Program: Respiratory Therapy

Course: Applied Respiratory Therapeutics

Lesson: Medical Gas Therapy

Why do we give patients Oxygen?

Lesson: Medical Gas Therapy

• Discuss the three indications for oxygen.

• Discuss the four hazards of oxygen therapy and how to avoid them.

• List the rules for administration of oxygen.

• Discuss hyperbaric O2 therapy.

• Discuss other medical gas therapies.

Major Student Performance Objective 1-Lecture

Administer safe oxygen therapy to the patient.

Supporting Student Performance Objectives:

Lesson: Medical Gas Therapy

• Correctly assemble, test for function, safely apply, and troubleshoot the following:

– Nasal cannula - Venturi oxygen device– Simple oxygen mask - Oxygen tent– Partial rebreathing oxygen - Croupette

mask– Non-breathing oxygen mask - Isolette

• Demonstrate how to analyze F1O2

– Calibrate the oxygen - Adjust delivery device analyzer as appropriate

– Analyze at an - Document the oxygen appropriate position concentration

Major Student Performance Objective 1 - Laboratory

Safely administer oxygen.

Supporting Student Performance Objectives:

Lesson: Medical Gas Therapy

• Treat Hypoxemia

• Decrease the work of breathing

• Decrease myocardial work

Indications for Oxygen Therapy

Lesson: Medical Gas Therapy

• Oxygen Toxicity

• Absorption Atelectasis

• Oxygen Induced Hypoventilation

• Retrolental Fibroplasia – RLF– ROP – retinopathy of prematurity

Hazards of Oxygen Therapy

Lesson: Medical Gas Therapy

• Oxygen concentrations less than 40% rarely cause oxygen toxicity.

• 100% oxygen has not been shown to cause oxygen toxicity when used less than 24 hours.

• 100% oxygen is not contraindicated for brief periods in an emergency.

• Shapiro: “To allow a patient to be exposed to dangerous levels of hypoxia for fear of oxygen toxicity is intolerable.”

• Use minimal O2 concentrations to

achieve a state of no hypoxia.

• Monitor patients closely.

Guidelines for Oxygen Administration

Lesson: Medical Gas Therapy

• Patient’s VT 300 - 700 ml

• Respiratory rate lower than 25 BPM

• Consistent, regular, ventilatory patterns

Indications for Low Flow Devices

Lesson: Medical Gas Therapy

• FIO2 will vary according to patient’s ventilatory pattern.

• Factors influencing FIO2:

– 1. Patient’s ventilatory pattern– 2. Flow of gas– 3. Reservoir

• As VT increases, FIO2 decreases due to more entrainment of room air.

• As VT decreases, FIO2 increases due to less entrainment of room air.

• Respiratory rate will effect system if there is not adequate time for reservoir refill.

• FIO2 is:

– 1. Unpredictable

– 2. For the most part immeasurable

– 3. May vary from minute to minute

Low Flow Systems

Lesson: Medical Gas Therapy

• Nasal Cannula

• Nasal Catheter

• Simple O2 Mask

• Partial Rebreather Mask

• Non-Rebreather Mask

Low Flow Devices

Lesson: Medical Gas Therapy

• Meets all patient’s demands for gas delivered.

• Total system output must be at least 3 times patient’s minute volume.

• Consistent, predictable, measurable FIO2

• Criteria for high flow system:

• Systems - Venturi Masks

High Flow Systems

Lesson: Medical Gas Therapy

• To analyze high flow systems.

• Patients may not receive FIO2 analyzed if flow is not adequate.

• Used in measuring mechanical ventilation.

Use of Analyzers

Lesson: Medical Gas Therapy

• Paramagnetic or Physical Analyzers

• Electrical, Thermal Conductivity, Wheatstone Bridge

• Chemical

• Electrochemical Analyzers, Polarographic Principle, Clark Electrode, and Galvanic

Types of Oxygen Analyzers

Lesson: Medical Gas Therapy

Comparison of Oxygen Analyzers

Physical (paramagnetic)

Electrical (thermal conduction)

Electrochemical (polarographic)

Electrochemical(galvanic cell)

•Parameter measured Partial Oxygen Partial Partial Pressure Concentration Pressure Pressure

•Accurate with other gases? Yes Oxygen and Yes Yes

Nitrogen Only

•Sampling technique Intermittent Intermittent Continuous Continuous Static Sample Static Sample Dynamic Dynamic

•Use with flammable gases? Yes No Yes Yes

•Oxygen consumption No No Yes Yes

Lesson: Medical Gas Therapy

• Greater than 60% - Calibrate last to 100%

• Less than 60% - Calibrate last to 21%

• Should be calibrated once per shift

• Possible sources of error:– Weak batteries– Torn, wet, or leaky membranes– Positive pressure (PEEP or IPPB)– Altitude

Calibration

Lesson: Medical Gas Therapy

Patient Cases

Patient 1: I.M. QuickPatient:

Physical Findings:

Lab Data:

Order:

I.M. Quick, a forty-nine year-old male. Admitted with an exacerbation COPD. Patient is alert but slightly confused.

Pulse 120, regular, BP 136/90, temperature 380 C, respirations 24, slightly labored. Breath sounds are decreased in bases with prolonged expiratory phase. Loose, nonproductive cough. Patient has an IV and is in a regular room.

pH 7.32, PaCO2 59, HCO3 -32, PaO2 50, SaO2 84%, FiO2 0.21, WBC 11,200 Hgb 13.3, hematocrit 44

O2 via 0.28 Ventui (air entrainment) mask.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 2: Adolph PetroniPatient:

Physical Findings:

Lab Data:

Order:

Adolph Petroni, a seventy-two year-old male. Admitted this morning through the emergency department for shortness of breath secondary to COPD. Patient is alert and oriented, and is in a regular room.

Pulse 120, regular, BP 140/80, temperature 38.20 C, respiration 24, labored. Breath sounds decreased throughout with rhonchi superimposed over a prolonged expiratory phase. Patient has a productive cough with thick yellow sputum.

pH 7.44, PaCO2 58, HCO3 -38, PaO2 50, SaO2 83%, FiO2 0.21, WBC 9,800, Hgb 16.9, hematocrit 49

Oxygen via nasal cannula at 6 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 3: Mary PuschePatient:

Physical Findings:

Lab Data:

Order:

Mary Pusche, a seventy-year-old female. Admitted last night with a diagnosis of lung cancer. Patient is alert and oriented. She is on the oncology unit and is receiving chemotherapy

Pulse 132, regular, BP 96/40, temperature 37.60 C, respiration 32, shallow. Breath sounds are decreased throughout with fine crackles on inspiration. Chest expansion is decreased in both bases.

pH 7.52, PaCO2 26, HCO3 -21, PaO2 45, SaO2 86%, FiO2 0.21, WBC 3,800, Hgb 8.6, hematocrit 28

Oxygen via simple mask at 3 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 4: Philip FolkstonePatient:

Physical Findings:

Lab Data:

Order:

Philip Folkstone, a thirty-six year-old male. Admitted through the emergency department with pulmonary edema secondary to congestive heart failure. Patient is alert but anxious, he is on a cardiac monitor in the coronary care unit.

Pulse 140, thready, BP 106/60, temperature 36.90 C, respiration 34, shallow and labored. Breath sounds are decreased throughout with coarse crackles on inspiration. Chest expansion is decreased. Patient is sitting up in bed and is diaphoretic.

pH 7.50, PaCO2 28, HCO3 -22, PaO2 48, SaO2 85%, FiO2 nasal cannula at 2 Lpm. No other blood work done.Increase oxygen to 4 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 5: Bronco LanePatient:

Physical Findings:

Lab Data:

Order:

Bronco Lane, a fifty-nine year-old male. Admitted this morning with acute dyspnea secondary to pulmonary fibrosis. Patient is alert and oriented; he is in a regular room and has an IV.

Pulse 120, regular, BP 146/90, temperature 390 C, respiration 28, shallow, labored. Breath sounds are decreased throughout with fine crackles on inspiration. Chest expansion is decreased in both bases. The patient is not coughing.

pH 7.52, PaCO2 30, HCO3 -24, PaO2 42, SaO2 80%, FiO2 0.21, Hgb 10.2, WBC 9,400.

Oxygen via nasal catheter at 2 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 6: Brewster BakerPatient:

Physical Findings:

Lab Data:

Order:

Brewster Baker, a forty-five year-old male. Admitted through the emergency department with a probable myocardial infarction (pending outcome of cardiac enzymes). Patient is alert and very anxious, he is in a coronary care unit on a monitor.

Pulse 146, irregular, BP 166/102, temperature 37.20 C, respiration 26, slightly labored. Breath sounds normal, chest expansion is mostly normal. No coughing. Patient is sitting in semi-Fowlers position and is slightly diaphoretic.

pH 7.50, PaCO2 29, HCO3 -23, PaO2 72, SaO2 96%, FiO2 0.21, other blood work pending.

Oxygen via simple mask at 5 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 7: Laurie CablePatient:

Physical Findings:

Lab Data:

Order:

Laurie Cable, at twenty-six year-old female. Admitted to the emergency room with acute onset of shortness of breath. Patient is alert and somewhat anxious, she is seen in the emergency room.

Pulse 136, regular, BP 146/88, temperature 380 C, respiration 26, shallow and labored. Breath sounds decreased throughout with wheezing superimposed over a prolonged expiratory phase. Patient has a dry, nonproductive cough and nasal congestion.

SpO2 (pulse oximeter) 92% on room air.

Oxygen via nasal cannula at 5 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 8: Marion RavenwoodPatient:

Physical Findings:

Lab Data:

Order:

Marion Ravenwood, a thirty-six year-old female. Admitted two days ago with a prolapsed uterus. Had a hysterectomy yesterday. Patient is alert and oriented, she is in a regular room on the surgical floor, she has an IV.

Pulse 110, regular, BP 152/86, temperature 38.60 C, respiration 26, shallow. Breath sounds decreased especially in the bases, fine crackles in the bases. Patient has a weak, nonproductive cough.

SpO2 (pulse oximeter) 93% Hgb 12.4, WBC 12,200.

Oxygen via 35% Venturi (air entrainment) mask..

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?

Lesson: Medical Gas Therapy

Patient Cases

Patient 9: Julio DelgadoPatient:

Physical Findings:

Lab Data:

Order:

Julio Delgado, a sixty-four year-old male. Admitted last night with an acute exacerbation of chronic bronchiectasis. Patient is alert but anxious, he is in a regular room and has an IV.

Pulse 112, regular, BP 152/90, temperature 38.40 C, respiration 24, shallow, slightly labored. Breath sounds decreased with rhonchi on exhalation throughout both lungs. Patient has a weak productive cough with moderate amounts of thick, yellowish sputum. Patient is sitting up in bed.

pH 7.46, PaCO2 38, HCO3 -25, PaO2 54, SaO2 90%, FiO2 0.21, Hgb 17.4, WBC 13,200.

Oxygen via nasal cannula at 4 Lpm.

Would you implement this order as it is written?What would you recommend in its place?Would you add or delete anything from this order?