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Low Flow Device - Nasal Cannula

1-6 liters per minute (lpm)

22-44% FiO2

1 lpm = 24%

2 lpm = 28%

3 lpm = 32%

4 lpm = 36%

5 lpm = 40%

6 lpm = 44%

Low Flow Device - Simple Mask

5-10 lpm

35-60% FiO2

No Reservoir Bag

Low Flow Device - Non-rebreather Mask

10-15 lpm

60-90% FiO2

Has (3) valves - 1 reservoir bag, 2 exhalation valves

Valves keep room air from coming in

Do NOT let bag collapse

Low Flow Device - Partial Pressure Rebreather Mask

6-15 lpm

40-70% FiO2

Bag should NEVER completely collapse

Does NOT have exhalation (2) valves on the sides of masks

Has reservoir bag

High Flow O2 Device/Precise FiO2 - Venturi Mask

24%

28%

31%

35%

40%

50%

Chain of what device to start with

Nasal Cannula

Simple Mask

Partial Rebreather

Non-rebreather

OxyMask (has many holes in it)

1-15 lpm

24-90% FiO2

Over 4L for nasal cannula

use humidifier

nasal cannula lpm

1-6

nasal cannula FiO2

22-44%

nasal cannula 1 lpm %

24%

nasal cannula 2 lpm %

28%

nasal cannula 3 lpm %

32%

nasal cannula 4 lpm % fio2

36%

nasal cannula 5 lpm %

40%

nasal cannula 6 lpm %

44%

simple mask lpm

5-10

simple mask FiO2

35-60%

what does a simple mask lack

no reservoir bag

non-rebreather mask lpm

10-15

non-rebreather mask FiO2

60-90%

what does a non-rebreather mask have?

3 valves - 1 reservoir bag, 2 exhalation valves. valves keep room air from coming in.

bag: do not let bag collapse

partial pressure rebreather mask lpm

6-15

partial pressure rebreather mask FiO2

40-70%

what does a partial pressure rebreather mask have and not have?

has a reservoir bag (should never collapse).

does not have exhalation (2) valves on the sides of masks

Inspection: What You See

•Observe respiratory rate

•Work of breathing

•Chest shape

•Accessory muscle use

•Skin color and patient position

Types of chest abnormalities

barrel chest

kyphosis, scoliosis, kyphoscoliosis

lordosis, pectus excavatum, pectus carinatum

barrel chest

rounded, bulging chest shape that makes the rib cage look like it is permanently stuck in a deep breath. Common in people with COPD.

Increased anteroposterior (AP) diameter.

Kyphosis

Abnormal curvature of the upper spine, the anterior- to- posterior curvature gives the patient the (Humpback) shape.  People with chronic (lasts a long time) lung disease develop this.

Scoliosis

Lateral curvature of the spine that causes the vertebrae in the affected area to rotate flattening the rib cage anteriorly.  Again, this curvature interferes with the patient's ventilation because they are not able to move air in and out of the lungs.

Kyphoscoliosis

Combination of kyphosis and scoliosis. This extremely affects the patient's ability to inhale volume greatly affecting the patients respiratory effort. Because the heart is not able to pump effectively and the lungs are not able to help in breathing, fluid backs up into the lungs and cause congestive heart failure. So essentially it will feel as if the patient is drowning. Many patients with this pass early in life from respiratory infections.

Lordosis

Inward curvature of the lumbar spine, results in a sway back appearance

Pectus Excavatum

This is a congenital (born with) deformity

Funnel chest (the breastbone sinks inward into the chest at the sternum and xyphoid process, creating a caved or sunken look) 

If this is severe enough, it may result in decreased lung volumes because the patient can not expand their lungs like a person who does not have this condition.

Pectus Carinatum

(congenital deformity) breastbone and push outward, giving the chest a bird-like or pointed look.(pigeon chest) Even though it looks like it hurts, the patient does not suffer from any respiratory complications

Digital Clubbing

The angle between the nailbed and finger become increased giving the fingers and toes a concave look.  Usually the result or hypoxemia (not enough oxygen in the blood) or circulation issues.  You will find it difficult at times to place your pulse oximeter on the patients fingers due to the shape, when that happens you may also grab your SpO2 measurement from the patient's ear, forehead, or toe.

Bony landmarks on the Anterior chest

•Clavicle (collar bones)

•Suprasternal notch

•Sternal angle

•4^th rib

Bony structures on the Posterior chest

•Clavicle

•C7 vertebra prominens

•T1

•Scapula (Shoulder blades)

Vertical Divisional Lines

•Anterior Chest- midsternal line

•Midclavicular line

•Anterior midaxillary line

Lateral chest

•Anterior axillary line

•Midaxillary line

•Posterior axillary line

Posterior chest

•Right and left midscapular lines

•Vertebral line

Palpation: What You Feel

•Assess chest expansion

•Evaluate symmetry

•Check tactile fremitus

•Relate findings to disease processes

What is Palpation?

Physical assessment of the chest by the sense of touch

Symmetry

Place your hands on both sides of the chest (right and left) you are observing the motion of the patients chest wall.  As the pt. inhales deeply, our hands move apart equally in theory.  If not and one hand moves more than the other, this could be a clue to consolidation (airless, fluid-filled uncollapsed lung tissue), pleural effusion (fluid in the pleural space), atelectasis (loss of air in the lung tissue), or a pneumothorax (air in the pleural space).

Tactile fremitus

Say “99” while the RT palpates the patients chest.  This is the vibration felt as the pt is speaking. 

•Increased: Pneumonia, Consolidation

•Decreased: Pleural Effusion, Pneumothorax

Subcutaneous Emphysema

Presence of air beneath the skin in the subcutaneous tissues. Usually a complication of tracheostomy placement, pneumothorax, or from the ventilator.

Percussion: What You Hear (RHDF)

•Resonant = Normal

•Hyperresonant = Too much air

•Dull = Tissue or fluid

•Flat = No air

2 methods to percuss the chest, direct and indirect

Direct is when you tap on the chest with a finger using a sharp, short, stroke.  Indirect is placing a finger firmly against the chest and tapping on that finger. 

You are listening for different sounds.  Hyperresonance, resonance, dullness, and flatnesss.

Hyperresonance

Air trapping, air in an enclosed cavity (pneumothorax)- loud, low-pitched sound 

Resonance

Heard when you percuss normal lung tissue.  Low pitched sound with a long duration. Equal parts of air and tissue. 

Dullness

Medium intensity and pitch with a short duration.  More tissue or fluid than air.  Consolidation, atelectasis, fluid in the pleural space

Flatness

Low amplitude and pitch. More tissue than air. Pleural effusion

Disease Connections (EPPP)

•Emphysema → Hyperresonant

•Pneumothorax → Hyperresonant + Decreased Fremitus

•Pneumonia → Dull + Increased Fremitus

•Pleural Effusion → Dull + Decreased Fremitus

Classifications of medical gases

•Medical gases are classified as laboratory, therapeutic, or anesthetic gases

•Medical compressed gases are classified as either: Nonflammable (do not burn), Nonflammable but supportive of combustion (oxidizing), Flammable (burns readily, potentially explosive)

Laboratory gases

used for equipment calibration and diagnostic testing.

Therapeutic gases

used to relieve symptoms and improve the oxygenation of patients with hypoxemia

Anesthetic gases

combined with oxygen (O2) to provide anesthesia

medical gas safety systems

1. Oxygen Delivery Systems

2. Vacuum Systems

3. Medical Air Systems

Oxygen Delivery Systems

These systems provide a controlled supply of oxygen to patients, essential for respiratory support. They are designed to deliver oxygen at various flow rates, accommodating different clinical needs, such as low-flow systems for stable patients and high-flow systems for those requiring intensive care.

Vacuum Systems

used for airway suctioning, which is vital in emergency situations and for patients with respiratory issues. They help clear secretions from the airway, ensuring unobstructed breathing and preventing complications.

Medical Air Systems

These systems supply a mixture of gases used to power pneumatic equipment and support various medical procedures. They are integral in anesthesia delivery and other applications where a clean, dry air source is necessary.

Medical gas alarm panel

Medical gas alarm panels are essential safety devices in healthcare settings. They monitor the status of medical gas and vacuum systems, ensuring that gases are available and within safe operational limits.

The normal ranges are usually listed on the bottom of the panel with the designated normal values of the pressures it is measuring

Medical gas alarm panel Key Functions:

Monitoring

Alerting

Location

These panels are crucial for maintaining patient safety and ensuring that medical staff can respond quickly to any gas supply issues.

Medical gas alarm panel - monitoring

Continuously checks pipeline pressures and operational status of medical gases.

Medical gas alarm panel - alerting

Generates alarms when parameters exceed set thresholds or when faults are detected, alerting healthcare staff to potential issues.

Medical gas alarm panel - location

Typically installed near points of use, such as patient rooms or operating rooms, or in central locations like nurses' stations.

Oxygen (O2): what you need to know

Colorless, odorless, transparent, tasteless

Heavier than air

Nonflammable BUT ACCELERATES COMBUSTION

Used to treat low oxygen levels in the blood (hypoxemia), acute conditions like pneumonia, COPD, and with traumas or surgeries before, during, and after operations

Oxygen Advantages

Quickly restores normal oxygen levels in the organs like the brain and heart

Improves breathing because it reduces the patient's shortness of breath reducing the workload placed on the heart and lungs

Enhances recovery by helping patients heal faster, and increases mobility while using portable O2 tanks.

Oxygen Limitations

Does not treat the cause, it fixes the hypoxemia but does not fix the underlying disease, some can not afford the portable tanks and need to stay home near their oxygen concentrators

Dryness and irritation to the nose, sinuses, and airways

Patients run a risk of toxicity (too much Oxygen) over a long period of time, this can damage the lung tissue especially in patients who have chronic disease.

Oxygen Safety Issues

Fire hazards, never smoke or use open flames near o2 equipment.

Pressure dangers are also on the list of limitations because compressed gas cylinders are under high pressure. They can explode or become dangerous projectiles if damaged or dropped,

Medical Air: what you need to know

Colorless, odorless, dry, purified gas

21% oxygen and 78% nitrogen (manufactured drug)

Processed through OIL-FREE compressor systems (to eliminate moisture, oils, and toxic particulates before being delivered to the patients.)

Prescribed for human respiration and respiratory equipment calibration

Used as a base gas to dilute pure oxygen to give an exact Fraction of Inspired Oxygen(FiO2) tailored to a patients oxygenation needs (OR).

Used in neonatal and infant care because they are highly vulnerable to hyperoxia (state of being exposed to high levels of O2)

Used in aerosol and nebulizer therapy to convert liquid medications into an inhaled fine mist,

Used as a carrier gas to transport anesthetic agents

medical air advantages

Mitigates oxygen toxicity (meaning it reduces the harmful effects O2 can have

Low fire risk (nonflammable) safer to use near sources of ignition

Medical Air limitations

Inadequate for acute hypoxemia because it only contains 21% oxygen

Medical Air safety issues

system contamination (contaminates and moisture can enter the respiratory pipeline fostering microbial or bacterial growth in the hospital pipes)

toxic gas exposure can be a problem

pressure fluctuations can disrupt the performance of critical mechanical ventilators,

gas misconnections can also occur, and the result can be catastrophic.

Carbon Dioxide (CO2) what you need to know

non-flammable

highly soluble in blood

rapidly cleared by the lungs

used as insufflation gas to inflate and stabilize the abdominal or body cavities

radiographic contrast agent serving as an alternate for patients who are allergic to iodine contrast

used as a respiratory stimulant in patients with respiratory depression because it activates the central and chemoreceptors in the brainstem that drive the urge to breathe (not used as often due to already dangerously high levels the patient could have.)

carbon dioxide advantages

Low risk of allergic reactions, it can enhance blood flow and improve oxygen delivery in tissues, less expensive than other contrast agents

carbon dioxide limitations

Potential for hypercapnia (excess CO2 in the blood), limited use in certain conditions mentioned above

carbon dioxide safety issues

Monitoring required complications can occur if CO2 is being used for insufflation or as a contrast, RISK for embolism if CO2 enters the blood stream

Heliox (Helium) what you need to know

Odorless, tasteless, nonflammable, nonreactive with other elements, resists physical stress

Produced by liquification

Must be mixed with at least 20% O2 to sustain life for therapeutic purposes

Can manage severe airway obstruction/asthma attacks/stridor

Monitor patient for adequate oxygenation, it does not provide oxygen itself

Only works when helium concentration is high (80:20) or (70:30) mixtures

Limited benefits when FiO2 requirements increase

It helps to manage the airway because it is less dense than air or oxygen allowing gas to flow smoothly through tight or blocked airways (laminar flow)

Nitric Oxide (NO) what you need to know

Vasodilatory properties

Colorless, nonflammable, toxic gas that SUPPORTS combustion

Forms brown fumes

Strong respiratory irritant (chemical pneumonitis)

Can cause a fatal form of pulmonary edema

Methemoglobinemia

methemoglobinemia

blood disorder where an abnormal amount of methemoglobin builds up in the blood. This prevents red blood cells from effectively releasing oxygen to body tissues. Blood looks like chocolate. (treatment is methylene blue) IV quickly converts iron back to its normal state.

Nitrous Oxide (N2O) what you need to know

Colorless gas

Sweet odor and taste

Anesthetic agent (depresses the central nervous system) conscious sedation

Can support combustion, but can’t support life

Must ALWAYS be mixed with 20% O2

Known as Laughing gas

Conscious sedation is when you are awake and still able to talk

Oxygen tank Sizes

H cylinder

E cylinder

E-AA are considered small and used for patient transport

G and H are for stationary patients

Cylinder Safety Factor (E)

E cylinder 0.28 L/psi

Formula for calculating how long an “E” cylinder will last

Duration(minutes)= PSIG off tank x 0.28 (tank factor)/ Flow L/M

For every psi of pressure in the cylinder, there are about 0.28 liters of oxygen available. Crucial for calculating how long the oxygen will last based on the cylinders pressure and the flow rate being used.

Cylinder Safety Factor (H)

H cylinder 3.14 L/psi

Formula for calculating how long an “H” cylinder will last

Duration(minutes)= PSIG off tank x 3.14 (tank factor)/ Flow L/M

storage precautions of tanks/cylinders

Ventilation: Ensure storage areas are well-ventilated to prevent the accumulation of gases.

Temperature Control: Store cylinders in a cool, dry place away from heat sources and direct sunlight.

Secure Storage: Cylinders should be secured upright to prevent tipping and should be protected from physical damage.

transportation precautions of tanks/cylinders

Proper Securing: Cylinders must be secured in an upright position during transport to prevent movement and potential damage.

Leak Checks: Regularly inspect cylinders for leaks before and during transportation.

Avoiding Heat Sources: Keep cylinders away from flames, heat, and oil during transport.

Compliance with Regulations: Follow Department of Transportation (DOT) regulations for transporting hazardous materials.

general safety practices of tanks/cylinders

Personal Protective Equipment (PPE): Use appropriate PPE, such as gloves and goggles, when handling cylinders.

Training: Ensure personnel are trained in oxygen safety protocols.

Pressure Regulators

E cylinders have 2 prongs that line up for the tank and an “O” ring. Use pin-index regulators. Support lower flow rates up to 15 LPM

H tanks have use large-bore threaded regulators. Can handle higher flow rates, up to 25 LMP or more

pressure regulators a.k.a reducing valves

reduce cylinder pressure to a safe usable working pressure. The unit of measure is psi (pounds per square inch)

Manage force/pressure

flowmeters

Measure or regulate the exact volume or speed of fluid/gas passing through a system per unit of time. The unit of measure is lpm (Liters per minute)

Manage volume/speed

Thorpe Tube flowmeter

Flow meter device attached to a 50 psig gas source

Facilitates accurate flow adjustments/compensated

Calibrated in liters per minute

Not ideal to transport patients

Gravity Dependent- The tube must remain completely vertical to give an accurate reading.

Bourdon Gauge flowmeter

Uses a fixed orifice/operates under variable pressures that can be adjusted with a pressure reducing valve

When delivering a medical gas, use this whenever a flowmeter cannot be maintained in an upright position

ASSS American Standard Safety System

used with “H” cylinders- threaded high pressure connections

PISS Pin Index Safety System

used with “E” cylinders. Made with pins to align with valve outlet

DISS Diameter Index Safety System

Used with low pressure medical gas connections

Oxygen Analyzer

Device that measures the concentration of oxygen in a gas mixture

Displayed as a percentage

What is the atmosphere made up of

Nitrogen (N2)- 78%

Oxygen (O2)- 21%

Argon (Ar)- 1%

N2- 760 x .78=592.8

O2- 760 x .21= 159.6

Ar- 760 x .01= 7.6

Add all these up and it equals 760mmHg at sea level