O2 Therapy, Lung Expansion Therapy & Airway Clearance By Michael S. Allen, RRT Updated April 8, 2015

O2 Therapy, LET & BHT Key Note: Do least invasive therapy first Do least costly therapy first If patient condition severe, then do severe therapy

Oxygen (O2) Therapy Why: SpO2 lower than 90% SaO2 lower than 92% PaO2 lower than 80 mmHg Patient c/o SOB, dyspnea, or chest pain Patient Type: Anyone who meets above criteria regardless of age or diagnosis Exception: COPD, Emphysema, or Chronic CO2 retainer Premature neonate Devices Used: Nasal cannula Simple mask Air entrainment mask (aka: venti-mask) High Flow Nasal Cannula Non-Rebreather (NRB) Heated Humidified High Flow Nasal Cannula CPAP

No Smoking, Oxygen in Use

Oxygen therapy O2 devices Device: Limitations: FIO2: Nasal Cannula Adult = 0.25 Lpm – 6 Lpm RA = 20% Infant = 1/32, 1/16, 1/8 1L = 24% 2L = 28% 3L = 32% 4L = 36% 5L = 40% 6L = ~44%? FIO2 is what we deliver SpO2 is what we measure

Oxygen therapy O2 devices Device: Limitations: FIO2: Simple Mask 6 Lpm – 10 Lpm 35% – 50 %

Oxygen therapy O2 devices Device: Limitations: FIO2: “Venti” air-entrainment mask 3 Lpm 24 – 32% 6 Lpm 36 – 44% 8 Lpm 50 – ~70%

Oxygen therapy O2 devices Device: Limitations: FIO2: High Flow Nasal Cannula 3 Lpm – 12 Lpm questionable FIO2% (non heated) LPM flow titrated to SpO2

Oxygen therapy O2 devices Device: Limitations: FIO2: Non-rebreather (NRB) 8 Lpm – 15 Lpm 60% – 95% “flush” (~16–40 Lpm) 95% – ~100%

Oxygen therapy O2 devices Device: Limitations: FIO2: Oxymask FIO2 dictated by flow 1 LPM 24% - 25%   * Able to sxn patient, or 2 LPM 27% - 32% provide drink w/o removing mask. 4 LPM 34% - 40% 6 LPM 42% - 48% 8 LPM 49% - 55% 10 LPM 53% - 58% 12-15 LPM 59% - 65% It is suggested that this Oxymask can replace the NC, Simple mask, and NRB. However, assess for patient comfort and need. Refer to … www.youtube.com/watch?v=KDsNm72dBRU

Oxygen therapy O2 devices Device: Limitations: FIO2: Heated-Humidified 10 Lpm – 70 Lpm Blender needed for FIO2% High Flow Nasal Cannula excess rainout

Oxygen therapy O2 devices Device: Limitations: FIO2: CPAP used in ICU 21% – 100% Note, a patient’s CPAP is used for OSA, but a CPAP/BiPAP such as seen above is for Oxygen therapy.

Caution, Lung Expansion in Progress

Lung Expansion Therapy aka: Hyperinflation Therapy Why: Treat/Prevent Atelectasis Low lung volumes (as seen from a chest x-ray) Patient Type: Asthma, COPD, CHF, Pneumonia Decreasing SpO2 and/or increased need for O2 Atelectasis (BS = late inspiratory crackles; or as seen on chest x-ray) Fever Neuromuscular disorders Patients on bed-rest or bedridden Post Surgery (especially upper abdominal or thoracic) Devices Used: Deep breathing and cough (DB&C) Pursed Lip breathing Body Calisthenics Incentive Spirometer TheraPEP EzPAP IPPB CPAP/BiPAP

Devices for LET Deep-breath and Cough “DB&C”

Devices for LET Pursed Lip breathing

Devices for LET Patient position and Body Calisthenics

Devices for LET Incentive Spirometry

Devices for LET TheraPEP

Devices for LET EzPAP Refer to … www.youtube.com/watch?v=UA00oG7ou_I

Devices for LET IPPB Bird Mark 7 IPPB circuit Bennett PR-2

Devices for LET CPAP/BiPAP

BHT … I Need Help

Bronchial Hygiene Therapy AKA: Pulmonary Toilet or Airway Clearance Techniques Why: Increased mucus in airways Weak or non-productive (congested) cough Patient Type: Asthma, COPD, CHF, Pneumonia Bronchiectasis, Bronchiolectasis, Bronchiolitis, Bronchitis Ciliary dyskinetic syndrom Cystic Fibrosis Neuromuscular disorders Immobile, bed-rest or bedridden patients RSV Devices Used: Huff Cough TheraPEP Flutter or Acapella Chest Physiotherapy (CPT): Percussion (hands or percussion device) Percussor (pneumatic or electric) HFCWO (“the Vest”) Postural drainage Cough Assist (aka: insufflator-exsufflator) NT suction IPV (Intrapulmonary Percussive Ventilation)

Devices for BHT Huff Cough

Devices for BHT TheraPEP

Devices for BHT Flutter Acapella Aerobika oscillating PEP (OPEP) Refer to … www.youtube.com/watch?v=jZCjMQAlGcU Aerobika oscillating PEP (OPEP) Refer to … www.youtube.com/watch?v=n7X3QP8HJKA

Devices for BHT Chest Physio-Therapy (CPT) Hand percussion and hand-held device

Devices for BHT Chest Physio-Therapy (CPT) Pneumatic Percussor Electric Percussor

Devices for BHT Chest Physio-Therapy (CPT) High Frequency Chest Wall Oscilation (HFCWO)

Devices for BHT Postural Drainage

Devices for BHT Cough Assist Device

Devices for BHT Nasal-Tracheal Suction (NT sxn)

Devices for BHT IPV (Intrapulmonary Percussive Ventilation)

Medicine Delivery for BHT Percussive Nebulizer VORTRAN PercussiveNEB® • New improved modulator operates more consistently • Intrapulmonary percussive aerosol nebulizer • Mucus clearance (i.e. cystic fibrosis, COPD and post-op atelectasis) • High aerosol output • Automatic PEP • Single patient, multiple use • Pressure dial adjustable between SOFT to HARD setting • Home or hospital use • High flow compressor available for home use