Presentation on theme: "Oxygen Delivery, Bronchial Hygiene and Airway Clearance"— Presentation transcript:
1 Oxygen Delivery, Bronchial Hygiene and Airway Clearance Dana Evans, BHS, RRT-NPS, AE-CShawna Strickland, MEd, RRT-NPSUniversity of Missouri-ColumbiaRespiratory Therapy Clinical Instructors
2 Oxygen Cylinders Made of steel or aluminum Sizes Remember that steel is magnetic…don’t take a steel tank into the MRI suite!The aluminum tank is more suited to portabilitySizesTypically found in the hospital: E and HTypically found in the home: D and smaller
3 Oxygen Cylinders Identifiers Color (in the US: oxygen is green, air is yellow)Aluminum tanks have a color strip at the top and silver on the bottomSteel tanks are solid colors (unless it’s a gas mix)Identification label with contentsMedical oxygen is 99.5% pure
4 How do I get oxygen out of the tank? Equipment necessary:RegulatorTank keyTank Oxygen delivery deviceThings to remember:“crack and bleed”
5 How long does the tank last? Every size tank holds a different amount of gas (obviously, bigger tanks last longer than smaller tanks)What do I need to figure out the duration?Cylinder factorE cylinder factor = 0.28Flow rate of oxygen to the patientHow full is the tank?
6 Cylinder Duration Equation Your patient is wearing a nasal cannula with oxygen flowing at 2 LPM. He is using an E cylinder and it is full (2200 psig).Equation:0.28 x 22002 LPMThis tank will last 308 minutes…5 hours and 8 minutes
7 Try one on your own…Your patient is wearing a nasal cannula with oxygen flowing at 5 LPM. He is using an E cylinder and it is half full (1100 psig).How long will this tank last?62 min
8 Oxygen Orders Remember that oxygen is a drug… PRN It must be prescribed by a physician.PRNOxygen saturations via pulse oximeterSpO2
9 Suctioning Definition: Purpose: Important to remember: The removal of tracheobronchial and upper airway secretionsPurpose:To clear the airways of obstructions for improved gas exchange and prevent aspirationImportant to remember:This is always a sterile procedure when the patient has an endotracheal tube or tracheostomy tube
10 One-Use Sterile Catheters Sized in French (typically 6-14 Fr)Most catheters are 56 cm longCommon features:Thumb port to apply suctionSide holes in the distal tip for pluggingDistal tip is blunt and openFlexibleSome have markings for length (cm)
11 Closed-Circuit Catheters Common features:Endotracheal or tracheostomy tube adaptorSuction catheter inside sterile sheathThumb portLavage portPopular because:No disconnection from the ventilator (decreased VAP)Reduced costReduced exposure of HCP to infectious materials
12 Complications of Suctioning HypoxemiaCardiac arrhythmiasTrauma to airway mucosaAtelectasisContamination of lower airwayContamination of caregiversIncreased intracranial pressure
14 Manual Ventilation Purpose: To provide positive pressure ventilation and supplemental oxygen to a patient who isApneicBradycardicIntubated or trachedUnable to expand all lung areas due to weakness
15 Spontaneous Ventilation Ribs expand and diaphragm drops to create a negative pressure inside the thoracic cavityThe lungs fill with air because the atmospheric pressure greater than the intrathoracic pressureExhalation is passive (relying on chest recoil)
16 Positive Pressure Ventilation Concept:External pressure applied to the lung to move airExhalation is still passiveAdvantages:Provide ventilation and oxygen for those who can’t (for whatever reason) do it themselvesDisadvantages:Over-inflation can cause many pulmonary and hemodynamic complicationsUnder-inflation doesn’t allow adequate ventilation and oxygenation
17 Manual Resuscitators Three sizes: Adult (25 kg and larger) Pediatric (10-25 kg)Neonatal (less than 10 kg)
18 Features of Manual Ventilators Oxygen tubingOxygen reservoir (to provide more than 0.40 FiO2)Body of bagLots of one-way valves to direct air flowPatient adaptor (to mask or tube)Exhalation port (do not occlude this!)Optional PEEP valve
19 How to provide breaths with a manual ventilator… Breath rate: 12 per minuteThat works out to one every five secondsVolume:Watch the chestIt should gently rise while you squeeze the bag with two handsToo little volume: atelectasis and ↓oxygenationToo much volume: pneumothorax and ↓oxygenation
20 What questions do I need to ask before choosing a bronchial hygiene therapy? Does the patient have excessive mucus production?Does the patient have a weak, ineffective cough?Is the patient able to follow directions?Does the patient have a caregiver that can help administer therapy?Is the patient able to ambulate and/or change positions easily?What outcomes will be used to assess effectiveness of therapy?If the patient is currently receiving bronchial hygiene, when was the last time the appropriateness of the therapy was evaluated?Has anything in the patient’s condition changed since the last evaluation?
21 Traditional Bronchial Hygiene Directed CoughPostural DrainageExternal manipulation of the thoraxChest wall percussionChest wall vibration
23 Postural Drainage Positioning Use gravity to move secretions to the large airways so the patient can cough them out.
24 New Methods of Bronchial Hygiene Positive expiratory pressure (PEP)AcapellaFlutter valve therapyIntrapulmonary percussive ventilation (IPV)High frequency chest wall oscillation (HFCWO)
25 PEP Therapy This can be used with or without regular nebulizer therapy Using it with nebulizer therapy achieves two goals at onceWhen the patient exhales, positive pressure is created in the lungs.This pressure allows air to enter behind areas of mucus obstruction and keeps the airways open during exhalation.During exhalation, mucus is now able to move the mucus toward the larger airways and the patient can cough it out.
26 Contraindications to PEP Patients who are unable to tolerate the ↑ in work of breathingICP > 20 mm HgHemodynamic instabilityEpistaxisUntreated pneumothoraxRecent facial, oral or skull surgery or traumaEsophageal surgeryActive hemoptysisNauseaKnown or suspected tympanic rupture or other middle ear problem
28 Flutter Valve Therapy When correctly, the effect is 3-fold: Vibrations applied to the airway facilitate the loosening of secretionsThe increase in bronchial pressure helps avoid air trappingExpiratory air flows are accelerated and facilitate the upward movement of mucus
29 2 Stages of Flutter Technique Loosening and mobilizing mucusUsing flutter will increase the pressure on exhalation and recruit lung units similar to the PEP deviceStage 2Eliminating mucusCough or huff maneuver follows the flutter to help expel the secretions
30 Flutter “Tips” Tilt is important With the mouthpiece horizontal to the floor:Tilt cone up or down to get maximal effectFeel the patient’s chest and back for vibrationsClean the device on a regular basis by disassembling and soaking
31 IPVDelivers rapid, high-flow bursts of air (or oxygen) into the lungs.At the same time, it delivers therapeutic aerosols (medications that might open the airways like Albuterol).Requires compressed gas to work.
32 Acapella Similar to PEP but adds vibration therapy as well. Can be delivered with aerosol therapy.
33 Who can use the IPV?Patients who can breathe on their own with a mouthpiece or maskPatients who are intubated and on a mechanical ventilator.Patients who have a tracheostomy and may or may not be on a ventilator.
34 IPV Clinical Indications BronchiolitisCystic fibrosisChronic bronchitisBronchiectasisNeuromuscular disordersEmphysemaTreatments typically last for about minutes, depending on the individual patient and the medications that need to be given.
35 HFCWO: “The Vest”Patient wears vest and vest is secured with clasps or velcro.Vest is filled with air and the air is vibrated. This causes “shaking” of the patient’s chest, which will loosen the mucus.Designed for patient self-administration (home use).
36 HFCWO: “The Vest” Pieces and parts: Foot pedal (makes it go)Patient vest is chosen based on patient sizeAir pulse generatorWe can adjust ventilator flow and speed of vibrationsTreatments are usually about 30 minutes long.Most aerosolized medications can be administered at the same time.
37 How do we know that this worked? Increased sputum productionImproved breath soundsImproved chest x-rayImproved arterial blood gasesImproved oxygenation (SpO2 or SaO2)Patient subjective responseDo you feel better?