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  • 5/25/2014 Respiratory Therapy Cave: Adult Oxygen Therapy Made Easy

    http://respiratorytherapycave.blogspot.com/2010/08/oxygen-therapy-made-easy.html 1/38

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    Adult Oxygen Therapy Made EasyIf a patient is unable to oxygenate appropriately on room air, supplemental oxygen may beindicated. This Course should provide you with the wisdom you need to determine what oxygendevice to use (if any) and how much oxygen to give to your patient.

    First we need some basic definitions:

    Supplemental oxygen: Any device that provides more oxygen than what one would get breathingroom air.

    Hypoxemia: This is when the oxygen in the blood is low, and is generally measured by a PaO2 of 60or less, or a SpO2 of 90% or less.

    PaO2: This is the level of oxygen in the blood. It should be kept at 60 or better to avoid hypoxemia.Its obtained by invasive Arterial Blood Gas (ABG) or estimated by SpO2.

    SpO2: Also called oxygen saturation, pulse ox or sat. This is a noninvasive measurement of theamount of oxygen inspired that gets to the arteries. A normal SpO2 is about 98%. Be aware that apersons normal SpO2 decreases with age and with some disease processes. The only way it can get to100% is with supplemental oxygen.

    You can use your SpO2 to predict the PO2 using the 456, 789 rule as below:

    SpO2 70% = PO2 of 40SpO2 80% = PO2 of 50SpO2 90% = PO2 of 60 (This is what you want to maintain for most patients)

    Therefore, ideally, for most patients you will want the SpO2 to be 90% or greater, or as specified byhospital protocol, or specific physician order.

    Fraction of Inspired Oxygen (FiO2): This is the percent of oxygen a patient is inhaling. Room airFiO2 is 21%. By applying supplemental oxygen, the FiO2 can go as high as 100%.Indications for Oxygen Therapy:

    To correct hypoxemiaTo reduce oxygen demand on the heartSuspected or acute marcardial infarction (MI)Severe traumaPost anesthesia recovery

    Low flow oxygen devices: These are oxygen devices where some room air will be entrained, andtherefore the exact FiO2 cannot be calculated, however it can be estimated.How much FiO2 is delivered to the patient is dependent on:

    Liter flow set at the flowmeterRespiratory rate and pattern of the patientEquipment reservoir (stores oxygen)

    The following are low flow oxygen devices:

    1. Nasal Cannula: The nasal cannula is the most common oxygen device used and the mostconvenient for the patient. A nasal cannula at 2lpm is usually a good place to start.You may at times need to estimate the FiO2. How to estimate FiO2 on a nasal cannula? For everyliter per minute, the FiO2 increases by 4% as per the chart below:

    1 lpm = 24%2 lpm = 28%3 lpm = 32%4 lpm = 36%5 lpm = 40%6 lpm = 44%

    The liter flow on a nasal cannula should never exceed 6lpm, as studies show doing so is of no addedbenefit to the patient. Also note that the prongs of a nasal cannula should face down.

    A bubbler can be added to humidify the nose to prevent nasal drying and bleeds. This is automaticallyset up at flows greater than 4lpm, or as ordered by physician.

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  • 5/25/2014 Respiratory Therapy Cave: Adult Oxygen Therapy Made Easy

    http://respiratorytherapycave.blogspot.com/2010/08/oxygen-therapy-made-easy.html 2/38

    3. NonRebreather Mask (NRB): This is a mask that ideally will bring in 100% Fio2 so long as theliter flow is 15 and there is a good seal between the mask and the patient's face. And all three oneway valves are on the mask to prevent air entrainment.

    For legal purposes, however, one flap is always removed just in case the oxygen gets shut off. Andtherefore the highest FiO2 you can get from an NRB is 75%. The bag acts as a reservoir for oxygen,and therefore allows device to provide higher FiO2s to the patient.

    4. Partial Rebreather Mask (PRB): This is basically an NRB with both oneway valves removed fromthe mask. The estimated FiO2 is 6065%. Flow should be set at 615 lpm.

    High Flow Oxygen Devices: These devices meet the inspiratory flow of the patient, and generateaccurate FiO2s so long as there is a good seal between the mask and the patient's face. The flows aresuch that the patient will not be entraining room air that will lower the FiO2. Respiratory rate andtidal volume of the patient have no effect on FiO2 delivered.

    Ideally, the larger the entrainment port on the device the lower the FiO2, and the smaller theentrainment port the higher the FiO2. A major disadvantage is a mask is required, and this may be abit more uncomfortable than a nasal cannula.

    1. Venturi Mask: This mask is ideal for patients who are in respiratory distress with high tidalvolumes or high respiratory rate to guarantee a certain amount of oxygen.If a nasal cannula does not provide adequate oxygenation, Venturi Masks set from 28% to 40% areideal for COPD patients.

    Modern Venturi masks come with one or more color coded caps, and whichever one you use thedesired liter flow for that particular cap is written right on the cap. The Venturi Masks used at MMC are set up as follows:

    A. White cap:

    35% FiO2 set lpm at 940% FiO2 set lpm at 1250% FiO2 set lpm at 15

    B. Green cap:

    24% FiO2 set lpm at 3lpm26% FiO2 set lpm at 3lpm28% FiO2 set lpm at 6lpm30% FiO2 set lpm at 6 lpm

    The liter flow must be at least set at the recommended liter flow for any particular FiO2 that isdialed in. It's okay if it is set too high, yet if it's too low the patient may retain CO2 and the FiO2may not be lower than what you dialed in.

    2. Aerosol setup: This device will deliver anywhere from 21 to 100% FiO2 depending on how it is setup. The desired flow to set the flow meter at is written write on the capUsually a humidity device is connected to the flowmeter, and wide bore tubing connects this to thepatient's mask Wide bore tubing acts as a reservoir to obtain higher FiO2s.

    These are ideal for patients with tracheotomies because it allows for inspired air to be oxygenated,humidified and even heated if necessary. They can be hooked up to a simple mask, tracheotomymask, and even a tpiece.

    The flow may exceed the required flow, although if it is less the patient may retain CO2, and theFiO2 be lower than desired. On inhalation a mist should be seen coming from mask or reservoir.

    3. High flow nasal cannula: An Fio2 of 21% to 100% may be maintained because the flow meets thepatient's spontaneous inspiratory demand. This is made possible due to thicker tubing and humidifiedoxygen.

    Other oxygen devices you might see:

    1. BiPAP: This is a discussion for another day. Still, pressure can be given by a noninvasive maskover the patients face to improve ventilation, and to supply any FiO2 from 21% to 100%. These alsohave other means of improving oxygenation.

    4. Ventilator: This is also a discussion for another day. Yet for patients whose oxygen demandsexceed any of the above devices, intubation and ventilation with a ventilator may be required. Thesecan supply any FiO2 from 21% to 100%, and also have other means of improving oxygenation.

    Hazards of oxygen therapy:

    Oxygen may suppress the respiratory drive for some COPD patients, and should be usedwith caution.FIO2s greater than 60% for greater than three hours have been linked to increased risk forlung injury and other future consequences.

    What device do you use? Where to start?

    For most patients, you will start low and work your way up if neededWe usually start at 2lpm for most patients and adjust accordingly.

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  • 5/25/2014 Respiratory Therapy Cave: Adult Oxygen Therapy Made Easy

    http://respiratorytherapycave.blogspot.com/2010/08/oxygen-therapy-made-easy.html 3/38

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    Posted by Rick Frea at 10:50 AM

    Labels: oxygen, oxygen therapy

    If you have a patient in respiratory distress, you may want to start at 40%.However, if the patient is in severe respiratory distress, or is the victim of a trauma, you