Oxygen therapy& devices

Dr.Naseer
Learning objectives:
 Define the oxygen therapy
 Discuss the types of oxygen therapy & List indications of
O2 therapy
 List Complications of oxygen therapy (oxygen toxixcity)
 Classification of Oxygen Delivery Devices
 Characteristics, avantages and disadvantages of each
devices
 Demonstrate oxygen administration via different devices
 Oxygen therapy
- Definition:
(…., is the administration of oxygen at a concentrations greater than that in room air
(21%), to treat or prevent hypoxemia and thereby increasing the availability of
oxygen to the body tissues).
- Supplemental oxygen is used to treat medical conditions in which the tissues of the
body do not have enough oxygen

- Goals of O2 Therapy
I-General goals: O2 therapy is to maintain adequate tissue oxygenation while
minimizing cardiopulmonary work.
II- Specific clinical goals:
1- Correct documented or suspected acute hypoxemia.
2- Decrease symptoms associated with chronic hypoxemia.
3- Decrease the work load hypoxemia imposes on the cardiopulmonary system.
Indications
Short-Term Oxygen Therapy
 Long term O2 therapy (LTOT)

c
c.
3.
Long term O2 therapy (LTOT)
cont..,
 Assessing the need for O2 therapy
- Laboratory documentation of hypoxemia ( O2 Sat < 90% and/or PO2 < 60 mmHg on
breathing room air) either by:
** invasive method (ABG)
** Non invasive method (pulse oximetry)

- Specific clinical problems or disorders eg; CO poisoning, cyanide poisoning, shock,

acute myocardial infarction and some premature infants.

- Presence of Clinical manifestations of hypoxemia eg; tachypnea , cyanosis, tachycardia

and distressed overall appearance.
 Monitoring O2 Therapy

** invasive method (ABG)

** Non invasive method (pulse oximetry)

Physiological response of healthy indvidual on exposure to 100% of inspired oxygen

Exposure time (hr) Physiological response

0 – 12 hr - Normal pulmonary function,

- Tracheobronchitis
- Substernal chest pain

12 – 24 hr - Decreasing vital capacity

25 – 30 hr -Decreasing lung compliance,

- Increased P(A – a) O2 gradient
- Decrease exercise PO2

30 – 72 hr - Decreasing diffusing capacity

 Oxygen toxicity
Factors that determine the harmful effects of O2 therapy are:
1- Partial pressure of Oxygen (PO2).
2-Exposure time
- The higher the PO2 and exposure time the greater the likelihood of damages
- O2 toxicity primarily affect the lungs and CNS.
- I- Central nervous system (CNS)manifestations like tremors, twitching and
convulsions usually occurs with hyperbaric O2 therapy (high PO2).
II- Pulmonary toxicity
- Alveolitis,
- alveolar damage
- hyaline membrane formation with patchy infiltrate similar to bronchopneumonia
- and lastly ended by pulmonary fibrosis and pulmonary hypertension.
**Rule of thumb
- Avoiding O2 toxicity by limiting patient exposure to 100% O2 in less than 24 hrs
whenever possible.
- High FiO2 is acceptable if the concentration decreased to 70% within 2 days
and 50% or less in 5 days).
III- Other manifestations of O2 toxicity
A - Retinopathy of prematurity (ROP) or Retrolental fibroplasia which lead to
blindness.
B - Bronchopulmonary dysplasia in infants.
SO, the American Academy of Pediatric recommend keeping arterial PO2 in an infant
less than 80mmgh as the best way to minimize the risk of ROP.
C - Depression of ventilation in chronic hypoxemia patients eg; COPD as in this
situation the the stimulation of respiration depend on hypoxic derive.
D - Absorption Atelectasis due to nitrogen depletion the risk increased with prolonged
exposure to FiO2 more than 50%.
E - Fire hazards in case of O2 enriched environment.
- For proper medical use of oxygen we should have:
1- Oxygen source ( cylinder, concentrator or central piping system)
2- Regulators and flowmeters
3- Delivery Devices
Delivery of supplemental oxygen
(Delivery Devices)
 Oxygen delivery systems
• Classifications:
• Devices can be divided according to basic design into three categories:
1- Low-flow system ( ≤ 8 L/min) eg; nasal cannula & catheter and transtracheal catheter.
2- Reservoir system, eg; simple mask, partial and non rebreathing masks.
3- High-flow system ( > 8L/min), eg; air entrainment devices as venturi masks
• Devices can be divided according to FiO2 delivered into three categories:
1- Low FiO2 (< 35%)
NB: Some devices can deliver FiO2 across the
2- Moderate FiO2 (35%- 60%) full range of concentration (21%-100%), eg;
oxyhood and non-rebreathing circuit
3- High FiO2 (> 60%)
• Devices can be divided according to the resultant FiO2 delivered into two categories:
1- Fixed performance devices, eg; venturi mask
2- Variable performance devices, eg; nasal cannula and simple mask
Classification of Oxygen Delivery Systems (cont..,)
• Low flow systems
• Contribute partially to inspired gas patient’s breathing.
• Do not provide constant FIO2.
• Ex: nasal cannula, simple mask and Partial re-breatheing mask .
• High flow systems
• Deliver specific and constant percent of oxygen independent of
patient’s breathing
• Ex: Venturi mask & T-piece
 Nasal cannula
• It is a disposable plastic devise with two protruding prongs for insertion into the nostrils, connected to
an oxygen source.
• The nasal cannula is capable of delivering an FiO2 (fraction of inspired oxygen = oxygen concentration)
ranging from 22% to 44%, depending on the amount of flow.
• The flow rate through nasal cannula is ¼ - 8 L/min. But the commonly used flow rate ranging from 1 -
6 L/min
• Variable FiO2 because the adult inspiratory flow exceed 8L/min so, always dilute the flow of nasal
cannula (low &variable FiO2)
• Best use in home oxygen therapy with low to moderate FiO2.
Nasal cannula (cont..,)
 Nasal cannula (cont…)
Advantages:
• Inexpensive, well tolerated ,comfortable, disposible and easy to use especially in home setting.
• Patients can eat and drink.
• Can be used in infant, children and adults .
Disadvantages:
• Higher flow rates (above 6 liters/minute) through nasal cannula can cause irritation, and dryness of
the nasal mucosa & pharyngeal mucosa and epistaxis.
• May not suitable in mouth breathing patient and patient with nasal obstruction
• Easily dislodged so; need to be Checked frequently that both prongs are in patients nares
• Variable FIO2
-NB : Humidification of oxygen is needed if the flow rate is >4 L/m .
-Rule of thumb:
(…., for patient with normal rate and depth of breathing each 1L/min O2 increases the FiO2 (%)
approximately 4%). 1 L\min=24%, 2 L\min=28%, 3 L\min=32%, 4 L\min=36%, 5 L\min=40% and
6 L\min=44%
Transtracheal oxygen Catheter:
Transtracheal oxygen is delivered through a small flexible plastic
catheter which is percutaneously placed directly into the trachea
through an opening in the neck between the second and third
tracheal rings.
As the oropharynx is bypassed the dead space is reduced which
results in lower oxygen flow rates (0.25 L/m – 4L/m) being required
to correct hypoxaemia. FiO2 (fraction of inspired oxygen =
oxygen concentration) ranging from (22% to 35%), depending
on the amount of flow.

 The other advantage is that the oxygen tubing is less visible which may
increase the adherence with oxygen therapy, particularly ambulatory oxygen
as when the patient leaves the home they are likely to be less self-conscious.
 The FiO2 is variable due to the same reason mentioned in nasal cannula.
 Best use in home care or patient not accept nasal cannula or ambulatory
patients who need increased mobility
• Complications and disadvantages of Transtracheal oxygen catheter

• Catheter blockage by mucus

• Catheter displacement
• Cellulitis
• Subcutaneous emphysema
• Haemoptysis
• High cost
Face mask
The simple Oxygen mask
The partial rebreather mask
The non rebreather mask
The venturi mask
 Simple Oxygen mask
• Simple mask is made of clear, flexible , plastic or rubber that can be molded to fit the
face.
• It is held to the head with elastic bands.
• Some have a metal clip that can be bent over the bridge of the nose for a comfortable
fit.
• It has vents on its sides which allow room air to leak in at many places, thereby
diluting the source oxygen.
• The oxygen flow must be run at a sufficient rate, usually 5-10 L/min.
• So; The least oxygen flow rate is 5 L/min.
• if the flow rate is less than 5 L/min the mask volume acts as dead space and cause
CO2 rebreathing.
• The FiO2 is variable and depend on; O2 input flow, mask volume, extent of air leak
and patient breathing pattern.
Simple Oxygen mask cont..,)
 Simple Oxygen mask cont..,)
Advantages:
• Simple light weight easy to apply disposable and inexpensive.
• Delivery of FiO2 ranging from (35%-50%).
• Can be used in infants, children and adults.
Disadvantages:
• Limitation of access to patient's face for expectoration of secretions and other
needs (can not eat or talk).
• Possibility of aspiration if vomiting occur while wearing the mask. So, not suitable
for unconscious patients.
• Uncomfortable when facial trauma or burns are present.
• May cause drying and irritation of the eyes.
• Variable FiO2
-NB : Humidification of oxygen is needed if the flow rate is more than 5 L/m.
:Secure physician's order to replace mask with nasal cannula during meal time.
 Mask with Reservoir Bag
(Partial Rebreathing and Non- Rebreathing mask)

• The partial rebreathing mask is similar to that of the simple face mask, with the
addition of an oxygen reservoir bag that must remain inflated during both inspiration & expiration .
• The bag collect the first parts of the patients' exhaled air.
• Variable FiO2 (40%-80%) and best use in short term O2 therapy requiring moderate to high FiO2.
• The oxygen flow rate must be maintained at a minimum of 10 L/min to prevent collapse of the bag
and ensure that the patient does not rebreathe large amounts of exhaled air.
• The remaining exhaled air exits through vents.
• The Non- rebreathing mask; there is addition of one way valve (open only during
inspiration). When the patient exhales air, the one-way valve closes and all of the expired air is
deposited into the atmosphere, not the reservoir bag.
• In this way, the patient is not rebreathing any of the expired gas.
• As well as Valve over exhalation ports prevents air entrainment during inspiration.

• The oxygen flow must be run at a sufficient rate, usually at least 10 L/min to prevent bag collapse
during inspiration.
• This mask provides the highest but Variable FiO2 ( > 90% )
• The best use in short term O2 therapy requiring high FiO2.
• Advantages:
• Deliver moderate to high FiO2 in partial-rebreathing mask
• Deliver high FiO2 in non-rebreathing mask. Suitable for pt breathing spontaneous
with sever hypoxemia .
• Exhaled oxygen from the anatomic dead space is conserved in partial rebreathing
mask
• Used in infants, children and adults.
• Disadvantages:
• Like simple face mask plus;
• Malfunction can cause CO2 buildup and suffocation
• Expensive & costly
Air entrainment devices:
- Air Entrainment Mask (AEM) or venturi mask
- Air Entrainment Nebulizer

exhaled gas

oxygen

room air
Entrainment ratios
Systems FiO2 Entrainment ratio Flow rate (L/min)
(O2/Air)

Ventimasks 0.24 1 – 25 4
0.28 1 – 10 4
0.31 1–7 6
0.35 1–5 8
0.40 1–3 8
0.50 1 - 1.7 12
0.60 1–1 12

Aerosol 0.70 1 - 0.6 12

Air Entrainment Mask (AEM): Venturi or venti devices

Venturi mask. The colour of the mask aperture reflects the FiO 2 achieved
(24%: blue; 28%: white; 35%: yellow; 40%: red; 60%: green
 Venturi (venti) mask
- The mask is so constructed that there is a constant flow of room air blended with a fixed
concentration of oxygen
- It appears much like a simple face mask; however, it has a jet adapter placed between
the mask and the tubing to the oxygen source. The jet adapters come in various sizes
and are often color coded ( interchangeable venturi valves) or adjustable venturi
valve .
- The FiO2 is modified either by altering the size of the side ports or by altering the jet
orifice diameter.
- The greater the air dilution, and the lower the concentration of oxygen.
- The FiO2 delivered range from 24% to 60%, and flow rate range from 4 to 12 L/min.
- It is used primarily for patients with chronic obstructive pulmonary disease (COPD).
 Venturi (venti) mask
Advantages:
• Delivery of FiO2 which can be adjusted as needed (through the jet adaptor) is stable
precise FiO2.
• Useful in patients to whom delivery of excessive oxygen could depress the respiratory
drive (as in COPD with type II respiratory failure).
Disadvantages:
• Same as simple face mask.
Interchangeable venturi valves
 Tracheostomy Collar/ Mask

Inserted directed into trachea via trach tube

Is indicated for chronic o2 therapy need O2 flow rate 8 to 10L
Provides accurate FIO2
Provides good humidity.
Comfortable ,more efficient
Less expensive
Nasal Catheter
Nasal catheter
flow Rate 0.25-8L/min
FiO2: 0.22-0.45

Advantages Disadvantages
• Good stability • Difficult to insert
• Disposable • Change every 8 hrs
• Low cost • High flow increases back
pressure
• DNS or polyp may block
insertion
• May provoke swallowing or
gagging -aspiration
Nasal catheter
Best uses:
• During bronchoscopy
• Longterm care of infants
Nasal catheter
O2 flow rate L/min FiO2

1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44
Reservoir cannula
• 0.25 - 4 L /min
• FiO2- 0.22-0.35
Advantages Disadvantages
• Lower O2 cost • Unattractive
• Increased mobility • Poor compliance
• Less discomfort • Regularly replace every 3 weeks
Uses:
• Home care
• Ambulatory patients
 Oxymizer
Reservoir cannula Pendant
reservoir cannula reservoir cannula
Non rebreathing circuits
• FiO2 range 0.21-1
• Fixed FiO2
• Blending system to premix air O2
• Warmed, humidified by servo controlled heated humidifier
Air entrainment nebulizer
• 10-15L/min input
• Fixed FiO2 (0.28-1)
Advantages
• Temperature control Disadvantages
• Extra humidification • FiO2 <0.28 or >0.4 not ensured
• Varies with back pressure
• High infection rate
Air entrainment nebulizer…
 Oxygen (O2) tent
For children – not tolerating mask / catheter
Large capacity system with flow rate 12-15L/min
Variable FiO2 (FiO2 Up to 50%).
Advantages: Provides concurrent aerosol therapy
 Disadvantage
– Limited access
– Risk of fire
– Conflict in O2 therapy / nursing care
– Expensive, Requires cooling and Difficult to clean, disinfect
–
Oxygen hood
- Minimum flow 7 L / min to Advantage
prevent rebreathing • Full range of FiO2
• FiO2 0.21-1
• Fixed FiO2
Disadvantage
• Difficult to clean and disinfect
Incubator (Isolette)
• A venturi is used to add oxygen to the chamber

• Scavenging mechanism in built → air changes

• Humidification possible

• Temperature maintained

• Multiple access ports for nursing

• Infant can be transported

Incubators (Isolette)
 Manual resuscitation bags (MRB)
OR Bag – Valve Mask (BVM)
OR (Ambu Resuscitator)
- Manual resuscitation bags (MRB) are used to provide oxygen and
positive-pressure ventilation to a sealed airway such as a mask,
endotracheal tube, or tracheostomy tube.
- MRBs consists of a self-inflating bag; an oxygen inlet valve, ideally
capable of accepting an oxygen flow rate of 15 L/min; a non-rebreathing
valve(s), which directs the flow of oxygen-enriched gas to the patient and
prevents exhaled gases from entering the bag.
 Manual resuscitation bags (MRB)
OR Bag – Valve Mask (BVM)
OR (Ambu Resuscitator)
• Allows the delivery of an FiO2 up to 100%.
• Used during resuscitation of patient with
cardiopulmonary arrest and critically ill patients as ell
as preparation of patient to general anaesthesia.
• It can be used in both spontaneous and artificial
ventilation
 Bag – Valve Mask
(Ambu Resuscitator)
Pocket Mask
- Delivers O2 in both spontaneous & aponeic patient
- With the strategically placed 3M hydrophobic filter and One Way
Valve, both providers and patients can expect the highest levels of
protection.
- Allows use of both hands – for maintaining airway
- Many masks also have a built-in oxygen intake tube, allowing for
administration of 50-60% oxygen. Without being hooked up to an
external line, exhaled air from the provider can still provide sufficient
oxygen to live, up to 16%.
O2 Flow rate (L/min) Fi O2
5 0.40
10 0.50
15 0.80
Pocket masks
- Pocket mask versus BVM
While a pocket mask is not as efficient as a bag valve mask, it does have
its advantages when only one rescuer is available.
 As suggested by its name, the pocket mask benefits from a somewhat
easier portability when compared to the bag valve mask.
Also, in contrast to the bag valve mask, which requires two hands to
operate (one to form a seal and the other to squeeze the bag), the pocket
mask allows for both of the rescuer's hands to be on the patients head.
This hand placement provides a superior seal on the patient's face, and
allows the responder to perform a jaw thrust on patients suspected of a
spinal injury.
T-piece
Used on end of ET tube when
weaning from ventilator
Provides accurate FIO2
Provides good humidity
 Technique of oxygen administration
Steps Rational
•Assessment:
 Check the physician order. provide a baseline data for
 Assess vital signs , future assessment
 Assess level of consciousness Oxygen maybe depress the
 Assess the laboratory results, hypoxia drive ( decrease
especially the ABG analyses, respiratory rate , alteration in
mental states
 Assess risk of CO2 retention
with oxygen administration *If PaCO2 is decrease or normal
(ie; patient not express CO2
retention & can use oxygen
without fear)
Steps Rational
*Planning:
Wash hands. To prevent infection.
Prepare equipment
Oxygen source
plastic nasal cannula
connection tube,
Simple face mask
The partial rebreathering mask
The non rebreathering mask
The venturi mask
Humidifier filled with distilled water Humidification may not be
Flow meter ordered if oxygen flow rate < 4
L/min in case of nasal cannula
or 5 L/min in face mask
Steps Rational
*Implementation: To be sure you are
Identify the patient. performing the procedure
for the correct patient.
Explain procedure to the To gain his cooperation.
patient.
Assist the patient to a semi- This position permits
fowler's position if possible. easier chest expansion and
hence easier breathing.
Attach the oxygen supply To prevent dryness of
tube with humidification to mucous membrane.
the cannula , face mask.
Steps Rational
- Nasal Cannula
Allow 3-5 L oxygen to flow through the Low flow: (1 L\min=24%, 2 L\min
tubing. =28%, 3 L\min=32%, …etc)

Place the prongs in the patient's nostrils To facilitate oxygen administration
and adjust it comfortably. and comfort the patient.

Use gauze pads both behind the head or To reduce irritation and pressure
the ears and under the chin and tighten to and protect the skin.
comfort.
Steps Rational
Nasal Cannula (cont..,)
Adjust the flow rate to the ordered To provide optimal delivery of
level. oxygen to patient..

Encourage patient to breath through  To prevent wasting of oxygen

his nose with his mouth closed. and ensure inhalation of all
administered oxygen

Assess the patient nose and mouth and Oxygen dries the mucous
provide oronasal care at least every 8 membrane and cause irritation
hours.
Steps Rational
Face mask
Attach the oxygen supply tube to the mask .

Regulate the oxygen flow (according type of Ensure pt receive sufficient

mask). flow to meet respiratory
Position the mask over the patient's nose and demand & maintain accurate
mouth. concentration oxygen
And fit it securely, shaping the metal band on
the mask to the bridge of the nose.
Steps Rational
 Face mask (cont..,)

Adjust the elastic band around the patient's head To ensure a tight fit.
and tighten.

Use gauze pads both behind the head or the ears. To reduce irritation and
pressure and protect the skin.
Adjust the flow rate to the ordered level.
Steps Rational

Remove the mask and dry the There is danger of inhaling

skin every 2-3 hours if the powder if it is placed on the
oxygen is running continuously. mask.
 Don't powder around the
mask.

Wash your hands.

Evaluation
Breathing pattern regular and at normal rate.
 pink color in nail beds, lips, conjunctiva of eyes.
 No confusion, disorientation, difficulty with cognition.
Arterial oxygen concentration or hemoglobin
 Oxygen saturation within normal limits (either in pulse
oximetry or ABG).
Documentation:

Date and time oxygen started.

Method of delivery.
Oxygen concentration and flow rate.
Patient observation.
Add oronasal care.
NB:
• Oxygen in concentrations up to 100 % can be administered in
the transport and initial management of critically ill
patients. If needed, an Fio2 of 100 % can be used for up to
24 h without significant lung injury.

• Oxygen at an Fio2 of 50 % or less can be administered

safely to most patients for several weeks.