1. Oxygen Delivery Devices
By Dr H. El sharkawy

2. Administration of Oxygen
Need for Oxygen
Hazards
Delivery Devices
Hyperbaric Oxygen
Other Medical Gases

3. 5 Indications for Oxygen Therapy
Suspected or Documented hypoxia
Severe trauma MI
Post op
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4. Hazards of Oxygen Therapy
Ventilatory depression
Absorption atelectasis
ROP(retinopathy of prematurity
Oxygen toxicity
Fire hazard
Contamination
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5. Delivery Devices Low and High Flow
Getting the gas to the patient

6. Low Flow Device Definition
FiO2 can vary with:
Patient’s respiratory rate and pattern
Flow of gas from the equipment
Equipment reservoir
Does NOT fully meet patient’s inspiratory demand
Needs additional mixing with room air
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7. Low Flow Oxygen Low Flow Nasal cannula Simple oxygen mask
Non-rebreathe mask
Face tent
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8. Nasal Cannula
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9. Nasal Cannula Delivers about 24 to 44% FiO2
Flow is set at 1 to 6 liters for adults
0.1 to 0.9 with newborns (special flowmeter)
FiO2 varies with patient respiratory rate and volumes
Add moisture over 4 L/min or with pt comfort
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10. Simple Mask
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11. Simple Mask Delivers 40 to 50% oxygen
Need at least 5 L/min to flush out CO2
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12. Non – Rebreathe Mask
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13. A reservoir system Delivers better oxygenation then simple mask.
The most oxygen without intubation
50 to 70% oxygen (some say %)
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14. Something New (VIASYS)
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15. The Hi-Ox 80
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16. Helps patients more ways than one
Provides an FiO2 of >80% at a flow of 8 L/min
Studies show that high FiO2
Reduces nausea post operatively
Reduces s/p infections by 50%
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17. Trach Mask
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18. Trached? Usually blue tubing connected to heated aerosol.
Can use transport tee
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19. T-piece
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20. Tee Piece Must be intubated With aerosol mist setup or transport tee
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21. Face Tent
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22. Face Tent Ideal for post anesthesia Not enclosed and claustrophobic
Only for low oxygen concentrations
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23. Delivery Devices High Flow
Venturi (Entrainment) Mask
Aerosol mist setup

24. Definition of High Flow
Meets or exceeds patient inspiratory demand (usually textbook of 30 LPM)
Provides precise concentrations despite patients breathing pattern
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25. Why 30 Liters per minute? Based on minute volume
Respiratory rate times tidal volume
The number of breaths multiplied by the size of the breaths
People inspire one-third of the time.
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26. Air Entrainment Mask
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27. Venturi Masks
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28. Entrainment Ratios
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29. Venturi – High flow device
Ideal for use with CO2 retainers
Matches patient demand
Usually 24 to 50% (some have up to 100% running at flush)
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30. Aerosols and Nebulizers
Jet nebulizers
Small volume nebs
Aerosol setups
Aerosol output calculations
Aerosol density calculations
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31. Keep the flow up!
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32. Monitoring Oxygen Therapy
Pulse Oximetry
Arterial Blood gases
Work of Breathing
Tidal Volume and Respiratory Rate
Pulse and Blood Pressure
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33. Less common used O2 delivery
Head hoods
Pendant or reservoir nasal cannula
Bi-flow
Tracheal catheters
Croup tents
Incubators
Hyperbaric chamber
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34. Head Hood
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35. Head Hood
Newborns only
Watch for cooling
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36. Pendant Reservoir
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37. Reservoir Cannula
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39. Tracheal Catheter
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40. Nasal Catheter
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41. Oxygen (Croup) Tent
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42. Croup Tent
Can supply 30 to 50% oxygen
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43. Incubator
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44. Oxygen Blender
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45. Functional Diagram of Blender
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46. Blenders Found on all ventilators
Easiest and most accurate way to deliver oxygen at precise percentages
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47. Even Less Commonly Used

48. Hyperbaric Oxygen (High Pressure Oxygen)
Monoplace Chamber
Multiplace Chamber

49. Hyperbaric Oxygen
Used to increase the amount of oxygen carried in the blood.
HENRY’S LAW – the amount of gas dissolved in a liquid is directly related to the partial pressure of the gas(es) above the liquid.
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50. Hyperbaric Oxygen Reduce the size of the air bubbles in the body
Air Embolism
Decompression sickness
Boyle’s Law – Pressure and Volume are inversely related.
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51. Indications for HBO Decompression sickness(inflammation mouth)
Diver with the ‘bends’
Gas Embolism
Reduces the size of the bubbles
Carbon monoxide and Cyanide poisoning
Decreases half life of CO bond
Severe anemia (blood loss)
Wound healing
Ischemic skin grafts, flaps, burns
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52. Monoplace HBO Chamber
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53. Hyperbaric Chambers
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54. Carbogen Heliox Nitric Oxide
Other Gases
Carbogen
Heliox
Nitric Oxide

55. Carbogen Usually 95% oxygen and 5% carbon dioxide
Treats singulitus (hiccups)
Provides a challenge to stimulate breathing in some patients
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56. Heliox Useful with ventilators and in ER Upper airway narrowing
Croup
Asthma
Stridor
Tracheal tumors
The less dense gas is ideal for the tight passage through a narrow passage
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57. Nitric Oxide
Treatment of neonates with hypoxic respiratory failure associated with pulmonary hypertension
A significant improvement has been noted with premature infants
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58. Nitrous Oxide Used with anesthesia
Don’t get confused between NO and N2O
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59. That’s all folks
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60. Respiratory Failure Immediate Assessment & Treatment
Indications For Intubation
Non-Invasive Ventilatory Options
Therapeutic Thoracentesis
Initial Ventilator Settings
Tempo: seconds… Reflex Reaction
1 – 5 minutes.. … Emergency Assessment
20 minutes…. Additional Therapy
Goal: Stabilize the Patient within 20 minutes!

61. “Doctor…Your patient is in Respiratory Distress….?”
“Reflex” Reaction…..
Vitals
Including pulse ox
Oxygen….
50% face mask
“Albuterol Neb”
0.5 cc solution mixed with 2.5 cc NS (= 2.5mg)

62. “Emergency” Assessment Focused Exam / Important Labs / Differential
DOES THIS PATIENT NEED TO BE INTUBATED!!!
“The Look” vs “VOPS”

63. “The Look” Speech Pattern Vital Signs Breathing Pattern Air Movement
Accessory Muscles
Retractions
Thoraco-Abdominal Paradox
Hoover’s Sign
Pulsus Paradox
Air Movement
Cyanosis
Patient’s Own Assessment

64. Assessment and Treatment - Continued
Focused Physical
Wheezing vs Crackles vs No Breath Sounds
Pulse Oximeter/ABG
CXR
CHF
Pneumonia
Effusions
Atelectasis
Pneumothorax
Clear
what should you think of?
Therapeutic Thoracentesis
Oxygen
Bronchodilators
Adequate Nursing / Monitoring
? Non-Invasive Ventilation
“CPAP” or “BiPAP”

65. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion

66. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion

67. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion

68. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion

69. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax
Atelectasis
Pulmonary Edema
Effusion

70. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion

71. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion

72. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Effusion

73. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Crackles
Effusion

74. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
(Crackles)
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Crackles
Effusion

75. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
Crackles, Egophony
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Crackles
Effusion
Egophony

76. Focused Exam Breath Sounds Fremitus Pectoriloquy Percussion
Extra Sounds
Bronchospasm
Wheezing
Pneumonia 
(Bronchial)
Dull
Crackles, Egophony
Pneumothorax 
Hyper-resonant
Atelectasis
Pulmonary Edema
Crackles
Effusion
Egophony

77. Common CXR Dilemmas White Out Pneumo vs Skin Fold Three Major Causes:1. 2. 3.
How to Distinguish:
Pneumo vs Skin Fold
How to Distinguish:

89. Emergency Needle Decompression
Prepare area (i.e., Betadine).
Technique:
14 or 16-gauge IV catheter
Second intercostal space
Superior to the third rib
Midclavicular line
1-2 cm from the sternal edge
hold perpendicular to the chest wall
listen for the hissing sound of air escaping
remove the needle while leaving the catheter in place.
Prepare the patient for tube thoracostomy.

90. Therapeutic Thoracentesis
If effusion is large and symptoms are significant.
Otherwise, if non-urgent, call the Pulmonary Procedure Fellow in the morning (63893)
Technique
Common Mistakes
Preparation
Location (specific rib)
Comfort
Angle
Volume

91. Oxygen How Much? Type of Delivery Device
Once Saturated is More Better?
? Blunting Drive to Breath ?
Type of Delivery Device

92. Oxygen Delivery Devices
Nasal Cannula
24-44% FIO2
? FIO2 per liter

93. Oxygen Delivery Devices
Nasal Cannula
24-44% FiO2
Simple Face Mask
40 –60% FiO2

94. Oxygen Delivery Devices
Nasal Cannula
24-44% FiO2
Simple Face Mask
40 –60% FiO2
Non-Rebreather Mask
“resevoir” with one-way valve
60-100% FiO2

95. Oxygen Delivery Devices
Venturi Mask
Includes a valve allowing precise FiO2 delivery (? Advantage for COPD patients)
24-40% FiO2

96. Oxygen Delivery Devices
Nasal Cannula
24-44% FiO2
Simple Face Mask
40 –60% FiO2
Non-Rebreather Mask
“resevoir” with one-way valve
60-100% FiO2
Venturi Mask
Includes a valve allowing precise FiO2 delivery (? Advantage for COPD patients)
24-40% FiO2

97. Bronchodilators Indication Which One(s)? Any Wheezing
Any “Silent” Chest
? Other
Which One(s)?
Albuterol – 2.5 to 5 mg (0.5 to 1 cc of 0.5% sltn)
Ipratropium – 500 mcg (one vial)

98. CPAP / BiPAP CPAP Continuous Positive Airway Pressure CPAP  PEEP
Redistributes Edema Fluid
Reduces Atelectasis
Reduces WOB in COPD by Counterbalancing auto-PEEP
BiPAP
Bilevel Positive Airway Pressure
EPAP  CPAP  PEEP
IPAP  PS
Augments TV
Reduces Atelectasis
Reduces WOB

99. BiPAP Indications Acute Pulmonary Edema COPD Exacerbation
PEEP/CPAP redistributes the alveolar edema
COPD Exacerbation
reduces WOB caused by auto-PEEP
Pulmonary Infiltrates in the BMTU
Post-Extubation Failures
reduces atelectasis…...buys time…maybe

100. BiPAP Initial Settings: Titrate to Effect:
EPAP = 5 cm H2O
IPAP = 3 cm H2O
Titrate to Effect:
Get rid of “The Look”
 EPAP to improve oxygenation and counter-balance auto-PEEP (hard to assess!)
 IPAP to  TV &  RR
Requires Close Nursing Supervision

101. Initial Vent Settings Initial Goal… A good place to start:
Get rid of “The Look”
aka “Rest” the patient
A good place to start:
a/c, TV = 500 cc, RR = 12
FiO2 = 100%, PEEP = 5 cm H2O