Chapter 41: Part 2

simple mask

A reservoir of oxygen. It is designed to fit over a client's nose and mouth Variable FiO2 at 35-50% Minimal flow is 5 L/min due to possible CO2 rebreathing

Oxymask

- Only device to deliver Fi02 of 24-90% - 0 probability of CO2 rebreathing on low flow rates - variable FiO2 oxygen delivery device

problems with reservoir systems

- Patient on cannula breathing out of mouth -Nurse "weans" patient from 8 L/min to 2 L/min on a simple mask (min flow of this mask is 5 L/min) -Reservoir bag completely collapsing during inhalation - Reservoir bag remains completely inflated during inhalation and exhalation

disadvantages of a low flow nasal canula

-Are easily dislodged from a restless patient -Flows above 6-8 L/min can produce nasal discomfort, including nasal dryness and bleeding -Nasal conditions such as: deviated septum, mucosal edema, excessive mucous drainage, and polyps may interfere with adequate oxygen delivery

Oxygen Hood (Oxyhood)

-Best method for delivering controlled O2 to infants -No less than 7 L/min due to possible CO2 rebreathing

advantages of a low flow nasal canula

-Disposable -Additional humidification is required only when the flow exceeds 4 L/min -Can be used both on adults and children -Best tolerated oxygen delivery device

critically ill with moderate to severe hypoxemia

-FiO2 greater than 60% -Reservoir or high flow system -Non rebreather

emergencies when hypoxemia is suspected

-Give highest FiO2 possible -Cardiac arrest, trauma, shock, etc -true high flow or closed reservoir device -non rebreather

indications for HFNC

-Hypoxemic respiratory failure -Hypoxic post cardiac surgery patients -Post extubation -Left ventricular heart failure -Possibly some COPD patients

Types of HFNC

-Optiflow -Airvo 2 -Vapotherm

Incubators (Isolette)

-can be used with oxyhood -unable to control precise O2 -everytime door opens the FiO2 decreases

Nitric Oxide Therapy

-causes selective vasodilation and decreases pulmonary vascular resistance -reduces shunting -used in near-term infants for respiratory failure associated with pulmonary hypertension -extremely expensive -alternative lower cost therapies are Flolan

Oxygen tent

-clear plastic enclosure over patient's entire bed and best for toddlers so they can still play in bed -regulating cooling and FiO2 can be difficult -No way of knowing precise FiO2 delivered

Helium oxygen therapy (heliox)

-decrease WOB due to airway obstruction (asthma, croup, etc) -lighter and less dense = ^ flow -Helium always mixed with O2 -80/20 -70/30 -delivered via tight-fitting non rebreathing mask with high flow

air entrainment system

-directs a high pressure O2 source though a small nozzle or jet surrounded by ports -depends on air to O2 ratio and amount of flow resistance downstream for the mixing site -all high flow systems

High Flow Nasal Cannula (HFNC)

-higher oxygen flow than standard nasal cannula -O2 is warmed to 37 degrees C and 100% saturated by external heater/humidifier - large delivery prongs intended to fill each nare - could result in CPAP - Flows up to 40-60 L/min

common problems with low flow devices

-inaccurate flows -system leaks and obstructions -device displacement -skin irritation

acutely ill but stable with mild to moderate hypoxemia

-low to moderate FiO2 -post operative, recovering from acute MI -nasal cannula or simple mask

carbon dioxide oxygen therapy (carbogen)

-not common, but used for: -Hiccoughs -Carbon monoxide poisoning -prevents complete washout of CO2 during cardiopulmonary bypass -available in 5/95% or 7/93%

Troubleshooting Heliox

-poor vehicle for aerosol transport -reduces effectiveness for coughing -distort's patient's voice -hypoxemia can be a problem (only delivers 20% or 30% O2)

chronic lung disease with an acute on chronic hypoxemia

-remember hazards of depression of ventilation -SaO2 goal is 88-92& -Want precise/low FiO2 -AEM is #1 choice, especially if they have irregular breathing pattern -#2 choice is nasal cannula

other uses of hyperbaric oxygen therapy

-wound therapy -decompression sicnkess -multiple sclerosis

Minute Ventilation (VE)

how many liters of air you breath in and out in one minute; VE = VT x RR

Estimated flow needs

how much flow a patient NEEDS to maintain minute ventilation (VE); 3 x VE

multiplace, monoplace

hyperbaric oxygen therapy is administered in either _______________ (12 or more people) or ____________ chambers (1 person)

partial pressure, PAO2

hyperbaric oxygen therapy will have an increase in the ATM pressure which increases ________________ and increases _________

low flow (variable system), reservoir, high flow (fixed system), enclosure device

the 4 oxygen delivery systems are:

reservoir cannula

Designed to maintain FiO2 at lower flow rates by using a reservoir and can reduce oxygen use as much as 50% to 75% No humidification needed

Non-rebreather mask

Has one or both valves closed on the mask to limit the mixing of room air with oxygen. The vents allow exhalation but remain closed on inhalation. The reservoir bag has a valve to store oxygen for inhalation but does not allow entry of exhaled air 1 liter reservoir bag with flow set to prevent bag from collapsing Variable FiO2 - 60-80% (but CAN be 100% when used correctly and both valves on mask closed)

Low flow nasal catheter

Primarily used for procedures where a cannula or other device can not be used, bronchoscopy or long term care of infants

Partial rebreather mask

Similar to a simple face mask, but is equipped with a reservoir bag (with no valve on bag) for the collection of the first part of the patient's exhaled air (dead space air). The remaining exhaled air exits through vents. The air in the reservoir is mixed with 100% oxygen for the next inhalation 1 liter reservoir bag with flow set to prevent bag from collapsing Variable FiO2 - 40-70%

high flow devices

To qualify as this type of device, a system should provide at least 60 L/min (or greater) of total flow to exceed (or equal) the patient's peak inspiratory flow

anatomical dead space, flow, lung mechanics, CPAP, metabolic

a HFNC mechanism of action: to flush out __________________ which replaces it with what % O2 you are giving. Meeting ______ demands of a patient (less air entrained with mouth closed). Maximizes ___________ due to gas being humidified. Can possibly result in a ______ affect. And improveds _______________ expenditure

variable delivery

a __________ system provides only some of the inspired gas flow, the patient must draw the remainder of the gas flow from the surrounding air and the the FiO2 delivery will be an approximate amount which can vary based on several factors

blending system

a ______________ is used when air entrainment devices can't provide a high enough O2 concentration or high enough flow. Built in on ventilators. Mix O2 and air. Alarms when one gas source fails or is unplugged

fixed delivery

a _______________ system will provide all of the patient's inspiratory gas flow needs and under most circumstances the FiO2 delivery will remain stable

>60%

a high flow device can deliver ___________ oxygen

FiO2

a high flow system can guarantee a fixed _________

FiO2, irregular breathing

a high flow system is most suitable for patient's that require a precise ______ or with __________ patterns

21-35%

a low flow device can deliver _________ oxygen

nasal passage, uvula

a low flow nasal catheter is inserted by gently advancing it into the floor of the _________ until you see the tip behind and above the _______

35-60%

a medium flow device can deliver __________ oxygen

variable, tidal volume

a reservoir system is classified as a ___________ device, but can be a fixed device as long as the stored volume of air equals or exceeds the patient's ________ and there are not any air leaks

dilute, room air

air entrainment systems ______ 100% oxygen with entrained _________ and will never be able to provide 100% O2 due to the mixing of the air

40%

air entrainment systems are good systems for providing a controlled FiO2 at concentrations less than or equal to _______ and when they are set above this percentage they must be evaluated to deliver adequate flow rates

bypassed upper airway (artificial airway), humidification

an air entrainment nebulizer is a choice of delivery for patient's that have a ________________ since we do not have ____________ provided by the upper airways. This device is NOT a humidifier

35% or less

an air entrainment nebulizer should be treated as a fixed FiO2 device only when set to deliver FiO2 of

increases, total output flow

an air entrainment system works as the oxygen flows through the restricted orifice the velocity ________ which pulls in (or entrains) room air through the air entrainment port, increasing the ___________ from the device

reservoir masks

are all variable FiO2 and consist of 3 types (simple mask, partial rebreathing mask, non rebreathing mask)

nasal and pendant

examples of reservoir cannula's are:

downstream resistance

if you have _________ you will have an increase in FiO2, decrease in flow and will need to pull in more air from the delivery device

decrease, increase

if you have a bigger entrainment port you will have a ________ in FiO2 and an ___________ in the total output of flow

increase, decrease

if you have a larger sized jet you will have a __________ in FiO2 and a ____________ in the total output of flow

increase, decrease

if you have a smaller entrainment port you will have a __________ in FiO2 and a ________ in the total output of flow

decrease, increase

if you have a smaller sized jet you will have a _________ in the FiO2 and a __________ in the total output of flow

FiO2 delivery

in a fixed delivery system it does not matter how the patient is breathing (slow, shallow, fast, rapid, etc) the _____________ will remain the same

4% increase in inspired

in a low flow nasal canula there is an approximately a ____________ oxygen concentration for every liter of supplemental oxygen administered at normal tidal volumes and rates due to the fact of the patient inspiring in the rest of their flow needs from room air (ex: room air; 21%, 1 L/min 24%, 2 L/min 28%, etc.)

take a breath

in a variable delivery system the amount of air will not only vary by how much ambient air the patient is breathing but by how a patient choose to

higher, lower

in an air entrainment system the more air entrained, the ________ the total output but the delivered FiO2 is _________ (because you have more air being entrained from the ports so the FiO2 needed to meet the patient's inspiratory flow needs is lower)

high flow device

is a fixed device and will ALWAYS meet the patient's inspiratory needs

low flow transtracheal catheter, 1/4 to 4 L/min

is surgically placed in the trachea through the neck by a physician and is used with flow rates of

air entrainment nebulizer, humidification, heat

pneumatically powered nebulizer (produces an aerosol) and can provide additional ___________ and ___________

low flow system

provide supplemental oxygen directly to the airway at flows of 8L/min or less and does not meet the patient's inspiratory flow needs due to the variable flow

reservoir systems

provides a mechanism to gather and store O2 between patient's breaths

disadvantages of low flow transtracheal catheter

requires careful maintenance and cleaning complications such as infection are possible

air embolism, carbon monoxide poisoning

the 2 most common acute conditions for which hyperbaric oxygen therapy is administered is for:

face mask, face shield (used post op for people with facial surgery/trauma), trach collar (patient's with tracheostomy), briggs adapter or T piece (patient's with ET tube or tracheostomy)

the 4 devices we can use as an air entrainment nebulizer to deliver aerosol are:

jet size, air entrainment port size

the amount of air entrained into the stream will depend on two factors:

air, water

the entrainment port on a air entrainment nebulizer serves two purposes: entrainment of _______ and to entrain ________ into the jet stream producing an aerosol

inspiratory flow needs

the main distinguishing factor between a low flow variable device vs high flow device is if the device meet's the patient's

venturi mask

the most common air entrainment mask is the

stable, humidification

the most common problems with venturi mask's are providing enough total output of flow to ensure a ________ FiO2 and providing extra __________

inspiratory flow rate, tidal volume, oxygen flow delivered

the precise FiO2 given to a patient using a low flow system will depend on the patient's:

boost the total output of flow, flow on the flow meter

the solution if you are not meeting the patient's flow needs with an air entrainment MASK is to _________________. For a 35% AEM at 8 L/min total output = 48 L/min which is not enough for the 60 L/min for the patient. To increase the total output of flow we need to increase the _________. So 8 L/min to 12 L/min would give us a total output of 72 L/min

briggs adapter, one way valve, nebulizers, low concentration, commerical dual

the solution if you are not meeting the patient's flow needs with an air entrainment NEBULIZER is 5 options: add a 6" reservoir to expiratory side of _________, provide inspiratory reservoir with a ____________, connect 2 or more ___________ together, set the device to a ____________ of O2 while bleeding in O2, and ______________ flow systems

minute ventilation, fixed FiO2

the type of patient's for a venturi mask: High or changing demands such as an increase in ______________ (^ RR, ^VT, Cheyne stokes, Biots, Kussmals) A stable/guaranteed ____________ which the patient is unable to change based on their breathing patterns Babies, especially premies CO2 retainers

velocities

the venturi mask employs a simple restricted jet through which oxygen flows at high __________ so the smaller the jet the greater the velocity of O2 flow, the more air entrained and the lower the FiO2

hyperbaric oxygen therapy

therapeutic use of O2 at pressure greater than 1 ATM (usually 2-3 ATM)

peak inspiratory flow rate

to assume a controlled FiO2 in a venturi mask the total flow must be high enough to exceed the patient's __________

visual inspection, mist, peak inspiratory flow

two ways to assess if the flow is meeting the patient's needs from a air entrainment nebulizer device: __________________ with a Briggs adaptor and you observe a _______ exiting the tube throughout inspiration. As long as mist is seen, FiO2 is fixed and ensured. The second way is to compare to the patient's _________________ (VE x 3) and as long as the nebulizer is exceeds this value the FiO2 is ensured

advantages of low flow transtracheal catheter

uses 40-60% less flow to achieve same PaO2 by nasal cannula more esthetically pleasing

performance, purpose, patient

when you choose the best device to use you want to: match the ______________ of a device to the ________ and the ____________

low flow device

will have a variable FiO2 due to the patient pulling in ambient air

12-15 L/min

with an air entrainment nebulizer the small jets limit the input flow to ___________ so increasing the flow via the flowmeter is not an option if you are not meeting the patient's flow needs