Transcript Slide 1

Oxygen Delivery Devices and Strategies for H1N1 Patients
Pandemic Planning Education
Subcommittee October 2009
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Outline
 Introduction
 Oxygen Delivery Devices
 Optimization of Oxygenation
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Introduction
 Oxygen is a drug
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Has a Drug Identification Number (DIN)
Colorless, odorless, tasteless gas
Makes up 21% of room air
Is NOT flammable but does support combustion.
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Indications for Oxygen Therapy
 Hypoxemia
– Inadequate amount of oxygen in the blood
– SPO2 < 90%
– PaO2 < 60 mmHg
 Excessive work of breathing
 Excessive myocardial workload
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What does hypoxemia look like?
 Tachycardia
 Agitation
 Diaphoresis
 Cyanosis
 *Tachypnea*
 Dyspnea
 Accessory
muscle use
*Adult response – pediatric and neonatal
patients experience bradycardia
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Hazards of Oxygen Therapy
 Absorption atelectasis
– Likely with high FIO2 in presence of partial or
complete small airway obstruction
 Oxygen toxicity
 Retinopathy of prematurity
 Oxygen induced hypoventilation
– Rare condition manifesting in some COPD
patients with chronic high plasma bicarbonate
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Oxygen Therapy Devices
2 Types
 Fixed
– A device that meets all the patients inspiratory flow
demands.
– Designed to deliver a specific oxygen concentration to
patient
 Variable
– Does not meet all inspiratory demands of the patient so
some room air is breathed in
– Oxygen concentration will vary with changes in the depth
and rate of breathing
– in general, the oxygen concentration is  by  the size of
the reservoir
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Fixed Device Cold Nebulizer
 For adults set O2 flowmeter
at maximum (flush)
 28-100% O2 selectable on
collar - generally only reliable
up to 50%
 H1N1 standard requires dry
bottle routed through Fisher
Paykal humidifier
 Rapid respiratory rate may
decrease delivered FIO2
 Do not use for patient transport
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Fixed Device High Flow Cold Nebulizer
 Delivery at 60%, 65%, 75%,
85%, 96% selected by
rotating collar
 H1N1 standard requires dry
bottle routed through Fisher
Paykal humidifier
 flowmeter must always be
set to maximum!!
 Do not use for patient
transport
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Fixed Device High Flow Cold Nebulizer
mask with Tusks
 Corrugated tubing added to
aerosol mask exhalation
ports to  reservoir volume
and  oxygen concentration
 Strategy to increase FIO2 in
mask when patient
hyperventilating AND SpO2
not maintained
 Should be employed with
High Flow Nebulizer
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Face Tent
 Use with a cold nebulizer
 The “tent” portion is directed
upwards
 Uses: children and any
patients who find mask
claustrophobic or have had
facial/nasal surgery
 Not optimal for high FIO2
requirements
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Tracheostomy Collar
 Provides humidity &
oxygen for
tracheostomy patients
via cold neb
 adults - 10-15 LPM up
to ‘flush’
 O2 adjusted on cold
neb but maximum is
usually 50%
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Fixed Device Venturi Mask
 Deliver a specific O2
concentration - 24%, 28%,
31%, 35%, 40%, 50%
 Concentration adjusted by
changing the Venturi jet
 minimum required O2 flow
rate is stamped on the
base of each Venturi jet
 O2 flow determines
accuracy of FIO2 delivered
 Usually used for COPD
patients with
demonstrated oxygen
induced hypoventilation
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Variable Flow Nasal Cannula
 22% - 40%
 Stable is FIO2 based on:
– Respiratory rate
– O2 flowrate
– Reservoir capacity of
nasopharynx
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adults  6 LPM
infants/toddlers  2 LPM
children  3 LPM
FIO2 is not affected by
mouth breathing
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Variable Device High Flow Nasal
Cannula
 Flow rates from 6-15 LPM
 For patients that require >
6 LPM O2 but cannot
tolerate a mask
 Larger tubing inner
diameter permits higher O2
flow
 Tubing is always green
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Variable Device Simple Oxygen
Mask
 Flow rate of 5-10 LPM
 35% -50% O2
 O2 flow and respiratory
rate determine stability
of delivered FIO2
 CAUTION Set flow rate
must be > 5 LPM (adult
and children) to flush
exhaled carbon dioxide
from mask
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Variable Device Non-rebreathe
Mask
 Adults > 12 LPM
 60% - 90%
depending on mask
fit
 CAUTION Always
ensure reservoir
bag remains
partially inflated
during inspiration
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Variable Device Non-rebreathe
Mask with Filter
 CAUTION Always ensure
reservoir bag remains
partially inflated during
inspiration Ensure bag does
not deflate during inspiration
 Valving system directs
exhaled gas through
bacterial filter
 May be used for transport of
H1N1 isolation patients
 Must be assembled from
stock Y’s, one way valves
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Self Inflating Manual Resuscitator
 Insert HME or bacterial
filter between mask and
bagger
 If mask is retained
following use, clean
with disinfecting wipe
 Cap the bagger when
not in use
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Manual Ventilation
 For Respiratory Arrest:
– Deliver 1 breath every 5 to 6 seconds (10 to 12
breaths per minute).
– For cardiac arrest deliver 2 breaths after every 30
compressions - deliver 8 to 10 breaths per minute
without interrupting CPR once airway secured
– Ensure that you have attached the EtCO2
sampling line to the correct port on the HME. The
EtCO2 sampling port has ridges to screw on the
sampling line male
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 Avoid hyperventilation which may result in:
– Impaired hemoglobin function with reduced O2
delivery to tissues
– Gastric distension
– Increased intrathoracic pressure causing:
– decreased venous return to the heart and
diminished cardiac output.
– Increased intracranial pressure
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Complications
 Gastric distension is the most common
adverse event in manual ventilation
 Distension may impair lung expansion
 Palpate the abdomen at commencement of
bagging
 Watch for visual distension and recheck
palpation - request gastric tube placement if
abdominal rigidity is noted
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Optimization of Oxygen Therapy
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Hypoxemia
 Hypoxemia is defined as:
– Low levels of oxygen in the blood
PaO2 of less than 60 mmHg (moderate)
SpO2 of less than 90%
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Manifestations of Hypoxemia
 Hypoxemia will affect vital signs by:
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Increased heart rate
Increased blood pressure
Increased respiratory rate
CAUTION tachycardia is the adult response to hypoxemia –
children and neonates will react to hypoxemia with
bradycardia that may rapidly deteriorate to cardiac arrest
– Hypoxemia in neonates and children requires rapid
intervention and correction
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Hypoxemia and H1N1
 Decompensation in hospitalized H1N1
Patients often begins with a decrease in
SpO2 and increased oxygen demand
 Be alert - and communicate even minor
increases in oxygen flows or requirements
for higher FIO2 devices
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Causes of Hypoxemia
 Shunt
 Hypoventilation
– As carbon dioxide increases oxygen falls
 V/Q mismatching (ventilation/perfusion) serious complications
of H1N1 produce V/Q mismatch
– Pneumonia
– Pulmonary edema
– ARDS
 Increased diffusion gradient
– asbestosis
– Early pulmonary edema
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Oxygen Therapy
 Goal of therapy is an SPO2 of >90% or for
documented COPD patients 88–92%
 As SPO2 normalizes the patients vital signs should
improve”
– Heart rate should return to normal for patient
– Respiratory rate should decrease to normal for patient
– Blood pressure should normalize for patient
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Optimization
 My SpO2 is < 90%, what next?
– Is the pulse oximeter working/accurate
 Do I have a good signal?
 Heart rate plus/minus 5 bpm?
 Is there adequate perfusion at the probe site?
 Can the probe be repositioned?
 Do other vital signs or clinical manifestations give
evidence of hypoxemia?
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Optimization cont.
 Check my source!
– Ensure the O2 delivery
device is attached to
oxygen not medical air.
– Follow tubing back to
source and ensure
patency
– Are all connections tight?
 Is the flow set high
enough?
– All nebs especially high
flow large volume nebs
need to be run at the
highest rate.
– Turn flow meter to
maximum for large
volume nebs.
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Optimization cont.
 Reposition patient.
– Avoid laying patient flat
on back.
– Raise head of bed.
– Encourage deep
breathing/coughing
 Listen to chest.
– Wheezing?
 Do they need a
bronchodilator?
– Crackles?
 Encourage deep
breathing/cough.
 Are they fluid
overloaded?
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Optimization cont.
Can I improve the mechanics of
breathing?
– Patient position
– Pursed lip breathing
– Abdominal breathing.
– Anxiety relief?
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Optimization cont.
 Increase the flow:
– With nasal prongs, increase the flow rate by 1 -2
lpm increments until target SpO2 is reached.
– High flow nasal prongs can be maximally set at
15 lpm.
– Call for physician assessment Medical if high
oxygen flows are required.
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Optimization cont.
 What do I do if my patient is really hypoxemic (on
low flow oxygen)?
– Assess patient to determine cause of increasing oxygen
requirements.
– Best short term solution is non-rebreathe mask at 15 lpm.
(reservoir stays inflated)
– Goal saturation is still 88 – 92%.
– Increase flow as required until re-assessed by physician
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Optimization cont.
 What do I do if my patient is really hypoxemic
(on high flow oxygen)?
– Assess patient to determine cause of increasing
oxygen requirements.
– Adjust FIO2 upwards in 10% increments titrating
for target SPO2.
– Call physician for further assessment
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H1N1 points of emphasis
 H1N1 decompensation requiring ICU
admission usually begins with a systemic
inflammatory response and pulmonary
edema
 CXR may not correlate with degree of
oxygenation impairment
 Gradually increasing oxygen requirement
is a sentinel sign of impending respiratory
failure
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H1N1 points of emphasis
 H1N1 Patients with escalating O2 needs
warrant frequent monitoring for signs of
impending respiratory failure
 If a critical care triage system is
operative, know the patient’s
classification and prepare equipment
accordingly – endotracheal intubation
may not be an option
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