Oxygen Therapy Advice

5/25/2014 Respiratory Therapy Cave: Adult Oxygen Therapy Made Easy
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Adult Oxygen Therapy Made Easy
If a patient is unable to oxygenate appropriately on room air, supplemental oxygen may be
indicated. This Course should provide you with the wisdom you need to determine what oxygen
device to use (if any) and how much oxygen to give to your patient.
First we need some basic definitions:
Supplemental oxygen: Any device that provides more oxygen than what one would get breathing
room air.
Hypoxemia: This is when the oxygen in the blood is low, and is generally measured by a PaO2 of 60
or less, or a SpO2 of 90% or less.
PaO2: This is the level of oxygen in the blood. It should be kept at 60 or better to avoid hypoxemia.
Its obtained by invasive Arterial Blood Gas (ABG) or estimated by SpO2.
SpO2: Also called oxygen saturation, pulse ox or sat. This is a noninvasive measurement of the
amount of oxygen inspired that gets to the arteries. A normal SpO2 is about 98%. Be aware that a
persons normal SpO2 decreases with age and with some disease processes. The only way it can get to
100% is with supplemental oxygen.
You can use your SpO2 to predict the PO2 using the 456, 789 rule as below:
SpO2 70% = PO2 of 40
SpO2 80% = PO2 of 50
SpO2 90% = PO2 of 60 (This is what you want to maintain for most patients)
Therefore, ideally, for most patients you will want the SpO2 to be 90% or greater, or as specified by
hospital protocol, or specific physician order.
Fraction of Inspired Oxygen (FiO2): This is the percent of oxygen a patient is inhaling. Room air
FiO2 is 21%. By applying supplemental oxygen, the FiO2 can go as high as 100%.
Indications for Oxygen Therapy:
To correct hypoxemia
To reduce oxygen demand on the heart
Suspected or acute marcardial infarction (MI)
Severe trauma
Post anesthesia recovery
Low flow oxygen devices: These are oxygen devices where some room air will be entrained, and
therefore the exact FiO2 cannot be calculated, however it can be estimated.
How much FiO2 is delivered to the patient is dependent on:
Liter flow set at the flowmeter
Respiratory rate and pattern of the patient
Equipment reservoir (stores oxygen)
The following are low flow oxygen devices:
1. Nasal Cannula: The nasal cannula is the most common oxygen device used and the most
convenient for the patient. A nasal cannula at 2lpm is usually a good place to start.
You may at times need to estimate the FiO2. How to estimate FiO2 on a nasal cannula? For every
liter per minute, the FiO2 increases by 4% as per the chart below:
1 lpm = 24%
2 lpm = 28%
3 lpm = 32%
4 lpm = 36%
5 lpm = 40%
6 lpm = 44%
The liter flow on a nasal cannula should never exceed 6lpm, as studies show doing so is of no added
benefit to the patient. Also note that the prongs of a nasal cannula should face down.
A bubbler can be added to humidify the nose to prevent nasal drying and bleeds. This is automatically
set up at flows greater than 4lpm, or as ordered by physician.
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common sense in their wall locker when they come
into work. Every situation is unique, and the use of
judgement at appropriate times is the hallmark of a
true professional. Anthony L. DeWitt, AARC Times
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3. NonRebreather Mask (NRB): This is a mask that ideally will bring in 100% Fio2 so long as the
liter flow is 15 and there is a good seal between the mask and the patient's face. And all three one
way valves are on the mask to prevent air entrainment.
For legal purposes, however, one flap is always removed just in case the oxygen gets shut off. And
therefore the highest FiO2 you can get from an NRB is 75%. The bag acts as a reservoir for oxygen,
and therefore allows device to provide higher FiO2s to the patient.
4. Partial Rebreather Mask (PRB): This is basically an NRB with both oneway valves removed from
the mask. The estimated FiO2 is 6065%. Flow should be set at 615 lpm.
High Flow Oxygen Devices: These devices meet the inspiratory flow of the patient, and generate
accurate FiO2s so long as there is a good seal between the mask and the patient's face. The flows are
such that the patient will not be entraining room air that will lower the FiO2. Respiratory rate and
tidal volume of the patient have no effect on FiO2 delivered.
Ideally, the larger the entrainment port on the device the lower the FiO2, and the smaller the
entrainment port the higher the FiO2. A major disadvantage is a mask is required, and this may be a
bit more uncomfortable than a nasal cannula.
1. Venturi Mask: This mask is ideal for patients who are in respiratory distress with high tidal
volumes or high respiratory rate to guarantee a certain amount of oxygen.
If a nasal cannula does not provide adequate oxygenation, Venturi Masks set from 28% to 40% are
ideal for COPD patients.
Modern Venturi masks come with one or more color coded caps, and whichever one you use the
desired liter flow for that particular cap is written right on the cap.
The Venturi Masks used at MMC are set up as follows:
A. White cap:
35% FiO2 set lpm at 9
B. Green cap:
24% FiO2 set lpm at 3lpm
30% FiO2 set lpm at 6 lpm
The liter flow must be at least set at the recommended liter flow for any particular FiO2 that is
dialed in. It's okay if it is set too high, yet if it's too low the patient may retain CO2 and the FiO2
may not be lower than what you dialed in.
2. Aerosol setup: This device will deliver anywhere from 21 to 100% FiO2 depending on how it is set
up. The desired flow to set the flow meter at is written write on the cap
Usually a humidity device is connected to the flowmeter, and wide bore tubing connects this to the
patient's mask Wide bore tubing acts as a reservoir to obtain higher FiO2s.
These are ideal for patients with tracheotomies because it allows for inspired air to be oxygenated,
humidified and even heated if necessary. They can be hooked up to a simple mask, tracheotomy
mask, and even a tpiece.
The flow may exceed the required flow, although if it is less the patient may retain CO2, and the
FiO2 be lower than desired. On inhalation a mist should be seen coming from mask or reservoir.
3. High flow nasal cannula: An Fio2 of 21% to 100% may be maintained because the flow meets the
patient's spontaneous inspiratory demand. This is made possible due to thicker tubing and humidified
oxygen.
Other oxygen devices you might see:
1. BiPAP: This is a discussion for another day. Still, pressure can be given by a noninvasive mask
over the patients face to improve ventilation, and to supply any FiO2 from 21% to 100%. These also
have other means of improving oxygenation.
4. Ventilator: This is also a discussion for another day. Yet for patients whose oxygen demands
exceed any of the above devices, intubation and ventilation with a ventilator may be required. These
can supply any FiO2 from 21% to 100%, and also have other means of improving oxygenation.
Hazards of oxygen therapy:
Oxygen may suppress the respiratory drive for some COPD patients, and should be used
with caution.
FIO2s greater than 60% for greater than three hours have been linked to increased risk for
lung injury and other future consequences.
What device do you use? Where to start?
For most patients, you will start low and work your way up if needed
We usually start at 2lpm for most patients and adjust accordingly.
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Posted by Rick Frea at 10:50 AM
Labels: oxygen, oxygen therapy
If you have a patient in respiratory distress, you may want to start at 40%.
However, if the patient is in severe respiratory distress, or is the victim of a trauma, you
may want to simply start at 100% and decrease as appropriate
All patients suspected of chronic heart failure should be placed on 100% FiO2 and adjusted
down from there.
All patients who are suspected to be CO2 retainers should be started on 2lpm or, if in
respiratory distress, on a venturi mask set no higher than 40%.
Still, a majority of patients do quite well on 2lpm.
How much oxygen does a patient need?
Ideally, whatever oxygen device is needed to maintain a SpO2 of 90% or greater or as otherwise
specified by a specific oxygen protocol or physician order is indicated.
Oxygen supplementation for uncomplicated acute coronary syndrome is no longer routinely indicated
and should only be applied only if the oxyhemoglobin saturation is less than or equal to 94 percent.
The old recommendation was to place all patients complaining of chest pain on 4lpm with the belief
that it would increase oxygen to the heart and decrease work of breathing. I'm simply noting this
here because some physicians prefer to stick with the old recommendations, and that's fine.
Sedatives, analgesics (like Morphine) and anesthesia may also depress respiratory drive, and these
patients are often placed on oxygen. The amount used is usually 23 lpm via nasal cannula, however
this depends on the patient, physician, or protocol.
How to determine if oxygen therapy is working:
You know oxygen therapy is working when:
SpO2 improved to patient normal (or as determined by physician)
Respiratory rate improves
Patient tidal volume is not erratic
Patient notes improved work of breathing
Pulse is normal or improved or improving
Blood pressure is improved or improving
Underlying condition is improving, or whatever occurred to cause the hypoxemia
How long with an ecylinder last?
So you want to use an ecylinder to take a patient to xray and you want to know if you have enough
oxygen in the tank to make it there. You can use the following formula:
ecylinder time remaining = .30 (PSI) / LPM
Related Links:
Oxyhemoglobin Dissociation Curve
ABG Interpretation Made Easy
How to know if a patient is a CO2 retainer
Why do people breathe?
Recommend this on Google
Post a Comment
1 comment:
Aiesha Grant said...
Thanks so much for providing this valuable resource! I'm taking resp care procedures lab and it
is very fast paced! As we often have to work in groups and travel to four different stations to
set up different equipment, practice on mannequins etc. This article was wellwritten and
wellorganized so I was able to better understand the application of what I was doing. Also
helped clarify the names of some equipment and even gave me a nice trick for remembering
SpO2 and Po2. I will never forget the 456,789 rule. =)
September 8, 2012 at 11:20 PM
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5/25/2014 Respiratory Therapy Cave: Adult Oxygen Therapy Made Easy

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