1. Oxygen Delivery Devices and Strategies for H1N1 Patients
Pandemic Planning Education Subcommittee October 2009 1

2. Outline Introduction Oxygen Delivery Devices
Optimization of Oxygenation 2

3. Introduction Oxygen is a drug Has a Drug Identification Number (DIN)
Colorless, odorless, tasteless gas
Makes up 21% of room air
Is NOT flammable but does support combustion. 3

4. Indications for Oxygen Therapy
Hypoxemia
Inadequate amount of oxygen in the blood
SPO2 < 90%
PaO2 < 60 mmHg
Excessive work of breathing
Excessive myocardial workload 4

5. What does hypoxemia look like?
Tachycardia
Agitation
Diaphoresis
Cyanosis
*Tachypnea*
Dyspnea
Accessory muscle use
*Adult response – pediatric and neonatal patients experience bradycardia 5

6. Hazards of Oxygen Therapy
Absorption atelectasis
Likely with high FIO2 in presence of partial or complete small airway obstruction
Oxygen toxicity
Retinopathy of prematurity
Oxygen induced hypoventilation
Rare condition manifesting in some COPD patients with chronic high plasma bicarbonate 6

7. Oxygen Therapy Devices 2 Types
Fixed
A device that meets all the patients inspiratory flow demands.
Designed to deliver a specific oxygen concentration to patient
Variable
Does not meet all inspiratory demands of the patient so some room air is breathed in
Oxygen concentration will vary with changes in the depth and rate of breathing
in general, the oxygen concentration is  by  the size of the reservoir 7

8. Fixed Device Cold Nebulizer
For adults set O2 flowmeter at maximum (flush)
28-100% O2 selectable on collar - generally only reliable up to 50%
H1N1 standard requires dry bottle routed through Fisher Paykal humidifier
Rapid respiratory rate may decrease delivered FIO2
Do not use for patient transport 8

9. Fixed Device High Flow Cold Nebulizer
Delivery at 60%, 65%, 75%, 85%, 96% selected by rotating collar
H1N1 standard requires dry bottle routed through Fisher Paykal humidifier
flowmeter must always be set to maximum!!
Do not use for patient transport 9

10. Fixed Device High Flow Cold Nebulizer mask with Tusks
Corrugated tubing added to aerosol mask exhalation ports to  reservoir volume and  oxygen concentration
Strategy to increase FIO2 in mask when patient hyperventilating AND SpO2 not maintained
Should be employed with High Flow Nebulizer 10

11. Face Tent Use with a cold nebulizer
The “tent” portion is directed upwards
Uses: children and any patients who find mask claustrophobic or have had facial/nasal surgery
Not optimal for high FIO2 requirements 11

12. Tracheostomy Collar
Provides humidity & oxygen for tracheostomy patients via cold neb
adults LPM up to ‘flush’
O2 adjusted on cold neb but maximum is usually 50% 12

13. Fixed Device Venturi Mask
Deliver a specific O2 concentration - 24%, 28%, 31%, 35%, 40%, 50%
Concentration adjusted by changing the Venturi jet
minimum required O2 flow rate is stamped on the base of each Venturi jet
O2 flow determines accuracy of FIO2 delivered
Usually used for COPD patients with demonstrated oxygen induced hypoventilation 13

14. Variable Flow Nasal Cannula
22% - 40%
Stable is FIO2 based on:
Respiratory rate
O2 flowrate
Reservoir capacity of nasopharynx
adults  6 LPM
infants/toddlers  2 LPM
children  3 LPM
FIO2 is not affected by mouth breathing 14

15. Variable Device High Flow Nasal Cannula
Flow rates from 6-15 LPM
For patients that require > 6 LPM O2 but cannot tolerate a mask
Larger tubing inner diameter permits higher O2 flow
Tubing is always green 15

16. Variable Device Simple Oxygen Mask
Flow rate of 5-10 LPM
35% -50% O2
O2 flow and respiratory rate determine stability of delivered FIO2
CAUTION Set flow rate must be > 5 LPM (adult and children) to flush exhaled carbon dioxide from mask 16

17. Variable Device Non-rebreathe Mask
Adults > 12 LPM
60% - 90% depending on mask fit
CAUTION Always ensure reservoir bag remains partially inflated during inspiration 17

18. Variable Device Non-rebreathe Mask with Filter
CAUTION Always ensure reservoir bag remains partially inflated during inspiration Ensure bag does not deflate during inspiration
Valving system directs exhaled gas through bacterial filter
May be used for transport of H1N1 isolation patients
Must be assembled from stock Y’s, one way valves 18

19. Self Inflating Manual Resuscitator
Insert HME or bacterial filter between mask and bagger
If mask is retained following use, clean with disinfecting wipe
Cap the bagger when not in use 19

20. Manual Ventilation For Respiratory Arrest:
Deliver 1 breath every 5 to 6 seconds (10 to 12 breaths per minute).
For cardiac arrest deliver 2 breaths after every 30 compressions - deliver 8 to 10 breaths per minute without interrupting CPR once airway secured
Ensure that you have attached the EtCO2 sampling line to the correct port on the HME. The EtCO2 sampling port has ridges to screw on the sampling line male 20

21. Avoid hyperventilation which may result in:
Impaired hemoglobin function with reduced O2 delivery to tissues
Gastric distension
Increased intra­thoracic pressure causing:
decreased venous return to the heart and diminished cardiac output.
Increased intracranial pressure 21

22. Complications
Gastric distension is the most common adverse event in manual ventilation
Distension may impair lung expansion
Palpate the abdomen at commencement of bagging
Watch for visual distension and recheck palpation - request gastric tube placement if abdominal rigidity is noted 22

23. Optimization of Oxygen Therapy23

24. Hypoxemia Hypoxemia is defined as: Low levels of oxygen in the blood
PaO2 of less than 60 mmHg (moderate)
SpO2 of less than 90% 24

25. Manifestations of Hypoxemia
Hypoxemia will affect vital signs by:
Increased heart rate
Increased blood pressure
Increased respiratory rate
CAUTION tachycardia is the adult response to hypoxemia – children and neonates will react to hypoxemia with bradycardia that may rapidly deteriorate to cardiac arrest
Hypoxemia in neonates and children requires rapid intervention and correction 25

26. Hypoxemia and H1N1
Decompensation in hospitalized H1N1 Patients often begins with a decrease in SpO2 and increased oxygen demand
Be alert - and communicate even minor increases in oxygen flows or requirements for higher FIO2 devices 26

27. Causes of Hypoxemia Shunt Hypoventilation
As carbon dioxide increases oxygen falls
V/Q mismatching (ventilation/perfusion) serious complications of H1N1 produce V/Q mismatch
Pneumonia
Pulmonary edema
ARDS
Increased diffusion gradient
asbestosis
Early pulmonary edema 27

28. Oxygen Therapy
Goal of therapy is an SPO2 of >90% or for documented COPD patients 88–92%
As SPO2 normalizes the patients vital signs should improve”
Heart rate should return to normal for patient
Respiratory rate should decrease to normal for patient
Blood pressure should normalize for patient 28

29. Optimization My SpO2 is < 90%, what next?
Is the pulse oximeter working/accurate
Do I have a good signal?
Heart rate plus/minus 5 bpm?
Is there adequate perfusion at the probe site?
Can the probe be repositioned?
Do other vital signs or clinical manifestations give evidence of hypoxemia? 29

30. Optimization cont. Check my source! Is the flow set high enough?
Ensure the O2 delivery device is attached to oxygen not medical air.
Follow tubing back to source and ensure patency
Are all connections tight?
Is the flow set high enough?
All nebs especially high flow large volume nebs need to be run at the highest rate.
Turn flow meter to maximum for large volume nebs. 30

31. Optimization cont. Reposition patient. Listen to chest.
Avoid laying patient flat on back.
Raise head of bed.
Encourage deep breathing/coughing
Listen to chest.
Wheezing?
Do they need a bronchodilator?
Crackles?
Encourage deep breathing/cough.
Are they fluid overloaded? 31

32. Optimization cont. Can I improve the mechanics of breathing?
Patient position
Pursed lip breathing
Abdominal breathing.
Anxiety relief? 32

33. Optimization cont. Increase the flow:
With nasal prongs, increase the flow rate by 1 -2 lpm increments until target SpO2 is reached.
High flow nasal prongs can be maximally set at 15 lpm.
Call for physician assessment Medical if high oxygen flows are required. 33

34. Optimization cont.
What do I do if my patient is really hypoxemic (on low flow oxygen)?
Assess patient to determine cause of increasing oxygen requirements.
Best short term solution is non-rebreathe mask at 15 lpm. (reservoir stays inflated)
Goal saturation is still 88 – 92%.
Increase flow as required until re-assessed by physician 34

35. Optimization cont.
What do I do if my patient is really hypoxemic (on high flow oxygen)?
Assess patient to determine cause of increasing oxygen requirements.
Adjust FIO2 upwards in 10% increments titrating for target SPO2.
Call physician for further assessment 35

36. H1N1 points of emphasis
H1N1 decompensation requiring ICU admission usually begins with a systemic inflammatory response and pulmonary edema
CXR may not correlate with degree of oxygenation impairment
Gradually increasing oxygen requirement is a sentinel sign of impending respiratory failure 36

37. H1N1 points of emphasis
H1N1 Patients with escalating O2 needs warrant frequent monitoring for signs of impending respiratory failure
If a critical care triage system is operative, know the patient’s classification and prepare equipment accordingly – endotracheal intubation may not be an option 37