Oxygen Therapy

1. Therapy
By Ame M.(BSc, MSc in EMCC)

2. Outline
 Definition of O2 therapy
 Indications
 Methods of O2 delivery
 Non invasive ventilation
- CPAP and BIPAP
- BVM ventilation
 Complications of O2 therapy
 Monitoring of patient on O2 therapy

3. Definition
 Oxygen therapy is the administration of
oxygen at a concentration of pressure greater
than that found in the env’tal atmosphere.
 Purpose
 to increase oxygen saturation in tissues where the
saturation levels are too low due to illness or
injury.

4. Indications …
 Cardiac and respiratory arrest
 Hypoxemia (PaO2 < 60 mmHg, Sat <90%)
 Hypotension
 Low CO and Metabolic Acidosis (bicarbonate <18mmol/l)
 Respiratory distress (RR>24/minute)
 Severe trauma
 Acute illness
 CO poisoning
 Severe anaemia
 MI
 Perioperative patients
In general any pt w/documented or suspected hypoxia
needs oxygen

5. Hypoxemia
 Inadequate amount of oxygen in
the blood
 SPO2 < 90%
 PaO2 < 60 mmHg
 If the partial pressure of O2
(PaO2) is less than the level
predicted for the individual’s age,
hypoxemia is said to be present.
Hypoxia
 Hypoxia refers to a
condition where the amount
of oxygen available to the
cells is not adequate to meet
metabolic need.

6. Signs of hypoxia
 Tachypnea
 Paleness
 Tachycardia
 Mild hypertension
 Restlessness
 Headache
 Lethargic
 Tachypnea
 Cyanosis
 Bradycardia
 Hypotension
 Arrhythmias
 Confusion
 Impaired judgment
Mild to moderate Severe

7. Assessment of need
 Need is determined by;
 measurement of inadequate oxygen tension and/or
saturation.
 invasive or non-invasive methods, and/or the
presence of clinical indicators.
ABG
Pulseoxymetry
Clinical presentation

8. Goals of oxygen therapy
1. Treat hypoxemia
2. Decrease work of breathing
3. Decrease myocardial work

9. Oxygen therapy
To ensure safe and effective treatment remember:
 Oxygen is a prescription drug.
 Prescriptions should include:
1. Flow rate
2. Delivery system
3. Duration
4. Instructions for monitoring.
Monitoring resps oxygen sats not definitive tool need to be looking at
other things accessory muscles etc.

10. Components of Oxygen
delivery methods
1. Oxygen supply
2. Flow meter
3. Oxygen tubing
4. Delivery device
5. Humidifier

11. Types of Oxygen Delivery Systems
 There are two main types of oxygen delivery
systems:
1. Compressed gas cylinders;
2. Oxygen concentrators for medical use.
Oxygen Cylinders
Oxygen concentrator
21%
100%

12. Calculation of Cylinder Duration
 D, E and H cylinders are most common
 Cylinders are considered empty at < 500 psi
 Each cylinder has a tank factor for estimating contents
of a full or partially full cylinder using pressure
 H cylinder = 3.14
 E cylinder = 0.28
 D cylinder = 0.16
 Formula for cylinder duration
Duration =
Cylinder pressure X Tank factor
Litter flow

13. Calculation of Cylinder Duration
 67 y.o. female is on E cylinder of oxygen with 1200
PSI pressure via nasal cannula running at 3 litters per
minute, Needs to go to CT (30 minutes).
 How long will the tank last?
Duration =
Cylinder pressure X Tank factor
Litter flow
=
1200 psi X 0.28
3 Litter
= 𝟏𝟏𝟐 𝒎𝒊𝒏𝒖𝒕𝒆𝒔
 Plenty of time !

14. Oxygen therapy
Humidification
 Is recommended if more than 4 litres/min is
delivered. >4L/min
 Helps prevent drying of mucous membranes.
 Helps prevent the formation of tenacious
sputum.

15. Absolute Contraindications
 The use of some O2 delivery devices (e.g.,
nasal cannulas and nasopharyngeal catheters
in neonates and paediatric patients that have
nasal obstructions)
 Potential Adverse Effects
 Oxygen toxicity
 Depression of ventilation in a selected population
 Retinopathy of prematurity
 Absorption atelectasis

16. Oxygen toxicity
 Pulmonary oxygen toxicity
 100% O2 given for 12 hrs or more
 80% O2 for >24 hrs
 60% O2 for > 36 hrs

17. Signs and symptoms of oxygen toxicity
 Non-productive cough
 Nausea and vomiting
 Sub sternal chest pain
 Fatigue
 Nasal stuffiness
 Headache
 Sore throat
 Hypoventilation

18. Methods of oxygen
administration:

19. Classification
 According to design
 Low flow
 Reservoir
 High flow
 Enclosure
 According to performance
 Fixed
 variable

20. Low Flow
 Gas flow of apparatus is insufficient to meet
all inspiratory requirements.
 Do not provide a constant or known
concentration of inspired O2
 The oxygen concentration is not determined
only estimated

21. High flow
 Gas flow of the apparatus is sufficient to meet
all inspiratory requirements.
 Provide Total inspired air
 Specific % of O2 is delivered independently
 Requires constant and precise amount.

22. According to design
Low flow
 Nasal cannula
 Nasal catheter
 Trans tracheal catheter
Reservoir
 Simple mask
 Partial rebreathing mask
 Non rebreathing mask
High flow
 Air entrainment mask
 Blending system
Enclosure
 Oxyhood
 Tent

23. According to performance
 Fixed FiO2
 If the system provides all the patient’s
inspired gas
 Variable FiO2
 If the system provides only some of the
inspired gas, the patient draws the remaining
from surrounding air.

24. How to select
 Purpose
 Patient
Age
Level of Consciousness
Pattern of breathing
 Performance of the device
level of FiO2 that is needed

25. 1. Nasal cannula (prongs):
 It is a disposable plastic devise with two
protruding prongs for insertion into the
nostrils, connected to an oxygen source.
 Used for low-medium concentrations of
Oxygen (24-44%).

26. Methods of oxygen administration:
 1- Nasal cannula

27. Disadvantages
Advantages
Priority Nursing
Interventions
Amount
Delivered FiO2
(Fraction
Inspired Oxygen
Method
may cause
irritation to the
nasal and
pharyngeal
mucosa
if oxygen flow
rates are above
6 liters/minute
Variable FIO2
 Client able
to talk and
eat with
oxygen in
place
Easily used
in home
setting
Check frequently
that both prongs
are in clients nares
Never deliver
more than 2-3 Lmin
to client with
chronic lung
disease
Low flow
24-44 %
1 Lmin=24%
2 Lmin=28%
3 Lmin=32%
4 Lmin=36%
5 Lmin=40%
6 Lmin=44%
Nasal
Cannula

28. 2. Nasal catheter- Uses

29. 2. Nasal catheter
FiO2: 0.22-0.45
Advantages
 Good stability
 Disposable
 Low cost
Disadvantages
 Difficult to insert
 Change every 8 hrs.
 High flow increases back pressure
 DNS or polyp may block insertion
 May provoke swallowing or
gagging -aspiration

30. 3. Face mask
 The simple Oxygen mask
 The partial rebreather mask:
 The non rebreather mask:
 The venturi mask:

31. 3. The simple Oxygen mask
 Simple mask is made of clear, flexible, plastic
or rubber that can be molded to fit the face.
 It is held to the head with elastic bands.
 Some have a metal clip that can be bent over
the bridge of the nose for a comfortable fit.

32. The simple Oxygen mask
 It delivers 35-60% oxygen.
 A flow rate of 6-10 liters per minute.
 It has vents on its sides which allow room air
to leak in at many places, thereby diluting the
source oxygen.
 Often it is used when an increased delivery of
oxygen is needed for short periods.

33. Tracheostomy mask
Simple face mask

34. Oxygen Delivery System
4. Face Tent
 Can replace oxygen mask
when masks are poorly
tolerated by clients
 Provides oxygen concentration
at 30-50% with flow rates of
4-8 LPM

35. Disadvantages
Advantage
s
Priority
Nursing
Interventions
Amount
Delivered
F1o2(Fraction
Inspired
Oxygen)
Method
Tight seal required
to deliver higher
concentration
Difficult to keep
mask in position over
nose and mouth
Potential for skin
breakdown (pressure,
moisture)
Wasting
Uncomfortable for pt
while eating or talking
Can
provide
increased
delivery of
oxygen for
short
period of
time
Monitor client
frequently to
check placement
of the mask.
Support client
if claustrophobia
is concern
Secure
physician's
order to replace
mask with nasal
cannula during
meal time
Low Flow
6-10 Lmin
35%-50%
Simple
mask

36. 5. The partial rebreather mask:
 A mask with a reservoir bag and must remain
inflated during both inspiration & expiration.
 It collects the first part of the patients' exhaled air.
 It is used to deliver oxygen concentrations up to 80%.
 The oxygen flow rate must be maintained at a
minimum of 6 L/min to ensure that the patient does
not rebreathe large amounts of exhaled air.
 The remaining exhaled air exits through vents.

37. Partial rebreather mask
 O2 directed into reservoir
 Insp: draw gas from bag &
room air
 Exp: first 1/3 of exhaled gas
goes into bag (dead space)
 Dead space gas mixes with
‘new’ O2 going into bag
 Deliver ~80% O2
Exhalation
ports
O2
Reservoir

38. Disadvantages
Advantages
Priority Nursing
Interventions
Amount Delivered
F1o2 (Fraction
Inspired Oxygen)
Method
Requires
tight seal
(eating and
talking
difficult,
uncomfortable
Not as
drying to
mucous
membranes
Client can
inhale room
air through
openings in
mask if
oxygen
supply is
briefly
interrupted
Set flow rate so
mask remains
two-thirds full
during
inspiration
Keep reservoir
bag free of twists
or kinks
Low Flow
6 Lmin
75-80%
oxygen
Partial
Rebreather
Mask

39. 6. The Non rebreather mask
 This mask provides the highest concentration of oxygen (95-100%)
at a flow rate 6-15 L/min.
 It is similar to the partial rebreather mask except two one-way valves
prevent conservation of exhaled air.
 When the patient exhales air. the one-way valve closes and all of the
exhaled air is deposited into the atmosphere, not the reservoir bag.
 In this way, the patient is not rebreathing any of the exhaled gas.

40. Non-rebreathing mask
 Valve prevents exhaled gas
flow into reservoir bag
 Valve over exhalation ports
prevents air entrainment
 Delivers ~100% O2, if bag
does not completely
collapse during inhalation.
O2
Reservoir
One-way valves

41. Disadvantages
Advantages
Priority Nursing
Interventions
Amount
Delivered
FiO2
Method
Impractical for
long term Therapy
Malfunction can
cause CO2 buildup
Expensive
Feeling of
suffocation
Uncomfortable
Delivers the
highest possible
oxygen
concentration
Suitable for pt
breathing
spontaneous
with sever
hypoxemia
Maintain flow rate
so reservoir bag
collapses only slightly
during inspiration
Check that valves
and rubber flaps are
function properly
(open during
expiration )
Monitor SaO2 with
pulse oximeter
Low Flow
6-15 L min
80%-100%
Non-
rebreather
MASK

42. 7. Venturi mask
 It gives high flow concentration of
oxygen.
 40-50%
 At liters flow of 4-15 L/min.
 The mask is so constructed that
there is a constant flow of room air
blended with a fixed concentration
of oxygen.

43. The venturi mask
 is designed with wide- bore tubing and various color - coded jet
adapters.
 Each color code corresponds to a precise oxygen concentration
and a specific liter flow.
The venturi system,
 Room air dilutes the oxygen entering the tubing to a certain
concentration.
 The amount of air drawn in is determined by the size of the
orifice (jet adapter).
The narrower the jet adapter, the greater the air dilution, and the
lower the concentration of oxygen.
 It is used primarily for patients with chronic obstructive
pulmonary disease (COPD).

44. Air entrainment devices
oxygen
room air
exhaled gas

45. The ventimask…
 24% blue
 28% white
 35% yellow
 40% red
 60% green

46. Disadvantages
Advantages
Priority Nursing
Interventions
Amount
Delivered
F1o2
Meth
od
uncomfortable
Risk for skin
irritation
produce resp
depression in COPD
pt with high oxygen
conc 50%
Delivers
most precise
oxygen conc
Doesn’t dry
mucous
membranes
(humidity
Requires careful
monitoring to verify
FiO2 at flow rate
ordered
Check that air
intake valves are not
blocked
Oxygen
from 40-
50%
of 4-15
L/min.
Venturi
Mask

47. 8. T-piece
 Used on end of ET tube when weaning from
ventilator
 Provides accurate FiO2
 Provides good humidity

48. 9. Oxygen Hood
High oxygen device
 Clear plastic shell encompasses the baby's head
 Well tolerated by infants
 Size of hood limits use to younger than age 1 year
 Allows easy access to chest, trunk, and extremities
 Allows control of Oxygen Delivery:
 Oxygen concentration
 Inspired oxygen temperature and humidity
 Delivers 80-90% oxygen at 10-15 liter per minute
48

49. Non-Invasive
Ventilation

50. Definition of NPPV
 Noninvasive Positive
Pressure Ventilation
(NPPV) is a ventilatory-
assist technique used in
the management of
impending respiratory
failure as an alternative to
endotracheal intubation.

51. Equipment

52. Non invasive positive pressure
ventilations (NPPV)
 They are used to decrease the work of breathing by reducing
the effort of the respiratory muscles and diaphragm.
 And also augments alveolar ventilation and can improve
alveolar gaseous exchange.
 CPAP and BIPAP are the methods used for this purpose.
 CPAP delivers continuous pressure during both inspiration and
expiration.
 where as BIPAP deliver pressure set separately for inspiration
pressure (IPAP) and expiratory pressure (EPAP) , and IPAP
must be set at higher than that of EPAP.

53. CPAP vs Intubation
CPAP
 Non-invasive
 Easily discontinued
 Easily adjusted
 Use by EMS levels down to
EMT-Basic
 Minimal complications
 Does not require sedation
 Comfortable
Intubation
 Invasive
 Intubated stays intubated
 Requires highly trained
personnel
 Significant complications
 Can require sedation or RSI
 Potential for infection

54. 1. CPAP
 Used to apply continuous positive pressure to the
airways via nasal or face mask.
 Usually well-tolerated and it is similar to use of
PEEP.
 Reduces work of breathing and Improves ventilation
to collapsed areas of lung by keeping the alveoli
open.

55. Indications for CPAP
 CHF
 Pulmonary Edema
 Near Drowning
 Inhalation Exposure
 COPD
 Asthma
 Pneumonia

56. 2. BiPAP
 Bi-Level pressure support the Inspiratory Positive Airway Pressure
(IPAP) & Expiratory PAP (EPAP).
 IPAP is the pressure support machine gives to help patients own
inspiration.
 It helps to reduce WOB and increase alveolar ventilation.
 EPAP in turn is essentially PEEP and help to prevent alveolar collapse.
 Indications
 Exacerbation of COPD with Respiratory acidosis.
 Type II respiratory failure with chest wall deformity or neuromuscular
disease.
 Failure of CPAP.
 Pneumonia with respiratory acidosis.
 Others like ARDS, post-op respiratory failure

57. COMPARISON OF CPAP & BIPAP
INDICAIONS
Indications for CPAP
 CHF
 Pulmonary Edema
 Near Drowning
 Inhalation Exposure
 COPD
 Asthma
 Pneumonia
Indications for BiPAP
 Exacerbation of COPD with
Respiratory acidosis.
 Type II respiratory failure with chest
wall deformity or neuromuscular
disease.
 Failure of CPAP.
 Pneumonia with respiratory acidosis.
 Others like ARDS, post-op
respiratory failure

58. Initial setting in CPAP and BIPAP
 If CPAP is used, start with low pressures (5cmH2O) and
increase in increment of 2cmH2O as tolerated up to 12
cmH2O.
 In case of BIPAP initially to set the IPAP 8-10 cmH2O
and EPAP 2-4 cmH2O is preferred.
 Keep the head of patient elevated.
 Be cautious in increasing pressure as it may cause opening
of esophageal sphincter and gastric distention.
 And the goals are to achieve exhaled tidal volume >7ml/kg,
RR<25, SaO2 >90% and the most important thing patient
comfort.

59. Contraindications to NIVs
 Patients with severe respiratory failure without a spontaneous
respiratory drive.
 Inability to maintain a patent airway or adequately clear secretions
 Acute sinusitis or otitis media
 Risk for aspiration of gastric contents
 Hypotension
 Pre-existing pneumothorax or pneumomediastinum
 Epistaxis
 Recent facial, oral or skull surgery or trauma
 History of allergy or sensitivity to mask materials where the risk from
allergic reaction outweighs the benefit of ventilatory assistance.

60. Advantages of NIVs
 Best in conditions when
 ETT is contraindicated or postponed
 Patient Refuse intubation
 Post operative patients
 Avoid re-intubation if RF develops
 Improve gas exchange and pulmonary function

61. Advantages …
 Noninvasiveness
 Application (compared with endotracheal intubation)
 Easy to implement
 Easy to remove
 Allows intermittent application
 Improves patient comfort
 Reduces the need for sedation
 Oral patency (preserves speech, swallowing, and cough,
reduces the need for nasoenteric tubes)
 Avoids the complications of endotracheal intubation
 Early (local trauma, aspiration)
 Late (injury to the hypo pharynx, larynx, and trachea,
nosocomial infections)

62.  DISADVANTAGES of NIV
 Airway cannot be protected
 No direct access to bronchial tree for suction if
secretions are excessive
 Mask uncomfortable/claustrophobic to the patient
 May cause facial pressure sores
 Potential Complications
 Cardiovascular compromise
 Skin break down and discomfort from mask
 Gastric distention
 Increased intracranial pressure
 Pulmonary barotrauma

63. Effects of CPAP
 CPAP results in
 increased CVP
 increased PVR (RV afterload)
 increased PAWP (wedge pressure)
 decreased RVEDV (preload)
 decreased LVEDV (preload)
 decreased LV afterload

64. Positive Pressure Ventilation
 Increased Intrathoracic Pressure
 Increased Baroreceptors
 Increased Antidiuretic Hormone
 Increased Renal Nerve Stimulation
 Increased Renin - angiotensin - aldosterone.

65. Positive Pressure Ventilation
 Pressure, Inferior Vena Cava
 Decreased Mean Arterial Pressure
 Decreased Cardiac Output
 Decreased Cardiac Filling
 Decreased Left Ventricular Size
 Decreased Atrial Natriuretic Factor
 Decreased Urine Volume
 Decreased Urine Sodium Excretion

66. Nursing responsibilities
Assessment
 Skin
 Breathing pattern
 Chest movement
 Lung sound
 Presence of clinical signs of hypoxemia,
hypercarbia and toxicity

67. Evaluation of therapy
 Blood pressure
 Pulse rate
 Perfusion
 Level of consciousness
 Respiratory rate
 Work of breathing
 SPO2

68. Evaluation:
 Breathing pattern regular and at normal rate.
 pink color in nail beds, lips, conjunctiva of
eyes.
 No confusion, disorientation, difficulty with
cognition.
 Arterial oxygen concentration or hemoglobin
 Oxygen saturation within normal limits.

69. Pulse Oximetry
 My SpO2 is < 90%, what next?
 Is the pulse oximetery 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

70. Optimization
 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
 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?
 Are they fluid overloaded?

71. Protocol for titration of oxygen
therapy
 Oxygen Titration
 Protocols are written to allow staff to increase or
decrease flows or FIO2
 Usually done by one department for consistency
 Keep SPO2 > 92% for most patients
 Keep SPO2 between 88% and 92% for patients
with COPD
 Greatly reduce the use of oxygen

72. Documentation:
 Date and time oxygen started.
 Method of delivery Device.
 Oxygen concentration and flow rate FIO2.
 Patient observation. SpO2
 Add oronasal care to the nursing care plan
 Usage of therapy (continuous or prn), Indication

73. Summary
 Oxygen is a drug and should be administered
keeping following things in mind
 Mode of administration
 Flow rate
 Fio2
 Treatment goal
 Monitoring
 When to stop

74. THE END