2’s. This is not for CO2 retainers unless it is an emergency situation.
Slide63Non-Rebreathing Mask
Used primarily in emergencies and for short-term administration of high concentrations of oxygen
One way valves
Slide64Non-Rebreathing Mask
Differentiated from partial rebreathing mask by presence of valve between mask And reservoir bag
http://www.youtube.com/watch?v=VV5w4qerBDg
http://www.youtube.com/watch?v=fyg5FnGk0zA
Slide65Non-Rebreathing Mask
Sufficient flow must be maintained; evidenced by reservoir bag always being at least partially inflated
Usually has anti-entrainment valve on only one side of mask; precaution against suffocation in the event of oxygen source failure
Slide66Non-Rebreathing Mask
Advantages
Able to deliver relatively high concentrations of oxygen (F
I
O
2
between 0.60 and 0.80)
Theoretically able to deliver up to F
I
O
2
of 1.00
Economical
Easy to apply
Slide67Non-Rebreathing Mask
Disadvantages
Uncomfortable for many patients
Must be removed for eating, speaking, expectorating
Slide68Non-Rebreathing Mask
Disadvantages
May allow vomitus to be aspirated
Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails
Slide69Reservoir (Oxygen Conserving) Cannula
Uses a reservoir to trap and build up oxygen that the patient inspires. Uses up to 4 LPM of oxygen, and is worn in the same manor as a nasal cannula.
There
are two types: pendant and nasal pillow.
The pendant cannula hangs down to chest and forms a pendant reservoir for oxygen. The nasal pillow is a mustache reservoir the sits on the upper lip. Both types are unattractive for the patient but saves money by using less flows 0.25 LPM to 4 LPM.
Primary use in home care and/or ambulatory patients
Slide70Reservoir Cannula
Oxymizer and Oxymizer Pendant brand reservoir cannulas store oxygen in a reservoir during exhalation and deliver a bolus of 100% oxygen upon the next inhalation. These devices were originally designed for portable home oxygen therapy. However, they are finding increasing use in acute care settings for patients who are difficult to supply oxygen via standard nasal cannulas and as high-delivery alternatives to oxygen delivery via a face mask
Nasal Pillow and Pendant
Slide71Reservoir Cannula
Reservoir cannula
Pendant reservoir cannula
Slide72Slide73Reservoir (Oxygen Conserving) Cannula
Advantages
Lowers oxygen usage, thereby lowering cost
Allows greater mobility secondary to longer duration of cylinder
Slide74Reservoir (Oxygen Conserving) Cannula
Disadvantages
Unattractive (many home care cannulas are now hidden into hats, visors…)
Must be replaced regularly (See manufacturer’s specifications), increasing cost
Breathing pattern affects performance
Slide75Transtracheal Catheter
Teflon catheter surgically inserted between second and third trachea rings
Increases the anatomic reservoir during expiration providing greater bolus of oxygen to be inspired
Slide76Transtracheal Catheter
Used primarily in home care and for ambulatory patients who will not accept nasal oxygenNot commonly used. Surgically inserted into the trachea by MD. Uses less flow than a nasal cannula or a nasal catheter. Good for long term oxygen use on patients that do not tolerate nasal cannulas and need increased mobility. Needs a humidifier at any flow. Needs to be changed and clean periodically to prevent mucus plugs.
Slide77Transtracheal Catheter
Advantages
Able to deliver very low flows of oxygen (1/4 to 4 L/min.)
Uses less oxygen, lowering costs
Slide78Transtracheal Catheter
Advantages
Improvement in compliance with therapy
Humidification not required because of low flows
Slide79Transtracheal Catheter
Disadvantages
High initial cost (surgical procedure)
Possibility of infection
Slide80Transtracheal Catheter
Disadvantages
Easily plugged by mucus
If removed for replacement, tract may close
Slide81Transtracheal Catheter
Slide82Nasal Catheter
Less
commonly used. Long term nasal cannula that bypasses the upper airway
.
Used during
bronchoscopys
and for long term use in children. Soft and smooth open distal end facilitates non-traumatic insertion, Proximal end is fitted with color coded funnel shape connector for easy connection to oxygen source. Uses less flow than a nasal cannula but delivers the same oxygen concentration. Requires a humidifier at any flow. Hard to insert and may cause gagging and aspiration if inserted to deeply.
Changed every 8 hours!
Slide83Nasal Catheter
Slide84Figure 16-8: Nasal catheter for oxygen administration.
Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999.
Slide85OxyMask
Developed in 2005Open mask design, FIO2 based on flow inputted into mask as indicated on package. Not considered a high flow device, as the % may varyRanges from 25-90% O2
Slide86Oxygen Devices
Venturi
Mask Setup
http://www.youtube.com/watch?v=qJ9ZIAYAKBY&feature=related
Large Volume Nebulizer
http://www.youtube.com/watch?v=0HUJs0FgkoY&feature=related
Simple Mask
http://www.youtube.com/watch?v=fIdioyC4Bjc&feature=related
Overall:
http://www.youtube.com/watch?v=OW-LkJv61eo&feature=related
Slide87
High Flow Oxygen Systems
Provide a flow of oxygen equal to or exceeding the patient’s peak inspiratory flow
Use either air entrainment or blending to provide precise concentrations of oxygen
Slide88High Flow Oxygen Systems
Conditions that may require high flow systems
V
T
> 700 ml
f > 25 breaths per minute
Irregular breathing pattern
Need for delivery of precise concentration of oxygen
Slide89High Flow Oxygen Systems
Delivery devices
Air entrainment (Venturi) mask
Air entrainment nebulizer
Blending systems
Slide90Venturi Mask
Set flow dependent upon final concentration of oxygen desired
Concentrations available between 24% and 50%
As the FIO2 is increased the total flow decreases
The device depends on the
venturi
entrainment size, the input flow and obstructions
http://www.youtube.com/watch?v=zdIXQVVuLs4
Slide913 designs. Two change the entrainment window size to increase/decrease FIO2, the other has colored adapters. The flow required is indicated on the device
Slide92Venturi Mask
Calculation of total flow to the patient
2 ways (memorizing ratios or magic box)
Both methods give you the ratio. Add the ratio together then multiply by the flow the patient is set on. To determine if you are meeting a patients total flow take this total flow and compare it to a patients (
Ve
x3)
Slide93
Figure 16-12: Magic box to determine oxygen-to-air ratio when mixing O
2
and air. Examples are shown for 40% and 60% O
2
.
Slide94Magic Box
Set up magic box with given % O2 in the middle of boxPlace 100 and 21 and subtract from 40. This gives you the ratio.
Slide95Memorizing ratios:
.28
.30
.35
.40
.50
.60
Primary ratios
Slide96Slide97Venturi Mask
Advantages
Inexpensive
Easy to apply
Stable, precise concentration
Ideal for COPD, as it gives high flow and also precise FIO2
Maybe adapter for
Trach
use
Slide98Venturi Mask
Disadvantages
Generally limited to adult use
Uncomfortable, noisy
Slide99Venturi Mask
Disadvantages
Must be removed for eating, speaking, expectorating
F
I
O
2
varies if entrainment port occluded or in the presence of back pressure, or water in tubing if using a LVN
If port occluded FIO2 increases
Slide100Air Entrainment Nebulizer
Generally no more than 15 L/min. input; should maintain output of at least 60 L/min
Used when aerosol is desired, e.g., patients with artificial airways
Slide101Venturi Mask
Slide102Color adaptor type- Orifice size changes
Venturi valveFlow rateOxygen deliveredcolor(l/min)(%)Blue224White428Yellow635Red840Green1260Treatment with oxygen60% or/>101 rebreathing90-94
Slide103Figure 16-18C: Changes in air entrainment by changing jet size or changing size of the entrainment port.
Slide104Air Entrainment Nebulizer
AdvantagesStable, precise concentration when FIO2 > 0.28 And < 0.40Provides aerosolInexpensiveEasy to apply
Slide105LVN
Used when upper airway is bypassed (ETT,
Trach
)
Used for croup, stridor
Not used for Asthmatics
Typically given- Bland aerosol with sterile water
Slide106Figure 16-14B: Large-volume nebulizers.
Courtesy of Teleflex Incorporated. Unauthorized use prohibited
Slide107Figure 16-15A: Aerosol mask
(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.
Slide108Figure 16-15B: Briggs T piece
(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.
Slide109Figure 16-15C: Face tent
(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.
Slide110Figure 16-15D: Tracheostomy collar
(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.
Slide111Figure 16-17: Injection nebulizer, in which additional flow is injected at the outlet of the nebulizer.
Courtesy Jeffrey J. Ward, R.R.T.
Slide112Figure 16-26: Equipment for heliox administration to spontaneously breathing patients.
Slide113Figure 16-20: High-flow oxygen delivery system using two flow meters.
Courtesy of Dr. Dean Hess
Slide114Air Entrainment Nebulizer
Disadvantages
Increased risk of infection
F
I
O
2
varies if entrainment port occluded or in the presence of back pressure
Slide115Components of an Air Entrainment Device
Slide116Aerosol Mask
Slide117Large Volume Nebulizer
http://www.youtube.com/watch?v=0HUJs0FgkoY
T
his also uses
Bernoullis
principle and has an adjustable FIO2. The nebulizer provides cool mist to patients with stridor or upper airway edema. Also used for patients with artificial airways in need of humidification. It is also utilized for patients with thick tenacious secretions. The flow is set between 8 and 15 LPM. The concentration of O2 is 28% to 100%. The higher the concentration the lower the total flow due to the closing of the
venturi
which adds or takes away air dilution. The nebulizer sometimes requires two flow meters when using higher FIO2 in order to achieve proper misting.
Slide118Blending Systems
Generally used when high flows (> 60 L/min.) required
Separate pressurized air and oxygen sources required
Slide119Blending Systems
Manually blended system
Each gas manually set with flowmeter
Total flow and desired F
I
O
2
must be calculated
Slide120Blending Systems
To confirm proper operation of an O2 blending system there are three major steps.
1.) Make sure that the inlet pressures of the air and O2 are within the specifications of the manufacturer.
2.) Test the alarms for low air and O2 by disconnecting the sources
seperately
. Make sure that the safety bypass system is working correctly.
3.) Make sure to analyze the O2 concentration at levels of 100%, 21% and at desired FIO2.
The use of a blender is for when O2 concentrations need to be provided at a higher rate or flow. Flow meters have limitations and therefore cannot provide these higher rates like a blender can do.
Slide121Blending Systems
Manually blended systemWill deliver precise FIO2 if calculated correctlyDeviation of either flow changes FIO2 and total flow
Slide122Blending Systems
Oxygen blender
Able to deliver very precise concentrations
Able to deliver high flows across a wide range of concentrations
Slide123Blending Systems
Oxygen blender
Must check with analyzer periodically to confirm proper operation and eliminate possibility of blender failure
Slide124Oxygen Blending Device
Slide125Enclosure Systems
One of the oldest approaches to oxygen administration
Provides patient with controlled atmosphere
Used primarily with infants and children
Slide126Enclosure Systems
Oxyhood
Used for neonates and infants that requires oxygen from 21% up to 100%. Flows must be set at a minimum of 7 LPM to prevent CO2 build up. A hood covers the infants head without directly attaching to the patient. The hood is comfortable but difficult to clean. The FIO2 is measured at the bottom near the patients face with an O2 analyzer due to layering affects of oxygen. The hood amplifies sound, so minimize noise around the babies sensitive ears. A humidifier is used instead of a nebulizer due to the noise factor. Used for Nitrogen washout for pneumothorax or as a weaning tool off nasal CPAP
Slide127Oxygen Hood
Used with infants
Minimum flow normally of 7 L/min
Slide128Oxygen Hood
Disadvantages
Noise level can cause auditory damage
Difficult to clean and/or disinfect
Slide129Oxygen Hood
Disadvantages
Need to ensure neutral thermal environment is maintained by using warmed gas, especially with premature infants
Slide130Oxygen Hood
Slide131Enclosure Systems
Delivery devices
Oxygen tent
Oxygen hood
Incubator (isolette)
Slide132Oxygen Tent
Generally uses 12 – 15 L/minCan produce FIO2 of 0.40 to 0.50Used with children/rare, Croup
Slide133Oxygen Tent
Slide134Oxygen Tent
Advantage
Simultaneously produces aerosol
Allows child movement while maintaining F
I
O
2
Slide135Oxygen Tent
Disadvantages
Expensive
Cumbersome to use
Limits access to patient
Slide136Oxygen Tent
Disadvantages
Fire hazard
Difficult to clean and/or disinfect
Slide137Incubator
Slide138Incubator (Isolette)
Used with infants to provide complete control of environmentAble to provide maximum FIO2 of 0.50 at 8 to 15 L/min
Slide139Incubator (Isolette)
Advantages
Provides complete environment
Stable F
I
O
2
Slide140Incubator (Isolette)
Disadvantages
Limited access to infant
Expensive
Difficult to clean and disinfect
Slide141Incubator (Isolette)
Disadvantages
Fire hazard
Noise level can cause auditory damage
Slide142Hyperbaric Oxygen Therapy
Therapeutic use of oxygen at pressures greater than 1 atmosphere (expressed as ATA or atmospheric pressure absolute)
Slide143Hyperbaric Oxygen Therapy
Physiologic effects
Hyperoxygenation of blood plasma and tissue
Reduction in bubble size
Vasoconstriction
May be helpful in decreasing edema
Slide144Hyperbaric Oxygen Therapy
Physiologic effects
Neovascularization
Creation of new capillary beds
Enhanced immune function
Aids in white blood cell function
Slide145Hyperbaric Oxygen Therapy
Indications
Air embolism
Carbon monoxide poisoning
Decompression sickness
Acute traumatic ischemia
Slide146Hyperbaric Oxygen Therapy
Indications
Necrotizing soft tissue infection (gangrene)
Ischemic skin graft
Intracranial abscess
Acute peripheral arterial insufficiency
Slide147Hyperbaric Oxygen Therapy
Complications and hazards
Barotrauma
Pneumothorax
Tympanic membrane rupture
Gas embolism
Slide148Hyperbaric Oxygen Therapy
Complications and hazards
Oxygen toxicity
Fire
Decrease in cardiac output
Slide149Hyperbaric Oxygen Therapy
Complications and hazards
Sudden decompression
Claustrophobia
Slide150Hyperbaric Oxygen Therapy
Methods of administration
Fixed hyperbaric chamber
Capable of holding caregivers and patients
Has airlock to allow entry and egress of caregivers
Slide151Hyperbaric Oxygen Therapy
Methods of administration
Fixed hyperbaric chamber
May be large enough to allow multiple patients
Only patient receives supplemental oxygen
Slide152Fixed Hyperbaric Chamber
Slide153Hyperbaric Oxygen Therapy
Methods of administration
Monoplace chamber
Large enough for single patient only
Chamber kept at F
I
O
2
of 1.0 during patient treatment
Slide154Monoplace Chamber
Slide155Nitric Oxide (NO) Therapy
Normally produced in the body
Slide156Figure 16-28A: INOmax delivery system.
Courtesy of IKARIA
Slide157Figure 16-28B: (B) INOvent delivery system.
Courtesy of IKARIA
Slide158Nitric Oxide (NO) Therapy
Mechanism of action
Activates guanylate cyclase which catalyzes production of cGMP, leading to vascular smooth muscle relaxation
Slide159Nitric Oxide (NO) Therapy
Mechanism of action
Improves blood flow to ventilated alveoli, reducing intrapulmonary shunting
Results in decrease in pulmonary vascular resistance
Slide160Nitric Oxide (NO) Therapy
Indications
Treatment of neonates with hypoxic respiratory failure with associated pulmonary hypertension
Slide161Nitric Oxide (NO) Therapy
Indications
Potential uses
RDS
Primary pulmonary hypertension
Cardiac transplantation, including pulmonary hypertension following surgery
Slide162Nitric Oxide (NO) Therapy
Indications
Potential uses
Acute pulmonary embolism
COPD
Sickle cell disease
Pulmonary hypertension related
to
congenital heart disease
Slide163Nitric Oxide (NO) Therapy
Adverse effects
In high concentrations (5000 to 20,000 ppm), causes pulmonary edema that can be fatal
Direct damage to cells
Slide164Nitric Oxide (NO) Therapy
Adverse effects
Impaired surfactant production
Increase in left ventricular filling pressure
Paradoxical response
Methemoglobinemia
Slide165Nitric Oxide (NO) Therapy
Dosage
In neonates, initial dose is 20 ppm; continued for up to 14 days or until underlying oxygen desaturation is resolved
Frequently can be reduced to 6 ppm at the end of 4 hours
Slide166Administration of NO
Patient preparation
Stabilize the patient as much as possible
Possibly sedate or paralyze patient
Support blood pressure as needed
Slide167Administration of NO
System features
Delivery of precise, stable level of nitric oxide
Capable of scavenging of nitric oxide
Limited production of nitrogen dioxide (NO
2
)
Slide168Administration of NO
Monitoring therapy
Inhaled levels of NO and NO
2
Ventilatory status
Slide169Administration of NO
Discontinuing therapy
Monitor for rebound effect
Patient must be able to maintain adequate oxygenation
Patient must be able to maintain hemodynamic stability
Slide170Figure 16-28A: INOmax delivery system.
Courtesy of IKARIA
Slide171Figure 16-28B: (B) INOvent delivery system.
Courtesy of IKARIA
Slide172INOvent Delivery System
For administration of nitrous oxide to mechanically ventilated patients
Slide173Helium-Oxygen (Heliox) Therapy
Used to decrease the work of breathing in the presence of turbulent gas flow in the large airways
Slide174Helium-Oxygen (Heliox) Therapy
Used with bronchodilator therapy to treat acute obstructive disorders (e.g., status asthmaticus); must use correction factor (multiply observed flow by 1.8) for flowmeter
Slide175Helium-Oxygen (Heliox) Therapy
Methods of administration
Generally cannulas are not effective because of high rate of diffusion
Best method – snug fitting, non-disposable non-rebreathing mask
May be administered through cuffed tracheal airway with positive pressure
Slide176Helium-Oxygen (Heliox) Therapy
Hazards
Elevation of vocal pitch caused by low density gas passing through vocal cords
Cough less effective
Hypoxemia secondary to using too low an oxygen concentration
Slide177Oxygen Monitoring – Polarographic Analyzer
Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2%
Has a response time of 10 to 30 seconds
Slide178Oxygen Monitoring – Polarographic Analyzer
Utilizes an electrochemical principle for operation
Blood or gas sample is separated from electrode sample by oxygen permeable membrane
Slide179Polarographic Analyzer
Slide180Polarographic Analyzer
Slide181Electrochemical Principle for Operation
Oxygen diffuses through the membrane into the electrolyte solution where a polarizing voltage causes electron flow
Silver in the anode is oxidized and the flow of electrons reduces oxygen and water of the electrolyte to hydroxyl ions at the platinum cathode
Slide182Figure 16-23: Oxygen analyzer.
Courtesy of Amvex Corporation
Slide183Electrochemical Principle for Operation
The greater the number of oxygen molecules reduced, the greater the electron flow between the anode and the cathode
The current generated is equivalent to the partial pressure of oxygen and is displayed as a percentage
Slide184Galvanic Analyzer
Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2%
Has a response time as long as 60 seconds
Slide185Galvanic Analyzer
Utilizes an electrochemical principle for operation
Has a gold anode and lead cathode
Current flow is generated by the chemical reaction itself resulting in slower response time
Slide186Galvanic Analyzer
When the chemicals in the sensor are depleted, the sensor must be replaced
Slide187Galvanic Analyzer
Slide188Galvanic Analyzer
Slide189Oximetry
Utilizes the principle of spectrophotometry
Every substance has a unique pattern of light absorption which varies predictably with the amount of the substance present
Slide190Oximetry
Each form of hemoglobin, e.g., oxyhemoglobin, carboxyhemoglobin, methemoglobin, has a unique pattern
Slide191Oximetry
Comparison
of
light transmitted through
a
blood sample
at
two
or
more specific wavelengths allows
the
measurement
of
two
or
more forms
of
hemoglobin
Oxyhemoglobin
absorbs less red light
and more
infrared light than reduced hemoglobin
Comparison of
light absorption yields
%HbO
2
and %Hb
Slide192CO-Oximetry
Uses three different wavelengths of light
Able to distinguish and measure Hb, HbO
2
, HbCO, and metHb
Results reported as S
a
O
2
to distinguish from pulse oximetry
Slide193CO-Oximeter
Slide194Pulse Oximetry
Utilizes principle of spectrophotometry with the principle of photoplethysmography (utilization of light to detect tiny volume changes in tissue during pulsatile blood flow)
Uses only two wavelengths of light compared to CO-oximeter
Slide195Pulse Oximetry
Red and infrared LEDs alternately transmit light through tissue to a receiver
Slide196Pulse Oximetry
Does not distinguish between different forms of hemoglobin, so can be inaccurate in cases of carbon monoxide poisoning or with higher levels of methemoglobin
Results reported as S
p
O
2
Slide197Pulse Oximetry
Slide198Transcutaneous Monitoring
Used primarily with neonatal and pediatric patients; changes in skin composition make results less reliable for adults
Skin sensor containing oxygen and carbon dioxide electrodes is attached to the skin, usually in the abdominal area
Slide199Transcutaneous Monitoring
Sensor contains a heating element to heat the skin
Increases perfusion in the area of the sensor
Allows diffusion of oxygen and carbon dioxide more readily
Slide200Transcutaneous Monitoring
Oxygen and carbon dioxide diffuse through the skin into the electrolyte solution and are analyzed by the two electrodes and reported as mm Hg
Results reported as P
tc
O
2
Slide201Correlation of PtcO2 With PaO2
Age Group
P
tc
O
2
/P
a
O
2
Ratio
Premature
infants
1.14:1
Neonates
1.00:1
Children
0.84:1
Adults
0.79:1
Older
adults
0.68:1
Slide202Factors Affecting Accuracy
Poor perfusion
Improper sensor application
Use of vasodilator drugs
Variation in skin characteristics
Slide203Factors Affecting Accuracy
Hyperoxemia
Inadequate heating of sensor
Lack of contact between sensor and skin
Slide204Transcutaneous Monitor
Slide205Carbon Dioxide Monitoring – Severinghaus Electrode
Variation of Sanz electrode
Used to measure pH
Consists of two electrodes or half cells
Measuring half cell contains silver-silver chloride rod surrounded by solution of constant pH and enclosed by pH-sensitive glass membrane
Slide206Carbon Dioxide Monitoring – Severinghaus Electrode
Variation of Sanz electrode
Sample passes over glass membrane, changing electrical potential of the measuring electrode
Reference half cell of mercury-mercurous chloride produces constant potential
Slide207Carbon Dioxide Monitoring – Severinghaus Electrode
Variation of Sanz electrode
Difference in potential between electrodes is proportional to H
+
concentration and is displayed as pH
Slide208Carbon Dioxide Monitoring – Severinghaus Electrode
Severinghaus electrode is Sanz electrode that is exposed to an electrolyte solution in equilibrium with the sample through a CO
2
permeable membrane
Slide209Carbon Dioxide Monitoring – Severinghaus Electrode
CO
2
diffuses through the membrane and dissociates into H
+
and HCO
3
-
ions.
The greater the concentration of CO
2
, the greater the number of H
+
ions
Slide210Carbon Dioxide Monitoring – Severinghaus Electrode
Change in pH of the solution proportional to change in PCO
2
Used primarily in blood gas analyzer and transcutaneous monitor
Slide211Carbon Dioxide Monitoring – Capnometry
Used during mechanical ventilation and general anesthesia
Placed inline between ventilator circuit and endotracheal or tracheostomy tube
Infrared light is passed through a sample chamber
Slide212Carbon Dioxide Monitoring – Capnometry
Carbon dioxide absorbs infrared light
The amount of infrared light passing through the sample chamber is compared to a reference chamber
Slide213Carbon Dioxide Monitoring – Capnometry
The less infrared light, the greater the concentration of carbon dioxide
Result read out as P
ET
CO
2
Slide214Capnometry
Slide215Colorimetric Carbon Dioxide Analysis
Uses an indicator that changes color when exposed to different levels of carbon dioxide
Most units are either blue or purple in the absence of carbon dioxide and change to yellow when exposed to carbon dioxide
Slide216Colorimetric Carbon Dioxide Analysis
Unit is disposable
Placed on endotracheal tube following intubation to confirm placement of ET tube
May give false negative readings in states of very low pulmonary perfusion
Slide217Colorimetric Carbon Dioxide Analysis
May give false positive readings if large volumes of carbonated drinks were consumed prior to intubation
Does not give a numeric result
Slide218Colorimetric Carbon Dioxide Analyzer
Slide219Nebulizers
Hand Held Nebulizers/ also know as small volume nebulizers may be given via aerosol mask, blow by, inline on the vent/bipap or by mouth piece, given on air or oxygenSmall volume nebulizers contain less than 200 ml of fluidSet flow 6-8 L, a typical treatment lasts 10-15 minutes, when the neb starts to sputter, shake contents
Slide220
Oxygen Devices
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