Section 2.pdf

Section 2 Medical Gas Therapy Equipment  Indications for Oxygen Therapy Hypoxemia is defined in the CPGs – as a PaO2 < 60 mmHg or an SaO2 < 90% for patients in the acute care setting – as a PaO2 < 55 mmHg or SaO2 < 88% in patients breathing room air in the su...

Section 2 Medical Gas Therapy Equipment  Indications for Oxygen Therapy Hypoxemia is defined in the CPGs – as a PaO2 < 60 mmHg or an SaO2 < 90% for patients in the acute care setting – as a PaO2 < 55 mmHg or SaO2 < 88% in patients breathing room air in the sub-acute or home care settings Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 2  Indications for Oxygen Therapy (continued) – as a PaO2 of 56-59 mmHg or an SaO2 or SpO2 < 89% in a sub-acute or home care setting in association with cor pulmonale congestive heart failure erythro-cythemia with hematocrit > 56 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 3  High- and Low-Flow Oxygen Delivery Systems High-Flow Oxygen Delivery System – Delivers all of the patient’s inspiratory flow needs Low-Flow Oxygen Delivery Devices – Provide part of a patient’s inspiratory gas flow needs Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 4 Low-Flow Oxygen Delivery Devices Nasal Cannula/Nasal Catheter Reservoir Cannula/Pendant Cannula Transtracheal Catheter Simple Oxygen Mask Partial Rebreathing/Non-Rebreathing Masks HiOx80 Disposable High FIO2 Oxygen Mask Vapotherm 2000i Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 5  Low-Flow Oxygen Delivery Devices Nasal Cannula (up to 44%) – Delivers 1 to 6 LPM into anatomic reservoir Anatomic reservoir approx. 50 ml 1st 50 ml @ 100%, then air entrainment – FIO2 varies w/ Vt & RR – “Rule of 4’s” Start w/ 20% Add 4% for every 1L of O2 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 6 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 7  Nasal Cannula Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 8 Nasal Cannula 9  Low-Flow Oxygen Delivery Devices Nasal catheter – Similar to NC, but slightly more invasive – Passes through nose & turbinates to rest in oropharynx @ level of uvula Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 10  Nasal Catheter Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 11  Low-Flow Oxygen Delivery Devices Reservoir Cannula/Pendant Cannula – Goal: maintiain FIO2 @ lower flow – Provides a small reservoir (to be used in addition to anatomical) Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 12 Pendant Cannula 13  Reservoir Cannula Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 14  Low-Flow Oxygen Delivery Devices Transtracheal Catheter – Continuous, long-term O2 – Surgically inserted into trachea @ 2nd cartilage ring – Uses less flow than a NC (59% less) – Hazards: Infection subQ emphysema hemoptysis Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 15  Transtracheal Catheter Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 16 Transtracheal Catheter 17  Low-Flow Oxygen Delivery Devices Simple Oxygen Mask (35-55%) – Minimum Flow Rate = 5 LPM – Adds reservoir space (fills during pause) – FIO2 varies w/ Vt & RR – 5-12 LPM Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 18  Simple O2 Mask Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 19  Simple O2 Mask Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 20  Low-Flow Oxygen Delivery Devices Partial Rebreathing Mask – a.k.a. reservoir mask – Pt. Rebreathes some exhaled gas 1st 1/3 of expiration is anatomic dead space Additional O2 fills bag during pause – Up to 70% O2 – Reservoir should not collapse Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 21  Low-Flow Oxygen Delivery Devices Non-Rebreathing Mask – a.k.a. reservoir mask – Minimum flow of 10LPM – One-way valves: b/t bag & mask (prevents rebreathing) b/t mask & RA (reduces entrainment) – Up to 100% O2 (depending on flow, RR, Vt) Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 22  Partial Rebreathing Mask Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 23  Non-Rebreathing Mask Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 24  Low-Flow Oxygen Delivery Devices HiOx80 Disposable High FIO2 Oxygen Mask – Designed for FIO2 w/ less entrainment – No entrainment ports – Better seal – 750ml reservoir – Up to 80% O2 @ only 8 LPM Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 25  HiOx80 Disposable Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 26  High-Flow Nasal Cannulas High-flow nasal cannula (HFNC) systems – Can achieve high FIO2 levels by – Washes out CO2 from the nasopharyngeal dead space – Generates gas flows that exceed the inspiratory flow needs of most patients. – Include a patient interface, a gas delivery device to control oxygen flow, and a humidifier. Increased flow means we need to humidify for our patients! 27  Vapotherm – 5 to 40 LPM @ up to 99% relative humidity – Vapor transfer cartridge (0.01 microns) – Rain-out is minimized – Up to 40 LPM via NC, 20 LPM via transtracheal catheter Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 28  Vapotherm Precision Flow Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 29  Vapotherm Cartridge Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 30 Fischer & Paykel AIRVO 2 31 Fischer & Paykel OptiFlow 32  High-Flow Oxygen Delivery Systems Venturi or HAFOE Mask Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 33  Venturi/HAFOE Mask Jet cleaves RA & uses viscous shearing to entrain Ratio of air entrainment to O2 flow: L of air entrained = 1.0-FIO2 L of O2 FIO2-0.21 (FIO2 = desired concentration) Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 34 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 35  Let’s Do the Math A patient is ordered a 40% venti mask. She is breathing @ a rate of 18 bpm w/ a minute volume of 8L & an I:E ratio of 1:2. Is the device providing adequate flow if the flowmeter is set @ 8LPM? Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 36  Entrainment Ratios Oxygen Percentage Air:O2 Ratio Total Parts 100 0:1 1 70 0.6:1 1.6 60 1:1 2 50 1.7:1 2.7 40 3:1 4 35 5:1 6 30 8:1 9 28 10:1 11 24 25:1 26 37 Cool Mist Aerosol w/ Venturi Helps reduce swelling by promoting vasoconstriction of blood vessels 38  High-Flow Oxygen Delivery Systems Anesthesia Bag-Mask Systems – a.k.a. “flow-inflating bag” (vs. self-inflating) – Drawbacks: Cannot bag sans gas source – Benefits: 100% FiO2 Can “feel” lung compliance Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 39 Flow Inflating Bag 40  Oxygen Enclosures or Environmental Devices Incubator Head Box or Oxyhood Mist Tents Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 41  Oxygen Enclosures or Environmental Devices Incubator – Controls infant environmental T0 & FIO2 – Frequent hands-on care reduces efficiency of O2 regulation Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 42  Incubator Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 43 Infant Temperature Regulation Brown Fat White Fat 44  Oxygen Enclosures or Environmental Devices Head Box or Oxyhood – Encloses infant’s head – Flow adjusted to prevent entrainment – Gas is premixed (blender), heated, humidified – Often used w/ incubator – Must analyze O2 near head! Variations in O2 concentration may occur Layering Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 45 46 Gas Densities O2: 1.429 g/L Air: 1.29 g/L CO2: 1.98 g/L He: 0.1785 g/L N2O: 1.98 g/L NO: 1.34 g/L Copyright ©2005 by What do gas densities tell us about the layering effect? O2 Analyzation 48  Head Box Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 49  Oxygen Enclosures or Environmental Devices Mist Tents – a.k.a. “croupettes” – Primarily used for aerosol therapy – FIO2 may be somewhat controlled Nursing care Difficult to seal Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 50  Croupette for infants Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 51  Hyperbaric Oxygen Therapy Definition – defined by the Undersea Hyperbaric Medical Society (UHMS) – exposure of a patient or patients to a pressure greater than one atmosphere absolute while breathing 100% oxygen either continuously or intermittently – https://www.youtube.com/watch?v=1wrLfZ4jI O0 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 52  Physiological Effects of Hyperbaric Oxygen Therapy Trapped Gas Bubbles, When Exposed to the Increased Pressure during Hyperbaric Treatment, Will Decrease in Size (Boyle’s Law) Supersaturation of Plasma with Oxygen – Up to 1500 mmHg – Improved O2 transport Increased Elimination of Other Gases – N, CO Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 53  Conditions That May Benefit Gas gangrene Radiation necrosis CO/Cyanide poison Ischemic tissue transplants Necrotizing soft tissue infections Decompression sickness Refractory osteomyelitis Refractory anaerobic infections Severe acute anemia/hemmorrhage Crush injury/trauma Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 54  Physiological Effects of Hyperbaric Oxygen Therapy (continued) Increased Ability of White Blood Cells to Fight Infections Neovascularization to Poorly Perfused Tissues Lethal to anaerobic microorganism Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 55  Equipment for Hyperbaric Oxygen Therapy Monoplace Chamber – 1 pt. @ a time – Typically pressurized w/ O2 Multiplace Chamber – More than 1 pt. @ a time – Pressurized w/ RA, O2 via NRB, etc. – Healthcare provider may accompany pt. Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 56 Monoplace Hyperbaric Chamber 57 Multiplace Chamber 58 Multiplace Chamber 59  He/O2 Therapy Helium–oxygen (heliox) Low density of gas improves ability of gas to move around obstruction. Clinical application – Exacerbation of asthma – Treatment of postextubation stridor – Treatment of refractory croup – Treatment of severe airway obstruction in chronic bronchitis and emphysema Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 60  Helium–Oxygen Therapy (Cont.) Available concentrations – 80% Helium and 20% oxygen – 70% Helium and 30% oxygen – 60% Helium and 40% oxygen 61  Helium–Oxygen Therapy (Cont.) Can be administered through an endotracheal tube or well-fitted nonrebreather. Actual flow: due to low density of gas oxygen flowmeters are not accurate. Correction factors used to determine actual flow rate of gas: – 80:20—1.8 × liter flow – 70:30—1.6 × liter flow – 60:40—1.4 × liter flow 62 Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 63  Carbon Dioxide/Oxygen Therapy CO2/O2 therapy has been used for many years for the treatment of various disorders (ex: singultus). Gas mixtures are available in 5/95% and 7/93% carbon dioxide–to-oxygen mixtures. Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 64  Nitric Oxide (NO) Therapy Inhaled nitric oxide therapy is used to treat persistent pulmonary hypertension in newborns. Nitric oxide is highly reactive and can combine with oxygen or water to form nitrogen dioxide (NO2) or nitric acid (HNO3), respectively. Nitric oxide is delivered via the I-NOvent. Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 65  Nitric Oxide (NO) Therapy Dangers: – NO2 – Rebound vasoconstriction (Don’t wean too fast!) Method of action: – Short-acting – Delivered directly to lung Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 66  I-Novent Copyright ©2005 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 67