10 Principles of Oxygen Therapy

Objectives Define the following terms: Blow-by method Humidifier Hydrostatic test Liter flow Nasal cannula Non-rebreather mask O ring continued on next slide

Objectives Define the following terms: Oxygen concentration Oxygen supply tubing Pin index system Pressure gauge Pressure regulator Reservoir bag Supplemental oxygen continued on next slide

Objectives Explain the benefits of supplemental oxygen. Explain the indications for the need of supplemental oxygen. Explain the potential hazards of working with high-pressure cylinders. Explain the safe practices when working with high-pressure cylinders. continued on next slide

Objectives Differentiate between the common sizes of oxygen cylinders used in EMS. Describe the purpose and functions of an oxygen regulator. Explain the indications for the use of a nasal cannula. Explain the indications for the use of a non-rebreather mask. continued on next slide

Objectives Demonstrate the proper use of a non-rebreather mask. Demonstrate the proper use of a nasal cannula. Demonstrate the ability to add supplemental oxygen to a pocket mask and/or bag-mask device. Demonstrate the proper technique for attaching a regulator to a cylinder. continued on next slide

Objectives Demonstrate the ability to identify and troubleshoot a leaky oxygen cylinder/regulator. Recognize the value that supplemental oxygen might offer for most ill and injured patients.

Topics Importance of Oxygen Hazards of Oxygen Oxygen Therapy Equipment Administering Oxygen

IMPORTANCE OF OXYGEN

Importance of Oxygen Oxygen is a drug. Oxygen concentration is the amount being delivered to the patient. The air we breathe contains 21 percent oxygen. Supplemental oxygen is 100 percent oxygen. Critical Thinking: The air we exhale contains about 16 percent oxygen. Compare and contrast mouth-to-mouth rescue breaths to providing supplemental oxygen.

Importance of Oxygen Patient may need oxygen for: Respiratory or cardiac compromise Cardiac arrest Shock Major blood loss Injury to lungs or chest Airway obstruction Stroke Teaching Tip: Use web resources or a lung sound simulator to demonstrate lung sounds (normal and abnormal). At a minimum, this should include a patient in respiratory distress (e.g., CHF or COPD).

Importance of Oxygen Common Indicators Abnormal signs and symptoms Significant mechanism of injury Increased level of distress Talking Point: Identifying what is normal is an important first step to learning what is abnormal. Class Activity: Using stethoscopes, direct students to work in pairs to listen to each other's lung sounds. Ask that they continue their practice of listening to normal lung sounds at home with family members.

Think About It What physiological needs are met by adequate breathing? What are some causes of inadequate breathing? What are the signs of inadequate breathing?

HAZARDS OF OXYGEN

Hazards of Oxygen Oxygen may be under 2,000 pounds per square inch (psi) of pressure (full tank). If tank is punctured or valve breaks off, supply tank and valve can become deadly projectiles. Talking Point: A small car (e.g., VW Beetle) weighs approximately 2,000 lbs. Imagine this weight on each inch of the tank's inner surface!

Hazards of Oxygen Oxygen itself is nonflammable, but it greatly increases rate and intensity of combustion. Oxygen and oil do not mix. Teaching Tip: Check web resources for oxygen tank related explosions and fires; share video and/or articles with students.

Think About It Do not underestimate the dangers of oxygen. What safety precautions should the EMR take when working with oxygen cylinders? Which placards are used by the U.S. Dept. of Transportation for pressurized oxygen? Teaching Tip: Direct students to consult the US DOT Emergency Response Guidebook (ERG) for the placard symbols.

OXYGEN THERAPY EQUIPMENT

Oxygen Therapy Equipment Oxygen-delivery System Oxygen source Regulator Delivery device Oxygen Cylinders Aluminum cylinders filled with pressurized oxygen

Figure 10.1 The components of a typical oxygen-delivery system.

Oxygen Therapy Equipment Oxygen Cylinders Various sizes, identified by letters D cylinder 425 liters oxygen Jumbo D cylinder 640 liters oxygen E cylinder 680 liters oxygen Talking Point: Explain to students that the large cylinder housed in most ambulances is an M cylinder. EMTs may refer to it as their "in-house" oxygen. Once placed in the ambulance, the patient will typically be transferred to this larger source of oxygen.

Figure 10.2 Various sizes of portable oxygen cylinders.

Oxygen Therapy Equipment Oxygen Cylinders Pressure gauge determines pressure remaining in tank. Never allow to go completely empty. Never allow pressure in oxygen cylinder to fall below 200 psi. Critical Thinking: Why should the tank not be allowed to fall below 200 psi?

Oxygen Therapy Equipment Oxygen System Safety Never allow smoking. Never use around open flames or sparks. Never use grease or oil. Never put tape on cylinder. Discussion Question: What should you do if you arrive on scene to find a patient in need of oxygen while a family member is smoking in the same room? continued on next slide

Oxygen Therapy Equipment Oxygen System Safety Never store near high heat or in a closed vehicle parked in the sun. Keep portable cylinders lying flat. Use pressure gauges and regulators. Ensure O ring is in good condition. Talking Point: Some O rings are loose and separate from the tank. Use care not to loose the O ring. continued on next slide

Oxygen Therapy Equipment Oxygen System Safety Valves/connections hand-tight only Open and close all valves slowly. Store in cool, ventilated room. Have hydrostatically tested. Critical Thinking: Why is it important to hand-tighten valves and connections?

Oxygen Therapy Equipment Oxygen Regulators Pressure in full oxygen cylinder 2,000 psi Regulators have three functions. Reduce tank pressure Display tank pressure Control delivery of oxygen Class Demonstration: Demonstrate a regulator leak (e.g., when O ring is not "seated" properly) and show how to resolve the problem.

Figure 10.3 Pressure regulators, one on and one off the tank.

Oxygen Therapy Equipment Oxygen Regulators Connecting the Regulator Pin index system Safety system used to ensure proper regulator is used for specific gas Largest pin is oxygen port. O ring ensures airtight seal between regulator and tank valve. Class Activity: Have several D size oxygen tanks and regulators available. Demonstrate and then direct students to properly connect the regulator.

Figure 10.4 The pin index safety system (PISS).

Oxygen Therapy Equipment Oxygen Regulators Humidifiers Unbreakable container of sterile water Oxygen becomes more comfortable for patient to breathe. Many EMS systems no longer use humidifiers due to infection risk. Talking Point: Humidified oxygen may be seen in patient's homes when they are on continuous oxygen therapy. It is also used for long EMS transports. To minimize infection risk; only one-time use disposable sterile water containers should be used.

Oxygen Therapy Equipment Oxygen-Delivery Devices Nasal cannula Used to deliver low concentrations of supplemental oxygen to breathing patient Nonrebreather mask Used to deliver high concentrations of supplemental oxygen Discussion Question: In what cases would you choose to use a nasal cannula for your patient? A nonrebreather?

Table 10.3 Oxygen-Delivery Devices

Figure 10.5a Example of an adult nasal cannula. continued on next slide

Figure 10.5b Example of an adult nasal cannula properly placed on the face of the patient.

Oxygen Therapy Equipment Oxygen-Delivery Devices Nonrebreather mask Face mask One-way valve Reservoir bag Inflate bag before placing on patient's face. Always ensure adequate oxygen flow (12–15 lpm). Class Activity: If possible to obtain a sufficient supply of nonrebreather masks; distribute one to each student and have them place one on their face without supplemental oxygen. This should help emphasize the importance of always ensuring adequate oxygen supply before placing the mask on a patient's face.

Figure 10.6a Example of an adult nonrebreather mask. continued on next slide

Figure 10.6b Example of an adult nonrebreather properly placed on the face of a patient.

Oxygen Therapy Equipment Oxygen-Delivery Devices Venturi mask Adjustable "jets" that allow user to more accurately determine specific oxygen concentration Talking Point: Venturi masks or "simple" face masks may not be commonly used in the EMS setting. continued on next slide

Oxygen Therapy Equipment Oxygen-Delivery Devices Blow-by Delivery Used for patient who will not tolerate traditional mask or cannula placed on face Especially good for small children Teaching Tip: Demonstrate placing the end of an oxygen tube into the bottom of a paper cup and allow students to examine. This technique is useful for small children since a cup is a familiar item and less scary to them.

Think About It What is the length of time an oxygen cylinder can be used? How often should the oxygen regulator be checked for adequate pressure? Answer #1: It depends upon the amount of oxygen in the cylinder and the flow rate of the oxygen. Answer #2: The regulator should be checked for adequate pressure before every shift and after every call.

ADMINISTERING OXYGEN

Administering Oxygen Step-by-step process of preparing oxygen-delivery system and administering oxygen Three devices Pocket mask with oxygen inlet Bag-mask device Demand-valve device Discussion Question: What are the advantages and disadvantages of a pocket mask?

10.1.1 Remove the plastic wrapper or cap protecting the cylinder yoke. continued on next slide

10.1.2 Keep the plastic washer that is available in some setups. continued on next slide

10.1.3 Quickly open the main valve for one second to remove any dust. continued on next slide

10.1.4 Ensure that O-ring is present on the regulator oxygen port. continued on next slide

continued on next slide 10.1.5 Place the regulator on the yoke, and tighten the T-screw hand-tight. Do not overtighten. continued on next slide

10.1.6 Attach tubing from the delivery device.

10.2.1 Explain the need for oxygen therapy. continued on next slide

10.2.2 Open the main valve one full turn. continued on next slide

10.2.3 Adjust the flow to appropriate rate. continued on next slide

continued on next slide 10.2.4 Be sure to fill the reservoir bag prior to placing it on the patient by turning on the flow and placing your finger over the valve inside the mask. continued on next slide

10.2.5 Position the oxygen-delivery device on the patient. continued on next slide

10.2.6 Secure the cylinder during transfer.

10.1.1 Remove the plastic wrapper or cap protecting the cylinder yoke. continued on next slide

10.1.2 Keep the plastic washer that is available in some setups. continued on next slide

10.1.3 Quickly open the main valve for one second to remove any dust. continued on next slide

10.1.4 Ensure that O-ring is present on the regulator oxygen port. continued on next slide

continued on next slide 10.1.5 Place the regulator on the yoke, and tighten the T-screw hand-tight. Do not overtighten. continued on next slide

10.1.6 Attach tubing from the delivery device.

10.2.1 Explain the need for oxygen therapy. continued on next slide

10.2.2 Open the main valve one full turn. continued on next slide

10.2.3 Adjust the flow to appropriate rate. continued on next slide

continued on next slide 10.2.4 Be sure to fill the reservoir bag prior to placing it on the patient by turning on the flow and placing your finger over the valve inside the mask. continued on next slide

Administering Oxygen Pocket Mask with Oxygen Inlet Bag-Mask Device Delivers higher concentrations of oxygen than pocket mask alone Bag-Mask Device Capable of accepting supplemental oxygen Works best when used by two rescuers Talking Point: The proper use of the Bag-Mask device is a difficult skill to master, especially by one rescuer. The EMR should practice frequently.

Figure 10.7 Example of a typical pocket face mask with one-way valve.

Figure 10.8 Example of an adult bag-mask device connected to an oxygen supply.

Administering Oxygen Demand-Valve Device Delivers oxygen through regulator that can deliver 100 percent oxygen "on demand" when patient inhales Monitor patient carefully when providing assisted ventilations. Talking Point: Many departments have abandoned the use of demand-valve devices due to the risk of patient injury.

Administering Oxygen General Guidelines for Oxygen Therapy Explain you would like to provide oxygen because it will help the patient feel better. Explain how the device fits on the face and delivers the oxygen. Gently place device on face and confirm patient is comfortable. Adjust as necessary. continued on next slide

Administering Oxygen General Guidelines for Oxygen Therapy Remind patient to breathe as normally as possible. If patient is anxious and reluctant to accept device, provide extra reassurance. Monitor patient closely. Class Activity: Direct students to work in pairs to role-play oxygen administration using a nasal cannula and nonrebreather.

Think About It What are the advantages and disadvantages of each type of oxygen delivery device? Why is it important, if at all possible, to explain to a patient what you are doing during oxygen administration? When is it appropriate NOT to administer oxygen?

SUMMARY

Summary Most ill or injured patients will benefit from supplemental oxygen. Oxygen is stored and transported in portable containers called cylinders. Important to keep high-pressured cylinders lying flat on ground to minimize damage. continued on next slide

Summary Cylinders should be stored in cool environment and away from sources of flame or heat. Commonly used cylinders in EMS are the D, Jumbo D, and E cylinders. Pressure regulator used to reduce pressure of oxygen coming out of cylinder. continued on next slide

Summary Two devices used to provide supplemental oxygen Nasal cannula can deliver oxygen concentrations up to 44 percent. Nonrebreather mask capable of delivering oxygen concentrations up to approximately 90 percent. continued on next slide

Summary Amount of supplemental oxygen provided to patient determined by: Mechanism of injury Signs and symptoms Level of distress continued on next slide

Summary When a patient is not breathing adequately, provide positive pressure ventilations. Can be performed by using: Pocket mask Bag-mask Demand-valve device

REVIEW QUESTIONS

Review Questions What are the benefits of supplemental oxygen? What are the potential hazards of working with high-pressure cylinders? When working with high-pressure cylinders, what safe practices should you employ? continued on next slide

Review Questions What size oxygen cylinder is commonly carried in an O2 bag by EMS? What is the purpose and function of an oxygen regulator? continued on next slide

Review Questions What are the indications for the use of the following: Nasal cannula? Non-rebreather? Pocket mask? Bag-mask?

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