Oxygen Therapy

Mrs. H.M.C.M.Herath
Lecturer
Faculty of Nursing
University of Colombo
 OUTLINE

• Methods of Delivery
• Complications of Oxygen Therapy
• Nursing Management of Patient Receiving Oxygen
Therapy
• Artificial Airways
• Nursing Management of Patient with an Artificial
Airway, and PPV
 Methods of Delivery

• Oxygen therapy can be administered by many

different devices.

• However, common problems associated with

these devices include system leak and
obstructions, device displacement and skin
irritation.

• These devices are categorized as low flow,

reservoir and high flow systems.
 Methods of Delivery CONT:

Low Flow Systems

• Low flow system delivers supplemental oxygen
directly into the patient’s airway at a flow rate of
8L/min or fewer.

• This oxygen flow is insufficient to meet the patient’s

inspiratory requirements and results in a variable
fraction of inspired oxygen as supplemental oxygen
is mixed with room air.
 Methods of Delivery CONT:

Reservoir System
• Reservoir systems are designed to accumulate and
store oxygen between breaths.

• In this method, patient can draw oxygen from the

reservoir even his/ her inspiratory flow exceeds the
oxygen flow of the oxygen delivery system, to meet the
patient’s inspiratory requirements.

• When compared to low flow system, mixing of oxygen

with room air is minimal.
 Methods of Delivery CONT:
High Flow Systems
• High flow system delivers oxygen to patient’s airway in
an amount sufficient to meet patient’s inspiratory
volume requirements.

• High flow nasal cannula, a type of high flow system

delivers warmed, humidified oxygen to the patient
using a blending system.

• This system provides more comfort and better

tolerance to patients as it reduces the work of
breathing especially in acute lung failure.
 Complications of Oxygen Therapy
Oxygen Toxicity

• Oxygen toxicity can occur in patients who inhale oxygen

concentrations of greater than fifty percent for more
than 24 hours.

• Patients who require intubation, mechanical ventilation,

and high oxygen concentrations for longer periods are at
risk of developing oxygen toxicity.

• Clinical features of oxygen toxicity include; substernal

chest pain that is aggravated by deep breathing, dry
cough and tracheal irritation.
 Complications of Oxygen Therapy

Oxygen Toxicity CONT:

In addition, nasal stuffiness, sore throat, eye and ear
discomfort may occur.

However, chest radiographs and pulmonary function

tests will not show any changes until the clinical
features become severe.

Once the normal oxygen concentration is established,

these clinical features may reverse rapidly.
 Complications of Oxygen Therapy CONT:

Carbon dioxide Retention

• Carbon dioxide retention can occur due to administration of
high concentrations of oxygen.

• This complication is mainly occurring in a percentage of

patients with Chronic Obstructive Pulmonary Diseases (COPD).

• In COPD, normal stimulus to breathe (increasing CO2 levels) is

muted and that decrease the levels of oxygen in the lungs.

• If hypoxemia is corrected by the administration of oxygen, the

stimulus to breathe is diminished by developing
hypoventilation.

• As a result of that carbon dioxide levels will increase further.

 Nursing Management of Patient Receiving Oxygen
Therapy
• Clear oral, nasal and tracheal secretions as
necessary.
• Maintain the patency of airway.
• Setup the oxygen equipment and administer
through heated and humidified system.
• Monitor the oxygen litre flow.
• Monitor position of the oxygen delivery device.
• Frequently check oxygen delivery device to ensure
that the prescribed oxygen concentration is being
delivered.
 Nursing Management of Patient Receiving Oxygen
Therapy CONT:
• Monitor the effectiveness of oxygen therapy by using Arterial
Blood Gas (ABG) analysis and pulse oximetry.

• Monitor patient’s ability to tolerate removal of oxygen while

eating.

• Change oxygen delivery device from mask to nasal prongs during

meals as tolerated.

• Monitor the signs of oxygen toxicity.

• Monitor patient’s anxiety related to need for oxygen therapy.

• Monitor for skin breakdown from friction of oxygen delivery

device.
 Artificial Airways
Pharyngeal Airways
• Pharyngeal airways are used to maintain patency of
patient’s airway by keeping tongue away from
obstructing the upper airway.

• Two types of pharyngeal airways include

oropharyngeal and nasopharyngeal airways.

• Incorrect insertion of airways may cause trauma to

the oral and nasal cavity, gagging, obstruction of
airway due to usage of large airways, laryngospasm
and vomiting.
 Artificial Airways CONT:
Oropharyngeal airways
• Oropharyngeal airways are curved, firm, hollow plastic tubes with a rectangular
opening.

• These airways are available in various sizes.

• The proper size is determined by holding the airway against the side of patient’s
face and measuring the vertical height from the corner of the mouth to the angle
of the jaw.

• Improperly sized oropharyngeal airways cause obstruction of airway. When the

airway is properly placed, the tip of the airway lies above the epiglottis at the base
of the tongue.

• Oropharyngeal airways should be used only in unconscious patients who has

absent or diminish gag reflex.

• Otherwise patients are more prone to vomit as airway insertion induce gag reflex.
 Artificial Airways CONT:

Oropharyngeal airways
 Artificial Airways CONT:
Nasopharyngeal airways
• Nasopharyngeal airways are soft rubber hollow
tubes which are available in various sizes.

• The appropriate size is determined by holding the

airway against the side of patient’s face and ensuring
that it extends from the tip of the nose to the ear
lobe.

• When the airway is properly placed, the tip of the

airway lies above the epiglottis at the base of the
tongue.
Artificial Airways CONT:

Nasopharyngeal airways
 Artificial Airways CONT:
Laryngeal Mask Airways
• The laryngeal mask airway (LMA) is a supraglottic airway device
which is initially used in the operating room setting.

• Currently, it is more commonly used accessory device in the critical

care setting as an important device in the management of difficult
airways.

• It is a safe and effective method of securing an airway and provides

an airtight seal over the glottic opening to provide effective gas
exchange.

• It also can be used as a temporary airway in the field or for

interhospital transport.

• Further, during bronchoscopies and various airway procedures, LMAs

can be used such as percutaneous dilatational tracheostomies.
Artificial Airways CONT:

Laryngeal Mask Airway

 Artificial Airways CONT:
Endotracheal Tubes (ETT)
• Endotracheal tubes are plastic flexible tubes which are available in various sizes.

• ETT are most commonly used for providing short term airway management.

• On one end of the tube has a cuff that is inflated with the use of pilot balloon while
other end of the tube is a 15mm adaptor that facilitates connection to a manual
resuscitation bag, T tube or ventilator.
•
• Endotracheal tubes are mainly indicated for maintenance of airway patency,
protection of airway from aspiration, application of positive pressure ventilation
and use of high oxygen concentrations.

• ETT can be inserted through orotracheal or nasotracheal route. Orotracheal route

is preferred in emergency situations as it is easier to insert.

• However, nasotracheal route provide greater comfort to the patient over time and
used in patients with jaw fracture.
Artificial Airways CONT:

Endotracheal tube
 Artificial Airways CONT:
ETT Intubation
• Rapid sequence intubation (RSI) is a process which
is often used to intubate critically ill patients.

• RSI is considered safer for patients as it reduces the

risk of aspiration.
 Artificial Airways CONT:
ETT Intubation CONT:
Step 1- Preparation
• The first step of RSI is gathering and organizing required
equipment for ETT intubation.

• It include a suction system with catheters, manual

resuscitation bag with a mask connected to 100% oxygen,
a laryngoscope with assorted blades, various sizes of ETTs,
bougie and a stylet.

• All equipment should be in working order.

• In addition, patient should be prepared for the procedure

by inserting an intravenous access and attaching to a
pulse oximetery.
 Artificial Airways CONT:

ETT Intubation CONT:

Step 2- Preoxygenation
• In the second step, 100% oxygen should be
administered for 3-5 minutes via a tight fitting
face mask.

• If the patient is unable to maintain adequate

spontaneous ventilations, then assisted
ventilations are initiated with a manual
resuscitation bag.
 Artificial Airways CONT:
ETT Intubation CONT:
Step 3- Pretreatment
• While the patient is being preoxygenated, patient
should be pretreated with adjunct medications to get
rid of physiologic responses to intubation.

• Atropine, lidocaine and fentanyl are commonly used

medications in this step.

• If possible, pretreatment should be administered 3

minutes before the next step.
 Artificial Airways CONT:
ETT Intubation CONT:
Step 4- Paralysis with Induction
• In this step, paralytic agent and sedative agent are
administered to achieve induction and paralysis.

• Sedative agents, such as midazolam, ketamine, etomidate and

propofol are used to facilitate rapid loss of consciousness.

• To achieve muscle paralysis, succinylcholine and rocuronium

are commonly used.

• Cricoid s pressure should be applied with the loss of eyelash

reflex to protect the airway by preventing vomiting and
aspiration.
 Artificial Airways CONT:
ETT Intubation CONT:
Step 5- Protection and Positioning
• The patient should be positioned with neck flexed
and head slightly extended in the sniff position.

• Dental devices should be removed if present.

• The oral cavity and pharynx should be suctioned.

 Artificial Airways CONT:
ETT Intubation CONT:
Step 6- Placement of ETT
• Next, ETT is inserted into the trachea, cuff is inflated and
placement is confirmed.

• Then patient is assessed for bilateral breath sounds and chest

movements.

• Absence of breath sounds indicate esophageal intubation

whereas breath sounds heard over one side indicate main
stem bronchial intubation.

• Once the tube placement is verified, remove cricoid pressure.

Finally chest radiograph is taken to confirm the tube
placement.
 Artificial Airways CONT:
ETT Intubation CONT:
Step 7- Post Intubation Management
• Finally, ETT is secured to patient’s face by pasting a
plaster tape.

• Thus, it prevents tube movement and potential

dislodgement.

• Note the level at the incisor teeth and record in

notes and handover at each change of shift.
 Artificial Airways CONT:
ETT Intubation CONT:
Complications associated with ETT intubation

• Complications associated with ETT intubation include;

 Nasal and oral trauma
 Pharyngeal trauma
 Vomiting
 Aspiration
 Tracheal rupture (rare)
 Hypoxemia and hypercapnia

• In addition, nasal and oral inflammation and ulceration, laryngeal and

tracheal injuries, sinusitis, otitis, tube obstruction and displacement can
occur due to ETT in place.

• On the other hand some complications can occur days to weeks after
removing the ETT. These include; laryngeal and tracheal stenosis and cricoid
abscess.
 Artificial Airways CONT:
Tracheostomy Tubes
• Tracheostomy tube is the preferred way of managing airway when long
term intubation is required.

• Further, tracheostomy is indicated in conditions such as upper airway

obstruction due to trauma, tumors or swelling and need to facilitate airway
clearance due to spinal cord injury.

• Tracheostomy tubes are made up of plastic or metal and may have single or
double lumens.

• Single lumen tracheostomy tubes contain a cuff which is connected to a

pilot balloon and an obturator, which is used during tube insertion.

• Double lumen tracheostomy tubes consist of cuff, obturator and an inner

cannula, that can be removed and reinserted when do cleaning.
Artificial Airways CONT:

Tracheostomy tube
 Artificial Airways CONT:
Tracheostomy Tubes
• Tracheostomy tube provide the best route of long term
airway management as it avoid oral, nasal, pharyngeal and
laryngeal complications linked with ETT.

• The tube is shorter, wider in diameter and less curved than

ETT thus, resistance to air flow is minimal and make breathing
easier.

• Other advantages of tracheostomy tube include easier

suctioning, greater comfort to the patient, capability of
patient to eat or talk if possible and easier ventilator weaning.
 Artificial Airways CONT:
Tracheostomy Tubes
Complications associated with Tracheostomy tube
• Complications associated with tracheostomy tube insertion
include;
 Misplacement of the tracheostomy tube
 Haemorrhage
 Laryngeal nerve injury

• In addition, stomal infection, tracheoesophageal fistula,

haemorrhage, tube obstruction and displacement can occur due
to tracheostomy tube in place.

• On the other hand some complications can occur days to weeks

after removing the tracheostomy tube.

• These include; tracheal stenosis and tracheocutaneous fistula.

 Nursing Management of Patient with an Artificial
Airway

• Nursing interventions for the patient with an

artificial airway include
providing humidification,
managing the cuff,
suctioning,
establishing method of communication and
providing oral care.
 Nursing Management of Patient with an Artificial
Airway CONT:

Humidification
• In normal circumstances, humidification is carried out by mucosal
layer of the upper respiratory tract.

• However, external means of humidification is required when this

area has bypassed as occurs with ETT and tracheostomy tubes or
when supplemental oxygen is used.

• Various humidification devices add water to inhaled gas to prevent

drying and irritation of respiratory tract, to prevent undue loss of
body water, and to facilitate secretion removal.

• The humidification should provide inspired gas conditioned

(heated) to body temperature and saturated with water vapor.
 Nursing Management of Patient with an Artificial
Airway CONT:

Cuff Management
• Generally low pressures, high volume cuffed tubes
are used in order to prevent complications.

• Proper cuff inflation techniques and cuff pressure

monitoring are crucial when caring with a patient
with artificial airway.
 Nursing Management of Patient with an Artificial
Airway CONT:

Suctioning
• Suctioning is a sterile procedure and often essential to
maintain the patency of airway in patients with an ETT or
tracheostomy tube.

• Indications for suctioning include coughing, secretions in the

airway, respiratory distress, presence of rhonchi on
auscultation, increased peak airway pressures on the
ventilator, and decreasing oxygenation saturation.

• Complications associated with suctioning include, hypoxemia,

atelectasis, bronchospasms, dysrhythmias, increased
intracranial pressure and airway trauma.
 Nursing Management of Patient with an Artificial
Airway CONT:

Endotracheal Extubation
• Extubation is the process of removing ETT.

• Before the cuff of an ETT is deflated, in preparation for

removal, it is essential to remove secretions which may
present above the tube cuff.

• Complications of extubation include; sore throat,

stridor, hoarseness, vocal cord immobility, pulmonary
aspiration and cough.
 Nursing Management of Patient with an Artificial
Airway CONT:
Nursing interventions associated with the removal of ETT from
nasopharyngeal or oropharyngeal airway

• Elevate the head of bed to 75 degrees.

• Instruct patient about the procedure.
• Oxygenate patient and suction endotracheal tube.
• Deflate endotracheal cuff and remove ETT.
• Encourage patient to cough and expectorate sputum.
• Administer oxygen as ordered.
• Encourage coughing and deep breathing.
• Suction airway if necessary.
• Monitor for respiratory distress.
• Monitor vital signs.
• Encourage voice rest for 4-8 hours as appropriate.
• Monitor ability to swallow and talk.
 Invasive Mechanical Ventilation

• Mechanical ventilation is the process of using an

apparatus to facilitate respiration for the purpose of
enhancing pulmonary gas exchange.

• Indications for mechanical ventilation include

reversing hypoxemia, hypercarbia; relieving
respiratory distress, preventing atelectasis and
respiratory muscle fatigue, permitting sedation,
decreasing oxygen consumption, and stabilizing the
chest wall.
Invasive Mechanical Ventilation CONT:

Ventilator
 Invasive Mechanical Ventilation CONT:
Types of Ventilators
• There are two types of ventilators; such as positive
pressure ventilators and negative pressure
ventilators.

• Negative pressure ventilators are applied externally

to patients and diminish the atmospheric pressure
surrounding the thorax to initiate inspiration.

• Positive pressure ventilators use a mechanical drive

to mechanism to force air into patient’s lungs
through ETT or tracheostomy tube.
 Invasive Mechanical Ventilation CONT:

Ventilator Mechanics
• In order to ventilate the patient properly, there are
four phases of ventilations such as; trigger, limit,
cycle and baseline to complete by the ventilator.

• The ventilator uses four different variables such as;

volume, pressure flow and time to begin, sustain,
and terminate each of these phases.
 Invasive Mechanical Ventilation CONT:
Ventilator Mechanics CONT:

Trigger
• Initiate the change from exhalation to inspiration.

• Breaths may be pressure triggered or flow triggered depending on sensitivity setting of

ventilator and patient’s inspiratory effort; or time triggered, depending on the rate
setting of the ventilator.

Limit
• Maintain the inspiration. Breaths can be pressure limited, flow limited or volume
limited. Limit variable only sustain inspiration and not end it.

Cycle
• End the inspiration. Breaths can be pressure cycled, flow cycled or volume cycled and
time cycled.

Baseline
• Variable that controlled during exhalation. Pressure is almost always used to adjust this
variable.
 Invasive Mechanical Ventilation CONT:

Ventilator Settings
• Each ventilator has a patient monitoring system
that allows all aspects of the patient’s ventilator
pattern to be assessed, monitored and exhibited.
Ventilator Settings –table.
 Invasive Mechanical Ventilation CONT:

Complications of Mechanical Ventilation

• Ventilator induced lung injury
• Cardiovascular compromise
• Gastrointestinal disturbances
• Patient-ventilator dyssynchrony
• Ventilator associated pneumonia
 Invasive Mechanical Ventilation CONT:
Weaning
• The gradual withdrawal of mechanical ventilator and the re-
establishment of spontaneous breathing are known as
weaning.

• Weaning should begin only after the requirement for

ventilator support has been corrected and patient stability
has been achieved.

• Length of time on ventilator, sleep deprivation and nutritional

status also required to consider before start weaning.

• Factors that affect patient’s ability to wean include ability of

the lungs to participate in ventilation, respiration,
cardiovascular performance and psychological readiness.
 Invasive Mechanical Ventilation CONT:
Readiness to Wean
• All patients who are in mechanical ventilation
should be screened daily to recognize their
readiness to wean.

• The screen should include level of consciousness

psychological and hemodynamic stability, adequacy
of oxygenation and ventilation, spontaneous
breathing capacity and respiratory rate and pattern.
 Invasive Mechanical Ventilation CONT:
Weaning methods

• Weaning method selected depend on the patient,

patient’s pulmonary status, and length of time on
the ventilator.

• T-piece trials, SIMV, PSV are the main types of

weaning methods.
 Invasive Mechanical Ventilation CONT:

T piece trials
• T piece trials involve alternating periods of ventilatory support
(usually ACV or CMV) and periods of spontaneous breathing.

• The trial initiated by removing patient from ventilator and allowing

breathing spontaneously on a T-piece oxygen delivery system. After a
set amount of time, it is required to place the patient back on the
ventilator again.

• The goal of this trial is to progressively increase the time which is

spent off the ventilator.

• During the weaning process, the patient is observed closely for

respiratory muscle fatigue.
 Invasive Mechanical Ventilation CONT:

SIMV
• The goal of SIMV weaning is the gradual transition from
ventilator support to spontaneous breathing.

• SIMV weaning is begun by placing the ventilator in the

SIMV mode and slowly decreasing the rate.

• This method increase work of breathing.

• The patient should be closely monitored for signs of

respiratory muscle fatigue.
 Invasive Mechanical Ventilation CONT:

Pressure Support
• This method consists of placing the patient on the
pressure support mode and setting the pressure at a
level that make easier the patient’s achieving a
spontaneous tidal volume of 10-12mL/Kg.

• PSV augments the patient’s spontaneous breaths with a

positive pressure. During the weaning process, the level
of pressure support is gradually reduce in increments of
3-6 cmH2O, while the tidal volume is maintained at 10-
15mL/Kg until a level of 5 cmH2O is achieved.
 Invasive Mechanical Ventilation CONT:
Weaning intolerance indicators
• Decrease level of consciousness
• Systolic blood pressure increased or decreased by 20mmHg
• Diastolic blood pressure greater than 100mmHg
• Heart rate increased by 20beats/minute
• Respiratory rate greater than 30 breaths per minute or less than 10 breaths per
minute
• Respiratory rate increased by 10 breaths per minute
• Spontaneous tidal volume less than 250mL
• Arterial partial pressure of CO2 increased by 5-10mmHg, pH less than 7.30 or both
• Oxygen saturation based on pulse oximeter less than 90%
• Use of accessory muscles of ventilation
• Diaphoresis
• Paradoxical chest wall movement or chest abdominal asynchrony
 Nursing Management of Patient with Mechanical Ventilation

• Consult with other health care professional in selection of a ventilator mode

(initial mode usually volume control with breath rate).

• Initiate setup and application of the ventilator.

• Ensure that ventilator alarms are on.

• Monitor ventilator settings including temperature and humidification frequently.

• Check all ventilator connections regularly.

• Administer muscle paralyzing agents, sedatives as ordered.

• Monitor for conditions that increase oxygen consumption (fever, seizure,

shivering, pain).

• Monitor for factors that indicate increased work of breathing (lowered head of
the bed, biting of ETT, condensation in ventilator tubes).
Nursing Management of Patient with Mechanical Ventilation
• Monitor for symptoms that indicate increased work of breathing
(increased heart rate or respiratory rate, increased BP).

• Use aseptic techniques when suctioning.

• Monitor pulmonary secretions for amount, color and consistency.

• Pause NG feeding during suctioning and 30 minutes before chest

physiotherapy.

• Monitor for mucosal damage to oral, nasal and tracheal tissue.

• Promote adequate fluid and nutritional intake.

• Document all changes to ventilator settings with rationale for

changes.
THANK YOU