Comprehensive Notes on Oxygen Delivery and Airway Management

Oxygen Delivery Methods and Considerations

Initial Actions

  • Non-Rebreather Mask: In emergency situations, immediately apply a non-rebreather mask and turn the oxygen flow all the way up.

Oxygen Concentration

  • Room Air: Consists of approximately 21% oxygen, with the remainder being nitrogen and other inert gases.

  • Nasal Cannula:

    • Each liter of oxygen via nasal cannula increases the FiO2 (fraction of inspired oxygen) by approximately 3-5% (use 5% for easier calculation). The exact percentage varies depending on the mask type.

  • Calculating Oxygen Percentage:

    • 1 liter: 21% (room air) + (1 * 5%) = 26%

    • Oxygen  Percentage=21+(Liters  per  Minute∗5)Oxygen \; Percentage = 21 + (Liters \; per \; Minute * 5)

    • 4 liters: 21% + (4 * 5%) = 41%

    • 6 liters: 21% + (6 * 5%) = 51%

  • Non-Rebreather Mask (15 liters): Delivers approximately 96% oxygen, which is essentially 100%.

    • 21+(15∗5)=9621 + (15 * 5) = 96

Prioritization of Patient Care

  • Hands-on learning and patient care are paramount. Prioritize practical application of knowledge, especially in critical situations like COVID, where high-flow oxygen delivery was crucial.

  • During COVID, various masks were used, sometimes in combination (masks on top of masks), to maximize oxygen delivery.

Maximum Oxygen Concentration

  • The maximum oxygen concentration achievable is 100%. This means every molecule in the respiratory system is oxygen.

  • Even with multiple oxygen sources (e.g., 15 liters + 15 liters), the maximum FiO2 remains 100%.

PEEP (Positive End-Expiratory Pressure)

  • PEEP involves inflating the lungs fully and maintaining inflation even during exhalation.

  • It is used for patients with collapsing alveoli, often due to conditions like pneumonia affecting surfactant production.

Nasal Cannulas

  • Advantages: Cheap and relatively comfortable.

  • Oxygen Delivery: Can deliver up to approximately 50% oxygen.

  • Situations for Oxygen Administration:

    • Central nervous system (CNS) emergencies

    • Cardiac emergencies

    • Respiratory emergencies

  • Example: A patient with a CNS emergency and a pulse oximetry reading of 97% might still benefit from 2 liters of oxygen via nasal cannula.

  • Respiratory Distress: Recognize and respond to signs and symptoms of respiratory distress.

Simple Face Masks

  • Flow rate: 5-10 liters per minute.

Carbon Dioxide (CO2) Considerations

  • Mask Flow Rates: Maintain minimum flow rates to prevent CO2 buildup.

  • CO2 Inhalation: Insufficient flow rates can lead to patients rebreathing their own CO2, potentially causing suffocation (hypercapnia).

  • Non-Rebreather Mask Reservoir: Fill the reservoir bag to offset CO2 buildup within the mask.

  • Pillow Treatment: Avoid inappropriately applying oxygen masks at low flow rates (e.g., 2 liters), as this can be detrimental.

Advanced Airway Management

  • Aerosol Masks, Trach Collars, T-Piece Adapters: Used for patients with tracheostomies or those requiring ventilator support.

  • T-Piece Adapters: Allow connection to a ventilator and assessment of a patient's ability to breathe independently.

  • Weaning from Ventilation: Gradually reduce ventilator support using a T-piece to assess patient readiness for extubation.

  • Facetape: Used to help secure masks when standard methods are not viable.

High-Flow Nasal Cannula

  • An alternative to BiPAP/CPAP, offering greater comfort.

  • Delivers heated and humidified air with controlled FiO2.

Venturi Mask

  • Provides accurate oxygen delivery, especially for patients with COPD requiring precise FiO2 levels (e.g., 35%).

  • Uses color-coded valves to adjust FiO2 without complex calculations.

Oxygen Delivery Systems

  • Progression: Nasal cannula → Simple face mask → Masks with bags (partial and non-rebreather).

  • Non-Rebreather vs. Partial Rebreather: Non-rebreather masks have valves preventing room air entrainment, ensuring higher FiO2 delivery.

High-Flow Systems

  • Heated, humidified, and allow for controlled FiO<em>2FiO<em>2. The goal is to displace CO</em>2CO</em>2 with increased oxygen in cases of respiratory acidosis or alkalosis.

  • Can also be used to force oxygen into hypoxic patients.

CPAP, BiPAP, and APAP

  • CPAP/APAP: Primarily used for sleep apnea (continuous positive airway pressure).

  • BiPAP: Used for patients needing predictable breathing support (biphasic positive airway pressure).

Discharge Planning

  • Starts upon patient admission.

  • Ensure the patient's home environment is safe and they can manage their respiratory needs.

  • Resting/Ambulation Study: Assessing patient's oxygen saturation & heart rate during activity (walking) to determine if they can maintain adequate oxygenation without support. Discharge should not occur if they cannot breathe adequately at home.

  • Home Oxygen: Patients should receive oxygen tanks and appropriate education before discharge.

Oxygen Tank Safety

  • Storage: Tanks must be stored properly to prevent accidents.

  • Hazards: A compromised tank valve can turn the tank into a projectile, causing significant damage.

    • Liquid oxygen tanks last for significantly longer periods compared to standard tanks.

  • Oxygen Concentrators: Devices that compress regular air into higher oxygen concentrations.

Oxygen Toxicity

  • Excessive oxygen can be harmful.

  • Symptoms: Blurry vision, headaches, muscle twitching, jerky breathing, painful breathing, potentially leading to acute respiratory distress.

  • Oxygen is considered a drug and must be administered safely.

Complications of Oxygen Therapy

  • Atelectasis: Development of pockets of collapse in the lungs.

  • Mucosal Membrane Drying: Occurs with oxygen flow rates above 4 liters per minute; humidification is essential for long-term therapy.

    • Symptoms: Nosebleeds, discomfort and increased risk of infection.

  • Infections:

    • Ventilator-Acquired Pneumonia (VAP): Preventable through consistent oral care (q2hr);

    • Dried mucous membranes impairs the body's defense mechanisms. Mucus traps pathogens, so keeping it moist supports the body's natural defenses.

  • Aspiration: Air forced into the airway can increase risk of vomiting and aspiration into the lungs.

    • Patients at risk should have NG tubes placed and receive antiemetics.

Invasive Interventions: Endotracheal Tubes (ET Tubes)

  • Rapid Sequence Intubation (RSI):

    • Used in cases of respiratory distress

    • Involves administering a paralytic and a sedative.

    • Always administer the sedative medication first before the paralytic. Sedation is crucial to avoid the experience of sleep paralysis.

  • ET Tube Complications:

    • Obstruction

    • Apnea

    • High risk for aspiration

    • Inadequate airway clearance

    • Respiratory distress

    • Abnormal ABGs

Post-Intubation Care

  • ICU Monitoring: Patients require ICU care for constant titration of oxygen and medications.

  • Circadian Rhythm: Adjust sedation levels according to the patient's natural circadian rhythm.

  • Unplanned Extubation: Patients may attempt to remove the ET tube, especially as they become more alert.
    *Implications of pulling out ET Tube: *If the diaphragm is not working, the patient will die. If the diaphragm IS working, there will be trauma and aspiration because of a baloon on the end of the ET tube.*
    ET tubes have a balloon on the end, so if pulled, it will cause trauma to the voice box.

ET Tube Management

  • Oral Care: Essential to prevent VAP and address pressure increases.

  • ETT Repositioning: Change position of tube in the mouth to prevent pressure injuries.

  • Maximum ET Tube Duration: Two weeks; after which a tracheostomy should be considered.

    • Sedatives slow metabolism and healing

  • Decannulation: Accidental removal of the tracheostomy tube.

  • Pneumothorax: Air leaking into the space between the lungs and chest wall.

  • Emphysema: Air trapped in tissues.

  • Tracheal Stenosis: Narrowing of the trachea.

  • Transesophageal Fistulas: Abnormal connection between the trachea and esophagus, can heighten aspiration risk.

Intubation Education Video Summary

  • Purpose: To help the patient breathe, and can be short or long term depending on the situation. The ET tube leads down the windpipe, or trachea in order to get oxygen into the lungs.

  • What happens during the procedure?

    • The patient will receive a sedative and a paralytic.

    • An oxygen mask is put on the patient to ensure the patient can breathe for a few minutes.

    • The doctor will then tilt the head back to make it easier to put in the breathing tube. A tool will be used to move the tongue fromt he back of the throat in order to visualize the vocal cords easier. The breathing tube gets put into the throat, and gently pushed until it reaches the windpipe.

    • The tool is taken out, and the tube is secured into place. The tube will be taped to the mouth.

    • The tube is connected to the ventilator, which is a machine that helps you breathe. The tube can go throught the nose, or through a cut made in your neck, called a tracheostomy.

  • CO2 Detection: A device to measure CO2 is put on the patient after intubation. The device is purplish in color, and then turns yellow after the ambu bag is let go and air comes out. This means the CO2 is present, and it is a good indication that we are in the trach and not the esophagus.
    X-rays are still needed to look for barotrauma.

  • Ventilator Waveforms: Red color signals the machine is in full control, green signals the patient is doing some of the work on their own.

  • Ventilator can: Help you breathe easier until you can breathe on your own, help you get more oxygen into your body and less carbon dioxide out, give you needed air supply, decrease the amount of energy your body uses, open an airway, protect your lungs, and remove blockages from the airway.

Environmental Awareness

  • The general survey is not just about the patient - also about the environment/room.

  • Suction: Is an important part of the room set-up, because one of the risks of intubation is aspiration.

  • Devices such as pumps, ventilators, iPad machines, and suction replace a body function.