basics of oxygen therapy

BASICS OF OXYGEN

THERAPY

Oxygen Therapy for Adults in the Acute Care Facility for Chronic

and Acute conditions

By:

CLAIRE VELASQUEZ – CONSTANTINO

REGISTERED RESPIRATORY THERAPIST

Learning objectives:

Define the oxygen therapy and its indications

Discuss the type of oxygen therapy

List the purpose of using the oxygen therapy

Explain the procedure

Demonstrate the procedure

List Complication of oxygen therapy and hazards

DEFINITION

• Oxygen therapy is the administration of oxygen at concentrations greater than that of ambient air.

• Intent of treating or preventing the symptoms and manifestations of hypoxia.

• Is the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care.

INDICATIONS• Head trauma or acute head injury• Acute TachypneaRespiratory rate increased from normal (RR)

normal range 12 – 24 breaths per minute (bpm)

Significant respiratory rates increasing to more than 30 bpm

Visible with a Hemodynamic monitor or an ordinary monitor

Acute Tachycardia• Heart Rate increased from normal (HR)

Increased Myocardial work

Normal range 60 – 100 beats per minute (bpm)

Significant heart rate increasing to more than 110 bpm

Visible with a Hemodynamic monitor or an ordinary monitor

Acute Hypoxemia

Oxygen Saturation level is decreased (desaturation)

Normal range for saturation 90-100 SpO2

Significant decrease of oxygen saturation level below 85.

Visible with a Hemodynamic monitor or an ordinary monitor or can be internally checked via ABG.

CONTRAINDICATIONS

THERE ARE NO CONTRAINDICATIONS

WHY?

BUT…. KEEP IN MIND

•High levels of oxygen in the blood and tissue can be helpful or damaging depending on circumstances

COMPLICATIONS/PRECAUTIONS

Oxygen should be handled with precautions :

SIDE EFFECTS

OXYGEN IS A DRUG

Absorption Atelectasis

Atelectasis - refers to the partial or complete collapse of the lungs.

• Absorption Atelectasis Refers to the condition where the reduction of nitrogen concentration in the lungs causes a collapse.

WHY?

Absorption atelectasis

A B A B

100% O2

oxygennitrogen

PO2 =673

PCO2 = 40

PH2O = 47

A B

After ~15 minutes,

blood N2 is depleted.

Poorly ventilated &

well perfused units (A)

become atelectactic.

The air you breathe contains nearly 78% of nitrogen.

nitrogen - helps keep the alveoli open and prevents the collapse of the alveoli.

Hospital settings:

surgery and general anesthesia, large amounts of oxygen are usually administered. This decreases the nitrogen concentration in the air and leads to absorption atelectasis.

Patients who had gone heart or lung surgery and abdominal surgery?

WHY?

Oxygen Induced Hypoventilation

• Suppression of ventilation

• Can lead to increased CO2 and carbon dioxide narcosis

Oxygen Toxicity

Occurs due to inspiration of a high concentration of oxygen for a prolonged period of time.

Oxygen concentration greater than 50% over 24 to 48 hours can cause pathological changes in the lungs.

More evident in infants especially prematurely delivered. (retinopathy of prematurity and in some fibrotic lung –stiffness develops to pulmonary fibrosis) in adults is mostly coincides with oxygen induced hypoventilation in copdpatients.

PRECAUTIONS – FIRE HAZARD..

Signs and symptoms of oxygen toxicity

-Non-productive cough-Nausea and vomiting-Substernal chest pain-Fatigue-Nasal stuffiness-Headache-Sore throat-Hypoventilation-Nasal congestion-Dyspnea-Inspiration pain

GOALSREVERSE ALL THE INDICATIONS

EQUIPMENT

LOW FLOW DEVICES ?

HIGH FLOW DEVICES?

How do you

DIFFERENTIATE

WHAT IS: LOW FLOW

The delivery of oxygen to the patient with variability of concentration

ORThe oxygen concentration is not determined only

estimatedOR

The FI,O2 is influenced by breath rate, tidal volume and pathology.

WHY?

Depending on:

- Breathing pattern

• If the breathing is fast or labored what happens to the concentration of oxygen?

• How do we know that the patient is having labored breathing just by looking?

• And what do we do first as medical practitioners? –A. call the doctor?–B. Increase the oxygen?

• Breathing pattern is slow

• What happens to the concentrations of oxygen being delivered?

• Is it going to be higher even were giving a small amount?

• Will the concentration of oxygen were giving be the same?

WHY?

LOW FLOW OXYGEN DELIVERY

DEVICES

NASAL CANNULA

HOW TO USE?

disposable.

plastic devise with two protruding prongs for insertion into the nostrils, connected to an oxygen source.

- The standard nasal cannula delivers an inspiratory oxygen fraction (FIO2) of 24-44% at supply flows ranging from 1-6 L·min-1.

- The formula is FIO2 = 20% + (4 × oxygen litreflow). The FIO2 is influenced by breath rate, tidal volume and pathophysiology.

- The slower the inspiratory flow the higher the FIO2.

Delivers 24 to 44% oxygen at 1 to 6 L/min

• 1 = 24

• 2 = 28

• 3 = 32

• 4 = 36

• 5 = 40

• 6 = 44

FACTSADVANTAGES

Patients are able

to talk and eat with

oxygen in place

Easily used in home setting

DISADVANTAGESmay cause irritation

to the nasal and pharyngeal mucosa

if oxygen flow rates are above 4 liters/minute Variable FIO2

NURSING INTERVENTION

Check frequently that both prongs

are in clients nasal nares

Never deliver more than 2-3

L\min to patients with chronic lung

disease if patient doesn’t need it.

SIMPLE OXYGEN MASK

Simple mask is made of clear, flexible , plastic or rubber that can be molded to fit the face.

It is held to the head with elastic bands.

Some have a metal clip that can be bent over the bridge of the nose for a comfortable fit

O2 inlet

Exhalation

ports

• Open ports for exhaled gas

• Air entrained through ports if O2 flow through does not meet peak inspiratoryflow

• 5 – 10 liters per minute

• < 5 liters will not flush CO2 from mask

• 40 – 60% FIO2 approximately depending on the pattern of breathing.

FACTSADVANTAGES

• Can provide increased

delivery of oxygen for

short period of time

• The face mask is indicated in patients with nasal irritation or epistaxis.

• It is also useful for patients who are strictly mouth breathers.

DISADVANTAGES-Tight seal required to deliver higher concentration

- Difficult to keep mask in position over nose and mouth

-Potential for skin breakdown due(pressure, moisture)

- Uncomfortable for pt while eating or talking.

- Obtrusive, uncomfortable and confining.

- It muffles communication, obstructs coughing.

NURSING INTERVENTION

Monitor client frequently to check

placement of the mask.

Support client if claustrophobia is concern

Secure physician's order to replace mask

with nasal cannula during meal time

PARTIAL REBREATHING MASK

• Mask is a simple mask with a reservoir bag.

• Same as the Non re-breathing bag but..without a one way valve.

• Low flow, medium concentration

• 50 – 70%

• 8 – 12 liters per minute

• Bag should remain at least 1/3 full during inspiration

• Allow the mixture or oxygen and carbon dioxide in the mask.

Partial Rebreather mask

Exhalation

ports

O2

Reservoir

• O2 directed into reservoir

• Insp: draw gas from bag & ? room air

• Exp: first 1/3 of exhaled gas goes into bag (dead space)

• Dead space gas mixes with ‘new’ O2 going into bag

• Deliver ~60% O2

FACTSADVANTAGES

- Can inhale room air through openings in mask if oxygen supply is briefly interrupted.

- Not as drying to mucous membranes

DISADVANTAGES

- Requires tight seal

- Eating and talking difficult, uncomfortable

-

NURSING INTERVENTION

Set flow rate so mask remains two-

thirds full during inspiration

Keep reservoir bag free of twists or

kinks

Prevents the reservoir bag to collapse

or be empty

Prevents anyone to squeeze the

bag while on the patient.

NON REBREATHING MASKthe one-way valve closes and all of the expired air is

deposited into the atmosphere, not the reservoir bag.

This mask provides the highest concentration of oxygen

(95-100%) at a flow rate 8-15 L/min.

It is similar to the partial rebreather mask except two one-way valves prevent conservation of exhaled air.

Non-Rebreathing Mask

• Valve prevents exhaled gas flow into reservoir bag

• Valve over exhalation ports prevents air entrainment

• Delivers ~100% O2, ifbag does not completely collapse during inhalation

O2

Reservoir

One-way valves

FACTS

ADVANTAGESDelivers the highest possible oxygen concentration

Suitable for pt breathing spontaneous with sever hypoxemia

DISADVANTAGES- Impractical for long term Therapy

- Malfunction can cause CO2 buildup

-- suffocation

Expensive

Feeling of suffocation

Uncomfortable

NURSING INTERVENTIONMaintain flow rate so reservoir bag collapses only slightly during inspiration

Check that valves and rubber flaps are function properly (open during expiration )

Monitor SaO2 with pulse oximeter

Never allow anybody to squeeze the bag empty

Non-rebreathing system

Reservoir

Gas source

Room air

Expiratory

gas

To patient

One way valves

Estimating FiO2

O2 Flow rate FiO2 O2 Flow rate FiO2 O2 Flow rate FiO2

Nasal cannula Oxygen mask Mask with reservoir

1 0.24 5-6 0.4 6 0.6

2 0.28 6-7 0.5 7 0.7

3 0.32 7-8 0.6 8 0.8

4 0.36 9 0.80+

5 0.4 10 0.80+

6 0.44

HIGH FLOW DELIVERY DEVICES

Or

FIXED

DELIVERY SYSTEMS

AIR ENTRAINMENT DEVICES• High flow device (o2 concentration)

• Entrains air through side ports to achieve high flows

• Variable entrainment ports and/or jets adjust FIO2

• Air Entrainment or Venti Masks

• Manufacturer recommends liter flows for each FIO2

The Venturi SystemRoom air dilutes the oxygen entering

the tubing to a certain concentration

The amount of air drawn in is determined by the size of the orifice (jet adapter).

Applying the Bernoulli principle

How does it work?

exhaled gas

oxygen

room air

VENTURI MASK

Oxygen from 24 - 50%

At liters flow of 4 to 15 L/min.

The mask is so constructed that there is a constant flow of room air blended with a fixed concentration of oxygen

Is designed with wide- bore tubing and various color - coded jet adapters.

Each color code corresponds to a precise

It is high flow concentration of oxygen.

Oxygen concentration and a specific liter flow.

FACTSADVANTAGESDelivers most

precise oxygen

concentration

Doesn’t dry

mucous membranes

(humidity)

DISADVANTAGESuncomfortable

Risk for skin irritation

produce respiratory depression in COPD patient with high oxygen concentration 50%

NURSING INTERVENTION

Maintains on the patient’s face all the time.

Makes sure that the flow from the flow meter is appropriately on the level prescribed.

Produce respiratory depression in COPD patient with high oxygen concentration 50%

TRACHEOSTOMY COLLAR

Directed into trachea

Is indicated for chronic o2 therapy need

O2 flow rate 8 to 10L

Provides accurate FIO2

Provides good humidity.

Comfortable ,more efficient

Less expensive

FACTSADVANTAGES

• Delivers high concentrations of oxygen directly to the lungs.

• Stable and not moved when the patient is moved or cleaned.

• Maintains saturation levels.

DISADVANTAGES• Viscosity of secretions

• Ability to cough and expectorate

• Clinical status

• Systemic hydration

• Patient compliance

• Method of humidification in use

• if any of the above list remain a problem the current method of humidification may be inadequate

NURSING INTERVENTIONS

• Suctioning

• Maintains patent bronchial airway

• Make sure the tracheostomy site is clean and uninfected

• Check the cuff pressure if needed to be inflated or the trach tube is properly secured.

• Make sure adequate humidification is present to prevent further complications

Additional devices for high flow

• T-PIECE ADOPTOR

Used on end of ET tube

Prove when weaning from

ventilator

is accurate FIO2

Provides good humidity

ASSEMBLY

Technique of oxygen administration

RationalSteps

provide a baseline data for

future assessment

Oxygen may depress the

hypoxia drive ( decrease

respiratory rate , alliterate

mental states

Check the physician order.

Assesses physical condition

Assess vital signs ,

Assess level of consciousness

Assess the laboratory results,

especially the ABG analyses,

Assess risk of CO2 retention

with oxygen administration

Wash hands.

Prepare equipment

plastic nasal cannula

connection tube

Administering oxygen by nasal cannula

RationalSteps

Humidification maybe

not be ordered if the flow

rate is <4 /l/min

To be sure you are

performing the procedure

for the correct patient.

To gain his cooperation.

This position permits

easier chest expansion and

hence easier breathing.

To prevent dehydration

of mucous membrane.

Humidifier filled with distilled

water .

Flow meter

No smoking signs

Identify the patient.

Explain procedure to the

patient.Assist the patient to a semi-

fowler's position if possible.

Attach the oxygen supply tube

with humidification to the

cannula , face mask.

RationalSteps

Low flow

1 L\min=24%

2 L\min=28%

3 L\min=32%

4 L\min=36%

5 L\min=40%

6 L\min=44%

To facilitate oxygen

administration and comfort

the patient.

To reduce irritation and

pressure and protect the skin.

Allow 3-5 L oxygen to flow

through the tubing.

Place the prongs in the

patient's nostrils and adjust it

comfortably.

Use gauze pads both behind

the head or the ears and under

the chin and tighten to comfort.

RationalStepsTo provide optimal

delivery of oxygen to

patient..

Oxygen dries the mucous

membrane and cause

irritation

Adjust the flow rate to the

ordered level.

Encourage patient to breath

through his nose with his mouth

closed.

Assess the patient nose and

mouth and provide oronasal care

at least every 8 hours.

Administering oxygen by Face Mask

RationalSteps

Ensure pt receive flow sufficient to meet respiratory demand & maintain accurate concentration oxygen

Produce the flow rate ( 5 -10/min) Attach the oxygen supply tube to

the mask .

Regulate the oxygen flow.

Position the mask over the

patient's nose and mouth.

And fit it securely, shaping the

metal band on the mask to the

bridge of the nose.

RationalSteps

There is danger of

inhaling powder if it is

placed on the mask.

Remove the mask

and dry the skin every

2-3 hours if the oxygen

is running

continuously.

Don't powder

around the mask.

Wash your hands.

Administering oxygen by:

• The partial re-breather mask

• The non-rebreather mask

• The venturi mask

RationalSteps

to ensure correct air / oxygen mix

Attach tubing to flow meter Show the mask to pt & explain

procedure Turn on oxygen flowmeter &

prescribed rate ( usually indicated on mask )

Place mask over pt nose & mouth under chin

Evaluation:

Breathing pattern - regular and at normal rate.

Color - nail beds, lips, conjunctiva of eyes -pink

No confusion, disorientation, difficulty with cognition.

Arterial oxygen concentration or hemoglobin within normal

Oxygen saturation within normal limits.

Assessment. Identify the type of oxygen equipment and

oxygen source in your facility

Hospitals – O2 inlet or O2 cylinders (E type)

in clinics – O2 inlet or O2 cylinders (E type)

Documentation:Date and time oxygen started.

Method of delivery.

Oxygen concentration and flow rate.

Patient observation.

Add oronasal care to the nursing care plan

THANK YOU FOR LEARNING WITH ME

HAVE A PLEASANT DAY