OXYGEN DEVICES HTTP://WWW.YOUTUBE.COM/WATCH?V=1T7TGKQCIGI RT 210A Oxygen Therapy – Indications* • Documented hypoxemia (PaO2 and/or SaO2 decreased below patients baseline) • An acute care situation in which hypoxemia is suspected (cardiopulmonary arrest, stroke, Pneumo…) • Severe trauma *From the AARC Clinical Practice Guideline Oxygen Therapy – Indications* • Acute myocardial infarction • Short term therapy or surgical intervention *From the AARC Clinical Practice Guideline Indications • When a patient exhibits signs, symptoms or situations that indicate oxygen therapy there are very few contradictions. A patient may need oxygen to keep the workload of the heart and lungs at a normal level. If an asthmatic patient has an asthma attack and their airways are becoming restrictive they won't be able to bring in as much air to their lungs. In this case you want the air that they are able to bring into their lungs to have higher levels of oxygen than what room air alone can provide. One indication for oxygen is short-term therapy. In many of these situations a patient may have normal SaO2 values but are in a situation where hypoxia may be common. Some of these may be postoperative patients, CO2 poisoning, cyanide poisoning, shock, trauma, acute MI or some premature babies. Oxygen can sometimes be better used as a preventative than a treatment. Hypoxemia • When the a patient develops hypoxemia their breathing rate will begin to rise proportionally along with their heart rate to compensate for the demand of oxygen. • Pulmonary vasoconstriction and hypotension develop. This in turn will increase the workload on the right side of the heart and over time can lead to heart failure. • Tachypnea, tachycardia, dyspnea, lethargy/confusion develop with severe hypoxemia • Other visual symptoms include restlessness and headaches. Oxygen Therapy – Contraindications* • There are no specific contraindications to oxygen therapy when indications are judged to be present *From the AARC Clinical Practice Guideline Oxygen Therapy – Hazards and Complications* • Ventilatory depression (if you supersede a patients need) • Absorption atelectasis • Oxygen toxicity *From the AARC Clinical Practice Guideline Oxygen Therapy – Hazards and Complications* • Fire hazard (combustible) • Retinopathy of prematurity • Bacterial contamination (when using humidity or aerosol) *From the AARC Clinical Practice Guideline Ventilatory Depression • Patients at risk: • COPD patients with hypercapnea, again only if the patient receives more PaO2 than they require, the FIO2 does not necessarily matter during an exacerbation, always give them enough to support appropriate tissue oxygenation. Ventilatory Depression • Mechanism of action • Patient has “normal” PaCO2 > 60 mmHg (chronic hypercapnea) • Response of central chemoreceptors blunted • PaO2 decreases to < 55 mmHg Ventilatory Depression • Mechanism of action • Decrease in oxygen level triggers response by peripheral chemoreceptors, if they • Rate and depth of breathing increase Ventilatory Depression • Mechanism of action • When supplemental oxygen administered, PaO2 can rise to > 55 mmHg, removing stimulus to peripheral receptors • Hypoventilation results Absorption Atelectasis • Two contributing factors • FIO2 > 0.50 • Air trapping What are the types of atelectasis? • Passive • From hypoventilation, typically post surgical pain, weakness, diaphragm weakness • Resorptive • When there is endobronchial obstruction, there is no more ventilation and air gets absorbed from alveoli. Alveoli collapse with significant loss of lung volume. Example: Lobar atelectasis from endobronchial lung cancer. • Relaxation • Normally lungs are held close to chest wall by the negative pressure in pleura. In pneumothorax or pleural effusion the negative pressure in pleura is lost. Lung relaxes to its resting position. • Adhesive • Surfactant is necessary for keeping the alveoli open. In ARDS and Pulmonary embolism there is loss of surfactant and alveoli collapse. Absorption Atelectasis • Mechanism of action • At higher FIO2, nitrogen in alveolus is replaced by oxygen • With obstruction of the airway, oxygen is rapidly absorbed into the capillary without replacement in the alveolus Absorption Atelectasis • Mechanism of action • Removal of oxygen causes decrease in volume of alveolus, resulting in alveolar collapse or atelectasis Absorption Atelectasis • Mechanism of action • May also occur in patients with low tidal volumes as a result of sedation, pain, or CNS dysfunction • Oxygen is absorbed faster than it can be replaced • Alveoli gradually decrease in volume • May eventually lead to complete collapse • May occur even without supplemental oxygen Oxygen Toxicity • Two contributing factors • FIO2 > 0.50 • Time of exposure Oxygen Toxicity • Pathophysiological changes • Damage to capillary epithelium • Interstitial edema • Thickening of alveolar capillary membrane Oxygen Toxicity • Pathophysiological changes • Destruction of type I alveolar cells • Proliferation of type II alveolar cells • Formation of exudate Oxygen Toxicity • Pathophysiological changes • Decrease in ventilation/perfusion ratio • Physiologic shunting • Hypoxemia Oxygen Toxicity • Mechanism of action • Overproduction of free radicals • Safe level: FIO2 ≤ 0.50 Oxygen Toxicity Fire Hazard • Risk increases as oxygen level increases • Greatest risks include operating rooms and selected procedures • Laser bronchoscopy may cause intratracheal ignition in presence of increased FIO2 Retinopathy of Prematurity (ROP) • Occurs in premature and low birth weight infants • Causative factor • Increased PaO2 usually greater than 80 mmHg • Covered in neonatal section of curriculum • http://www.youtube.com/watch?v=BVYwo-RmDNE Bacterial Contamination • Associated with equipment Assessment of the Hypoxemic Patient • Clinical signs of hypoxemia • Tachypnea • Tachycardia • Anxiety Assessment of the Hypoxemic Patient • Clinical signs of hypoxemia • Cyanosis • Present when there are 5 grams of desaturated hemoglobin • May not be present in instances of severe anemia • May be present in absence of hypoxemia in presence of polycythemia Assessment of the Hypoxemic Patient • Clinical signs of hypoxemia • Confusion • Lethargy • Coma Assessment of the Hypoxemic Patient • Laboratory data • Arterial blood gas results (PaO2) • Saturation (SpO2) • Increased levels of lactic acid may indicate hypoxia • O2 delivery in COPD patients: • http://www.youtube.com/watch?v=XFieSB3TzK 4 Assessment of the Hypoxemic Patient • Specific clinical conditions • Myocardial infarction • Generally given 100% oxygen, especially in ED • Recent research may show that high FIO2 may cause vasoconstriction of the coronary arteries, contributing to cardiac ischemia Assessment of the Hypoxemic Patient • Specific clinical conditions • Trauma • Overdose Monitoring the Physiologic Effects of Oxygen • The symptoms of hypoxia are cognitive impairment, cardiac rhythm and conduction dysfunction, and renal dysfunction. • Monitoring arterial blood gas analysis is standard for documenting oxygenation, ventilation, and acid–base balance. • Pulse oximetry is the most common form of continuously monitoring oxygen saturation. • Oxygen analyzers are used to measure the concentration of oxygen administered to patients. Oxygen Devices • http://www.youtube.com/watch?v=OWLkJv61eo&feature=related • Low flow systems • High flow systems • Positive pressure (vents, IPPB, resuscitation bags) • Hyperbaric chamber Low Flow Oxygen Systems • Deliver flows at less than the patient’s inspiratory flow rate, diluting the inspired oxygen with room air • FIO2 varies dependent upon the specific device and the patient’s inspiratory flow Low Flow Oxygen Systems • Conditions required for low flow systems • VT between 300 and 700 mL • f < 25 breaths per minute • Regular breathing pattern Nasal Cannula • • • • Used on adults pediatrics and neonates Adult flows: 0.5-6L Infant/neonatal flows: typically less than 1 L Typically a low flow device but may be high flow if given as a high flow nasal cannula • Add humidity for flows over 4L or anytime a infant/neonate or pediatric is on any amount of O2 Delivery Devices – Nasal Cannula • Advantages • Economical • Comfortable – better patient compliance • Patient able to eat, speak, and cough with cannula in place • Mouth breathing not a significant factor Estimating FiO2 Nasal Cannula flow rate FIO2 1L .24 2L .28 3L .32 4L .36 5L .40 6L .44 O2 mask flow rate FIO2 5-6 L 0.4 6-7 L 0.5 7-8 L 0.6 NC • • • • • 0.5 LPM = 22% 1 LPM = 24% 2 LPM = 28% 3 LPM = 32% 4 LPM = 36% starting at 4 LPM a bubble humidifier is required to prevent • 5 LPM = 40% irritating the nasal mucosa which can cause nose bleeds or • 6 LPM = 44% drying of mucus. Delivery Devices – Nasal Cannula • Disadvantages • Imprecise concentration of oxygen delivered • May fluctuate according to patient’s breathing pattern • May cause irritation to nares, nasal airway, or ears (around ear), may use cushion around ear • Easily dislodged Delivery Devices – Nasal Cannula • Flows generally not greater than 6 L/min • May use with very low flows, less than L/min • Flows ≤ 4 L/min do not require use of humidifier ¼ Figure 16-9A: Nasal cannula with elastic strap. (A) Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999. Figure 16-9B: Over-the-ear style nasal cannula. Figure 16-9C: Various styles of nasal prongs. Courtesy of Teleflex Incorporated. Unauthorized use prohibited Nasal Cannula Keep flange against upper lip NC should be adjusted below chin, do not place behind head, choking risk; unless applying to neonates/small peds. On infants, tape to face Nasal Cannula • Insert the nasal cannula into your nose and breathe through your nose normally. • If you’re not sure whether oxygen is flowing, place the cannula in a glass of water. Bubbles mean that oxygen is flowing. • Patients may use extension tubing for increased mobility Simple Mask/O2 mask © Corbis/age fotostock Figure 16-10B: Simple O2 mask. Simple Oxygen Mask • Typically given for short term use, during deliveries, in the ER • Flows begin at 5-6L at least to prevent rebreathing exhaled CO2 • Max flow is around 10-12L • DO not add a bubble humidifier • Not used regularly by RT’s Simple Mask • Used for patients in need of oxygen in the range of 35% to 50%. • Again this is a estimation since it is a low flow device. This mask is used on children through adults but not neonates. The mask can be uncomfortable and needs to be removed to eat. Used for short term or emergency use requiring moderate O2 use such as CHF, Pulmonary Emboli, Pulmonary Fibrosis, Labor, Surgery, Heart attack, and a multitude of other diseases. Not for CO2 retainers. Delivery Devices – Simple Oxygen Mask • Advantages • Can deliver moderate concentrations (FIO2 between 0.35 and 0.55 at flows of 5 to 10 L/min) • Economical • Mouth breathing not a factor Delivery Devices – Simple Oxygen Mask • Disadvantages • Uncomfortable for most patients • Must be removed for eating, speaking, expectorating • May allow vomitus to be aspirated Delivery Devices – Simple Oxygen Mask • Disadvantages • May allow accumulation of CO2 and rebreathing if flow is inadequate • Can irritate skin and cause pressure sores • http://www.youtube.com/watch?v=tBUjR5HDqNs&feature =related Aerosol Mask • Used for the delivery of aerosol. Either by: • Small volume nebulizer or Large volume nebulizer • Can be a face or trach mask • FIO2 dependent on device in • it is used Partial Rebreathing Mask • No one way valves • Otherwise looks identical to a non rebreathing mask Partial Rebreathing Mask • Originally used in anesthesia; currently used for short-term therapy requiring moderate to high FIO2, Not a commonly used mask • Has a reservoir bag that fills with oxygen but also exhaled CO2. Delivers up to 60% O2 with flows of 10-15 LPM. The bag should not deflate on inspiration, if it does INCREASE THE FLOW. Used for the delivery of moderately high FIO2’s and is given for the same reasons a simple mask is given. Usually seen in emergency rooms. Not for CO2 retainers. This is a low flow oxygen device, the patient should be breathing adequately and simply need an increased FIO2. Partial Rebreathing Mask • Advantages • Able to deliver moderate concentrations of oxygen (FIO2 between 0.40 And 0.70) • Economical • Mouth breathing not a factor Partial Rebreathing Mask • Disadvantages • Uncomfortable for many patients • Must be removed for eating, speaking, expectorating Partial Rebreathing Mask • Disadvantages • May allow vomitus to be aspirated • Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails Non Rebreathing mask (NRB) • Looks similar to the partial rebreathing mask except this one has 3 one way valves that prevents the patient from exhaling CO2 into the reservoir bag. • Instead the bag is filled with 100% O2 that the patient inhales. This device is set at flows of 10-15 LPM and is similar to the partial rebreathing mask in that the bag should not deflate on inspiration. • This device can deliver 55% to 95% oxygen depending on how many one way valves are present. This mask is given in all emergencies, for nitrogen washout, ARDS, heart attack, pulmonary embolism, CHF, pnemothorax, pneumonia, and a multitude of other diseases in which the patient is spontaneously breathing but requires high FIO2’s. This is not for CO2 retainers unless it is an emergency situation. Non-Rebreathing Mask • Used primarily in emergencies and for shortterm administration of high concentrations of oxygen One way valves Non-Rebreathing Mask • Differentiated from partial rebreathing mask by presence of valve between mask And reservoir bag • http://www.youtube.com/watch?v=VV5w4qer BDg • http://www.youtube.com/watch?v=fyg5FnGk0z A Non-Rebreathing Mask • Sufficient flow must be maintained; evidenced by reservoir bag always being at least partially inflated • Usually has anti-entrainment valve on only one side of mask; precaution against suffocation in the event of oxygen source failure Non-Rebreathing Mask • Advantages • Able to deliver relatively high concentrations of oxygen (FIO2 between 0.60 and 0.80) • Theoretically able to deliver up to FIO2 of 1.00 • Economical • Easy to apply Non-Rebreathing Mask • Disadvantages • Uncomfortable for many patients • Must be removed for eating, speaking, expectorating Non-Rebreathing Mask • Disadvantages • May allow vomitus to be aspirated • Possible suffocation hazard if anti-entrainment valves in place and the oxygen source fails Reservoir (Oxygen Conserving) Cannula • Uses a reservoir to trap and build up oxygen that the patient inspires. Uses up to 4 LPM of oxygen, and is worn in the same manor as a nasal cannula. • There are two types: pendant and nasal pillow. The pendant cannula hangs down to chest and forms a pendant reservoir for oxygen. The nasal pillow is a mustache reservoir the sits on the upper lip. Both types are unattractive for the patient but saves money by using less flows 0.25 LPM to 4 LPM. • Primary use in home care and/or ambulatory patients Reservoir Cannula • Oxymizer and Oxymizer Pendant brand reservoir cannulas store oxygen in a reservoir during exhalation and deliver a bolus of 100% oxygen upon the next inhalation. These devices were originally designed for portable home oxygen therapy. However, they are finding increasing use in acute care settings for patients who are difficult to supply oxygen via standard nasal cannulas and as high-delivery alternatives to oxygen delivery via a face mask Nasal Pillow and Pendant Reservoir Cannula • Reservoir cannula • Pendant reservoir cannula Reservoir (Oxygen Conserving) Cannula • Advantages • Lowers oxygen usage, thereby lowering cost • Allows greater mobility secondary to longer duration of cylinder Reservoir (Oxygen Conserving) Cannula • Disadvantages • Unattractive (many home care cannulas are now hidden into hats, visors…) • Must be replaced regularly (See manufacturer’s specifications), increasing cost • Breathing pattern affects performance Transtracheal Catheter • Teflon catheter surgically inserted between second and third trachea rings • Increases the anatomic reservoir during expiration providing greater bolus of oxygen to be inspired Transtracheal Catheter • Used primarily in home care and for ambulatory patients who will not accept nasal oxygen • Not commonly used. Surgically inserted into the trachea by MD. Uses less flow than a nasal cannula or a nasal catheter. Good for long term oxygen use on patients that do not tolerate nasal cannulas and need increased mobility. Needs a humidifier at any flow. Needs to be changed and clean periodically to prevent mucus plugs. Transtracheal Catheter • Advantages • Able to deliver very low flows of oxygen (1/4 to 4 L/min.) • Uses less oxygen, lowering costs Transtracheal Catheter • Advantages • Improvement in compliance with therapy • Humidification not required because of low flows Transtracheal Catheter • Disadvantages • High initial cost (surgical procedure) • Possibility of infection Transtracheal Catheter • Disadvantages • Easily plugged by mucus • If removed for replacement, tract may close Transtracheal Catheter Nasal Catheter • Less commonly used. Long term nasal cannula that bypasses the upper airway. • Used during bronchoscopys and for long term use in children. Soft and smooth open distal end facilitates non-traumatic insertion, Proximal end is fitted with color coded funnel shape connector for easy connection to oxygen source. Uses less flow than a nasal cannula but delivers the same oxygen concentration. Requires a humidifier at any flow. Hard to insert and may cause gagging and aspiration if inserted to deeply. Changed every 8 hours! Nasal Catheter Figure 16-8: Nasal catheter for oxygen administration. Adapted from Scanlan CL, et al. Egan’s Fundamentals of Respiratory Care. 7th ed. Mosby; 1999. OxyMask • Developed in 2005 • Open mask design, FIO2 based on flow inputted into mask as indicated on package. • Not considered a high flow device, as the % may vary • Ranges from 25-90% O2 Oxygen Devices • Venturi Mask Setup • http://www.youtube.com/watch?v=qJ9ZIAYAKBY&feature=rel ated • Large Volume Nebulizer • http://www.youtube.com/watch?v=0HUJs0FgkoY&feature=rel ated • Simple Mask • http://www.youtube.com/watch?v=fIdioyC4Bjc&feature=relat ed • • Overall: • http://www.youtube.com/watch?v=OWLkJv61eo&feature=related High Flow Oxygen Systems • Provide a flow of oxygen equal to or exceeding the patient’s peak inspiratory flow • Use either air entrainment or blending to provide precise concentrations of oxygen High Flow Oxygen Systems • Conditions that may require high flow systems • VT > 700 ml • f > 25 breaths per minute • Irregular breathing pattern • Need for delivery of precise concentration of oxygen High Flow Oxygen Systems • Delivery devices • Air entrainment (Venturi) mask • Air entrainment nebulizer • Blending systems Venturi Mask • Set flow dependent upon final concentration of oxygen desired • Concentrations available between 24% and 50% • As the FIO2 is increased the total flow decreases • The device depends on the venturi entrainment size, the input flow and obstructions • http://www.youtube.com/watch?v=zdIXQVVuLs4 3 designs. Two change the entrainment window size to increase/decrease FIO2, the other has colored adapters. The flow required is indicated on the device Venturi Mask • Calculation of total flow to the patient • 2 ways (memorizing ratios or magic box) • Both methods give you the ratio. Add the ratio together then multiply by the flow the patient is set on. To determine if you are meeting a patients total flow take this total flow and compare it to a patients (Ve x3) Figure 16-12: Magic box to determine oxygen-to-air ratio when mixing O2 and air. Examples are shown for 40% and 60% O2. Magic Box • Set up magic box with given % O2 in the middle of box • Place 100 and 21 and subtract from 40. This gives you the ratio. Memorizing ratios: .28 .30 .35 .40 .50 .60 Primary ratios Venturi Mask • Advantages • Inexpensive • Easy to apply • Stable, precise concentration • Ideal for COPD, as it gives high flow and also precise FIO2 • Maybe adapter for Trach use Venturi Mask • Disadvantages • Generally limited to adult use • Uncomfortable, noisy Venturi Mask • Disadvantages • Must be removed for eating, speaking, expectorating • FIO2 varies if entrainment port occluded or in the presence of back pressure, or water in tubing if using a LVN • If port occluded FIO2 increases Air Entrainment Nebulizer • Generally no more than 15 L/min. input; should maintain output of at least 60 L/min • Used when aerosol is desired, e.g., patients with artificial airways Venturi Mask Color adaptor type- Orifice size changes Venturi valve Flow rate Oxygen delivered color (l/min) (%) Blue 2 24 White 4 28 Yellow 6 35 Red 8 40 Green 12 60 Treatment with oxygen 60% or/>101 rebreathing 90-94 Figure 16-18C: Changes in air entrainment by changing jet size or changing size of the entrainment port. Air Entrainment Nebulizer • Advantages • Stable, precise concentration when FIO2 > 0.28 And < 0.40 • Provides aerosol • Inexpensive • Easy to apply LVN • Used when upper airway is bypassed (ETT, Trach) • Used for croup, stridor • Not used for Asthmatics • Typically given- Bland aerosol with sterile water Figure 16-14B: Large-volume nebulizers. Courtesy of Teleflex Incorporated. Unauthorized use prohibited Figure 16-15A: Aerosol mask (A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999. Figure 16-15B: Briggs T piece (A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999. Figure 16-15C: Face tent (A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999. Figure 16-15D: Tracheostomy collar (A) Adapted from Fink JR, Hunt GE. Clinical Practice of Respiratory Care. Lippincott Williams & Wilkins; 1999. Figure 16-17: Injection nebulizer, in which additional flow is injected at the outlet of the nebulizer. Courtesy Jeffrey J. Ward, R.R.T. Figure 16-26: Equipment for heliox administration to spontaneously breathing patients. Figure 16-20: High-flow oxygen delivery system using two flow meters. Courtesy of Dr. Dean Hess Air Entrainment Nebulizer • Disadvantages • Increased risk of infection • FIO2 varies if entrainment port occluded or in the presence of back pressure Components of an Air Entrainment Device Aerosol Mask Large Volume Nebulizer • http://www.youtube.com/watch?v=0HUJs0FgkoY • This also uses Bernoullis principle and has an adjustable FIO2. The nebulizer provides cool mist to patients with stridor or upper airway edema. Also used for patients with artificial airways in need of humidification. It is also utilized for patients with thick tenacious secretions. The flow is set between 8 and 15 LPM. The concentration of O2 is 28% to 100%. The higher the concentration the lower the total flow due to the closing of the venturi which adds or takes away air dilution. The nebulizer sometimes requires two flow meters when using higher FIO2 in order to achieve proper misting. Blending Systems • Generally used when high flows (> 60 L/min.) required • Separate pressurized air and oxygen sources required Blending Systems • Manually blended system • Each gas manually set with flowmeter • Total flow and desired FIO2 must be calculated Blending Systems • To confirm proper operation of an O2 blending system there are three major steps. 1.) Make sure that the inlet pressures of the air and O2 are within the specifications of the manufacturer. 2.) Test the alarms for low air and O2 by disconnecting the sources seperately. Make sure that the safety bypass system is working correctly. 3.) Make sure to analyze the O2 concentration at levels of 100%, 21% and at desired FIO2. The use of a blender is for when O2 concentrations need to be provided at a higher rate or flow. Flow meters have limitations and therefore cannot provide these higher rates like a blender can do. Blending Systems • Manually blended system • Will deliver precise FIO2 if calculated correctly • Deviation of either flow changes FIO2 and total flow Blending Systems • Oxygen blender • Able to deliver very precise concentrations • Able to deliver high flows across a wide range of concentrations Blending Systems • Oxygen blender • Must check with analyzer periodically to confirm proper operation and eliminate possibility of blender failure Oxygen Blending Device Enclosure Systems • One of the oldest approaches to oxygen administration • Provides patient with controlled atmosphere • Used primarily with infants and children Enclosure Systems • Oxyhood • Used for neonates and infants that requires oxygen from 21% up to 100%. Flows must be set at a minimum of 7 LPM to prevent CO2 build up. A hood covers the infants head without directly attaching to the patient. The hood is comfortable but difficult to clean. The FIO2 is measured at the bottom near the patients face with an O2 analyzer due to layering affects of oxygen. The hood amplifies sound, so minimize noise around the babies sensitive ears. A humidifier is used instead of a nebulizer due to the noise factor. Used for Nitrogen washout for pneumothorax or as a weaning tool off nasal CPAP Oxygen Hood • Used with infants • Minimum flow normally of 7 L/min Oxygen Hood • Disadvantages • Noise level can cause auditory damage • Difficult to clean and/or disinfect Oxygen Hood • Disadvantages • Need to ensure neutral thermal environment is maintained by using warmed gas, especially with premature infants Oxygen Hood Enclosure Systems • Delivery devices • Oxygen tent • Oxygen hood • Incubator (isolette) Oxygen Tent • Generally uses 12 – 15 L/min • Can produce FIO2 of 0.40 to 0.50 • Used with children/rare, Croup Oxygen Tent Oxygen Tent • Advantage • Simultaneously produces aerosol • Allows child movement while maintaining FIO2 Oxygen Tent • Disadvantages • Expensive • Cumbersome to use • Limits access to patient Oxygen Tent • Disadvantages • Fire hazard • Difficult to clean and/or disinfect Incubator Incubator (Isolette) • Used with infants to provide complete control of environment • Able to provide maximum FIO2 of 0.50 at 8 to 15 L/min Incubator (Isolette) • Advantages • Provides complete environment • Stable FIO2 Incubator (Isolette) • Disadvantages • Limited access to infant • Expensive • Difficult to clean and disinfect Incubator (Isolette) • Disadvantages • Fire hazard • Noise level can cause auditory damage Hyperbaric Oxygen Therapy • Therapeutic use of oxygen at pressures greater than 1 atmosphere (expressed as ATA or atmospheric pressure absolute) Hyperbaric Oxygen Therapy • Physiologic effects • Hyperoxygenation of blood plasma and tissue • Reduction in bubble size • Vasoconstriction • May be helpful in decreasing edema Hyperbaric Oxygen Therapy • Physiologic effects • Neovascularization • Creation of new capillary beds • Enhanced immune function • Aids in white blood cell function Hyperbaric Oxygen Therapy • Indications • Air embolism • Carbon monoxide poisoning • Decompression sickness • Acute traumatic ischemia Hyperbaric Oxygen Therapy • Indications • Necrotizing soft tissue infection (gangrene) • Ischemic skin graft • Intracranial abscess • Acute peripheral arterial insufficiency Hyperbaric Oxygen Therapy • Complications and hazards • Barotrauma • Pneumothorax • Tympanic membrane rupture • Gas embolism Hyperbaric Oxygen Therapy • Complications and hazards • Oxygen toxicity • Fire • Decrease in cardiac output Hyperbaric Oxygen Therapy • Complications and hazards • Sudden decompression • Claustrophobia Hyperbaric Oxygen Therapy • Methods of administration • Fixed hyperbaric chamber • Capable of holding caregivers and patients • Has airlock to allow entry and egress of caregivers Hyperbaric Oxygen Therapy • Methods of administration • Fixed hyperbaric chamber • May be large enough to allow multiple patients • Only patient receives supplemental oxygen Fixed Hyperbaric Chamber Hyperbaric Oxygen Therapy • Methods of administration • Monoplace chamber • Large enough for single patient only • Chamber kept at FIO2 of 1.0 during patient treatment Monoplace Chamber Nitric Oxide (NO) Therapy • Normally produced in the body Figure 16-28A: INOmax delivery system. Courtesy of IKARIA Figure 16-28B: (B) INOvent delivery system. Courtesy of IKARIA Nitric Oxide (NO) Therapy • Mechanism of action • Activates guanylate cyclase which catalyzes production of cGMP, leading to vascular smooth muscle relaxation Nitric Oxide (NO) Therapy • Mechanism of action • Improves blood flow to ventilated alveoli, reducing intrapulmonary shunting • Results in decrease in pulmonary vascular resistance Nitric Oxide (NO) Therapy • Indications • Treatment of neonates with hypoxic respiratory failure with associated pulmonary hypertension Nitric Oxide (NO) Therapy • Indications • Potential uses • RDS • Primary pulmonary hypertension • Cardiac transplantation, including pulmonary hypertension following surgery Nitric Oxide (NO) Therapy • Indications • Potential uses • Acute pulmonary embolism • COPD • Sickle cell disease • Pulmonary hypertension related to congenital heart disease Nitric Oxide (NO) Therapy • Adverse effects • In high concentrations (5000 to 20,000 ppm), causes pulmonary edema that can be fatal • Direct damage to cells Nitric Oxide (NO) Therapy • Adverse effects • Impaired surfactant production • Increase in left ventricular filling pressure • Paradoxical response • Methemoglobinemia Nitric Oxide (NO) Therapy • Dosage • In neonates, initial dose is 20 ppm; continued for up to 14 days or until underlying oxygen desaturation is resolved • Frequently can be reduced to 6 ppm at the end of 4 hours Administration of NO • Patient preparation • Stabilize the patient as much as possible • Possibly sedate or paralyze patient • Support blood pressure as needed Administration of NO • System features • Delivery of precise, stable level of nitric oxide • Capable of scavenging of nitric oxide • Limited production of nitrogen dioxide (NO2) Administration of NO • Monitoring therapy • Inhaled levels of NO and NO2 • Ventilatory status Administration of NO • Discontinuing therapy • Monitor for rebound effect • Patient must be able to maintain adequate oxygenation • Patient must be able to maintain hemodynamic stability Figure 16-28A: INOmax delivery system. Courtesy of IKARIA Figure 16-28B: (B) INOvent delivery system. Courtesy of IKARIA INOvent Delivery System • For administration of nitrous oxide to mechanically ventilated patients Helium-Oxygen (Heliox) Therapy • Used to decrease the work of breathing in the presence of turbulent gas flow in the large airways Helium-Oxygen (Heliox) Therapy • Used with bronchodilator therapy to treat acute obstructive disorders (e.g., status asthmaticus); must use correction factor (multiply observed flow by 1.8) for flowmeter Helium-Oxygen (Heliox) Therapy • Methods of administration • Generally cannulas are not effective because of high rate of diffusion • Best method – snug fitting, non-disposable nonrebreathing mask • May be administered through cuffed tracheal airway with positive pressure Helium-Oxygen (Heliox) Therapy • Hazards • Elevation of vocal pitch caused by low density gas passing through vocal cords • Cough less effective • Hypoxemia secondary to using too low an oxygen concentration Oxygen Monitoring – Polarographic Analyzer • Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2% • Has a response time of 10 to 30 seconds Oxygen Monitoring – Polarographic Analyzer • Utilizes an electrochemical principle for operation • Blood or gas sample is separated from electrode sample by oxygen permeable membrane Polarographic Analyzer Polarographic Analyzer Electrochemical Principle for Operation • Oxygen diffuses through the membrane into the electrolyte solution where a polarizing voltage causes electron flow • Silver in the anode is oxidized and the flow of electrons reduces oxygen and water of the electrolyte to hydroxyl ions at the platinum cathode Figure 16-23: Oxygen analyzer. Courtesy of Amvex Corporation Electrochemical Principle for Operation • The greater the number of oxygen molecules reduced, the greater the electron flow between the anode and the cathode • The current generated is equivalent to the partial pressure of oxygen and is displayed as a percentage Galvanic Analyzer • Under ideal conditions of temperature, pressure, and humidity, accurate to ± 2% • Has a response time as long as 60 seconds Galvanic Analyzer • Utilizes an electrochemical principle for operation • Has a gold anode and lead cathode • Current flow is generated by the chemical reaction itself resulting in slower response time Galvanic Analyzer • When the chemicals in the sensor are depleted, the sensor must be replaced Galvanic Analyzer Galvanic Analyzer Oximetry • Utilizes the principle of spectrophotometry • Every substance has a unique pattern of light absorption which varies predictably with the amount of the substance present Oximetry • Each form of hemoglobin, e.g., oxyhemoglobin, carboxyhemoglobin, methemoglobin, has a unique pattern Oximetry • Comparison of light transmitted through a blood sample at two or more specific wavelengths allows the measurement of two or more forms of hemoglobin • Oxyhemoglobin absorbs less red light and more infrared light than reduced hemoglobin • Comparison of light absorption yields %HbO2 and %Hb CO-Oximetry • Uses three different wavelengths of light • Able to distinguish and measure Hb, HbO2, HbCO, and metHb • Results reported as SaO2 to distinguish from pulse oximetry CO-Oximeter Pulse Oximetry • Utilizes principle of spectrophotometry with the principle of photoplethysmography (utilization of light to detect tiny volume changes in tissue during pulsatile blood flow) • Uses only two wavelengths of light compared to CO-oximeter Pulse Oximetry • Red and infrared LEDs alternately transmit light through tissue to a receiver Pulse Oximetry • Does not distinguish between different forms of hemoglobin, so can be inaccurate in cases of carbon monoxide poisoning or with higher levels of methemoglobin • Results reported as SpO2 Pulse Oximetry Transcutaneous Monitoring • Used primarily with neonatal and pediatric patients; changes in skin composition make results less reliable for adults • Skin sensor containing oxygen and carbon dioxide electrodes is attached to the skin, usually in the abdominal area Transcutaneous Monitoring • Sensor contains a heating element to heat the skin • Increases perfusion in the area of the sensor • Allows diffusion of oxygen and carbon dioxide more readily Transcutaneous Monitoring • Oxygen and carbon dioxide diffuse through the skin into the electrolyte solution and are analyzed by the two electrodes and reported as mm Hg • Results reported as PtcO2 Correlation of PtcO2 With PaO2 Age Group PtcO2/PaO2 Ratio Premature infants 1.14:1 Neonates 1.00:1 Children 0.84:1 Adults 0.79:1 Older adults 0.68:1 Factors Affecting Accuracy • Poor perfusion • Improper sensor application • Use of vasodilator drugs • Variation in skin characteristics Factors Affecting Accuracy • Hyperoxemia • Inadequate heating of sensor • Lack of contact between sensor and skin Transcutaneous Monitor Carbon Dioxide Monitoring – Severinghaus Electrode • Variation of Sanz electrode • Used to measure pH • Consists of two electrodes or half cells • Measuring half cell contains silver-silver chloride rod surrounded by solution of constant pH and enclosed by pH-sensitive glass membrane Carbon Dioxide Monitoring – Severinghaus Electrode • Variation of Sanz electrode • Sample passes over glass membrane, changing electrical potential of the measuring electrode • Reference half cell of mercury-mercurous chloride produces constant potential Carbon Dioxide Monitoring – Severinghaus Electrode • Variation of Sanz electrode • Difference in potential between electrodes is proportional to H+ concentration and is displayed as pH Carbon Dioxide Monitoring – Severinghaus Electrode • Severinghaus electrode is Sanz electrode that is exposed to an electrolyte solution in equilibrium with the sample through a CO2 permeable membrane Carbon Dioxide Monitoring – Severinghaus Electrode • CO2 diffuses through the membrane and dissociates into H+ and HCO3- ions. • The greater the concentration of CO2, the greater the number of H+ ions Carbon Dioxide Monitoring – Severinghaus Electrode • Change in pH of the solution proportional to change in PCO2 • Used primarily in blood gas analyzer and transcutaneous monitor Carbon Dioxide Monitoring – Capnometry • Used during mechanical ventilation and general anesthesia • Placed inline between ventilator circuit and endotracheal or tracheostomy tube • Infrared light is passed through a sample chamber Carbon Dioxide Monitoring – Capnometry • Carbon dioxide absorbs infrared light • The amount of infrared light passing through the sample chamber is compared to a reference chamber Carbon Dioxide Monitoring – Capnometry • The less infrared light, the greater the concentration of carbon dioxide • Result read out as PETCO2 Capnometry Colorimetric Carbon Dioxide Analysis • Uses an indicator that changes color when exposed to different levels of carbon dioxide • Most units are either blue or purple in the absence of carbon dioxide and change to yellow when exposed to carbon dioxide Colorimetric Carbon Dioxide Analysis • Unit is disposable • Placed on endotracheal tube following intubation to confirm placement of ET tube • May give false negative readings in states of very low pulmonary perfusion Colorimetric Carbon Dioxide Analysis • May give false positive readings if large volumes of carbonated drinks were consumed prior to intubation • Does not give a numeric result Colorimetric Carbon Dioxide Analyzer Nebulizers • Hand Held Nebulizers/ also know as small volume nebulizers may be given via aerosol mask, blow by, inline on the vent/bipap or by mouth piece, given on air or oxygen • Small volume nebulizers contain less than 200 ml of fluid • Set flow 6-8 L, a typical treatment lasts 10-15 minutes, when the neb starts to sputter, shake contents