Oxygen delivery devices

Essentials course in EMEssentials course in EM hospital-based
 Emergency care:
1. Pre-hospital EMS
2. Hospital-based.
3. Disaster management
To Oxyen DevicesTo Oxyen Devices
By Dr. Fekri Eltahir Abdalla

Oxygen Delivery Devices

Oxygen Delivery Systems

Types of hypoxia
Types Definintion Typical cases
Hypoxic oxygen tension High altitude – hypoventilation – V/Q
mismatch.
Anemic carrying capacity Anemia – blood loss – CO poisoning
Stagnant perfusion Heart failure – Shock – ischemia
Histotoxic Cellular hypoxia Cyanide – other metabolic poisons –
shifting of O2-HB curve.

Oxygen dissociation curveOxygen dissociation curve
Decreased Temp.
Decreased 2,3 DPG
Decreased {H+}
Increased Temp.
Increased 2,3 DPG
Increased {H+}

Grading of hypoxia
Respiratory failure

How to manage Hypoxia
LOC
Resp. effort
Chest exam

Oxygen dose

Device characteristics
Device Mask Reservoir Total storage
Nasal prongs No 50 ml (DS) 50 ml
Simple mask 100 – 200 ml 50 ml (DS) 150 – 250 ml
Mask reservoir 100 – 200 ml 650 – 1050 ml 750 – 1250 ml
Venturi mask 100 – 200 ml 50 ml (DS) 150 – 250 ml
DS = dead space = air in the hypopharynx.
Mask reservoir = partial rebreathing & non-rebreathing masks.

Patient demand
Hypoxia

Respiratory Failure
Type 2 (Hypercapnic RF)Type 1 (Hypoxemic RF)
PaO2 < 60 mmHg
PaCO2 ( low or normal)
PaO2 < 60 mmHg
PaCO2 > 45 mmHg
COPD patient with PaCO2 of 60 mmHg, PaO2 of 61 mmHg and pH 7.37. Is there any
RF? Which type?
ABG
Not
Oximeter

PaO2-FiO2 ratio
 Normal PaO2/FiO2 is 300-500
 <200 indicates a clinically significant gas
exchange derangement
 Ratio often used clinically in ICU setting

Oxygen Devices ClassificationOxygen Devices Classification

Nasal Prongs

Nasal Prongs
Advantages Disadvantages
Tolerable (satisfaction + compliance) Flow limitation.?
Can use the mouth (eat, speak, treat) FiO2 limitation.?
Avoid high FiO2 in COPD. Nasal drying and irritation with high
flow rate?

Case 1:
 A young female presented with dry cough, fever and SOB. She was
found hypoxic at the triage (Sat 87%). The nurse put her in oxygen
using nasal prong at flow of 4 L/min. She improve a little pit to 91%
saturation. What your next best action to improve her oxygenation?
A. Shift her to simple mask at 5 L/min.
B. Shift her to non-rebreathing mask at 5 L/min
C. Increase the nasal prong flow to 5 L/min
D. No need to make any change.

Simple mask
Characteristics Advantages Disadvantages
Flow not < 5 L/ min
CO2 retention
Higher FiO2 compared to
nasal prong
Loose = air leak, mixed
room air (lower FiO2)
Loosely fitted to the face
Air leak – mixed room air
Can use nebulizer. Can not use the mouth to
eat, drink, speak
Max flow rate = 10 L/ min
FiO2 = 40 – 60 %
Approx = 4%/L/min
Can use venture. Limited FiO2 (Max 60%)
Pt demand not met in
some cases.
No reservoir bag
Storage ?

Case 1 continued
 As the patient had oxygen flow rate of 5 L/ min, her saturation
reached 93% for 15 min then she dropped again to 89%. The nurse
increased the flow to 6 L/min using nasal prong but the saturation
became 90% for 5 minutes. You decided to shift to simple mask.
What is the best flow rate to start with? And why?
A. Simple mask at 5 L/min
B. Simple mask at 6 L/ min
C. Simple mask at 7 L/min
D. Simple mask at 10 L/min

Case 2
 A known asthmatic young man resented with acute SOB and he was
found tachypneic (RR=35), tachycardic (HR = 120) and desaturated
(SPO2 = 88%). You found diffuse wheeze at auscultation with
decreased air entry bilaterally. You planned to give him oxygen plus
nebulized Ventolin initially, but he still continued desating while on
oxygen-powered nebulized therapy. Your best action of management
then is:
A. Shift to non rebreathing mask and continue nebulization.
B. Intubate the patient immediately for acute severe asthma.
C. Initiate non invasive mechanical ventilation and delay Ventolin therapy.
D. Put him on nasal prong plus continue nebulized Ventolin with simple mask at
maximum flow rate.

Mask plus reservoir
Simple
mask
Partial
rebreathing
mask
Non
rebreathing
mask

The device Characteristics Advantages Disadvantages
Simple mask
5 – 10 L/min
FiO2 ( 40 – 60%)
Mask – no
reservoir
Nebulizer or
venture port
Accepted FiO2
Considerable air
mixing -
No use of mouth
Partial mask
5 to max to
Keep bag inflated
Simple mask +
reservoir
Higher FiO2
FiO2 (up to 80 %)
Less room air
mixing - no use of
nebulizer or
venturi
Non rebreathing
5 to max to keep
bag inflated
Simple mask +
reservoir + one
way valve
Highest FiO2
Negligible room
air mixing
FiO2 (up to 95%)
No use of mouth,
venture or
nebulizer
Partial rebreathing/ non rebreathing

Case 3
 A known COPD patient on home oxygen (2 L per nasal prong)
presented with acute exacerbation. At triage was found
tachypneic and desat (SPO2 75%). The nurse started 4L O2 by
nasal prong and you add non oxygen power nebulized
Ventolin. After 20 min, saturation became 82%. You plan to
continue nebulization plus requesting ABG. What is the best
O2 delivery device for this patient at this level (ABG pending!)?
A. Simple mask at 5 L/min
B. Adjustable venture mask.
C. CPAP
D. Intubation and mechanical ventilation

Venturi mask
Characteristics Advantages Disadvantages
High flow device Controlled FiO2 Limited low FiO2
Room air mixing Suitable for chronic
CO2 retention
Ignores patient O2
demand
Adjustable valve Can use nebulizer
Use simple mask or
CPAP

Venturi mask

Positive pressure ventilation
Indications Advantages Disadvantages
Hypoxia despite full O2
Hypoventilation
CO2 retention
Decrease work of
breathing
Unprotected airway
Avoid intubation Gastric insufflation
Requirements Improve oxygenation Slow correction (time)
Conscious – cooperative
– vitally stable – airway
protected by their own –
reversible cause
Improve ventilation Tight mask problems
Decrease venous return

NIV Monitoring
Response
Physiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG should be obtained with 1 hour and, as
necessary, at 2 to 6 hour intervals.
Objective a) Respiratory rate
b) blood pressure
c) pulse rate
Subjective
a) dyspnea
b) comfort
c) mental alertness

NIV Monitoring
Mask
Fit, Comfort, Air leak, Secretions, Skin
necrosis
Respiratory muscle unloading
Accessory muscle activity, paradoxical
abdominal motion
Abdomen
Gastric distension

NIV Discontinue
 Inability to tolerate the mask because of discomfort
or pain
 Inability to improve gas exchange or dyspnea
 Need for endotracheal intubation to manage
secretions or protect airway
 Hemodynamic instability
 ECG – ischemia/arrhythmia
 Failure to improve mental status in those with CO2
narcosis.

Less dead space.
Claustrophobia
Can use mouth
Dyspnic are mouth
breather.
More dead space.
Clustrophobia

Method of NIV CPAP BiPAP
Name Continuous Positive
Airway Pressure
Bilevel Positive Airway
Pressure
Descriptions Preset ePAP (PEEP)
Pt initiate breathing
ePAP ( 4 to 20 cmH2O)
Open more alveoli
(recruitment)
Preset iPAP/ ePAP
Pt initiate breathing
Can set backup RR
iPAP (8 – 20 cmH2O)
ePAP (4 – 10 cm H2O)
Indications COPD – APE(decrease
venous return) – sleep
apnea
Acute hypercapnia –
cardiogenic APE – resp
muscle fatigue/paralysis

Indications Advantages Disadvantages
Severe hypoventilation
RR < 8/ min
Simple technique
(learning)
Uncontrolled
hyperventilation
Gastric – lung - ABG
Apnea Available Temporary
Cardiac arrest Positive pressure/ PEEP
Assist ventilation/O2
MOANS/ open airway
Effectiveness?
Preoxygenation in RSI High FiO2 100% Utilize medical personnel

Case 4
 While you are treating COPD patient with venturi mask
plus nebulized SABA, he is not improving and continued
desating after 1 hour of your management and his ABG
showed (pH 7.20, pCO2 65 mmHg, pO2 50 mmHg). His
vital signs: HR 125, RR 36, BP 85/54, GCS 14/15. what
is your best next action of management?
A. Shift to CPAP immediately.
B. Shift to BiPAP immediately.
C. Intubation and mechanical ventilation.
D. Give IV fluids and continue same plan.

Summary
 O2 is a drug, so it must be used judiciously.
 You should set your targets:
 Before you move to mechanical ventilation, consider to make the
maximum use of simple devices available.
 It is important to keep in mind each device capabilities and
limitations.
 Monitoring during O2 therapy is vital.
 NIV is an option but patient should meet the criteria for its
application.

Before The end

Questions?

Oxygen delivery devices

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