Oxygen Devices

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Oxygen Devices




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Slide1

Oxygen Deviceshttp://www.youtube.com/watch?v=1T7TGkQcIGI

RT 210A

Slide2

Oxygen 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

Slide3

Oxygen Therapy – Indications*

Acute myocardial infarctionShort term therapy or surgical intervention

*From the AARC Clinical Practice Guideline

Slide4

Indications

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. 

Slide5

Hypoxemia

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.

Slide6

Oxygen Therapy – Contraindications*

There are no specific contraindications to oxygen therapy when indications are judged to be present

*From the AARC Clinical Practice Guideline

Slide7

Oxygen Therapy – Hazards and Complications*

Ventilatory depression (if you supersede a patients need)Absorption atelectasisOxygen toxicity

*From the AARC Clinical Practice Guideline

Slide8

Oxygen Therapy – Hazards and Complications*

Fire hazard (combustible) Retinopathy of prematurityBacterial contamination (when using humidity or aerosol)

*From the AARC Clinical Practice Guideline

Slide9

Ventilatory 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.

Slide10

Ventilatory 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

Slide11

Ventilatory Depression

Mechanism of action

Decrease in oxygen level triggers response by peripheral chemoreceptors,

if they

Rate and depth of breathing increase

Slide12

Ventilatory Depression

Mechanism of action

When supplemental oxygen administered, P

a

O

2

can rise to > 55 mmHg, removing stimulus to peripheral receptors

Hypoventilation results

Slide13

Absorption Atelectasis

Two contributing factorsFIO2 > 0.50Air trapping

Slide14

What 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

.

Slide15

Absorption 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

Slide16

Absorption Atelectasis

Mechanism of action

Removal of oxygen causes decrease in volume of alveolus, resulting in alveolar collapse or atelectasis

Slide17

Absorption 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

Slide18

Oxygen Toxicity

Two contributing factors

F

I

O

2

> 0.50

Time of exposure

Slide19

Oxygen Toxicity

Pathophysiological changes

Damage to capillary epithelium

Interstitial edema

Thickening of alveolar capillary membrane

Slide20

Slide21

Oxygen Toxicity

Pathophysiological changes

Destruction of type I alveolar cells

Proliferation of type II alveolar cells

Formation of exudate

Slide22

Oxygen Toxicity

Pathophysiological changes

Decrease in ventilation/perfusion ratio

Physiologic shunting

Hypoxemia

Slide23

Oxygen Toxicity

Mechanism of action

Overproduction of free radicals

Safe level: F

I

O

2

≤ 0.50

Slide24

Oxygen Toxicity

Slide25

Fire 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

Slide26

Retinopathy 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

Slide27

Bacterial Contamination

Associated with equipment

Slide28

Assessment of the Hypoxemic Patient

Clinical signs of hypoxemia

Tachypnea

Tachycardia

Anxiety

Slide29

Assessment 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

Slide30

Assessment of the Hypoxemic Patient

Clinical signs of hypoxemia

Confusion

Lethargy

Coma

Slide31

Assessment 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

Slide32

Assessment 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

Slide33

Assessment of the Hypoxemic Patient

Specific clinical conditions

Trauma

Overdose

Slide34

Monitoring 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.

Slide35

Oxygen 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

Slide36

Low 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

Slide37

Low Flow Oxygen Systems

Conditions required for low flow systems

V

T

between 300 and 700 mL

f < 25 breaths per minute

Regular breathing pattern

Slide38

Nasal 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

Slide39

Delivery 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

Slide40

Estimating 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

Slide41

NC

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.

Slide42

Delivery 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

Slide43

Delivery 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

Slide44

Figure 16-9A: Nasal cannula with elastic strap.

(A) Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999.

Slide45

Figure 16-9B: Over-the-ear style nasal cannula.

Slide46

Figure 16-9C: Various styles of nasal prongs.

Courtesy of Teleflex Incorporated. Unauthorized use prohibited

Slide47

Nasal 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

Slide48

Nasal 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

Slide49

Simple Mask/O2 mask

Slide50

Figure 16-10B: Simple O

2 mask.

© Corbis/age fotostock

Slide51

Simple 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

Slide52

Simple 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.

Slide53

Delivery 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

Slide54

Delivery Devices – Simple Oxygen Mask

Disadvantages

Uncomfortable for most patients

Must be removed for eating, speaking, expectorating

May allow vomitus to be aspirated

Slide55

Delivery 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

Slide56

Aerosol 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

Slide57

Partial Rebreathing Mask

No one way valvesOtherwise looks identical to a non rebreathing mask

Slide58

Partial 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.

Slide59

Partial 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

Slide60

Partial Rebreathing Mask

Disadvantages

Uncomfortable for many patients

Must be removed for eating, speaking, expectorating

Slide61

Partial Rebreathing Mask

Disadvantages

May allow vomitus to be aspirated

Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails

Slide62

Non 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.

Slide63

Non-Rebreathing Mask

Used primarily in emergencies and for short-term administration of high concentrations of oxygen

One way valves

Slide64

Non-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

Slide65

Non-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

Slide66

Non-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

Slide67

Non-Rebreathing Mask

Disadvantages

Uncomfortable for many patients

Must be removed for eating, speaking, expectorating

Slide68

Non-Rebreathing Mask

Disadvantages

May allow vomitus to be aspirated

Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails

Slide69

Reservoir (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

Slide70

Reservoir 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

Slide71

Reservoir Cannula

Reservoir cannula

Pendant reservoir cannula

Slide72

Slide73

Reservoir (Oxygen Conserving) Cannula

Advantages

Lowers oxygen usage, thereby lowering cost

Allows greater mobility secondary to longer duration of cylinder

Slide74

Reservoir (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

Slide75

Transtracheal 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

Slide76

Transtracheal 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.

Slide77

Transtracheal Catheter

Advantages

Able to deliver very low flows of oxygen (1/4 to 4 L/min.)

Uses less oxygen, lowering costs

Slide78

Transtracheal Catheter

Advantages

Improvement in compliance with therapy

Humidification not required because of low flows

Slide79

Transtracheal Catheter

Disadvantages

High initial cost (surgical procedure)

Possibility of infection

Slide80

Transtracheal Catheter

Disadvantages

Easily plugged by mucus

If removed for replacement, tract may close

Slide81

Transtracheal Catheter

Slide82

Nasal 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!

Slide83

Nasal Catheter

Slide84

Figure 16-8: Nasal catheter for oxygen administration.

Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999.

Slide85

OxyMask

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

Slide86

Oxygen 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

Slide88

High 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

Slide89

High Flow Oxygen Systems

Delivery devices

Air entrainment (Venturi) mask

Air entrainment nebulizer

Blending systems

Slide90

Venturi 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

Slide91

3 designs. Two change the entrainment window size to increase/decrease FIO2, the other has colored adapters. The flow required is indicated on the device

Slide92

Venturi 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

.

Slide94

Magic 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.

Slide95

Memorizing ratios:

.28

.30

.35

.40

.50

.60

Primary ratios

Slide96

Slide97

Venturi 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

Slide98

Venturi Mask

Disadvantages

Generally limited to adult use

Uncomfortable, noisy

Slide99

Venturi 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

Slide100

Air 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

Slide101

Venturi Mask

Slide102

Color adaptor type- Orifice size changes

Venturi valveFlow rateOxygen deliveredcolor(l/min)(%)Blue224White428Yellow635Red840Green1260Treatment with oxygen60% or/>101 rebreathing90-94

Slide103

Figure 16-18C: Changes in air entrainment by changing jet size or changing size of the entrainment port.

Slide104

Air Entrainment Nebulizer

AdvantagesStable, precise concentration when FIO2 > 0.28 And < 0.40Provides aerosolInexpensiveEasy to apply

Slide105

LVN

Used when upper airway is bypassed (ETT,

Trach

)

Used for croup, stridor

Not used for Asthmatics

Typically given- Bland aerosol with sterile water

Slide106

Figure 16-14B: Large-volume nebulizers.

Courtesy of Teleflex Incorporated. Unauthorized use prohibited

Slide107

Figure 16-15A: Aerosol mask

(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.

Slide108

Figure 16-15B: Briggs T piece

(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.

Slide109

Figure 16-15C: Face tent

(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.

Slide110

Figure 16-15D: Tracheostomy collar

(A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999.

Slide111

Figure 16-17: Injection nebulizer, in which additional flow is injected at the outlet of the nebulizer.

Courtesy Jeffrey J. Ward, R.R.T.

Slide112

Figure 16-26: Equipment for heliox administration to spontaneously breathing patients.

Slide113

Figure 16-20: High-flow oxygen delivery system using two flow meters.

Courtesy of Dr. Dean Hess

Slide114

Air Entrainment Nebulizer

Disadvantages

Increased risk of infection

F

I

O

2

varies if entrainment port occluded or in the presence of back pressure

Slide115

Components of an Air Entrainment Device

Slide116

Aerosol Mask

Slide117

Large 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.

Slide118

Blending Systems

Generally used when high flows (> 60 L/min.) required

Separate pressurized air and oxygen sources required

Slide119

Blending Systems

Manually blended system

Each gas manually set with flowmeter

Total flow and desired F

I

O

2

must be calculated

Slide120

Blending 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.

Slide121

Blending Systems

Manually blended systemWill deliver precise FIO2 if calculated correctlyDeviation of either flow changes FIO2 and total flow

Slide122

Blending Systems

Oxygen blender

Able to deliver very precise concentrations

Able to deliver high flows across a wide range of concentrations

Slide123

Blending Systems

Oxygen blender

Must check with analyzer periodically to confirm proper operation and eliminate possibility of blender failure

Slide124

Oxygen Blending Device

Slide125

Enclosure Systems

One of the oldest approaches to oxygen administration

Provides patient with controlled atmosphere

Used primarily with infants and children

Slide126

Enclosure 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

Slide127

Oxygen Hood

Used with infants

Minimum flow normally of 7 L/min

Slide128

Oxygen Hood

Disadvantages

Noise level can cause auditory damage

Difficult to clean and/or disinfect

Slide129

Oxygen Hood

Disadvantages

Need to ensure neutral thermal environment is maintained by using warmed gas, especially with premature infants

Slide130

Oxygen Hood

Slide131

Enclosure Systems

Delivery devices

Oxygen tent

Oxygen hood

Incubator (isolette)

Slide132

Oxygen Tent

Generally uses 12 – 15 L/minCan produce FIO2 of 0.40 to 0.50Used with children/rare, Croup

Slide133

Oxygen Tent

Slide134

Oxygen Tent

Advantage

Simultaneously produces aerosol

Allows child movement while maintaining F

I

O

2

Slide135

Oxygen Tent

Disadvantages

Expensive

Cumbersome to use

Limits access to patient

Slide136

Oxygen Tent

Disadvantages

Fire hazard

Difficult to clean and/or disinfect

Slide137

Incubator

Slide138

Incubator (Isolette)

Used with infants to provide complete control of environmentAble to provide maximum FIO2 of 0.50 at 8 to 15 L/min

Slide139

Incubator (Isolette)

Advantages

Provides complete environment

Stable F

I

O

2

Slide140

Incubator (Isolette)

Disadvantages

Limited access to infant

Expensive

Difficult to clean and disinfect

Slide141

Incubator (Isolette)

Disadvantages

Fire hazard

Noise level can cause auditory damage

Slide142

Hyperbaric Oxygen Therapy

Therapeutic use of oxygen at pressures greater than 1 atmosphere (expressed as ATA or atmospheric pressure absolute)

Slide143

Hyperbaric Oxygen Therapy

Physiologic effects

Hyperoxygenation of blood plasma and tissue

Reduction in bubble size

Vasoconstriction

May be helpful in decreasing edema

Slide144

Hyperbaric Oxygen Therapy

Physiologic effects

Neovascularization

Creation of new capillary beds

Enhanced immune function

Aids in white blood cell function

Slide145

Hyperbaric Oxygen Therapy

Indications

Air embolism

Carbon monoxide poisoning

Decompression sickness

Acute traumatic ischemia

Slide146

Hyperbaric Oxygen Therapy

Indications

Necrotizing soft tissue infection (gangrene)

Ischemic skin graft

Intracranial abscess

Acute peripheral arterial insufficiency

Slide147

Hyperbaric Oxygen Therapy

Complications and hazards

Barotrauma

Pneumothorax

Tympanic membrane rupture

Gas embolism

Slide148

Hyperbaric Oxygen Therapy

Complications and hazards

Oxygen toxicity

Fire

Decrease in cardiac output

Slide149

Hyperbaric Oxygen Therapy

Complications and hazards

Sudden decompression

Claustrophobia

Slide150

Hyperbaric Oxygen Therapy

Methods of administration

Fixed hyperbaric chamber

Capable of holding caregivers and patients

Has airlock to allow entry and egress of caregivers

Slide151

Hyperbaric Oxygen Therapy

Methods of administration

Fixed hyperbaric chamber

May be large enough to allow multiple patients

Only patient receives supplemental oxygen

Slide152

Fixed Hyperbaric Chamber

Slide153

Hyperbaric 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

Slide154

Monoplace Chamber

Slide155

Nitric Oxide (NO) Therapy

Normally produced in the body

Slide156

Figure 16-28A: INOmax delivery system.

Courtesy of IKARIA

Slide157

Figure 16-28B: (B) INOvent delivery system.

Courtesy of IKARIA

Slide158

Nitric Oxide (NO) Therapy

Mechanism of action

Activates guanylate cyclase which catalyzes production of cGMP, leading to vascular smooth muscle relaxation

Slide159

Nitric Oxide (NO) Therapy

Mechanism of action

Improves blood flow to ventilated alveoli, reducing intrapulmonary shunting

Results in decrease in pulmonary vascular resistance

Slide160

Nitric Oxide (NO) Therapy

Indications

Treatment of neonates with hypoxic respiratory failure with associated pulmonary hypertension

Slide161

Nitric Oxide (NO) Therapy

Indications

Potential uses

RDS

Primary pulmonary hypertension

Cardiac transplantation, including pulmonary hypertension following surgery

Slide162

Nitric Oxide (NO) Therapy

Indications

Potential uses

Acute pulmonary embolism

COPD

Sickle cell disease

Pulmonary hypertension related

to

congenital heart disease

Slide163

Nitric Oxide (NO) Therapy

Adverse effects

In high concentrations (5000 to 20,000 ppm), causes pulmonary edema that can be fatal

Direct damage to cells

Slide164

Nitric Oxide (NO) Therapy

Adverse effects

Impaired surfactant production

Increase in left ventricular filling pressure

Paradoxical response

Methemoglobinemia

Slide165

Nitric 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

Slide166

Administration of NO

Patient preparation

Stabilize the patient as much as possible

Possibly sedate or paralyze patient

Support blood pressure as needed

Slide167

Administration 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

)

Slide168

Administration of NO

Monitoring therapy

Inhaled levels of NO and NO

2

Ventilatory status

Slide169

Administration of NO

Discontinuing therapy

Monitor for rebound effect

Patient must be able to maintain adequate oxygenation

Patient must be able to maintain hemodynamic stability

Slide170

Figure 16-28A: INOmax delivery system.

Courtesy of IKARIA

Slide171

Figure 16-28B: (B) INOvent delivery system.

Courtesy of IKARIA

Slide172

INOvent Delivery System

For administration of nitrous oxide to mechanically ventilated patients

Slide173

Helium-Oxygen (Heliox) Therapy

Used to decrease the work of breathing in the presence of turbulent gas flow in the large airways

Slide174

Helium-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

Slide175

Helium-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

Slide176

Helium-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

Slide177

Oxygen Monitoring – Polarographic Analyzer

Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2%

Has a response time of 10 to 30 seconds

Slide178

Oxygen Monitoring – Polarographic Analyzer

Utilizes an electrochemical principle for operation

Blood or gas sample is separated from electrode sample by oxygen permeable membrane

Slide179

Polarographic Analyzer

Slide180

Polarographic Analyzer

Slide181

Electrochemical 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

Slide182

Figure 16-23: Oxygen analyzer.

Courtesy of Amvex Corporation

Slide183

Electrochemical 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

Slide184

Galvanic Analyzer

Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2%

Has a response time as long as 60 seconds

Slide185

Galvanic 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

Slide186

Galvanic Analyzer

When the chemicals in the sensor are depleted, the sensor must be replaced

Slide187

Galvanic Analyzer

Slide188

Galvanic Analyzer

Slide189

Oximetry

Utilizes the principle of spectrophotometry

Every substance has a unique pattern of light absorption which varies predictably with the amount of the substance present

Slide190

Oximetry

Each form of hemoglobin, e.g., oxyhemoglobin, carboxyhemoglobin, methemoglobin, has a unique pattern

Slide191

Oximetry

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

Slide192

CO-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

Slide193

CO-Oximeter

Slide194

Pulse 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

Slide195

Pulse Oximetry

Red and infrared LEDs alternately transmit light through tissue to a receiver

Slide196

Pulse 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

Slide197

Pulse Oximetry

Slide198

Transcutaneous 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

Slide199

Transcutaneous 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

Slide200

Transcutaneous 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

Slide201

Correlation 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

Slide202

Factors Affecting Accuracy

Poor perfusion

Improper sensor application

Use of vasodilator drugs

Variation in skin characteristics

Slide203

Factors Affecting Accuracy

Hyperoxemia

Inadequate heating of sensor

Lack of contact between sensor and skin

Slide204

Transcutaneous Monitor

Slide205

Carbon 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

Slide206

Carbon 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

Slide207

Carbon Dioxide Monitoring – Severinghaus Electrode

Variation of Sanz electrode

Difference in potential between electrodes is proportional to H

+

concentration and is displayed as pH

Slide208

Carbon 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

Slide209

Carbon 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

Slide210

Carbon 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

Slide211

Carbon 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

Slide212

Carbon Dioxide Monitoring – Capnometry

Carbon dioxide absorbs infrared light

The amount of infrared light passing through the sample chamber is compared to a reference chamber

Slide213

Carbon Dioxide Monitoring – Capnometry

The less infrared light, the greater the concentration of carbon dioxide

Result read out as P

ET

CO

2

Slide214

Capnometry

Slide215

Colorimetric 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

Slide216

Colorimetric 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

Slide217

Colorimetric 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

Slide218

Colorimetric Carbon Dioxide Analyzer

Slide219

Nebulizers

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


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