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PRINCIPLES OF OXYGEN THERAPY 2.

Reservoir System
A reservoir system incorporates some type of device
The goal of oxygen therapy is to provide a sufficient to collect and store oxygen between breaths. When
concentration of inspired oxygen to permit full use of the the patients inspiratory flow exceeds the oxygen
oxygen-carrying capacity of the arterial blood; this flow of the oxygen delivery system
ensures adequate cellular oxygenation, provided the The patient is able to draw from the reservoir of
cardiac output and hemoglobin concentration are oxygen to meet his or her inspiratory volume needs.
adequate Less mixing of the inspired oxygen occurs with room
Oxygen is an atmospheric gas that must also be air than in a low-flow system.
considered a medication becauselike most other A reservoir oxygen delivery system can deliver a
medicationsit has detrimental as well as beneficial higher Fio2 than a low-flow system.
effects. Examples of reservoir systems are simple face
As a medication, it must be administered for good reason masks, partial rebreathing masks, and
and in a proper, safe manner. nonrebreathing masks
Oxygen is usually ordered in liters per minute (L/min), as 3. High-Flow System
a concentration of oxygen expressed as a percentage With a high-flow system, the oxygen flows out of the
(e.g.,40%), or as a fraction of inspired oxygen (Fio2) such device and into the patients airways in an amount
as 0.4. sufficient to meet all inspiratory volume
The primary indication for oxygen therapy is hypoxemia requirements.
The amount of oxygen administered depends on the This type of system is not affected by the patients
pathophysiologic mechanisms affecting the patients ventilatory pattern.
oxygenation status. In most cases, the amount required A high-flow system uses either an air-entrainment
should provide an arterial partial pressure of oxygen system or blending system to mix air and oxygen to
(Pao2) of greater than 60 mmHg or an arterial achieve the desired Fio2
hemoglobin saturation (Sao2) of greater than 90% during
rest and exercise. OXYGEN TOXICITY
The concentration of oxygen given to an individual The lung is designed to handle a concentration of 21%
patient is a clinical judgment based on the many factors oxygen, with some adaptability to higher concentrations,
that influence oxygen transport such as hemoglobin but adverse effects and oxygen toxicity can result if a
concentration, cardiac output, and arterial oxygen high concentration is administered for too long
tension It can occur in any patient who breathes oxygen
After oxygen therapy has begun, the patient is concentrations of greater than 50% for longer than 24
continuously assessed for level of oxygenation and the hours.
factors affecting it. The patients oxygenation status is Patients most likely to develop oxygen toxicity are those
evaluated several times daily until the desired oxygen who require intubation, mechanical ventilation, and high
level has been reached and has stabilized. oxygen concentrations for extended periods.
If the desired response to the amount of oxygen Hyperoxia, or the administration of higher-than-normal
delivered is not achieved, the oxygen supplementation is oxygen concentrations, produces an overabundance of
adjusted, and the patients condition is re-evaluated. It is oxygen free radicals. These radicals are responsible for
important to use this dose-response method so that the the initial damage to the alveolarcapillary membrane.
lowest possible level of oxygen is administered that will Oxygen free radicals are toxic metabolites of oxygen
still achieve a satisfactory Pao2 or Sao2. metabolism. Normally, enzymes neutralize the radicals,
preventing any damage from occurring. During the
METHODS OF DELIVERY administration of high levels of oxygen, the large number
1. Low Flow Systems of oxygen free radicals produced exhausts the supply of
Provide supplemental oxygen directly into patients neutralizing enzymes. Damage to the lung parenchyma
airway and vasculature occurs, resulting in the initiation of acute
8L/min or less respiratory distress syndrome (ARDS).
Because this flow is insufficient to meet the patients Signs and Symptoms:
inspiratory volume requirements, it results in a o Substernal chest pain
variable Fio2 as the supplemental oxygen is mixed o Dry cough
with room air. o Tracheal irritation
The patients ventilatory pattern affects the Fio2 of a o Pleuritic pain occurs on inhalation
low-flow system: as this pattern changes, differing o Dyspnea
amounts of room air gas are mixed with the constant o Nasal stuffiness
flow of oxygen. o Sore throat
A nasal cannula is an example of a low-flow device o Eye and ear discomforts
CARBON DIOXIDE RETENTION ARTIFICIAL AIRWAYS
In patients with severe chronic obstructive pulmonary 1. Oropharyngeal Airway
disease (COPD), carbon dioxide (CO2) retention may An oropharyngeal airway is made of plastic and is
occur as a result of administration of oxygen in high available in various sizes.
concentrations. The proper size is selected by holding the airway
A number of theories have been proposed for this against the side of the patients face and ensuring
phenomenon. that it extends from the corner of the mouth to the
o One states that the normal stimulus to breathe (i.e., angle of the jaw.
increasing CO2 levels) is muted in patients with COPD If the airway is improperly sized, it will occlude the
and that decreasing oxygen levels become the airway
stimulus to breathe. If hypoxemia is corrected by the An oral airway is placed by inserting a tongue
administration of oxygen, the stimulus to breathe is depressor into the patients mouth to displace the
abolished; hypoventilation develops, resulting in a tongue downward and then passing the airway into
further increase in the arterial partial pressure of the patients mouth, slipping it over the patients
carbon dioxide (Paco2) tongue
o Another theory is that the administration of oxygen When properly placed, the tip of the airway lies
abolishes the compensatory response of hypoxic above the epiglottis at the base of the tongue. It
pulmonary vasoconstriction. This results in an should be used only in an unconscious patient who
increase in perfusion of underventilated alveoli and has an absent or diminished gag reflex
the development of dead space, producing 2. Nasopharyngeal Airway
ventilationperfusion mismatch. As alveolar dead A nasopharyngeal airway is usually made of plastic
space increases, so does the retention of CO2. or rubber and is available in various sizes.
o One further theory states that the rise in CO 2 is The proper size is selected by holding the airway
related to the ratio of deoxygenated to oxygenated against the side of the patients face and ensuring
hemoglobin (Haldane effect). Deoxygenated that it extends from the tip of the nose to the ear
hemoglobin carries more CO2 compared with lobe.
oxygenated hemoglobin. Administration of oxygen A nasal airway is placed by lubricating the tube and
increases the proportion of oxygenated hemoglobin, inserting it midline along the floor of the naris into
which causes increased release of CO2 at the lung the posterior pharynx. When properly placed, the tip
level. Because of the risk of CO2 accumulation, all of the airway lies above the epiglottis at the base of
patients who are chronically hypercapnia require the tongue.
careful low-flow oxygen administration. 3. Endotracheal Tubes
An endotracheal tube (ETT) is the most commonly
ABSORPTION ATELECTASIS used artificial airway for providing short-term airway
Breathing high concentrations of oxygen washes out the management.
nitrogen that normally fills the alveoli and helps hold Indications for endotracheal intubation include
them open (residual volume). As oxygen replaces the maintenance of airway patency, protection of the
nitrogen in the alveoli, the alveoli start to shrink and airway from aspiration, application of positive-
collapse. pressure ventilation, facilitation of pulmonary toilet,
This occurs because oxygen is absorbed into the and use of high oxygen concentrations.
bloodstream faster than it can be replaced in the alveoli, An ETT may be placed through the orotracheal or
particularly in areas of the lungs that are minimally the nasotracheal route
ventilated. Rapid Sequence Intubation
o Preparation- Readily available equipment should
NURSING MANAGEMENT include a suction system with catheters and
Key nursing interventions include ensuring the oxygen is tonsil suction, an MRB with a mask connected to
being administered as ordered and observing for 100% oxygen, a laryngoscope handle with
complications of the therapy. assorted blades, a variety of sizes of ETTs, and a
Confirming that the oxygen therapy device is properly stylet.
positioned and replacing it after removal is important. o Preoxygenation- the patient is preoxygenated
During meals, an oxygen mask should be changed to a with 100% oxygen for 3 to 5 minutes via a tight-
nasal cannula if the patient can tolerate one. fitting face mask. If the patient is unable to
The patient receiving oxygen therapy should also be maintain adequate spontaneous ventilations,
transported with the oxygen. then assisted ventilations are initiated with an
In addition, oxygen saturation should be periodically MRB.The goal is to avoid positive pressure
monitored using a pulse oximeter. ventilation, if possible, as this intervention
increases the chances of gastric distention and
the risk of aspiration.
o Treatment- These medications include lidocaine, o Hypertension
fentanyl, and atropine. A very low dose of a 4. Tracheostomy tubes
paralytic agent may be administered to prevent tracheostomy tube is the preferred method of
fasciculations. airway maintenance in the patient who requires
o Paralysis with Induction- a sedative agent and a long-term intubation.
paralytic agent are administered in rapid Although no ideal time to perform the procedure has
sequence to achieve induction and paralysis. A been identified, it is commonly accepted that if a
variety of sedative agents, including etomidate, patient has been intubated or is anticipated to be
midazolam, ketamine, and propofol, are used to intubated for longer than 7 to 10 days, a
facilitate rapid loss of consciousness. Induction tracheostomy should be performed
dosages for these medications are usually A tracheostomy tube provides the best route for
slightly higher than the typical dosages used for long-term airway maintenance because it avoids the
sedation. The two most administered oral, nasal, pharyngeal, and laryngeal complications
neuromuscular blocking agents used to facilitate associated with an ETT. The tube is shorter, of wider
skeletal muscle relaxation are succinylcholine diameter, and less curved than an ETT; the
and rocuronium resistance to air flow is less, and breathing is easier.
o Protection and Positioning- The procedure is Additional advantages of a tracheostomy tube
initiated by positioning the patient with the include easier secretion removal, increased patient
neck flexed and head slightly extended in the acceptance and comfort, capability of the patient to
sniff position. The oral cavity and pharynx are eat and talk if possible, and easier ventilator
suctioned, and any dental devices are removed. weaning
Next cricoid pressure is applied to protect the Tracheostomy tubes are made of plastic or metal
airway by preventing vomiting and subsequent and may have one or two lumens. Single-lumen
aspiration of gastric contents. tubes consist of the tube; a built-in cuff, which is
o Placement of the Endotracheal Tube- the ETT is connected to a pilot balloon for inflation purposes;
inserted into the trachea, and placement is and an obturator, which is used during tube
confirmed. Each intubation attempt is limited to insertion.
30 seconds to prevent hypoxemia. After the ETT The double-lumen tubes consist of the tube with the
is inserted, the patient is assessed for bilateral attached cuff, the obturator, and an inner cannula
breath sounds and chest movement. Absence of that can be removed for cleaning and then
breath sounds is indicative of an esophageal reinserted or, if disposable, replaced by a new sterile
intubation, whereas breath sounds heard over inner cannula. The inner cannula can quickly be
only one side is indicative of a main stem removed if it becomes obstructed, making the
intubation. A disposable end-tidal CO2 detector system safer for patients with significant secretion
is used to initially verify correct airway problems. Single-lumen tubes provide a larger
placement, after which the cuff of the tube is internal diameter for airflow, so airflow resistance is
inflated and the tube is secured. Finally, a chest reduced, and the patient can ventilate through the
radiograph is obtained to confirm placement. tube with greater ease
The tip of the ETT should be approximately 3 to A tracheostomy tube is inserted by an open
4 cm above the carina when the patients head procedure or a percutaneous procedure
is in the neutral position. Complications during tracheostomy procedure
o Post-intubation management- After final o misplacement of the tracheal tube,
adjustment of the position is complete, the level o hemorrhage
of insertion (marked in centimeters on the side o laryngeal nerve injury
of the tube) at the teeth is noted. The ETT is o pneumothorax
then secured to patients face using tape or a o pneumomediastinum
commercial tube holder o cardiac arrest
Complications: Complications while the tracheostomy tube is in
o Nasal and oral trauma place
o Pharyngeal and hypopharyngeal trauma o Stomal infection
o Vomiting with aspiration o Hemorrhage
o Cardiac arrest o Tracheomalacia
o Tracheal rupture o Tracheoesophageal fistula
o Hypoxemia o Tracheoinnominate artery fistula
o Hypercapnia -> bradycardia o Tube obstruction and displacement
o Tachycardia Nursing Management
o Dysrhythmias
o Hypertension
o Providing humidification, managing the cuff, Limiting duration of suction to 10-15
suctioning, establishing a method of secs
communication, and providing oral hygiene. o Because the tube does not allow air flow over
o Because the tube bypasses the upper airway the vocal cords, developing a method of
system, warming and humidifying of air must be communication is also very important.
performed by external means. o Last, observing the patient to ensure proper
o Because the cuff of the tube can cause damage placement of the tube and patency of the
to the walls of the trachea, proper cuff inflation airway is essential.
and management are imperative. o Patient safety is critically important when caring
o CUFF INFLATION for a patient with an artificial airway, as loss of
The ML technique consists of injecting air the tube can result in loss of the patients
into the cuff until no leak is heard and then airway.
withdrawing the air until a small leak is o In the event of unintentional extubation or
heard on inspiration. Problems with this decannulation, the patients airway should be
technique include difficulty maintaining opened with the head tiltchin lift maneuver
positive end-expiratory pressure (PEEP) and and maintained with an oropharyngeal or
aspiration around the cuff. nasopharyngeal airway.
The MOV technique consists of injecting air o If the patient is not breathing, he or she should
into the cuff until no leak is heard at peak be manually ventilated with a manual
inspiration. This technique generates higher resuscitation bag and face mask with 100%
cuff pressures than does the ML technique oxygen.
o CUFF MONITORING o In the case of a tracheostomy, the stoma should
Cuff pressures should be maintained at 20 be covered to prevent air from escaping through
to 25 mm Hg (24 to 30 cm H2O) because it.
greater pressures decrease blood flow to o If the tracheostomy remains open then
the capillaries in the tracheal wall and lesser consideration should be given to ventilating the
pressures increase the risk of aspiration. patient through the stoma instead of the mouth.
Pressures in excess of 25 mm Hg (30 cm
H2O) should be reported to the physician. POSITION THERAPY
Cuffs are not routinely deflated because Positioning therapy can help match ventilation and
this increases the risk of aspiration perfusion through the redistribution of oxygen and
o In addition, the normal defense mechanisms are blood flow in the lungs, which improves gas
impaired and secretions may accumulate; thus, exchange. On the basis of the concept that
suctioning may be needed to promote secretion preferential blood flow occurs to the gravity-
clearance. dependent areas of the lungs, positioning therapy is
Complications: used to place the least damaged portion of the lungs
Hypoxemia into a dependent position. The least damaged
Atelectasis can occur when the suction portions of the lungs receive preferential blood flow,
catheter is larger than one half of the resulting in less ventilationperfusion mismatch.
diameter of the ETT. Excessive negative 1. Prone Positioning
pressure occurs when suction is used to improve oxygenation in patients with
applied, promoting collapse of the ARDS
distal airways It involves turning the patient completely over
Bronchospasms onto his or her stomach in the face-down
Cardiac dysrhythmias position.
Airway trauma Prone positioning can be used to facilitate the
Protocol mobilization of secretions and provide pressure
relief.
Hypoxemia can be minimized by giving
Prone positioning is contraindicated in patients with
the patient three hyperoxygenation
increased intracranial pressure, hemodynamic
breaths (100%Fio2) before suctioning
instability, spinal cord injuries, or abdominal surgery.
If exhibits signs of desat, hyperinflation
Patients who are unable to tolerate the face-down
(breaths at 150% tidal volume) should
position are also not appropriate candidates for this
be added
type of therapy
Atelectasis can be avoided by using a
2. Rotation Position
catheter with external diameter of less
May sosyal na bed
than one half of the internal diameter
Automated turning beds to provide rotation
of the ETT
therapy are often used in the critical care
setting. Kinetic therapy and continuous lateral
rotation therapy (CLRT) are two forms of
rotation therapy. The patient is continuously
turned from side to side with a rotation of 40
degrees or greater (kinetic therapy) or with a
rotation of less than 40 degrees (CLRT

PHARMACOLOGY
Bronchodilators and Adjuncts
Medications to facilitate removal of secretions and
dilate airways are of major benefit in the treatment
of pulmonary disorders.
Mucolytics are administered to help liquefy
secretions, which facilitates their removal.
Bronchodilators such as beta2-agonists and
anticholinergic agents aid in smooth muscle
relaxation and are of particular benefit to patients
with airflow limitations.
Steroids are often used in conjunction with beta2-
agonists to enhance their effects and to decrease
airway inflammation.
Neuromuscular Blocking Agents
Sedation is necessary in many patients to assist with
maintaining adequate ventilation. It can be used to
comfort the patient and to decrease the work of
breathing, particularly if the patient is fighting the
ventilator.
In some patients, sedation does not decrease
spontaneous respiratory efforts enough to allow
adequate ventilation, and patientventilator
dyssynchrony may develop.
Neuromuscular paralysis may be necessary to
facilitate optimal ventilation. Paralysis also may be
necessary to decrease oxygen consumption in the
patient who is severely compromised.
Nursing management of the patient receiving a
neuromuscular blocking agent should incorporate a
number of additional interventions.
Because paralytic agents only halt skeletal muscle
movement and do not inhibit pain or awareness,
they must be administered together with a sedative
or anxiolytic agent.
Pain medication is administered if the patient has a
pain producing illness or surgery.
Providing reorientation and explanations for all
procedures is critical because the patient can still
hear but cannot move or see.
The patient is also at high risk for developing the
complications of immobility, so interventions related
to the prevention of skin breakdown, atelectasis,
and deep vein thrombosis are also implemented.
Patient safety is another concern because the
patient cannot react to the environment. Special
precautions are taken to protect the patient at all
times

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