10/17/2016 OXYGEN DELIVERY: INDICATIONS AND USE OF EQUIPMENT COURSE OBJECTIVES COMMON CAUSES OF RESPIRATORY FAILURE

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1 OXYGEN DELIVERY: INDICATIONS AND USE OF EQUIPMENT J U L I E Z I M M E R M A N, R N, M S N C L I N I C A L N U R S E S P E C I A L I S T E L O I S A C U T L E R, R R T, B S R C C L I N I C A L / E D U C A T I O N C O O R D I N A T O R D E P A R T M E N T O F R E S P I R A T O R Y C A R E COURSE OBJECTIVES This course is designed to provide education on oxygen delivery and indications of use for numerous oxygen delivery devices. Learn concepts of oxygen delivery Learn when to apply oxygen and which device to use Understand UCSD policy for Bipap in the non-icu setting Oxygen Delivery PCU Series COMMON CAUSES OF RESPIRATORY FAILURE Obstructive airway disease COPD, asthma Respiratory muscle fatigue Chest wall injury, flail chest Abdominal ascites, hemoperitoneum, gastric distention Drugs, head injury, neurological disorders Pneumonia, atelectasis Pulmonary thromboembolism Pulmonary edema, cardiogenic edema Oxygen Delivery PCU Series

2 SYMPTOMS OF RESPIRATORY FAILURE Tachypnea > 30/min Bradycardia Severe Tachycardia Hypotension Severe use of accessory muscles Cyanosis Paradoxical breathing Absent breath sounds Inability to speak Decrease in Level of Consciousness Oxygen Delivery PCU Series INDICATIONS FOR SUPPLEMENTAL OXYGEN PaO2 of < 60 mmhg or SaO2 of < 92% Cardiac related: Low hemoglobin or oxygen carrying capacity (sickle cell) Hypoxemia Low cardiac output Pulmonary related Pulmonary disorders with chronically elevated CO2 Pulmonary embolus Sedation No Code/Comfort Care Oxygen Delivery PCU Series PRECAUTIONS AND /OR POSSIBLE COMPLICATIONS Potential for patients with chronically elevated CO 2 to experience respiratory depression with PaO 2 > or = 60 FiO 2 > 50% - absorption atelectasis, oxygen toxicity, and/or depression of ciliary and or leukocytic function may occur. Fire hazard in the presence of higher oxygen concentrations. Bacterial contamination associated with certain nebulization and humidification systems 2

3 TAKE HOME POINT NO ABSOLUTE CONTRAINDICATIONS TO OXYGEN THERAPY EXIST WHEN INDICATIONS ARE PRESENT! Oxygen Delivery PCU Series OXYGEN DELIVERY EQUIPMENT- RESUS Use with supplemental O2 60% to 100% delivered O2, highest acceptable O2 flow rate, the longest possible bag refill, and a reservoir for O2 collection to avoid entrainment of room air. Best used with artificial airways, Only use with unconscious patient Airway obstruction and subsequent hypoxemia, vomiting, and aspiration may occur if an airway is forced into a conscious or stuporous patient's mouth. Oxygen Delivery PCU Series NASAL CANNULA Method of choice for delivering oxygen to adult patients who require low flow Oxygen supplementation up to ~44%. Oxygen Delivery PCU Series

4 NASAL CANNULA LOW FLOW Low flow oxygen devicesactual FiO 2 delivered will fluctuate with respiratory rate and depth. Nasal Cannula 1-6 L/min Flow rates > 4L/min irritate and dry the nasopharynx Use of disposable pre-filled humidifier to prevent irritation and drying Flow Rate FiO HIGHER FLOW NASAL CANNULA Salter-Style HIGHER Flow Nasal Cannula: 7-15 L/min Salter High flow bubbler humidifier to reduce irritation and drying Oxygen Delivery PCU Series OXYMIZER Oxygen delivery device that will increase the FiO 2, by adding 18mL reservoir as additional source of O 2 gas adding extraordinarily high inspiratory flow rate: PTE, pulmonary fibrosis, PCP pneumonia, and Cystic Fibrosis. The comparisons formula for FiO2 in low flow devices under stable conditions are: Liter Flow Nasal Cannula Oxymizer Oxygen Delivery PCU Series

5 SIMPLE MASK Not in RC protocol PTU, PACU Face Mask 6-10 L/min Flush CO2 Oxygen Delivery PCU Series HIGH FLOW/ LOW FLOW AEROSOL NEBULIZERS High moisture density, low FiO 2 nebulizer or high FiO2 varible nebulizer Set the oxygen flow meter to liters, and set the required FiO 2 at 35-40% If the patient requires > 40% use the high flow FiO 2 variable flow nebulizer Oxygen Delivery PCU Series NON-REBREATHING MASK HIGHER FIO2 / LOW FLOW DEVICE Delivers Liters / min 60-90% oxygen Short term A non-rebreather may be used for patient transport or for treatment of pneumothorax. Mask with a reservoir bag with one way valve One valve is placed between the bag and the mask to prevent exhaled air from returning to the bag. Reservoir bag should remain at least 1/3 to 1/2 full on inspiration Minimum flow of 10 L/min on flow meter. The delivered FiO2 of this system is

6 VENTURI MASK Not in RC protocol Use for transport of patients with tracheostomies requiring supplemental oxygen FiO2 Flow Rate Oxygen Delivery PCU Series OPTIFLOW HIGH FLOW/HIGH FIO2 DEVICE Flows of 40 LPM or higher Special Cannula Requires blender to accurately blend Oxygen and Air to specific FiO2. CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Provides continuous amount of pressure to the airways. The pressure is typically set at 4 to 10 cm H20. The continuous pressure being applied never allows the alveoli to completely collapse or the airway to obstruct. CPAP is usually delivered via a face mask, nose mask, or nasal prongs. Oxygen Delivery PCU Series

7 BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) Indications: Patients who are not in acute respiratory failure and are able to protect their airway at all times as documented by primary physician in the medical record Obstructive Sleep Apnea Obesity Hypoventilation Syndrome As a palliative care measure symptomatic relief Comfort care with DNR/DNI orders Chronic nocturnal use Oxygen Delivery PCU Series BIPAP/CPAP- HOME SYSTEM USE OR SUSPECTED OSA POLICY 14. In the event the physician requests that the patient be allowed to utilize their home care equipment the RT will refer to the medical center policy on patient-owned medical equipment. Medical Center states: Patient-owned medical equipment (e.g., cpaps, bipaps, ventilators, etc.) that does not deliver pharmaceuticals may be allowed in the Medical Center for inpatient use with the approval of the patient s physician and the approval of the charge nurse. The patient s licensed medical care givers must inspect the medical device for any obvious defects or evidence of poor condition. Clinical Engineering can be asked for consultation on the condition of the equipment. The medical care givers must also have contingency plans in place in the event the patient s medical device should fail. The patient s medical device will not be entered into the UC San Diego Medical Center Equipment Database. The requesting physician must also understand that they must write an explicit order for patient to use home equipment and understand that such equipment is not the responsibility of the RC department to maintain or support. Oxygen Delivery PCU Series DOCUMENTATION REQUIREMENTS Patients condition prior to change in condition Vital sign changes Skin parameter changes Level of consciousness / response to stimuli Respiratory assessment Rate / increased work of breathing Breath sounds Pulse oximetry Notification of physician Orders received Patients response to interventions Oxygen Delivery PCU Series

8 TRACHEOSTOMY Surgical opening in the trachea just below the voice box Provides an alternative airway, bypassing the upper airway passages Oxygen Delivery PCU Series INDICATIONS FOR TRACHEOSTOMY Used to maintain an open, functional airway. To bypass an airway obstruction by tumors or a foreign body, larynx or tracheal injury, or soft tissue swelling To remove secretions from the distal tracheobronchial tree Prolonged need for mechanical ventilation Oxygen Delivery PCU Series NURSING IMPLICATIONS Assess the amount, color, and consistency of secretions Watch for signs and symptoms of respiratory insufficiency, hemorrhage, shock, or other problems related to surgery or the patient's condition Ensure airway remains patent by listening for bilateral breath sounds, Provide adequate humidification and hydration Oxygen Delivery PCU Series

9 TRACHEOSTOMY CARE Every shift Clean around the trach stoma, trach tube and under the white phlange with NS and cotton swab Change disposable or clean inner cannula Change the dressing and apply barrier cream to skin. Trach ties are changed a minimum of every day and prn when soiled. Twill Trach ties will be knotted (rather than a bow) to ensure that it won t come undone Perform oral care every 4 hours to prevent pneumonia Oxygen Delivery PCU Series TRACHEOSTOMY MASK Delivers O2 to patient with tracheostomy Place in front of tracheostomy with humidified O2 Oxygen Delivery PCU Series QUESTIONS? Eloisa Cutler, RRT,BSRC Department of Respiratory Care (x76693) Oxygen Delivery PCU Series