Oxygen Delivery Methods Dr Mazen Qusaibaty

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Is to maintain : Is to maintain : PaO 2 >8 kPa (60 ) PaO 2 >8 kPa (60 mmHg ) or or SpO 2 > 90% SpO 2 > 90% 3 Carter R. Oxygen and acid-base status: measurement, interpretation, and rationale for oxygen therapy. Chapter 5. In: Tiep BL, ed. Portable oxygen therapy: including oxygen conserving methodology. Mt. Kisco, NY, Futura Publishing Co.; pp

Why ?? Why ??  In order to Preserve cellular oxygenationPreserve cellular oxygenation Prevent tissue hypoxiaPrevent tissue hypoxia 4 Carter R. Oxygen and acid-base status: measurement, interpretation, and rationale for oxygen therapy. Chapter 5. In: Tiep BL, ed. Portable oxygen therapy: including oxygen conserving methodology. Mt. Kisco, NY, Futura Publishing Co.; pp

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Depends on: TTTThe patient’s oxygen requirement EEEEfficacy of the device RRRReliability EEEEase of therapeutic application PPPPatient acceptance 7 4th ed. Philidelphia, Lippincott-Raven Pub co, 1997; pp / JAMA1962; 179: / Anesthesiology 1976; 44: 71-73/Anaesthesia 1970; 25:

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Clean Air

Concentration of O2 in dry air = 21% [O2] = 21ml/dl FIO2 = 0.21

Respiratory rate Tidal volume IIIInvasive or noninvasive mechanical ventilation 22

The transfer of a Volume of substance per unit of Time 23

Volume / TimeVolume / Time 5 Liters/min5 Liters/min 24

1.Indication 2.Volume / Time ( L / min) 3.FIO2 (O2%) 25

26 Oxygen Delivery Methods First-Line Options Standard nasal cannula Venturi mask Second-Line Options Simple face mask Nonrebreathing face mask with reservoir and one- way valve Reservoir cannulas High-flow transtracheal catheters High-flow warmed and humidified nasal oxygen

27 Oxygen Delivery Methods First-Line Options Standard nasal cannula

28 Standard nasal cannula

FIO2 222 % Volume Flow Rate 1111 – 5 L / min 29 Tiep BL. Continuous flow oxygen therapy. In: Tiep BL, ed. Portable oxygen therapy: including oxygen conserving methodology. Mt. Kisco, NY, Futura Publishing Co.; pp

30 FIO 2 = 21 % + (4 × oxygen litre flow) FIO2 = 21% + (4 × oxygen litre flow) Exercise: 3 l/min Exercise: volume flow rate 3 l/min FIO 2 = 21 % + (4 × 3)=33 % Exercise: volume flow rate l/min FIO2 = 21% + (4 × 3)=33% Tiep BL. Continuous flow oxygen therapy. In: Tiep BL, ed. Portable oxygen therapy: including oxygen conserving methodology. Mt. Kisco, NY, Futura Publishing Co.; pp

31 Oxygen Delivery Methods First-Line Options Standard nasal cannula Venturi mask

A Venturi mask mixes oxygen with room airA Venturi mask mixes oxygen with room air  creating high-flow enriched oxygen of a settable concentration Burton GG, Hodgkin JE, Ward JJ. Respiratory Care - a guide to clinical practice. 4th ed. Philidelphia, Lippincott- Raven Pub co, 1997; pp

50% 31% 24% 40% 35% “Controlled oxygen therapy”

Allows a doctor to give “controlled oxygen therapy” Allow a specific percentage of oxygen to be delivered to the patient. The masks have color coded valves relating to the different percentages delivered 34

It provides an accurate and constant FIO2It provides an accurate and constant FIO2 Burton GG, Hodgkin JE, Ward JJ. Respiratory Care - a guide to clinical practice. 4th ed. Philidelphia, Lippincott- Raven Pub co, 1997; pp

36 Oxygen Delivery Methods Second-Line Options Simple face mask

The volume of the face mask is mL It delivers an FIO2 of 44440-60% 5555-10 L·min-1 37

The face mask is indicated in patients with NNNNasal irritation NNNNasal obstruction EEEEpistaxis 38

Inappropriate effects UUUUncomfortable and confining OOOObstructs coughing and impedes eating 39

40 Oxygen Delivery Methods Second-Line Options Simple face mask Nonrebreathing face mask with reservoir and one- way valve

The nonrebreathing face mask is indicated when an FIO2 >40% is required 41

It may deliver FIO2 up to 90% at high flow settings 42

FIO % 43

Oxygen flows into the reservoir at 8-10 L·min-1 44

45 Oxygen Delivery Methods Second-Line Options Simple face mask Nonrebreathing face mask with reservoir and one- way valve Reservoir cannulas

46 Reservoir cannulasR e s e r v o i r c a n n u l a s o p e r a t e b y s t o r i n g o x y g e n i n a s m a l l c h a m b e r d u r i n g e x h a l a t i o n f o r s u b s e q u e n t d e l i v e r y d u r i n g e a r l y p h a s e i n h a l a t i o n Dumont CP, Tiep BL. Using a reservoir nasal cannula in acute care. Critical Care Nurse 2002; 22: 41-46

47 Reservoir cannulasP a t i e n t s m a y b e w e l l o x y g e n a t e d a t l o w e r f l o w s Dumont CP, Tiep BL. Using a reservoir nasal cannula in acute care. Critical Care Nurse 2002; 22: 41-46

48 Reservoir cannulas L i t r e f l o w s o f = 8 L · m i n - 1 h a v e b e e n r e p o r t e d t o a d e q u a t e l y o x y g e n a t e p a t i e n t s w i t h a h i g h f l o w r e q u i r e m e n t Sheehan JC, O’Donohue WJ. Use of a reservoir nasal cannula in hospitalized patients with refractory hypoxemia. Chest 1996: 110.

49 Oxygen Delivery Methods Second-Line Options Simple face mask Nonrebreathing face mask with reservoir and one- way valve Reservoir cannulas High-flow transtracheal catheters

Delivers low flow rates (1 to 3 L/min) directly to the trachea through a small incision 50

Requires less oxygen (lower flows) because the upper airway dead space is bypassed 51

Can develop: IIIInfection IIIIrritation at site AAAA risk of accidental removal 52

Nasal oxygen has been administered at lows ranging from L·min-1 53

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57Monitoring An arterial blood gas (ABG)Or Oximetry is advised upon switching delivery devices Frequent monitoring is highly advisable in the unstable patient

58 Arterial Blood Gas

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You see a 65 year old man with shortness of breath in the emergency department He has smoked 30 cigarettes a day for 40 years 62

He has COPD His wife tells you that, over the last three days, he has had a cough productive of green sputum and has become increasingly short of breath 63

He is drowsy He is using his accessory muscles of respiration His temperature is 37.8°C 64

He has a heart rate of 104 beats a minute A blood pressure of 134/74 mm Hg His respiratory rate is 30 breaths a minute 65

His oxygen saturations are 99% on 15 litres of oxygen via a non- rebreather mask 66

His chest is dull to percussion in the right lower zone There are reduced breath sounds and coarse crackles in this area There are wheezes throughout all lung fields 67

His chest x ray shows consolidation in the right lower zone 68

He has had two previous admissions over the last year for similar symptoms But no episodes of intubation and ventilation 69

The emergency doctor checks an arterial blood gas and starts him on 15 litres of oxygen via a non- rebreather mask 70

pH 7.42 PaO2 7.8 kPa 60 mmHg PaCO2 5.4 kPa 41mmHg Lactate 1.1 mmol/l HCO mmol/l BE 4.5 mmol/l SaO2 86.3% 71

pH 7.42  PaO2 7.8 kPa 60 mmHg Nor PaCO2 5.4 kPa 41mmHg Lactate 1.1 mmol/l HCO mmol/l BE 4.5 mmol/l SaO2 86.3% 72

The most likely diagnosis is AAAAn infective exacerbation of chronic obstructive pulmonary disease 73

This shows Type I respiratory failure 74 British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:

AAAA low arterial oxygen tension (PaO2 <8.0 kPa 60 mmHg) AAAA normal (<6.0 kPa 45mmHg) or low arterial carbon dioxide tension (PaCO2) 75 British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax 2002;57:

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Acute Acute-on- chronic Chronic Location of care Respiratory failure

A.1 5 litres of oxygen via a non-re- breather mask B.2 litres of oxygen via nasal cannulae C.6 litres of oxygen via a Hudson mask D.G raded increases in oxygen via a Venturi mask to keep saturations at 88% to 92% 79

Is to give a quantifiable percentage of oxygen to keep the peripheral oxygen saturation (SpO2) at 88% to 92%. Venturi masks are ideal for this situation 80

This is not possible with a Hudson mask or nasal cannulaeThis is not possible with a Hudson mask or nasal cannulae 81

It is not necessary to achieve 100% saturations So it is unusual for patients to need 15 litres of oxygen via a non-re-breather mask 82

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