Lecture 11: Oxygen Delivery, Devices and Titration

Define FiO₂

Fraction of inspired oxygen

Define hypoxemia

Decreased oxygen tension in the blood

Define hypoxia

Inadequate tissue oxygenation at the cellular level

Define orthopnea

A condition in which 2 + pillows are required during sleep, due to shortness of breath when lying down

Define dyspnea

Difficulty breathing/shortness of breath

What is nebulization?

The process of adding moisture or medications to inspired air

MOA of incentive spirometry

Deep breathing exercise used to promote maximal sustained inhalation and prevent/treat atelectasis (Collapsed lung) by encouraging patients to increase their intake of air

How do you use an incentive spirometer?

1. Sit the patient upright in the chair or bed and hold up the spirometer to eye level and set the target marker to the recommended level

2. Exhale fully to completely empty the lungs

3. Seal the lips tightly around the mouth piece

4. Inhale slowly and deeply through the mouth with the focus of the filling the lungs completely without inhaling too quickly or forcefully

5. Once you've inhaled as deeply as possible hold your breath for 3-5 seconds (or as directed)

6. Remove the mouth piece and exhale slowly and fully

7. Rest for a few seconds and repeat the process 10 times per session and record your results

Tripod position

A position that may be assumed during respiratory distress to facilitate the use of respiratory accessory muscles

What patient type is Incentive spirometry usually used for?

Post operative patients

MOA of oxygen therapy

Used to relieve or prevent tissue hypoxemia

Oxygen therapy is used in conjunction with __________

Other interventions

What document is required to sustain and sometimes initiate oxygen therapy?

A prescribers order

Why are medication rights required with oxygen therapy?

Oxygen therapy is treated like a medication so all rights and checks apply

What is required once oxygen therapy is initiated?

Once initiated the patient needs to be continuously assessed

Under what circumstances can health care professionals initiate oxygen therapy without a prescriber's order?

-When pulse oximetry is less than or equal to 90%

-When no pulse oximetry is available, and patients have signs and symptoms of hypoxia

What does ongoing oxygen therapy require?

An authorized prescriber's order

List the ways oxygen can be supplied

-Piped into the wall (tanks are in the basement)

-Compressed gas cylinders (Mobile oxygen tanks)

-Oxygen concentrators (Battery or electrical powered oxygen tubing)

-Liquid oxygen systems

When would you need to humidify oxygen?

If the ordered flow rate exceeds 4L/minute

How should oxygen cylinders be safely stored (Films on demand)?

Upright and secured in a chain or holder so it doesn't trip over during transfer or while in storage

When using a portable oxygen cylinder what should the gauge be to ensure you have enough before transferring or ambulating the patient (Films on demand)?

The gauge on the cylinder should register in the green range, if not you'll need a backup source

What are low flow oxygen devices?

Devices that provide oxygen at a flow rate lower than the patient's inspiratory demand, meaning room air is mixed with the oxygen supply. The patient's breathing pattern influences the exact fraction of inspired oxygen (𝐹𝐼𝑂2)

What are high flow devices?

Devices provide oxygen at a flow rate that meets or exceeds the patient's inspiratory demand, ensuring that the 𝐹𝐼𝑂2 delivered is constant and not influenced by room air or the patient's breathing pattern

List the characteristics of high flow oxygen devices

-Flow rate needs to be set using meter on barrel

-Allows for more concise amounts

List the characteristics of a nasal cannula

-Flow rate: 1-6 L/minute

-Easy to use

-Patients can talk and eat without removal

-Can be used my mouth breathers

-Can irritate skin (i.e behind ears)

-Cause drying of nasal with 4L or greater

Can pediatric patients use nasal cannulas? If yes, how should they be used?

Yes, but with very low flow rates

List the characteristics of a simple face mask

-Flow rate: 6-10 L/minute

-Easy to apply but requires a tight fit

-Poor compliance as mask may be uncomfortable and must be removed when eating

List the characteristics of a partial or non rebreathing mask with reservoir bags

-Flow rate: 6-10 L/minute

-Delivers the highest percentage of oxygen with intubation or mechanical ventilation

-Valves must be secure and functioning

-Cannot eat or drink with mask in place

-Reservoir bag must be kept inflated

What do you need to ensure with partial or non rebreathing mask with reservoir bags

Ensure the reservoir bag is filled with oxygen or the patient may suffocate

What is the flow rate and oxygen percentage (Fi02) of a nasal cannula?

Flow rate: FiO₂

1L/min: FiO₂ of 24%

2L/min: FiO₂ of 28%

3L/min: FiO₂ of 32%

4L/min: FiO₂ of 36%

5L/min: FiO₂ of 40%

6L/min: FiO₂ of 44%

What is the flow rate and oxygen percentage (Fi02) of a simple mask?

Flow rate: 6-10L/min

FiO₂: 40-60%

What is the flow rate and oxygen percentage (Fi02) of a non rebreathing mask-reservoir?

Flow rate: 6-10L/min

FiO₂: 60-100%

What is the flow rate and oxygen percentage (Fi02) of a venturi mask?

Flow rate: 4-10L/min

FiO₂: 24-55%

What hazard symbol is associated with oxygen?

Oxygen is highly combustible, so no open flames or products that are combustible should be present when oxygen is in use (E.g. Cigarettes, oils, petroleum jelly)

Can you smoke near an oxygen supply?

You should never smoke near an oxygen supply. Smoking or having an open flame near an oxygen supply greatly increases the risk of fire or explosion

When using an oxygen supply what do you need to inform people about?

Inform everyone that oxygen is in the area such as a verbal reminder or signage

What do you need to ensure with electronics when using oxygen?

Ensure all electrical equipment is functioning or correctly grounded

Patients and families need _______ and ________ when using oxygen

Education on oxygen safety, discharge teaching

True or False: You should turn off oxygen when not in use?

True

1 multiple choice option

What do you need to ensure patients with oxygen needs have when they temporary leave the unit?

Ensure adequate portable oxygen supply should patients leave the unit (oxygen ticket)

When does oxygen toxicity occur?

Occurs when too high a concentration of oxygen (greater than 50-60%) is administered for an extended period (longer than 24 hours)

How does oxygen toxicity occur?

Causes an overproduction of free radicals, and if left untreated the free radicals can damage or kill cells

List the signs and symptoms of oxygen toxicity

-Substernal pain (discomfort behind or below the sternum)

-Paresthesia (tingling/numbness or pins and needles)

-Dyspnea (Shortness of breath)

-Restlessness

-Fatigue

-Malaise

-Progressive respiratory difficulty

-Refractory hypoxia

-Atelectasis (Collapse of a lung or part of a lung)

-Infiltrates

What is the best approach when dealing with oxygen?

Less is more

True or False: Oxygen should be titrated and kept near the lowest SpO2 target?

True

1 multiple choice option

List the ways you can prevent oxygen toxicity

-Use the lowest amount of oxygen to obtain the necessary partial pressure of oxygen (PaO2)

-Decrease or monitor the amount of time on higher oxygen levels

-Treat the underlying cause or why oxygen is needed (i.e. anemia, blood loss etc.)

-Monitor often for signs and symptoms and report immediately

When should you start weaning patients off oxygen?

When the SpO2 is at or above the target range

List the steps required to wean patients off oxygen

Step 1: Decrease oxygen by 1 L/minute QH and check SpO2 and respiratory rate (RR) QH

Step 2: Measure SpO2 a minimum of Q4H PRN (continuously or critically ill)

Step 3: Begin room air trial when at 1-2L/minute flow rate and when SpO2 is at or above the minimum target on 2 consecutive measurements at rest

Step 4: When oxygen therapy is discontinued, assess at the 15-30 minute mark and continue measuring SpO2 Q4H PRN

When would you titrate a patients oxygen?

When the SpO2 is below the target range

List the steps required to titrate patient oxygen

Step 1: Increase oxygen flow rate as needed (Consult RRT or MRHP is the patient is unresponsive to increased oxygen or as indicated in the order)

Step 2: Measure SpO2 after adjusting oxygen flow rate

Step 3: If SpO2 is within normal range or above target range keep within the lower end of the target range and wean when appropriate. If SpO2 is not within normal range repeat step 1

What is a nebulizer?

A machine that converts liquid medication into fine aerosolized mist allowing medication to be easily inhaled and vapor pulled deep into the lungs

List the characteristics of a nebulizer

-Oxygen or air driven

-Disperses inhaled medication

-Creates a small mist when attached to flow meter

-Often done prior to other interventions such as chest physio or deep breathing and coughing

What is diaphragmatic breathing?

A breathing technique that involves deep, abdominal breathing aimed at strengthening the diaphragm and improving respiratory efficiency

How does the diaphragm move during inspiration?

During inhalation, the diaphragm contracts and moves downward, causing the abdomen to expand outward as the lungs fill with air

How does the diaphragm move during expiration?

During exhalation, the diaphragm relaxes and moves upward, and the abdomen flattens as air is expelled

What is pursed lip breathing?

A breathing technique used to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and airway resistance

What is huff coughing?

A technique used to help clear mucus from the lungs in a controlled and effective way without the strain of traditional coughing (Beneficial for patients with COPD, cystic fibrosis, bronchitis)

List the types of chest physiotherapy

-Postural drainage

-Chest percussion

-Vibration

What is postural drainage?

A technique used to help clear mucus from the lungs by using gravity to assist in drainage

What is chest percussion?

A technique in which a caregiver or therapist rhythmically claps or taps on the chest or back (with a towel placed over the area) using cupped hands to help loosen mucus in the lungs to make it easier to cough it up and clear the airways

What does chest physiotherapy require to initiate?

A prescribers order

MOA of oropharyngeal and nasopharyngeal suctioning

Clears the oral airway to prevent pooling of secretions

What is the recommended timeline for performing oropharyngeal and nasopharyngeal suctioning?

No longer than 10-15 seconds

What does oropharyngeal and nasopharyngeal suctioning require?

A clean technique, care of the catheter, and PPE (Gloves, face guard)

What adverse outcomes can occur with oropharyngeal and nasopharyngeal suctioning?

Complications, check for desaturation

List the signs and symptoms of hypoxemia

-Dyspnea

-Tachypnea

-↓ LOC (level of consciousness)

-↑ WOB (work of breathing)

-Agitation

-Confusion/disorientation

-Tachycardia/Bradycardia

-Cyanosis

What is a late sign of hypoxemia?

Cyanosis

If a patient is breathing room air, what percent of Fi02 are they breathing in?

21%