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Respiratory Therapy 101

Respiratory Therapy 101. Understanding Oxygen Therapy in less than an Hour. Oxygen Cannula. Can safely be used at flow rates of 1-6 LPM Flow should not be turned above 6 LPM Produces 24% to 44% oxygen to patient. Oxygen Cannula. Liter Flow. % Oxygen. 24% 28% 32% 36% 40% 44%. 1 2

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Respiratory Therapy 101

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  1. Respiratory Therapy 101 Understanding Oxygen Therapy in less than an Hour

  2. Oxygen Cannula • Can safely be used at flow rates of 1-6 LPM • Flow should not be turned above 6 LPM • Produces 24% to 44% oxygen to patient

  3. Oxygen Cannula Liter Flow % Oxygen 24% 28% 32% 36% 40% 44% 1 2 3 4 5 6

  4. Oxygen Humidifiers • Used with oxygen cannulas to prevent nasal drying • May not be used at flow rates less than 3LPM (need to bubble to be effective) • Check water level and change as needed

  5. Oxygen Humidifiers

  6. Reservoir Cannulas • Stores oxygen in a reservoir on exhalation so the patient has more oxygen available on inhalation • Capable of providing higher oxygen percentage at a lower flow rate

  7. Two styles of Reservoir Cannulas

  8. Simple Oxygen Mask • Flow rate should be from 5 to 10 LPM • Flow rate should NOT be Less than 5 LPM • Oxygen delivery is approximately 35% to 50% • Short term use only • No Humidity

  9. Simple Mask

  10. 100% Non-Rebreather Mask • Set oxygen flow to a setting that does not allow the reservoir bag to collapse with the patient’s inspiration (10 – 15 LPM) • If tight fitting to patient’s face, 100% oxygen can be given • Usual oxygen percentage is 60% to 80% • USED BY EMS

  11. Non-rebreather Masks

  12. High Flow Systems Air Entrainment Mask(Venturi) • Percent of oxygen delivered depends on the LPM flow, the size of the jet, and the size of the entrainment port • Delivers a precise oxygen percentage • Entrainment ports must be kept open • Most accurate way to deliver O2 • Ideal for CO2 retainers

  13. High Flow System Air Entrainment Mask

  14. High Flow System Air Entrainment Mask • The flow of 100% oxygen through the mask and draws in a controlled amount of room air (21 per cent oxygen). • Commonly available masks deliver 24, 28, 31, 35, or 40 per cent oxygen. At concentrations above 24 per cent, humidification may be required. (Color coded – depending on manufacturer)

  15. High Flow System Air Entrainment Mask

  16. Oxygen Blender • Controls precisely the percent of oxygen the patient is receiving • High flow meter is required for use

  17. Oxygen Blender

  18. How do I know if my Patient is Oxygen Deprived??? ?

  19. Clinical Respiratory Signs of Hypoxia MILD to MODERATE SEVERE Tachypnea Dyspnea Cyanosis • Tachypnea • Dyspnea • Paleness

  20. Cardiovascular Signs of Hypoxia MILD to MODERATE SEVERE Tachycardia, eventual bradycardia, arrhythmia Hypertension and eventual hypotension • Tachycardia • Mild Hypertension • Peripheral Vasoconstriction

  21. Neurologic Signs of Hypoxia MILD to MODERATE SEVERE Somnolence Confusion Distressed appearance Blurred Vision Loss of Coordination Impaired judgment Slow reaction time Manic-Depressive activity Coma • Restlessness • Disorientation • Headaches • Lassitude

  22. Monitoring Oxygen with an Oximeter • Monitors the adequacy of arterial oxyhemoglobin saturation • Usually maintained at values above 90% • Only provides valuable data when patient has normal hemoglobin • Light and nail polish can alter saturation readings

  23. ETCO2 Monitoring Used with post surgical patients on PCA pumps, Epidurals and Mechanically Vented patients ETCO2 – measures ventilation, not saturation (end product of breathing is CO2) (See pamphlet)

  24. Monitoring Oxygen with ABG’s • Pa02 reflects oxygenation levels • Normal Pa02 is 80-100mmHg (<60 mmHg-needs intervention). • Pa02 Values below 55 mmHg are Critical • Normal Pa02 values decrease with age • Hypoxemia – low PaO2 <80

  25. ABG Review • pH = 7.35 to 7.45 <7.35 Acidic and > 7.45 Alkalotic • PaC02 = 35 to 45 • HC03 = 22-26 (28) • Cost of ABG ($800-$1500/draw) • Invasive Procedure • ROME = Respiratory – Opposite direction Metalbolic – Equal (same) direction

  26. What is CPAP??? • Continuous Positive Airway Pressure • Application of positive pressure to a patient’s airway throughout the respiratory cycle • Increases the patient’s FRC (functional residual capacity) • Improves oxygenation • Also, used to prevent airway collapse in treatment of obstructive sleep apnea

  27. What is BiPAP?? Non-Invasive Positive Pressure Ventilation (NIPPV) • Provides two levels of pressure to the patient • One pressure on the inspiration (IPAP) • One pressure on the expiration (EPAP) • May be used in patients with acute, short-term respiratory problems to avoid intubation and invasive mechanical ventilation • Improves the ability to remove CO2 and provide O2

  28. Facial and Nasal Masks

  29. Non-Invasive Positive Pressure Ventilator Support

  30. FiO2 • Fractional concentrated of inspired oxygen delivered • Percentage of Oxygen delivered or participating in gas exchange in the alveoli (0.21 to 1.0) • Expressed in %. (0.35 is 35%).

  31. Oh my GOD!! My patient is on a ventilator!

  32. Drager Ventilator

  33. BASIC VENTIALTOR MODES • VOLUME CONTROLLED – • tidal volume (volume of air inhaled) • PRESSURE CONTROLLED – • PIP (positive inspiratory pressure)

  34. Basic Ventilator ParametersBreath Rate (f) • Number of times per minute that inspiration is initiated (controlled by ventilator, patient or combination of both). • Two things to know: • Ventilator Setting (rate) (f) • Patient Rate (BPM) • Rate (f) setting and Patient breathing rate are not the same thing

  35. Basic Ventilator ParametersTidal Volume (vT) • Amount of gas delivered during an inspiration in ml or liters • Average adult tidal volume is 500-550 ml or .500 -.550 L • Setting in volume control modes • Not a setting but volume readings are measured in pressure control modes

  36. Basic Ventilator ParametersPeak Inspiratory Pressure (PIP) • Maximum pressure reached in the ventilator system during inspiration • Set parameter in pressure setting modes (Pressure Controlled Ventilation - PCV)

  37. PEEP • Positive End Expiratory Pressure • Application of a constant, positive pressure such that at the end of exhalation, airway pressure does not return to zero • Improves oxygenation

  38. Basic Ventilator ParametersBreath Types • Mandatory – ventilator controls all parts of breathing • Spontaneous – patient controls all parts of breathing • Assisted Breaths – patient controls breathing rate, breaths are assisted with a set Vt (tidal volume)

  39. Basic Ventilator ParametersCommon Modes of Ventilation • CMV • A/C • VC • SIMV • SIMV + PS • PSV

  40. CMV Mode (volume)most common type used is Assist Control (A/C) • Continuous mandatory ventilation • Continuous mechanical ventilation • Every breath is mandatory or assisted • Set minimum breath rate • CMV – patient does not determine breathing rate. • A/C – patient determines breathing rate. • Patient does not work • Delivery of a mandatory or assisted breath at a set rate

  41. SIMV Mode (volume , sometimes pressure) • A minimum number of breaths delivered with a tidal volume (assisted) is set on the ventilator. • Respiratory rate and tidal volumes are set • Patient may breath spontaneously between the number of set assisted breaths • Weaning mode (usually) • Set PEEP and sometimes pressure support is set

  42. Pressure Controlled Ventilation (pressure) • Delivers breaths at a preset pressure limit (equal to PIP). • When ventilator delivers a breath, it continues delivering the volume until the pre-set pressure limit is reached, then it stops delivering the breath. • Settings: Pressure limit (PIP) and I:E ratio but not the tidal volume (tidal volume will vary). • IMPORTANT NOTE: “unnatural feeling of breathing” – NEEDS SEDATION! • With control modes – increases mean airway and intrathoracic pressures rise, may decrease Cardiac Output, very important to monitor hemodynamics (BP, HR, CVP)

  43. Pressure Support Ventilation PSV (pressure) • Augments or assists spontaneous breathing efforts by delivering a high flow air to a selected pressure level early in inspiration and maintains that level throughout the inspiratory phase. • When PSV is used as a stand-alone mode the pressure support level is adjusted to achieve the targeted tidal volume and respiratory rate. (Vt and f are not set - patient determines own respiratory rate and tidal volume • Reduces the work of breathing for the patient by reducing the resistance of breathing through an ET tube and circuit tubing. • A lot of time this mode is combined with SIMV and CPAP mode. • At High pressures PSV can provide nearly total ventilator support. • Because level of pressure can be gradually decreased, endurance conditioning is enhanced in PSV modes. Great for weaning!

  44. CPAP Mode (pressure) • Not the same as CPAP by mask at home or is it???? • Supplies pressure throughout the respiratory cycle, helping to improve oxygenation in spontaneously breathing patients. • No setting on ventilator for rate or tidal volumes (patient determines own rate and their own tidal volume). • FiO2, PEEP, PS (pressure support) can be set. • Should not over sedate people on this mode. • Monitor breathing rate, apnea alarms!! • May be used on intubated or non-intubated patients via mask.

  45. Alarms • High inspiratory pressure or pressure limit • Low inspiratory pressure • Low exhaled tidal volume • High or low minute volume • Apnea • High rate or frequency • Low PEEP/CPAP

  46. High Inspiratory Pressure Alarm • Coughing • Secretions in the airway • Biting on the ET tube • Bronchospasm • Patient Ventilator asynchrony • Kinking of ventilator circuit

  47. Low Inspiratory Pressure • Low exhaled volume • Patient Disconnected • Circuit Leaks • Airway leaks

  48. When in Doubt Always Ask!!Your Respiratory Therapist Is Your Friend!!!!!!! They are here to help! And to keep your patients breathing forever!

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