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3 Goals of O2 therapy

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1- Relieve hypoxemia (pneumonia v/q mismatch, ARDS etc.) 2- Decrease the work of breathing (asthma, COPD) 3- Decrease the work of the heart (MI, pulm edema, CHF)

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Indications for O2 therapy

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Hypoxemia SOB Post cardiac/resp arrest Post surgery septic shock low Cardiac Output Resp or Cardiac arrest/failure MI

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When ordering O2 therapy you must include

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1 - they type of delivery system 2- Route of administration 3- flow setting or FIO2 setting

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Types of O2 delivery systems - Low flow

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Nasal Cannula Simple Mask Oxymask Face tent

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flow rate for nasal cannula

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1-6 lpm

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Simple mask flow rate for peds? flow rate for adult?

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4-10 lpm peds adults 6-10 lpm

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oxymask - flow rate

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1-15 lpm

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face tent flow rate

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10-15 lpm

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peds nasal canula goes up to

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4L

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Nasal canula approximation

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

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High flow oxygen systems

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Venturi Mask Nonrebreather mask High flow nasal cannula Aquanox Aerosol face mask

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High flow o2 is considered anything over

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6L all the high flow methods go up to 15 except aquanox goes up to 30

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flow rate of venturi mask

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5-15 (28% - 90%)

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Flow rate and concentration of nonrebreather

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8-15lpm 100%

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high flow nasal cannula - flow rate

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7-15 lpm

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aquanox flow rate

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15-30

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Aerosol face mask flow rate and concentration

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6-15 28-90%

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anything over ____ needs humidity so you don't dry out the lungs

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3-4L

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high flow alternative to the face tent

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Aerosol face mask

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why is He/O2 used?

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to bypass an upper airway OBSTRUCTIOn such as a tumor in the airway (He is lighter than O2 so it carries the O2 past the obstruction)

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2 dilutions for He/O2 therapy

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80% he and 20% O2 - less than room air 70% He and 30% O2 - more common mixture

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He/O2 us usually only delivered via

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Non re-breather at 6-10 lpm do NOT order w/ nasal canula

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All adult oxygen should be titrated to keep sats

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*keep sats above 90-92!!!* unless contraindicated!

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in neonates you can aim for _____ O2 sat

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85-88% depending on child's health status

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contraindications for keeping O2 sat at 90-92

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big mass in neck - can't get through (risk v reward) COPD - ok with lower sats ~86

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CPAP - what does it do? what does it not do?

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oxygenate pt by splinting the airways open during exhalation (does NOT VENTILATE!) so it won't help with ABGs

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Safe CPAP levels are between

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5-15 cmH20 with rare cases requiring up to 20-25

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Main indication for CPAP

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OBSTRUCTIVE sleep apnea

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CPAP O2 levels can range from _____ depending on the setting.

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21-100%

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To make sure the pt is benefitting from the CPAP you must check 2 things

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1 - make sure pt is oxygenating well 2- and that they do not feel extremely tired in the morning/during the day A full sleep study at a sleep lab is recommended

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Simple ABG values

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pH = 7.35-7.45 PaCO2 = 35-45 PO2 = 80-100 HCO3 = 22-26

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Difference between BIPAP and CPAP

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CPAP just oxygenates with continuous pressure BIPAP - used to VENTILATE a pt to avoid intubation

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what kind of pts would be on a BIPAP?

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those that you're trying to avoid intubation but need help ventilating pts with CHF, COPD exacerbations, Pulm edema etc.

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Indications for BIPAP

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CHF COPD exacerbations imepnding ventilatory failure apnea moderate to extreme dyspnea and hypoxemia that is not helped by O2 therapy

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2 levels of BIPAP

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IPAP EPAP

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IPAP =

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inspiratory positive airway pressure pressure that the machine will give when the pt is breathing IN (same as CPAP)

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EPAP =

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expiratory positive airway pressure pressure given when pt is breathing OUT

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Which BIPAP pressure is always greater?

answer

IPAP always greater than EPAP

question

Typical starting IPAP Typical starting EPAP

answer

10-15 cmH20 5-6

question

difference between IPAP and EPAP is

answer

delta P

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how to write order for BIPAP

answer

12/5 for (enter reason here) with FiO2 of __%

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FiO2 on BIPAP can range from

answer

21-100%

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2 big reasons for BIPAP order

answer

resp failure atelectasis

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BIPAP - the bigger difference between IPAP and EPAP, the more

answer

the pt ventilates (change in pressure is how they're ventilated)

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BIPAP - Anytime EPAP is increased, you must

answer

Increase IPAP the same or the pt will not ventilate the same

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BIPAP - to increase ventilation, do what to the IPAP/EPAP?

answer

Increase Ipap leave Epap alone

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think of ____ as CPAP. it contributes to the oxygenation of the pt.

answer

Epap so if pt has a low PaO2, you would increase EPAP

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if pt has a low PaO2 (on BIPAP) you would

answer

increase EPAP

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Only decrease EPAP if

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it is greater than 5

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if FiO2 is greater than 60%,

answer

always titrate O2 to 60% or lower first after FiO2 is 60% or lower, then begin titrating EPAP if needed

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for high or low pH on ABG, you can inc or dec. ventilation by 2 ways

answer

1 - change the Change in Pressure by inc/dec the IPAP 2 - inc/dec the rate (only do if they're sedated)

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Contraindications of CPAP/BIPAP

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1 - copious secretions 2- Inability to protect airway 3- Facial trauma 4- Gastric distension 5- Irritation or abrasions due to mask 6- Active resp or vent failure (intubate the pt) 7- Cardiac/resp arrest (intubate)

question

Mechanical Ventilation

answer

when you are using a machine or bag to breathe for a pt, or help pt with breathing. (including ambu bag)

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Indications for mechanical ventilation

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1 - acute resp failure (type 1) 2- Acute resp failure (type 2) 3- Impending ventilatory failure 4- Apnea

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Acute resp Failure type 1

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oxygenation problem PaO2 < 60 on FiO2 of 60% or more

question

Acute Resp Failure Type 2

answer

ventilatory failure PaCO2 > 50 and pH of 7.30-7.25 or lower

question

define impending vent. failure

answer

when someone is trending toward respiratory failure (an indication for mechanical ventilatioN & Bipap)

question

Ordering Mechanical Ventilation - order should include

answer

1. Mode 2. Vt (tidal volume) 3. Rate 4. FiO2 5. PEEP 6. Pressure support (if applicable)

question

intial settings: tidal volume Rate FiO2 PEEP

answer

Vt = 8-12ml/kg based on IDEAL body wt Resp Rate = 8-12 breaths/min FiO2 = 40-60% if on RA (if already on O2, go with the level of their O2, so 5L on nasal cannula, you'd do 40%) PEEP = 5-10 (start @ 5)

question

Rate and Vt directly effect

answer

pH and PaCO2

question

MV if you have a high Co2, then

answer

you can INCREASE the rate or tidal volume if CO2 is low then you must decrease the rate or tidal volume

question

FiO2 and PEEP directly affect

answer

PaO2

question

If PaO2 is low then

answer

increase the FiO2 first UP TO 60% If still low, then increase PEEP.

question

when weaning from the vent you ALWAYS

answer

decrease the FiO2 to under 60% before decreasing the PEEP

question

How to monitor a vent pt

answer

ABGs xray - if they have atelectasis, we're not venting them enough, check for pneumothorax, check tube is above carina breath sounds (check for crackles) appearance of chest wall level of sedation - they need to be sedated peek pressures on vent should not be exceeding 30

question

peak pressures on vent should not be exceeding

answer

30

question

if everything is well on the vent, then try

answer

spontaneous breathing trials this is when the RT would try the pt on CPAP with or without pressure support on the vent to see if the pt can breath for themselves

question

vent PEEP pressure measures

answer

airway resistance

question

Small volume Nebulizer

answer

device that will nebulize a single unit dose breathing medication such as albuterol, duoneb, xopenex (mostly bronchodilators)

question

Small Volume Nebulizers are mainly used in

answer

the hospital setting and at home for peds pts or the elderly

question

what do nebulizers require of the pt?

answer

req pt to be breathing spontaneously with a minimal understanding of the dvice

question

nebulizer used primarily in the ED

answer

heart nebulizer

question

what does a heart nebulizer do?

answer

nebuilze lg amt of medication over extended period of time, usually 1-8 hrs usually only done in ED or ICU b/c pt must be attached to a monitor - must watch HR when giving high doses

question

who gets a heart nebulizer?

answer

someone in severe bronchospasm to buy time for steroids to work

question

small canister device that is depressed into the mouth to deliver the medication

answer

MDI inhaler

question

What should you always use with an MDI?

answer

SPACER

question

what do MDIs require of the pt?

answer

spontaneous breathing decent understanding of the device

question

MDIs can also be given to who?

answer

pt on a vent given inline double or triple the normal dose of the MDI

question

What does a spacer do?

answer

gets more medicine from an MDI

question

without a spacer, about ___ % of the medicine is lost, but with a spacer, you only lose about ____ %.

answer

80-90% is lost only lose 30-40%

question

What is a rota-inhaler?

answer

twistable inhaler that delivers medicine after you twist the inhaler and take a breath (Comes with the medicine) reqs lots of pt understanding and effort to use the device

question

rota inhaler requires

answer

inspirator flow rates of at least 60 LPM

question

what is a DPI inhaler?

answer

dry powder inhaler same as a rota inhaler but you either turn a part of the device to prime it or place a pill into the device and then you breathe in

question

IPPB is a machine that is run off of ____ and ____ and is used to ... what's special bout it?

answer

oxygen and air apply positive pressure when the pt breathes in it has a nebulizer in it so you can give meds while doing positive pressure breathing theory is it will pop open collpased lungs and remove secretions

question

often used for atelectasis and pulmonary edema

answer

IPPB inhaled positive pressure breathing

question

Containdications of IPPB

answer

Unskilled practitioners and users massive pulm hemorrhage Untreated pneumothorax

question

an alternative to IPPB is

answer

EzPAP device provides pressure to breath out against and has shown better xray results than IPPB

question

test to qualify pt for home oxygen

answer

6 minute walk test nocturnal pulse ox

question

explain 6 min walk test

answer

an RT will walk pt without O2 on if pt drops to O2 sat below 88% they qualify for home O2 then walk the pt on O2 to see how many LPM they require

question

Nocturnal pulse ox

answer

probe on finger while pt sleeps if drops below 88% at night, repeat the study with O2 if O2 helps, this qualifies them for home O2 if it doesn't help, send them for a sleep study to qualify for CPAP home therapy

question

3 ways to suction airway

answer

1- Nasotracheal 2- Inline 3- Mouth with Yankauer suction device

question

Nasotracheal suction

answer

suction cath placed in nose and fed into trachea

question

Inline suction

answer

when a pt is on a vent there is a suction catheter placed inline with the vent obviously only done when intubated

question

Suction complications

answer

1. Trauma to mucosa 2. Contamination (when putting suction in them) 3. Hypoxemia - leading to tachy or arrhythmias (you're pulling air out) 4. BRADYCARDIA - from vagus nerve stimulation! (can code- CPR) 5. Bleeding

question

indicated for pt that can't cough to clear their own lungs

answer

Chest Physical Therapy

question

Chest Physical Therapy can be done using

answer

Hands Chest Vest Pneumatic powered percussor

question

Hazards and Contraindications to Chest Physical Therapy

answer

1. Soft tissue trauma 2. RIB CAGE TRUAMA/ FXs 3. HEMOPTYSIS 4. Metastatic concerns 5. PE 6. Pleural Effusion 7. TB (dont want them coughing out spores) 8. UNTREATED PNEUMOTHORAX

question

27y/o female in acute asthma attack in ED

answer

1. Check Sats 2. Apply O2 via nasal canula 1-6lpm to keep sats aboe 92% 3. Give bronchodilator via Small Volume Nebulizer (SVN)

question

smoker, lethargic, in ED pH = 7.2 CO2 = 110 HCO3 = 32 PO2 = 50

answer

BIPAP and repeat ABGS need to ventilate AND oxygenate

question

45 yr smoke hx, alert, admitted for SOB pH = 7.4 CO2 = 60 HCO3 = 38 O2 = 59

answer

Nasal cannula 1-2L COPD - their "normal" is a high CO2 and compensated bicarb

question

Hypoxic Drive Theory

answer

COPD and chronic CO2 retention (compensated resp acidosis) has to be somewhat hypoxic or they will stop breathing when given too much O2

question

acceptable O2 for COPD pt

answer

60-80 on ABGs 90-92% on Pulse Ox give lowest amt of O2 possible

question

look through the rest of the case studies once you've got this info down

answer

lots of em.

question

Normal Carbon Monoxide Hemoglobin

answer

1-3% with smoking it can be between 5-10% heavy smokers = 15%

question

what is considered CO poisoning?

answer

a COHb of over 20%

question

CO poisoning: if left on room air, how long would it take for CO to get out of your system? how long if on 100% O2 how long with hyperbaric oxygen

answer

3 hrs 80 mins on 100% O2 avg = 23 mins

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