Respiratory Therapy 101
Understanding Oxygen Therapy in
less than an Hour
Oxygen Cannula
• Can safely be used at
flow rates of 1-6 LPM
• Flow should not be
turned above 6 LPM
• Produces 24% to
44% oxygen to
patient
Oxygen Cannula
Liter Flow
% Oxygen
1
2
3
4
5
6
24%
28%
32%
36%
40%
44%
Oxygen Humidifiers
• Used with oxygen
cannulas to prevent
nasal drying
• May not be used at
flow rates less than
3LPM (need to bubble
to be effective)
• Check water level and
change as needed
Oxygen Humidifiers
Reservoir Cannulas
• Stores oxygen in a
reservoir on
exhalation so the
patient has more
oxygen available on
inhalation
• Capable of
providing higher
oxygen percentage
at a lower flow rate
Two styles of Reservoir Cannulas
Simple Oxygen Mask
• Flow rate should be from
5 to 10 LPM
• Flow rate should NOT be
Less than 5 LPM
• Oxygen delivery is
approximately 35% to
50%
• Short term use only
• No Humidity
Simple Mask
100% Non-Rebreather Mask
• Set oxygen flow to a
setting that does not
allow the reservoir bag
to collapse with the
patient’s inspiration (10
– 15 LPM)
• If tight fitting to
patient’s face, 100%
oxygen can be given
• Usual oxygen
percentage is 60% to
80%
• USED BY EMS
Non-rebreather Masks
High Flow Systems
Air Entrainment Mask
(Venturi)
• Percent of oxygen delivered
depends on the LPM flow, the
size of the jet, and the size of
the entrainment port
• Delivers a precise oxygen
percentage
• Entrainment ports must be kept
open
• Most accurate way to deliver
O2
• Ideal for CO2 retainers
High Flow System
Air Entrainment Mask
High Flow System
Air Entrainment Mask
• The flow of 100% oxygen through the mask and draws in a
controlled amount of room air (21 per cent oxygen).
• Commonly available masks deliver 24, 28, 31, 35, or 40 per
cent oxygen. At concentrations above 24 per cent,
humidification may be required. (Color coded – depending
on manufacturer)
High Flow System
Air Entrainment Mask
Oxygen Blender
• Controls precisely
the percent of
oxygen the patient
is receiving
• High flow meter is
required for use
Oxygen Blender
How do I know if my Patient is Oxygen
Deprived???
?
Clinical Respiratory Signs of Hypoxia
MILD to MODERATE
• Tachypnea
• Dyspnea
• Paleness
SEVERE
• Tachypnea
• Dyspnea
• Cyanosis
Cardiovascular Signs of Hypoxia
MILD to MODERATE
• Tachycardia
• Mild Hypertension
• Peripheral Vasoconstriction
SEVERE
• Tachycardia, eventual
bradycardia, arrhythmia
• Hypertension and eventual
hypotension
Neurologic Signs of Hypoxia
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MILD to MODERATE
Restlessness
Disorientation
Headaches
Lassitude
SEVERE
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Somnolence
Confusion
Distressed appearance
Blurred Vision
Loss of Coordination
Impaired judgment
Slow reaction time
Manic-Depressive activity
Coma
Monitoring Oxygen with an Oximeter
• Monitors the adequacy of
arterial oxyhemoglobin
saturation
• Usually maintained at
values above 90%
• Only provides valuable
data when patient has
normal hemoglobin
• Light and nail polish can
alter saturation readings
ETCO2 Monitoring
ETCO2 –
measures
ventilation, not
saturation (end
product of
breathing is
CO2)
(See
pamphlet)
Used with post
surgical patients
on PCA pumps,
Epidurals and
Mechanically
Vented patients
Monitoring Oxygen with ABG’s
• Pa02 reflects oxygenation levels
• Normal Pa02 is 80-100mmHg (<60 mmHgneeds intervention).
• Pa02 Values below 55 mmHg are Critical
• Normal Pa02 values decrease
with age
• Hypoxemia – low PaO2 <80
ABG Review
• pH = 7.35 to 7.45
<7.35 Acidic and > 7.45 Alkalotic
• PaC02 = 35 to 45
• HC03 = 22-26 (28)
• Cost of ABG ($800-$1500/draw)
• Invasive Procedure
• ROME = Respiratory – Opposite direction
Metalbolic – Equal (same) direction
What is CPAP???
• Continuous Positive Airway Pressure
• Application of positive pressure to a patient’s
airway throughout the respiratory cycle
• Increases the patient’s FRC (functional
residual capacity)
• Improves oxygenation
• Also, used to prevent airway collapse in
treatment of obstructive sleep apnea
What is BiPAP??
Non-Invasive Positive Pressure
Ventilation (NIPPV)
• Provides two levels of pressure to
the patient
• One pressure on the inspiration
(IPAP)
• One pressure on the expiration
(EPAP)
• May be used in patients with
acute, short-term respiratory
problems to avoid intubation and
invasive mechanical ventilation
• Improves the ability to remove
CO2 and provide O2
Facial and Nasal Masks
Non-Invasive Positive Pressure
Ventilator Support
FiO2
• Fractional concentrated of inspired oxygen
delivered
• Percentage of Oxygen delivered or
participating in gas exchange
in the alveoli (0.21 to 1.0)
• Expressed in %. (0.35 is 35%).
Oh my GOD!! My patient is on a
ventilator!
Drager Ventilator
BASIC VENTIALTOR MODES
1. VOLUME CONTROLLED –
– tidal volume (volume of air inhaled)
1. PRESSURE CONTROLLED –
– PIP (positive inspiratory pressure)
Basic Ventilator Parameters
Breath Rate (f)
• Number of times per minute that inspiration is
initiated (controlled by ventilator, patient or
combination of both).
• Two things to know:
»Ventilator Setting (rate) (f)
»Patient Rate (BPM)
• Rate (f) setting and Patient breathing rate are not
the same thing
Basic Ventilator Parameters
Tidal Volume (vT)
• Amount of gas delivered during an inspiration
in ml or liters
• Average adult tidal volume is
500-550 ml or .500 -.550 L
• Setting in volume control modes
• Not a setting but volume
readings are measured in
pressure control modes
Basic Ventilator Parameters
Peak Inspiratory Pressure (PIP)
• Maximum pressure
reached in the ventilator
system during inspiration
• Set parameter in pressure
setting modes (Pressure
Controlled Ventilation PCV)
PEEP
• Positive End Expiratory Pressure
• Application of a constant, positive pressure
such that at the end of exhalation, airway
pressure does not return to zero
• Improves oxygenation
Basic Ventilator Parameters
Breath Types
• Mandatory – ventilator
controls all parts of
breathing
• Spontaneous – patient
controls all parts of
breathing
• Assisted Breaths – patient
controls breathing rate,
breaths are assisted with a
set Vt (tidal volume)
Basic Ventilator Parameters
Common Modes of Ventilation
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CMV
A/C
VC
SIMV
SIMV + PS
PSV
CMV Mode (volume)
most common type used is Assist Control (A/C)
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Continuous mandatory ventilation
Continuous mechanical ventilation
Every breath is mandatory or assisted
Set minimum breath rate
– CMV – patient does not determine
breathing rate.
– A/C – patient determines breathing rate.
• Patient does not work
• Delivery of a mandatory or assisted
breath at a set rate
SIMV Mode (volume , sometimes
pressure)
• A minimum number of breaths delivered with
a tidal volume (assisted) is set on the
ventilator.
– Respiratory rate and tidal volumes are set
• Patient may breath spontaneously between
the number of set assisted breaths
• Weaning mode (usually)
• Set PEEP and sometimes
pressure support is set
Pressure Controlled Ventilation
(pressure)
• Delivers breaths at a preset pressure limit (equal to PIP).
• When ventilator delivers a breath, it continues delivering
the volume until the pre-set pressure limit is reached,
then it stops delivering the breath.
• Settings: Pressure limit (PIP) and I:E ratio but not the tidal
volume (tidal volume will vary).
• IMPORTANT NOTE: “unnatural feeling of breathing” –
NEEDS SEDATION!
• With control modes – increases mean airway and
intrathoracic pressures rise, may decrease Cardiac
Output, very important to monitor hemodynamics (BP,
HR, CVP)
Pressure Support Ventilation
PSV (pressure)
• Augments or assists spontaneous breathing efforts by delivering a
high flow air to a selected pressure level early in inspiration and
maintains that level throughout the inspiratory phase.
• When PSV is used as a stand-alone mode the pressure support
level is adjusted to achieve the targeted tidal volume and
respiratory rate. (Vt and f are not set - patient determines own
respiratory rate and tidal volume
• Reduces the work of breathing for the patient by reducing the
resistance of breathing through an ET tube and circuit tubing.
• A lot of time this mode is combined with SIMV and CPAP mode.
• At High pressures PSV can provide nearly total ventilator support.
• Because level of pressure can be gradually decreased, endurance
conditioning is enhanced in PSV modes. Great for weaning!
CPAP Mode (pressure)
• Not the same as CPAP by mask at home or is it????
• Supplies pressure throughout the respiratory cycle,
helping to improve oxygenation in spontaneously
breathing patients.
• No setting on ventilator for rate or tidal volumes
(patient determines own rate and their own tidal
volume).
• FiO2, PEEP, PS (pressure support) can be set.
• Should not over sedate people on this mode.
• Monitor breathing rate, apnea alarms!!
• May be used on intubated or non-intubated patients
via mask.
Alarms
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High inspiratory pressure or pressure limit
Low inspiratory pressure
Low exhaled tidal volume
High or low minute volume
Apnea
High rate or frequency
Low PEEP/CPAP
High Inspiratory Pressure Alarm
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Coughing
Secretions in the airway
Biting on the ET tube
Bronchospasm
Patient Ventilator asynchrony
Kinking of ventilator circuit
Low Inspiratory Pressure
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Low exhaled volume
Patient Disconnected
Circuit Leaks
Airway leaks
When in Doubt Always Ask!!
Your Respiratory Therapist Is Your Friend!!!!!!!
They are here to help!
And to keep your
patients breathing
forever!