1. Reaching Impact, Saturation, and
Epidemic Control (RISE):
Rational and Hygienic
Use of Oxygen
Training For Personnel Handling Oxygen Devices
Date
2. Purpose of the Training
At the end of this course, participants are expected to effectively oversee the devices for oxygen
therapy and the process of optimally delivering oxygen to patients, including rational and hygienic
use of medical oxygen.
3. Training Objectives
1.Understand medical oxygen and its importance in respiratory care
1.Understand the importance of oxygen therapy in COVID-19 case management
1.Correctly communicate on various oxygen storage and delivery devices used for
oxygen therapy
1.Understand the rationale and the procedure for the use of different oxygen therapy
devices- high flow and low flow- for optimally administering medical oxygen
1.Demonstrate the procedure for decontamination and disinfection of oxygen therapy
devices
1.Recognize the importance to address the ways to avoid or reduce the oxygen wastage
By end of this training, the participants will be able to:
4. Training Schedule
S. No. Sessions Methods Duration
Tea and registration of participants
1 Session I: Introduction and pre-test Group activity 30 mins
2 Session II: Introduction to medical oxygen and
oxygen therapy
Presentation discussion 30 mins
3 Session III: Oxygen storage and delivery devices Presentation discussion and on-site
demonstration
90 mins
4 Session IV: Oxygen therapy devices Presentation and demonstration- video
and hands-on
60 mins
5 Session V: Infection prevention and
decontaminating practices for oxygen devices
Presentation and hands-on demonstration 45 mins
6 Session VI: Ways to reduce oxygen wastage Presentation discussion 30 mins
7 Session VII: Post-training assessment and
transfer out
Group activity 45 mins
End of training
8. MEDICAL OXYGEN
8
● Medical oxygen is high purity oxygen that is used for medical treatments and is
developed for use in the human body.
● Oxygen is an essential medicine used to care for patients at all levels of the
healthcare system, including in surgery, trauma, heart failure, asthma, pneumonia
and maternal and childcare.
● Oxygen is the most important and essential of the drugs for saving the lives of
Covid-19 patients.
● The COVID-19 pandemic has accelerated global demand for oxygen and made the
delivery of oxygen supplies more urgent than ever.
9. MEDICAL GRADE
OXYGEN
An essential medicine
required at all levels of
the health care system
Only high quality, medical-
grade oxygen should be
given to patients
Oxygen of a minimum
90% purity and free from
any contamination
Oxygen is not a flammable gas,
but it easily supports
combustion
Some fuels, such as oil and
grease, burn almost
explosively when combined
with oxygen
Materials flammable in air
will burn vigorously in
oxygen
10. MEDICAL OXYGEN
10
● Usually accomplished by a large storage system of
liquid oxygen (minus 180 degree Celsius) at the
hospital which is evaporated into gaseous by vaporized
oxygen supply, pressures are usually around 345–
380 kPa (50.0–55.1 psi)
● The gaseous oxygen is stored in the cylinders at 2000
psi with a pressure regulator that allows to reduce the
pressure to 50 psi to the patient.
12. • Oxygen: A life-saving therapeutic medical gas used for
managing hypoxaemia
• Oxygen therapy or supplemental oxygen:
oThe provision of medical oxygen as a health-care
intervention
oAn essential element of basic emergency care
oRequired for surgery and the treatment of several
respiratory disease
• Medical oxygen:
oat least 90% pure oxygen
ofree from any contamination
OXYGEN THERAPY
13. WHERE IS OXYGEN THERAPY NEEDED?
PRIMARY LEVEL
(e.g. home, community care,
health post, health centre)
SECONDARY LEVEL
(e.g. district hospital)
TERTIARY LEVEL
(e.g. regional, specialized hospital,
specialized outpatient clinics)
• General ward
• Labour unit
• Neonatal resuscitation corner
• Emergency triage
• Transport to referral
• Emergency triage
• Labour and delivery room
• Neonatal care
• Paediatric and/or adult ward
• ICU
• Operating theatre
• Emergency triage
• Labour and delivery room
• ICU (neonatal, paediatric, adult)
• Paediatric and adult wards
• Surgery and recovery wards
• Cardiopulmonary ward
• Emergency ward
14. OXYGEN ECOSYSTEM
Oxygen Source
• Concentrator
• Cylinder
• PSA/VSA/VPSA
Plant
• Liquid Medical
Oxygen (ASU
Plant)
Distribution
• Central or sub-
central piping
• Transport (for
cylinders)
• Transport (for
Liquid Oxygen)
Regulation and
Conditioning
• Regulator
• Flowmeter
• Flowmeter
stand (flow
splitter)
• Humidifier
(heated and
non-heated)
• Blender
• CPAP
• BiPAP
• Ventilator
Delivery
• Nasal cannula
• Nasal catheter
• Masks
• Tubing
• Non ReBreather
Mask
Patient
Monitoring
• Pulse oximeter
• Multiparameter
monitor
15. DIFFERENT SOURCES OF MEDICAL OXYGEN
Clinical application
and/or use case
Can be used for all oxygen
needs, including- high-pressure
supply; facilities where power
supply is intermittent or
unreliable; ambulatory service
or patient transport; backup for
other systems.
Used to deliver oxygen at the
bedside or within close proximity to
patient areas. A single concentrator
can service several beds
Can be used for all
oxygen needs, including
high-pressure supply.
Can be used for all oxygen needs,
including- high-pressure supply and in
facilities where power supply is
intermittent or unreliable.
Appropriate level of
health system
Primary, secondary, possibly
tertiary (any medical unit
requiring oxygen).
Primary, secondary, possibly tertiary
(any medical unit requiring oxygen).
Secondary and tertiary. Secondary and tertiary.
Cylinders Concentrators Oxygen plant (PSA) Liquid oxygen
16. Thank You!
This presentation was made possible with support from the United States Agency for
International Development funded RISE program, under the terms of the cooperative
agreement 7200AA19CA00003. The contents are the responsibility of the RISE program and
do not necessarily reflect the views of USAID or the United States Government.
19. Liquid oxygen is stored, shipped, and handled in several types of containers,
depending upon the quantity required
The types of containers in use include cryogenic liquid cylinder/ DURA cylinder, and
cryogenic storage tank
Storage quantities vary from a few litres to many thousands of litres (In India IS
7396:2017 is followed)
Since heat leak is always present, vaporization takes place continuously
Rates of vaporization vary, depending on the design of the container, external
temperatures and the volume of stored product
Containers are designed and manufactured according to the applicable codes and
specifications for the temperatures and pressures involved
LIQUID OXYGEN CONTAINERS
Liquid oxygen is a cryogenic liquid,
pale blue in colour with a has a
boiling point of –297°F (–183°C).
It is a compressed form of oxygen,
required to be stored in the
vacuum insulated tank much
below -200°C, to ensure that the
oxygen remains in the liquid form.
20. CRYOGENIC LIQUID
CYLINDERS
(DURA CYLINDER)
• Cryogenic liquid cylinders are insulated, vacuum-jacketed
pressure vessel
• They are equipped with pressure relief valves and
rupture disks to protect the cylinders from pressure
buildup.
• Liquid containers operate at pressures in the range of
100 psig to 350 psig (24 atm) and have capacities
between 80 and 450 liters of liquid
• Oxygen may be withdrawn as a gas by passing liquid
through an internal vaporizer or as a liquid under its own
vapor pressure
21. CRYOGENIC STORAGE TANKS
• Customer installations generally include a tank, vaporizer,
and pressure control manifold.
• Tanks are generally cylindrical in shape and are mounted in
fixed locations as stationary vessels or on railcar or truck
chassis for easy transportation.
• All tanks are powder- and vacuum-insulated in the annular
space and equipped with various valves to control product
fill, pressure buildup, pressure-relief, product withdrawal,
and tank vacuum.
• Tanks are designed to national and international
specifications for the pressures and temperatures involved.
22. LMO- PROS & CONS
Pros
Liquid oxygen can be stored in a portable tank and connected
to a Central pipeline.
Liquid oxygen is highly concentrated, so more oxygen can be
stored in a smaller tank and ensure continuous supply at high
pressure.
Most cost-effective system for larger facilities.
Cons
Liquid oxygen cannot be stored for prolong time because it will
vaporize (evaporate) and build-up pressure inside storage tank.
The tank's content must be consumed and refilled often,
requiring the scheduling of deliveries.
The system need PESO license compliance.
23. GASEOUS OXYGEN
CYLINDERS
• Oxygen gas can be compressed and stored in cylinders.
• These cylinders are filled at a gas manufacturing plant, either via
a cryogenic distillation/ASUs in liquid oxygen form or a process
known as pressure swing adsorption (PSA) in gaseous oxygen
form or by an LMO-based re-filler and transported to health
facilities to be connected to manifold systems (groups of
cylinders linked in parallel) that are piped to areas of the health
facility; or cylinders can be used directly within patient areas.
• Cylinders do not require electricity, but they do require several
accessories and fittings to deliver oxygen, such as pressure
gauges, regulators, flowmeters, and, in some cases, humidifiers.
• Cylinders also require periodic maintenance, commonly provided
by gas suppliers at the point of refilling.
24. OXYGEN CYLINDER – PROS AND CONS
Pros
• Installation does not need
permission from any authority
like Petroleum and Explosives
Safety Organization (PESO).
• Space accommodating as
construction is long and linear.
• Easy setup, can also be used
bedside without medical gas
pipe system.
Cons
• Recommended as primary
source for small size hospital
up to 30 beds.
• Not recommended (specially in
current pandemic) as primary
source to ICU's.
• Erratic supply chain.
• Chances of carrying infection.
25. B-Type Small Medical Oxygen Cylinder (1.5 CU.M.)
• B-type high pressure seamless cylinder for medical oxygen
gas, cylinder is ISI marked conforming to IS:7285 part 2,
certified by the Bureau of Indian Standards (BIS) and
approved by the chief controller of explosive (CCOE)
Government of India.
• Cylinder made from manganese steel.
• 10.2 ltr. Water capacity (40 cu.ft.).
• Valve made of brass and chrome plated.
• Working pressure 150 kg. F/cm at 15 deg. C.
• Hydraulic test pressure 250 kg. F/cm .
• Colour code of the cylinder should be as per IS: 3933-
1966 with updating till date.
• Filled with medical oxygen gas of medical grade.
• Matching key cum spanner to release oxygen for each
cylinder separately.
• Minimum two years guarantee for cylinder.
OXYGEN CYLINDER TYPE B & D
D-Type Jumbo Medical Oxygen cylinder (7 CU.F.M.)
• Cylinder made from manganese steel.
• 46.7 Ltr. water capacity (220 CU.FT.).
• Valve made of brass and chrome plated.
• Working pressure 150 Kg. f/cm at 15 deg. C.
• Hydraulic test pressure 250 Kg. f/cm .
• Filled with medical oxygen gas of medical grade.
• Matching key cum spanner to release oxygen for each
cylinder separately.
• Minimum two years guarantee for cylinder.
B D
26. CYLINDER LABELLING
• Medical gas cylinders are required to be labelled, as the
primary means of identifying the contents of the
cylinder. The colour of the cylinder is only a guide.
• Labels for gas cylinders can be reduced in size and shape
to the dimensions specified in ISO 7225 – Gas cylinders –
Precautionary labels.
• The figure is an example of a typical label.
27. • Diamond hazard label: displaying the primary hazard with
additional hazard labels displaying any subsidiary hazards.
These labels will display the dangerous goods classification
number.
• UN number: preceded by the letters UN. The UN number is a
number assigned by the United Nations Committee of Experts
on the Transport of Dangerous Goods. The UN number for
compressed oxygen is UN 1072.
• Proper shipping name.
• Product name (may be omitted if the proper shipping name is
identical).
• Signal word, hazard and precautionary statements.
• EC number (if applicable).
• Package size and pressure.
• Company name.
• Address of the gas company.
• Additional company information.
• Contact telephone number.
29. CYLINDER NAMING & SIZING
• Oxygen cylinders are of different sizes.
• Cylinder sizes for medical gases are named alphabetically, unlike
industrial cylinders which are numbered.
• In India most commonly used cylinders are D type (Jumbo) and B
type (Portable) cylinders which contains gaseous oxygen. Dura
cylinders with liquid oxygen are also used in the region.
• Cylinders are fitted with customized valves (either pin index or
bullnose type) that are opened with valve keys, and with valve
guards for safety.
• The Pin Index Safety System (PISS) is designed to ensure the
correct gas is connected to the regulator or other equipment.
• The arrangement of the pins is unique for each gas, and the
positions of the holes on the cylinder valve must correspond with
the pins to prevent the use of the wrong gas.
• Some cylinders have built-in, integral pressure regulators, which
do not require a separate pressure regulator to be fitted to the
cylinder valve before use.
30. MEDICAL GAS PIPELINE SYSTEM
FUNDAMENTAL PRINCIPLES
• Standards
Designed as per IS 7396, to withstand the pressure at
every different section of the oxygen piping system
• Color
Oxygen pipeline in India is covered in White paint
• Pressure
Near the LMO plant :>15 bars
Wards and zones : > 5 - 7 bars
General delivery : 4-5 bars
31. MEDICAL GAS PIPELINE SYSTEM
FUNDAMENTAL PRINCIPLES
• Working
Oxygen pipeline system should gradually taper.
Its diameter should systematically reduce from the oxygen
plant to the delivery point
•Construction
Divided the pipeline system into different zones
Have pressure gauges to show pressure in the zones
Have a master alarm and zonal alarms if there is a drop in
pressure
32. COLOUR CODING FOR GASES
IN MGPS
• The international standard for the colour coding of gas pipeline is
ISO 32: 1977 Gas pipelines for medical use – Marking for
identification of content.
• According to the ISO standard, oxygen should be labelled as white.
• The figure shows differences in gas pipeline colour coding
between ISO and US standards.
33. WORKING OF MANIFOLD
• Jumbo manifold system has two banks and one reserve bank.
• Each bank connected to a common header with a separate
manifold pressure regulator & and banks alternately supply the
pipeline.
• Manifold system operates on differential pressure mechanism.
• The secondary bank comes into operation automatically when
content of the primary bank is exhausted.
• Manifold control panel assists in switching automatically between
left bank and right bank.
• Automatic control panel need no power or electricity requirement
for operation.
• In case of power failure, control panel has fail-safe mechanism, if
required.
• Both right and left bank opens in case of power failure and will
ensure unobstructed flow to hospital on self-displacement
method.
34. PRECAUTIONS WITH MGPS
Do not randomly add ventilators on your existing oxygen
piping system Consult a biomedical engineer / professional designer
Distribute new ventilators across the floor in the different
sections of the oxygen piping
Construct a high-capacity oxygen piping from the plant
from scratch and take it to the ICU unit
Train and appoint dedicated manpower across all shifts There should be at least one person at any given point of
time who understands the entire oxygen pipeline layout
Every ward or every zone should have zone or ward wise
drawings of the MGPS with clear indication of pressure
settings and valve positions
There should be display of the entire oxygen pipeline
layout with pressure setting and the valve positions at
centrally accessible places in hospitals
36. OXYGEN CONCENTRATORS- PATIENT
DELIVERY CONSUMABLES & ACCESSORIES
Patient Delivery Accessories
To deliver oxygen from the concentrator to the patient, oxygen outlet
adaptors and oxygen delivery tubing are necessary in addition to replaceable
nasal prongs and/or catheters.
Accessories to divide flow to multiple patients
•Flow rate of delivered oxygen must be continuously adjustable by the user
•Necessary because oxygen flow needs require adjustment over the course of
treatment, particularly important for premature newborns in whom excessive
oxygen therapy causes harm
•Patients are started at different flow rates depending on their age, clinical
condition and the type of breathing device used
FLOWMETER STAND
37. Options for dividing flow to multiple patients-
Some concentrators have two built-in flowmeters, with two corresponding oxygen outlets, to treat two patients
simultaneously.
This avoids the need for additional user assembly but is limited to a maximum of two patients that can be
treated at the same time.
Only some concentrators designated as paediatric have built-in flowmeters capable of titrating oxygen to very
low flows (0.1–0.2 LPM).
Flowmeter stands consisting of from two to five mounted meters can be used.
This has advantage of being more familiar to clinical staff who are used to using flowmeters on cylinders and
allows precise titration of flow to each individual patient (including down to 0.1 LPM).
38. • A four-way flow splitter assembly has been used as
a method to split flow.
• It consists of a four-way flow splitter block, nozzles
for 0.5, 1 and 2 LPM and blanking plugs.
• Flow splitters are less preferred than flowmeter
stands or built-in paediatric flowmeters, since the
corresponding blanking plugs are very easily lost or
misplaced.
• Flow splitters use nozzles that deliver oxygen at a
single fixed rate.
FLOW SPLITTER, NOZZLES AND
BLANKING PLUGS
39. SIMPLE OXYGEN PATIENT DELIVERY
INTERFACE EQUIPMENTS
•Oxygen cannula –
prongs that are placed
in the nose for providing
oxygen to patient
•Oxygen mask – covers
lower part of face
•Non-rebreather mask
(NRBM) – can deliver
higher concentrations of
oxygen than cannula
and regular mask
•Exhaled air exits
through 1 way valves
thus preventing any
rebreathing of exhaled
air or room air
41. ◦ Oxygen humidifiers are medical devices that can be
integrated into oxygen delivery systems to humidify
supplemental oxygen.
◦ Humidification is not necessary when oxygen is delivered at
relatively low flow rates through nasal prongs or nasal
catheters
◦ When oxygen is delivered at higher-than-standard flow rates,
or when methods of oxygen delivery bypass the nose, such
as when nasopharyngeal catheters are used, humidification
is needed – especially when cold oxygen is delivered from a
cylinder.
HUMIDIFIERS
There are various types of humidifiers, and their
designs differ in how they apply three main
principles :
1. Temperature: As the temperature of gas
increases, its ability to hold water vapour
increases.
2. Surface area: There is more opportunity for
evaporation to occur due to greater surface area
of contact between water and gas.
3. Time of contact: There is more opportunity for
evaporation to occur when a gas remains in
contact with water for long duration.
42. TYPES OF HUMIDIFIERS
Bubble humidifier – Non heated (reusable) Bubble humidifier – Non heated (single use) Bubble humidifier – heated
Description A reusable bottle that reduces the dryness of
oxygen by bubbling the gas through distilled water (or
water that has been boiled and cooled) at room
temperature.
A single-use bottle that reduces the dryness of
oxygen by bubbling the gas through distilled water at room
temperature.
A device consisting of a heat source and a humidification
chamber whereby the built-in heater warms the water in
the chamber to add moisture to the airstream as it passes
over the surface.
Merits Simple.
No power required.
Low cost.
Reusable.
Simple.
No power required.
Low cost.
Reusable.
Adjustable heat for more or less moisture.
More efficient at humidifying gas.
Drawbacks High risk of contamination (reduced by changing the water
frequently)
Decontamination required
Disposable/single-use.
More costly.
Risk of “rainout”.
High risk of contamination (reduced by changing the water
frequently).
Needs power source.
General
Comments
Works best at a water temperature of at least 30°C. Works best at a water temperature of at least 30°C. Works best at a water temperature of at least 37°C.
43. Thank You!
This presentation was made possible with support from the United States Agency for
International Development funded RISE program, under the terms of the cooperative
agreement 7200AA19CA00003. The contents are the responsibility of the RISE program and
do not necessarily reflect the views of USAID or the United States Government.
48. OXYGEN DELIVERY DEVICES
o Low flow (Variable performance devices)
Nasal cannula (prongs or spectacles)
Nasal catheters
Transtracheal catheter
Face mask
o Reservoir system (Variable performance
device)
Reservoir cannula
Simple face mask
Partial rebreathing mask
Non rebreathing mask
Tracheostomy mask
o High flow (Fixed performance devices)
Venturi mask (HAFOE)
Aerosol mask and T-piece with nebulizers
49. ◦ Consists of two soft prongs attached to oxygen supply
◦ A flow rate of 2-4 L/min delivers an FiO2 of 0.28-0.36
respectively
◦ FiO2 = 20% + (4 x oxygen litre flow)
◦ No increase in FiO2 if flow is more than 6L/min
◦ Nasopharynx acts as a reservoir
◦ If patient breaths through mouth, air flow produces a
Venturi effect in the posterior pharynx entraining oxygen
from the nose
◦ Available in different sizes and different prong shapes
NASAL CANNULA
50. 50
• Advantages
o Ideal for patients on long-term oxygen
therapy
o Light weight and comfortable
o The patient is able to speak, eat and
drink
o Humidification not required
o Low cost (Rs. 70/-)
• Disadvantages
o Can not provide high flow oxygen
o Irritation and cannot be used in nasal
obstruction
o FiO2 varies with respiratory efforts
o High flow rates are uncomfortable
NASAL CANNULA
51. ◦ Single lumen catheter, which is lodged into the anterior
naris by a foam collar, inserted to just above the uvula
◦ Oxygen flows of 2-3 L/min can be used. FiO2 = 35-40%
◦ Deep insertion can cause air swallowing and gastric
distension
◦ Must be repositioned every 8 hours to prevent
breakdown
◦ No advantages over nasal cannula
NASAL CATHETER
52. ◦ Transparent mask provided with side holes
◦ Reservoir capacity 100-250ml
◦ Different oxygen flow rates result in a highly variable and
unpredictable FiO2
◦ Rebreathing of CO2 can occur with oxygen flow rates of
less than 2L oxygen/min or if minute ventilation is very
high
◦ 4 L/min of oxygen flow delivers an FiO2 of about 0.35-0.4
provided there is a normal respiratory pattern
◦ Flow rates greater than 8L/min do not increase FiO2
SIMPLE FACE MASK
53. SIMPLE FACE MASK
• Advantages:
o Less expensive (RS 80/-)
o Can be used in mouth breathers
• Disadvantages:
o Uncomfortable
o Require tight seal
o Do not deliver highFiO2
o FiO2 varies with breathing efforts
o Interfere with eating, drinking,
communication
o Difficult to keep in position for long
o Chances of rebreathing are high
54. PARTIAL REBREATHING MASK
• Mask with reservoir bag of capacity 1 litre
• Oxygen flows directly into the reservoir bag, which fills during exhaustion
• Deliver an FiO2 between 0.6 and 0.8
• A minimum of 8L/min should enter the mask to remove exhaled CO2 and refill
oxygen reservoir
• Flow rate must be sufficient to keep bag 1/3 to ½ inflated at all times
• Advantages:
o Inspired gas not mixed with room air
o Patient can breathe room air through exhalation ports if oxygen supply gets
interrupted
• Disadvantages:
o More oxygen flow does not increase FiO2
o Interfere with eating and drinking
55. ◦ Provided with one-way valves between mask and bag,
exhalation ports
◦ FiO2 of 95% can be achieved with oxygen flow rates of
10 to 15 L/min
◦ Higher oxygen supply rates are required
◦ Desirable in cases where rebreathing of CO2 would be
detrimental, for example after head injury.
NON- REBREATHING MASK
56. NON- REBREATHING MASK
Advantages:
o Highest possible FiO2 without intubation
o Suitable for spontaneously breathing patients
with severe hypoxia
Disadvantages:
o Expensive
o Require tight seal, Uncomfortable
o Interferes with eating and drinking
o Not suitable for long term use
o Malfunction can cause CO2 build-up, suffocation
57. ◦ Clear plastic sheet that cover child’s upper body
◦ FiO2 50%
◦ Not reliable
◦ Limit access to patient
◦ Not useful in emergency situations
OXYGEN TENT
58. HIGH FLOW DEVICES
58
• Air Entrainment Mask (Venturi)
• High Flow Nasal Oxygen Therapy/ High Flow Nasal Cannula
• NIV (Non-invasive ventilation) Masks
• HAFOE (High air flow with oxygen enrichment mask) systems
• Anesthesia circuits
• Ventilators
• Non-invasive
• Invasive
59. ◦ Based on Venturi modification of Bernoulli principle
◦ Gas flow is sufficient to meet the demands of patient
◦ The plastic body of the mask with holes on both sides
◦ The proximal end of the mask consists of a venturi
device. The Venturi devices are color-coded and
marked with the recommended oxygen flow rate to
provide the desired oxygen concentration.
◦ Alternatively, a calibrated adjustable venturi device can
be used to deliver the desired FiO2
VENTURI MASK
61. ◦ Delivers fixed concentration of oxygen
◦ The size of the constriction determines the final concentration of
oxygen for a given gas flow
◦ As forward flow of inspired gas increases, the lateral pressure
adjacent and perpendicular to the vector of flow decreases,
resulting in entrainment of gas.
◦ The smaller the orifice is, the greater the negative pressure
generated, so the more ambient air entrained, the lower the FiO2
◦ FiO2 can be 0.24, 0.28, 0.31, 0.35, 0.4, 0.6
◦ Because of the high fresh gas flow rate, the exhaled gases are
rapidly flushed from the mask, via its holes.
◦ These masks are recommended when a fixed oxygen concentration
is desired in patients whose ventilation is dependent on the
hypoxic drive.
VENTURI MASK
63. VENTURI MASK
• Advantages:
o Fine control of FiO2 at fixed flow
o Fixed, reliable, and precise FiO2
o High flow comes from the air, saving the
oxygen cost
o Can be used for low FiO2 also
o Helps in deciding whether the oxygen
requirement is increasing or decreasing
• Disadvantages:
o Uncomfortable
o Expensive (400-600)
o Cannot deliver high FiO2
o Interfere with eating and drinking
64. ◦ Delivers heated and humidified oxygen via special
devices (e.g., Vapotherm)
◦ Rates up to 8 L/min in infants and up to 40 L/min in
children and adults
◦ High flow washes out cardon dioxide in anatomical
dead space
◦ Creates positive nasopharyngeal pressure
◦ FiO2 remains relatively constant
◦ Because gas is generally warmed to 37°C and
completely humidified, mucociliary functions remain
good and little discomfort is reported
HIGH FLOW NASAL CANNULA
65. ◦ When high oxygen concentration/ flow is required
◦ Inlet – separate pressurized air, oxygen source
◦ Gases are mixed inside either manually or with blender
◦ Output – mixture of air and oxygen with precise FiO2
and flow
◦ Ideal for spontaneously breathing patients requiring
high FiO2
HIGH FLOW NASAL CANNULA
66. Flow : 20 – 40 L/min
• Fio2 : Up to 100%
• Side-effects:
- Claustrophobia
- Pressure sore
• Also known as: BIPAP or Ventilator
NIV MASK (NON-INVASIVE VENTILATION)
67. ◦ Avoids intubation
◦ Reduces work of breathing
◦ BIPAP machine/Ventilator
◦ Contraindications
- Hemodynamic instability
- Multi organ failure
- Altered mental status
NON-INVASIVE VENTILATION
68. Thank You!
This presentation was made possible with support from the United States Agency for
International Development funded RISE program, under the terms of the cooperative
agreement 7200AA19CA00003. The contents are the responsibility of the RISE program and
do not necessarily reflect the views of USAID or the United States Government.
69. Session V: Infection Prevention and Decontaminating
Practices for Oxygen Devices
71. CLEANING AND DISINFECTION
OF RESPIRATORY EQUIPMENT
• Equipment used for respiratory therapy is considered
semi critical; such items should be cleaned and then
receive at least high-level disinfection between patients.
• Chemical germicides used for high-level disinfection
include
• Glutaraldehyde-based formulations (2%)
• Stabilized hydrogen peroxide (6%)
• Peracetic acid (variable concentrations, but ≤ 1% is
sporicidal)
• Sodium hypochlorite (5.25%, diluted to 1000 ppm available
chlorine – 1:50 dilution)
72. STEPS FOR CLEANING AND DISINFECTION OF
PLASTIC PIECES OF RESPIRATORY EQUIPMENT
Step-1: Wash the equipment with soap (e.g., liquid
dish soap) and clean water.
Step-2: Rinse the equipment completely with
clean water.
Step-3: Disinfect the equipment to inactivate any
remaining pathogens: There are several ways to
disinfect equipment, Safe methods of disinfection
include
Heat for heat-resistant equipment that can withstand high
temperature (e.g., 80 °C); such equipment can be disinfected using a
washer–disinfector.
If a washer or pasteurizer is not available, use a high-end or
commercial dishwasher with a “sanitize” feature that can reach 70 °C.
For plastic equipment that may not tolerate 80 °C and for equipment
that may be damaged by boiling, or in the absence of the equipment
described above, use chemical disinfection (e.g., soak in 1:100 sodium
hypochlorite solution for 30 minutes).
73. DISPOSABLE EQUIPMENT
Disposable equipment will be changed in the following manner:
• Visibly stained or soiled/ mechanically malfunctioning - Adult ventilator circuits and BiPAP or CPAP circuits,
Resuscitation Bags, other equipment's.
• Changed daily- Oral care devices (i.e., Yankauer and tubing) on all ventilator patients, Suction canisters, Oxygen
masks, nasal cannulas, and oxygen tubing are single patient use.
• As needed-
o Clear nipple adapters (Christmas trees) on flowmeters are reusable and will be wiped down, after a patient’s
hospital stay, by germicidal disposable wipes.
o Properly discard Disposable items after use.
o Periodically drain and discard any condensate that collects in the tubing of the mechanical ventilator, taking
precautions not to allow condensate to drain toward the patient.
Reference: Respiratory Care Infection Control. Policy No. 3364-136-06-01, The University of Toledo Medical Center Respiratory Care Department (https://www.utoledo.edu/policies/utmc/respiratory_care/pdfs/3364-136-06-01-respiratory-care-infection-control.pdf)
74. NON-DISPOSABLE EQUIPMENT
Small instruments/equipment will be processed in Central
Supply:
• Following patient use, items will be washed with an
approved detergent and warm water.
• Scrubbing will be performed beneath the surface of the
water in order to help prevent the aerosolization of
pathogens and free of secretions, pus, blood, other debris.
• If required soak the equipment for two hours in detergent
and warm water. Towel/air dried for 24 hrs.
• For sterilization follow a) steam under pressure b) the Sterrad
unit (hydrogen peroxide) c) Steris (peracetic acid) depending
on the material contents of the equipment and as per
Central Service recommendations.
• Appropriate personal protective equipment to be worn.
Large equipment cleaning/disinfection like mechanical ventilator:
• Wipe down the controls and entire outside of the equipment
with a compatible disinfectant (e.g. sodium hypochlorite
solution of 0.05% or 500 ppm for non-metal surfaces).
• Disinfect tubing using sodium hypochlorite solution of 0.1% or
1000 ppm, ensuring that the entire lumen of the tubing is
flushed.
• As required expiratory side tubing should be disassembled and
clean with a detergent, rinse, and then do high-level disinfection
or sterilization.
• Bacterial and viral filters are recommended on exhalation valves
when using for a patient care (ARI).
• Only in necessary clean respiratory and pressure lines.
75. Thank You!
This presentation was made possible with support from the United States Agency for
International Development funded RISE program, under the terms of the cooperative
agreement 7200AA19CA00003. The contents are the responsibility of the RISE program and
do not necessarily reflect the views of USAID or the United States Government.
79. WHY IS THERE SO MUCH MISUSE OF OXYGEN?
• Oxygen is safe to use
• Easily available in hospital
• Availability is considered free of cost
• No regulations by higher authorities
• No need for permission of any doctor or nursing staff before rotating the knob
Oxygen is considered a gas, not a drug ‼
Myths about oxgen ‼
81. FACTORS LEADING TO MISUSE OF OXYGEN
Lack of physician orders on use of oxygen
• Need for oxygen therapy
• Dose of oxygen (flow of O2, FiO2)
• Route of administration (Nasal prongs, face mask, H3FNC, O2 by hood or ventilator)
• Period of administration (Continous, intermittent or nocturnal)
• Targets of oxygen saturation
• Not reviewing oxygen orders regularly
82. FACTORS LEADING TO MISUSE OF OXYGEN
Nursing staff
• Lack of awareness of side effects of oxygen among healthcare workers and staff
• Staff time constraints
• Difficulties with changing long established behaviours
• Lack of enthusiasm by senior clinical staff
• Communication difficulties between doctors and nurses
• Lack of full time staff/ Rapid staff turnover
83. FACTORS LEADING TO MISUSE OF OXYGEN
• Lack of designated space and place for prescribing oxygen
• Notion that all sick patients need oxygen
• Higher targets of SpO2
• Patient transferred from other ward with oxygen therapy in situ
• Knowledge practice gap
• Delay in weaning from oxygen
84. FACTORS LEADING TO MISUSE OF OXYGEN
Delivery devices
• Incorrect choice of oxygen delivery devices
• Inappropriately worn oxygen delivery devices
• Non availability of proper oxygen delivery devices at all the places
• Non avalability of oxygen blenders to titrate FiO2
• Lack of knowledge about delivery devices
85. FACTORS LEADING TO MISUSE OF OXYGEN
Administration
• No quality check on oxygen usage
• No proper institutional guidelines
• Lack of education of healthcare staff about proper usage of oxygen
• No oxygen audit
86.
87. FACTORS LEADING TO WASTAGE OF OXYGEN
• Inappropraitely increasing oxygen flow
o Suctioning
o Nebulisation
o Cardio pulmonary resuscitation
o Transport
• Keeping FiO2 to 100% after resuscitation without monitoring SpO2
• Often forgets to close the flowmeter once use is completed
90. SIDE EFFECTS OF OXYGEN THERAPY
• Dryness of mucosa due to high flows
• Elevated PaO2 or hyperoxemia: Increased risk of
o Reactive oxygen species
o Absorption atelectasis in poorly ventilated areas
o Retinopathy of prematurity in newborns
o Risk of infection
o Mortality
o Increased hospital stay
91. • Coronary vasoconstriction - worsening of Myocardial Infarction
• Reperfusion injury
• Increase in infarct size
• Worsening of stroke
• False reassurance to the staff
• Hypercapnia in patients with type 2 respiratory failure
SIDE EFFECTS OF OXYGEN THERAPY
92. • Shortage of oxygen supply for the most needed person
• Increased cost of treatment
• Deaths due to hypoxemia
SIDE EFFECTS OF OXYGEN THERAPY
97. ASSESSMENT
• Assess patient thoroughly
• Dyspnea is not the sign of oxygen insufficiency
• Consider other causes also
o Metabolic acidosis
o Anxiety
o Pain
98. PRESCRIPTION
• Proper prescription of oxygen by doctors
• Document target saturations as per patient condition
o 94-98% for most acutely sick patients
o 88-92% for patients at risk of hypercapnic respiratory failure
• Proper recording of instructions over nursing chart
99. ADMINISTRATION OF OXYGEN
• Oxygen should be administered by trained nursing staff
• Proper selection of oxygen device
• Ensure adequate fit to avoid leakage
• Adjust flow rate to achieve target saturation range
• Use of closed suctioning device to prevent de-recruitment
100. Oxygen source
Oxygen delivery systems
Interface
Oxygen cylinders
Wall oxygen
Oxygen concentrators
Oxygen plants
Liquid oxygen
Nasal
prongs
Masks
Hood
Low flow systems
High flow systems
Nasal prongs
Face mask
Partial and non
rebreathing masks
Hood box
Venturi mask
HFNC
ADMINISTRATION OF OXYGEN
101. SELECTION OF OXYGEN DEVICE
Depends on
• Age of the patient
• Oxygen requirements/therapeutic goals
• Patient tolerance to selected interface
• Need for humidification
102. MONITORING
• Continous monitoring of SpO2 using pulse oximetry
• Pulse oximeter should be available wherever oxygen is used
• Titrate FiO2 and flow of oxygen carefully based on SpO2
• Record SpO2 on patient chart along with other vital signs
• Educate patient about the importance of proper delivery of oxygen
• Monitoring of arterial blood gas wherever indicated
103. RECOMMENDATIONS FOR ABG MONITORING
• All critically sick patients
• Severe hypoxemia (SpO2 less than 94%)
• Deteriorating saturation or increasing oxygen demand
• Type 2 respiratory failure
• Unreliable oximeter signal e.g - due to poor circulation
• Dyspnea with risk of metabolic acidosis e.g – Renal faliure, diabetes
104. PROPER GUIDELINES
• Formulate & implement local oxygen policy as per the recent guidelines
• Introduce standard oxygen prescribing system
• Clearly delineating section on drug chart for prescription of oxygen orders
• Dedicated oxygen order charts
• Standarise bedside documentation of oxygen administration
105. POLICY MAKERS
• Regular audits and QI check on proper usage of oxygen
• Regular training of doctors, nurse and healthcare professionals
• Regular email notification for dissemination of information
• Informational posters
• Nurse facilitated reminder system
• Address the perception of clinicians
107. WEANING
• Formulate oxygen-weaning protocols and guidelines
• Follow the proper steps of weaning protocol to improve the patient outcome
• Start titration of oxygen once SpO2 has reached the ordered weaning parameters
• Weaning frequency, set goals and alarms should be prescribed by a physician
• Strike off oxygen from the drug chart when it is not needed
• Consider other etiologies if there is difficulty in weaning from oxygen
o Low hemoglobin, fluid overload
o Lung collapse
111. Thank You!
This presentation was made possible with support from the United States Agency for
International Development funded RISE program, under the terms of the cooperative
agreement 7200AA19CA00003. The contents are the responsibility of the RISE program and
do not necessarily reflect the views of USAID or the United States Government.
