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
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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