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MEDICAL GAS THERAPY

OXYGEN THERAPY

 • Correct documented or suspected acute hypoxemia


 • Decrease symptoms associated with chronic
hypoxemia
 • Decrease the workload hypoxemia imposes on the
cardiopulmonary system
Correcting Hypoxemia

 O2 therapy corrects hypoxemia by increasing alveolar


and blood levels of O2.
 Correction of hypoxemia is the most tangible objective
of O2 therapy and the easiest to measure and
document.
Decreasing Symptoms of Hypoxemia

 In addition to relieving hypoxemia, O2 therapy can help


relieve the symptoms associated with certain lung
disorders.
 Specifically, patients with chronic obstructive pulmonary
disease (COPD) and some forms of interstitial lung
disease report less dyspnea when receiving
supplemental O2.
 O2 therapy also may improve mental function among
patients with chronic hypoxemia
Minimizing Cardiopulmonary Workload

 The cardiopulmonary system compensates for hypoxemia by


increasing ventilation and cardiac output.
 In cases of acute hypoxemia, supplemental O2 can decrease
demands on both the heart and the lungs.O2 therapy can reduce
both the high ventilatory demand and the work of breathing.
 Because O2 therapy increases blood O2 content, the heart does not
have to pump as much blood per minute to meet tissue demands.
This reduced workload is particularly important when the heart is
already stressed by disease or injury, as in myocardial infarction,
sepsis, or trauma.
Assessing the Need for Oxygen Therapy

 The first is the use of laboratory measures to document


hypoxemia.
 Second, a patient’s need for O2 therapy can be based on the
specific clinical problem or condition.
 Third, hypoxemia has many manifestations, such as tachypnea,
tachycardia, cyanosis, and distressed overall appearance.
Oxygen Toxicity

 O2 toxicity primarily affects the lungs and the central nervous system
(CNS).
 Two primary factors determine the harmful effects of O2: PO2 and
exposure time
 The higher the PO2 and the longer the exposure, the greater the
likelihood of damage. Effects on the CNS, including tremors,
twitching, and convulsions, tend to occur only when a patient is
breathing O2 at pressures greater than 1 atm (hyperbaric pressure).
Pulmonary effects can also occur with enriched O2 environments at
normal atmospheric pressures.
PROLONGED O2 EXPOSURE
-Damage capillary endothelium
-Interstitial edema follows
-thickens the alveolar-capillary
membrane
-If the process continues, type I
alveolar cells are destroyed,
and type II cells proliferate

-In the end stages, hyaline An exudative phase follows, resulting


membranes form in the alveolar from alveolar fluid buildup,
region, and pulmonary fibrosis which leads to a low ventilation/perfusion
and hypertension develop ratio, physiologic shunting, and hypoxemia
Oxygen Toxicity

 The toxicity of O2 is caused by overproduction of O2 free


radicals. O2 free radicals are by-products of cellular metabolism.
 If unchecked, these radicals can severely damage or kill cells.
 Normally, however, special enzymes such as superoxide
dismutase inactivate the O2 free radicals before they can do
serious damage.
 Antioxidants such as vitamin E, vitamin C, and beta-carotene
also can defend against O2 free radicals.
Oxygen Toxicity

 Results of most studies indicate that adults can breathe up to 50% for
extended periods without major lung damage.
 Rather than applying strict cutoffs, one can weigh both FiO2 and
exposure time in assessing the risks of high PO2
 The goal always should be to use the lowest possible FiO2
compatible with adequate tissue oxygenation
 Limit patient exposure to 100% O2 to less than 24 hours whenever
possible. High FiO2 is acceptable if the concentration can be
decreased to 70% within 2 days and 50% or less in 5 days
Depression of Ventilation

 The primary reason some patients with COPD hypoventilate when given
O2 is most likely suppression of the hypoxic drive.
 In these patients, the normal response to high partial pressure of carbon
dioxide (PCO2) is blunted, the primary stimulus to breathe being lack of
O2 as sensed by the peripheral chemoreceptors.
 The increase in the blood O2 level in these patients suppresses peripheral
chemoreceptors, depresses ventilatory drive, and elevates the PCO2.
 High blood O2 levels may disrupt the normal ventilation/perfusion
balance and cause an increase in dead space-to-tidal volume ratio
(VD/VT) and in PaCO2
Retinopathy of Prematurity

 also called retrolental fibroplasia,


is an abnormal eye condition
that occurs in some premature or
low-birth-weight infants who
receive supplemental O2.
 An excessive blood O2 level
causes retinal vasoconstriction,
which leads to necrosis of the
blood vessels. In response, new
vessels form and increase in
number.
Retinopathy of Prematurity

 Hemorrhage of these delicate new


vessels causes scarring behind the
retina. Scarring often leads to retinal
detachment and blindness.
 ROP most often affects neonates up
to approximately 1 month of age,
by which time the retinal arteries
have sufficiently matured.
 PO2 in an infant less than 80 mm Hg
as the best way to minimize the risk
of ROP
Absorption Atelectasis

 FiO2 greater than 0.50 presents a significant risk of absorption atelectasis.


 Nitrogen normally is the most plentiful gas in both the alveoli and the
blood.
 Breathing high levels of O2 quickly depletes body nitrogen levels.
 As blood nitrogen levels decrease, the total pressure of venous gases
rapidly decreases.
 Under these conditions, gases that exist at atmospheric pressure within any
body cavity rapidly diffuse into the venous blood.
 This principle is used for removing trapped air from body cavities. Giving
patients high levels of O2 can help clear trapped air from the abdomen or
thorax.
Absorption Atelectasis

 The risk of absorption atelectasis is greatest in patients breathing at low


tidal volumes as a result of sedation, surgical pain, or CNS dysfunction.
 In these cases, poorly ventilated alveoli may become unstable when
they lose O2 faster than it can be replaced.
 The result is a more gradual shrinking of the alveoli that may lead to
complete collapse, even when the patient is not breathing
supplemental O2
 For an alert patient, this is not a great risk because the natural sigh
mechanism periodically hyperinflates the lung.
Fire Hazard

 Fires seem to pose the greatest risk in operating rooms


 selected respiratory procedures
 Other situations associated with increased fire risk involve home care patients smoking
while receiving low-flow O2 and the use of aluminum O2 regulators.
 hyperbaric oxygen (HBO) therapy or therapy at increased atmospheric pressures)
 Effectively managing the fire triangle of O2, heat, and fuel is key.
 In addition, using scavenging systems to minimize O2 buildup beneath sterile drapes
during surgery or while performing tracheostomies can help reduce fire risk.
 Avoiding the use of inappropriate or outdated equipment such as aluminum gas
regulators and educating clinicians, patients and caregivers on safe O2 use are also
important measures. Additionally, fire prevention protocols for HBO therapy should be
strictly followed
Oxygen Delivery Systems:
Design and Performance

Low flow system


reservoir systems
high-flow systems
Design and Performance

 Whether a device delivers a fixed or variable FiO2 depends on how much of the
patient’s inspired gas it supplies.
 If the system provides all of the patient’s inspired gas, FiO2 remains stable, even
under changing demands.
 If the device provides only some of the inspired gas, the patient must draw the
remainder from the surrounding air. In this case, the more the patient breathes, the
more air dilutes the delivered O2, and FiO2 is lower.
 If the patient breathes less with this type of device, less air dilutes the O2, and FiO2
increases.
 A system that supplies only a portion of the inspired gas always provides a variable
FiO2.FiO2 supplied with such systems can vary widely from minute to minute and
even from breath to breath.
Low-Flow Systems

 Nasal Cannula
 a disposable plastic device consisting of
two tips or prongs approximately 1 cm
long that are connected to several feet of
small-bore O2 supply tubing
 The user inserts the prongs directly into the
vestibule of the nose while attaching the
supply tubing either directly to a flowmeter
or to a bubble humidifier.
 In most cases, a humidifier is used only
when the input flow is greater than 4 L/min.
Nasal Cannula

 Even with extra humidity, flow greater


than 6 to 8 L/min can cause patient
discomfort, including nasal dryness and
bleeding.
 Cannulas should not be used in
newborns and infants if their nasal
passages are obstructed, and flows
generally should be limited to 2 L/min
unless a specialized high-flow cannula
system is being used
 A high-flow nasal cannula, which is a
variation of a standard nasal cannula.
NASAL CANNULA

 FLOW 14-8 L/min (adults) ≤2 L/min (infants)


 FIO2 RANGE 22%-40%
 FIO2 STABILITY Variable
 ADVANTAGES Use on adults, children, infants; easy to use; disposable;
low cost; well tolerated
 DISADVANTAGE Unstable, easily dislodged; high flow uncomfortable; can
cause dryness, bleeding; polyps; deviated septum and
mouth breathing may reduce FiO2
 BEST USE Patient in stable condition who needs low FiO2; home care
patient who needs long-term therapy, low to moderate FiO2
while eating
Nasal Catheter
 short-term O2 administration during specialized
procedures such as a bronchoscopy
 A nasal catheter is a soft plastic tube with
several small holes at the tip that is inserted by
gently advancing it along the floor of either
nasal passage and visualizing it just behind and
above the uvula
 Once in position, the catheter is taped to the
bridge of the nose. If direct visualization is
impossible, the catheter may be blindly inserted
to a depth equal to the distance from the nose
to the earlobe.
Nasal Catheter
 When placed too deep, the catheter can provoke
gagging or swallowing of gas, which increases the
likelihood of aspiration.
 Nasal catheters also affect the production of
secretions; for this reason, a nasal catheter should
be replaced with a new one (placed in the
opposite naris) at least every 8 hours.
 Nasal catheters should be avoided in most
patients with maxillofacial trauma, basal skull
fracture, nasal obstruction, and coagulation
problems.
 It has also been determined that nasal catheters
are inappropriate for neonatal patients. As a result
of these notable limitations, nasal catheters are
rarely used today
Nasal Catheter
 FLOW 1/4-8 L/min
 FIO2 RANGE 22%-45%
 FIO2 STABILITY Variable
 ADVANTAGES use on adults, children, infants; good stability;
disposable; low cost
 DISADVANTAGE Difficult to insert; high flow increases back pressure;
needs regular changing; polyps, deviated septum
may block insertion; may provoke gagging, air
swallowing, aspiration
 BEST USE Procedures in which cannula is difficult to use
(bronchoscopy); long-term care of infants
Transtracheal Catheter
 A transtracheal O2 catheter was first
described by Heimlich in 1982.
 A physician surgically inserts this thin
polytetrafluoroethylene (Teflon) catheter
with a guidewire directly into the trachea
between the second and third tracheal rings
 A custom-sized chain necklace secures the
catheter in position.
 Standard tubing connected directly to a
flowmeter provides the O2 source flow.
Because flow is so low, no humidifier is
needed.
Transtracheal Catheter

 Because the transtracheal catheter resides


directly in the trachea, O2 builds up both
there and in the upper airway during
expiration.
 This process effectively expands the anatomic
reservoir and increases the FiO2 at any given
flow. Compared with a nasal cannula, a
transtracheal catheter needs about half of the
O2 flow to achieve a given arterial partial
pressure of oxygen (PaO2).
 Some need a flow of only 0.25 L/min to
achieve adequate oxygenation.
Transtracheal Catheter

 This reduced flow can be of great economic


and practical benefit to patients needing
continuous long-term O2 therapy because it
can greatly increase the duration of flow of
portable O2 systems.
 Transtracheal O2 therapy can pose problems
and risks, however, and these devices have
not received widespread acceptance.
 Careful patient selection, rigorous patient
education, and ongoing self-care with
professional follow-up evaluation can help
minimize these risks
Transtracheal Catheter

 FLOW 1/4-4 L/min


 FIO2 RANGE 22%-35
 FIO2 STABILITY Variable
 ADVANTAGES lower O2 use and cost; eliminates nasal and skin
irritation; improved compliance
 DISADVANTAGE High cost; surgical complications; infection;
mucous plugging; lost tract
 BEST USE Home care or ambulatory patients who need
increased mobility or do not accept nasal O2
Troubleshooting Low-Flow Systems

Common Problems
 inaccurate flow
 system leaks
 obstructions
 device displacement
 skin irritation
Reservoir Systems

 Reservoir systems incorporate a mechanism for gathering and storing O2 between


patient breaths.
 Patients draw on this reserve supply whenever inspiratory flow exceeds O2 flow into
the device.
 Because air dilution is reduced, reservoir devices generally provide higher FiO2 than
low-flow systems.
 Reservoir devices can decrease O2 use by providing FiO2 comparable with
nonreservoir systems but at lower flow.
 Reservoir systems in use at the present time include reservoir cannulas, masks, and
nonrebreathing circuits.
 In principle, enclosure systems, such as tents and hoods, operate as reservoirs
surrounding the head or body.
Reservoir Cannula

 designed to conserve O2 and are an alternative to the pulse-dose or demand-flow O2 systems


 There are two types of reservoir cannula: nasal reservoir and pendant reservoir.
Nasal Reservoir Cannula

 operates by storing approximately 20 ml of


O2 in a small membrane reservoir during
exhalation
 The patient draws on this stored O2 during
early inspiration.
 The amount of O2 available increases with
each breath and decreases the flow
needed for a given FiO2.
 Although the device is comfortable to
wear, many patients object to its
appearance and may not always comply
with prescribed therapy.
Pendant Reservoir System

 Helps overcome esthetic


concerns by hiding the reservoir
under the patient’s clothing on
the anterior chest wall
 Although the device is less visible,
the extra weight of the pendant
can cause ear and facial
discomfort.
Reservoir Cannula

ADVANTAGES DISADVANTAGES

 At low flow, reservoir  For these devices to function properly at


cannulas can reduce O2 use low flow, patients must exhale through
the nose (this reopens or resets the
50% to 75%. reservoir membrane).
 During exercise, reservoir  In addition, exhalation through pursed
cannulas can reduce flow lips may impair performance, especially
needs approximately 66%; during exercise. For these reasons,
the savings is approximately prescribed flow settings should be
individually determined by means of
50% at high flow clinical assessment, including SaO2
monitoring, during rest and exercise
Reservoir Cannula

 FLOW 1/4-4 L/minFIO2


 RANGE 22%-35%
 FIO2 STABILITY Variable
 ADVANTAGES Lower O2 use and cost; increased mobility; less
discomfort because of lower flow
 DISADVANTAGE Unattractive, cumbersome; poor compliance; must
be regularly replaced; breathing pattern affects
performance
 BEST USE Home care or ambulatory patients who need
increased mobility
Reservoir Masks

 (1) simple mask,


 (2) partial rebreathing mask,
 (3) nonrebreathing mask
Simple Mask

 disposable plastic unit designed to


cover both the mouth and the nose

 The body of the mask itself gathers and


stores O2 between patient breaths. The
patient exhales directly through open
holes or ports in the mask body. If O2
input flow ceases, the patient can
draw in air through these holes and
around the mask edge
Simple Mask

 if flow greater than 10 L/min is


needed for satisfactory
oxygenation, use of a device
capable of a higher FiO2 should
be considered. At a flow less
than 5 L/min, the mask volume
acts as dead space and causes
carbon dioxide (CO2)
rebreathing
Simple Mask

 FLOW 5-10 L/min


 RANGE 35%-50%
 FIO2 STABILITY Variable
 ADVANTAGES Use on adults, children, infants; quick, easy to apply;
disposable; inexpensive
 DISADVANTAGE Uncomfortable; must be removed for eating;
prevents radiant heat loss; blocks vomitus in
unconscious patients
 BEST USE Emergencies; short-term therapy requiring moderate
FiO2; mouth breathing patients requiring moderate FiO2
Partial Rebreathing Mask

 1-L flexible reservoir bag attached to the


O2 inlet
 has no valves
 During inspiration, source O2 flows into the
mask and passes directly to the patient.
During exhalation, source O2 enters the
bag. However, because no valves
separate the mask and the bag, some of
the patient’s exhaled gas also enters the
bag (approximately the first third).
Partial Rebreathing Mask

 Because it comes from the anatomic


dead space, the early portion of exhaled
gas contains mostly O2 and little CO2.
 As the bag fills with both O2 and dead
space gas, the last two-thirds of
exhalation (high in CO2) escapes out the
exhalation ports of the mask.
 As long as the O2 input flow keeps the
bag from collapsing more than about
one-third during inhalation, CO2
rebreathing is negligible
Partial Rebreathing Mask

 FLOW Minimum of 10 L/min (prevent bag collapse on


inspiration)
 RANGE 40%-70%
 FIO2 STABILITY Variable
 ADVANTAGES Same as simple mask; moderate to high FiO2
 DISADVANTAGE Same as simple mask; potential suffocation hazard
 BEST USE Emergencies; short-term therapy requiring moderate
to high FiO2
Nonrebreathing mask

 prevents rebreathing with one-way valves


 1-L flexible reservoir bag attached to the O2 inlet
 An inspiratory valve sits on top of the bag, and
expiratory valves cover the exhalation ports on the
mask body. During inspiration, slight negative mask
pressure closes the expiratory valves, preventing air
dilution. At the same time, the inspiratory valve on
top of the bag opens, providing O2 to the patient.
During exhalation, valve action reverses the
direction of flow. Slight positive pressure closes the
inspiratory valve, which prevents exhaled gas from
entering the bag. Concurrently, the one-way
expiratory valves open and divert exhaled gas out
to the atmosphere.
Nonrebreathing mask

 Because it is a closed system, a leak-free


nonrebreathing mask with competent valves and
enough flow to prevent more than one-third bag
collapse during inspiration can deliver 100% source gas.
 Large air leaks are the primary problem. Air leakage
occurs both around the mask body and through the
open (nonvalved) exhalation port. This open exhalation
port is a common safety feature designed to allow air
breathing if the O2 source fails.
 The port also allows air dilution whenever inspiratory flow
or volume is high. Although a disposable
nonrebreathing mask can deliver moderate to high O2
concentration, FiO2 still varies with the amount of air
leakage and the patient’s breathing pattern
Nonrebreathing mask

 FLOW Minimum of 10 L/min (prevent bag collapse on


inspiration)
 RANGE 60%-80%
 FIO2 STABILITY Variable
 ADVANTAGES Same as simple mask; high FiO2
 DISADVANTAGE Same as simple mask; potential suffocation hazard
 BEST USE Emergencies; short-term therapy requiring high
FiO2
Nonrebreathing Reservoir Circuit

 Although the nonrebreathing circuit requires


an elaborate combination of equipment and
supplies, it can be more versatile than a
nonrebreathing mask because it provides a
full range of FiO2 (21% to 100%) and can be
used for both intubated and nonintubated
patients.
 a typical nonrebreathing circuit incorporates
a blending system to premix air and O2.
 The gas mixture is warmed and humidified,
ideally with a servo-controlled heated
humidifier.
Nonrebreathing Reservoir Circuit

 Gas flows through large-bore tubing


into an inspiratory volume reservoir,
which includes a fail-safe inlet valve.
 The patient breathes through a
closed airway appliance, in this
case, a mask with one-way valves. A
valved T tube also can be used in
the care of a patient with an
endotracheal or a tracheostomy
tube.
Nonrebreathing Reservoir Circuit

 FLOW 3 × VE (prevent bag collapse on inspiration)


 RANGE 21%-100%
 FIO2 STABILITY Fixed
 ADVANTAGES Full range of FiO2
 DISADVANTAGE Potential suffocation hazard; requires 50 psi air/O2;
blender failure common
 BEST USE Patients who need precise FiO2 at any level (21%-
100%)
High-Flow Systems

 To qualify as a high-flow device, a system should provide at least


60 L/min total flow. This flow criterion is based on the fact that the
average adult peak inspiratory flow during tidal ventilation is
approximately three times the minute volume.
 Because 20 L/min is close to the upper limit of sustainable minute
volume for an ill person, a flow of 3 × 20, or 60 L/min, should
suffice in most situations. In a few rare circumstances, flow must
reach or exceed 100 L/min.
Principles of Gas Mixing

 All high-flow systems mix air and O2 to achieve a given FiO2. These gases are mixed with air-
entrainment devices or blending systems.
 Computations involving mixtures of air and O2 are based on a modified form of the dilution
equation for solutions:
O2 concentration in these two volumes

the final volume and


concentration of the volumes of the two gases being mixed
resulting mixture
Equations for Computing Oxygen
Percentage, Ratio, and Flow
Air-Entrainment Systems

 Air-entrainment systems direct a high-


pressure O2 source through a small
nozzle or jet surrounded by air-
entrainment ports
 The amount of air entrained at these
ports varies directly with the size of the
port and the velocity of O2 at the jet.
 The larger the intake ports and the
higher the gas velocity at the jet, the
more air is entrained
Air-Entrainment Systems

 Because they dilute source O2 with air, entrainment devices always provide
less than 100% O2.
 The more air they entrain, the higher is the total output flow, but the
delivered FiO2 is lower.
 High flow is possible only when low O2 concentration is delivered. For these
reasons, airentrainment devices function as true high-flow systems only at
low FiO2.
 If the flow output from an air-entrainment device decreases to less than a
patient’s inspiratory flow, air dilution occurs, and FiO2 becomes variable.
Air-Entrainment Systems

 FiO2 provided by air-entrainment devices depends on two key


variables: the air-to-O2 ratio and the amount of flow resistance
downstream from the mixing site. Changing the input flow of an air-
entrainment device alters the total output flow but has little effect on
delivered FiO2.
 Generally, FiO2 remains within 1% to 2% of that specified by the
manufacturer, regardless of input flow
 The size of the jet and entrainment ports of a device determines the
air-to-O2 ratio and the delivered FiO2.
One subtracts diagonally
First again from upper left to lower
right (disregard the sign).

desired O2
percentage

second One subtracts diagonally


from lower left to the upper
right (disregard the sign)
Air-Entrainment (Venturi) Mask

 first reported in 1941 by Barach and


Eckman (air entrainment)
 The system provided relatively high FiO2
(>40%) through the use of adjustable
air-entrainment ports that controlled the
amount of air mixed with O2. Almost 20
years later, Campbell31 developed an
entrainment mask that provided
controlled, low FiO2 and called the
device a Venturi mask or venti-mask.
Air-Entrainment (Venturi) Mask

 Rather than having an actual Venturi


tube that entrains air, these devices
have a simple restricted orifice or jet
through which O2 flows at high velocity.
 Air is entrained by shear forces at the
boundary of jet flow, not by low lateral
pressures. The smaller the orifice, the
greater the velocity of O2, and more air
is entrained
Air-Entrainment (Venturi) Mask

 For controlled FiO2 at flow high enough to


prevent air dilution, the total output flow of an
AEM must exceed the patient’s peak
inspiratory flow.29 With an entrainment ratio
exceeding 5 : 1, an AEM set to deliver less
than 35% O2 has little trouble meeting or
exceeding the 60 L/min high-flow criterion
(see previous Rule of Thumb).
 At settings greater than 35%, total AEM flow
decreases significantly, and FiO2 becomes
variable. For example, when set to deliver
50% O2, some AEMs provide 0.39 FiO2
Air-Entrainment Nebulizer

 Pneumatically powered airentrainment nebulizers have most of the


features of AEMs but have added capabilities, including additional
humidification and temperature control.
 Humidification is achieved through production of aerosol at the nebulizer
jet.
 Temperature control is provided by an optional heating element.
 In combination, these added features allow delivery of particulate water
(in excess of needs for body temperature and pressure, saturated) to the
airways.
 These devices are also widely known as jet nebulizers or large volume
nebulizers.
Air-Entrainment Nebulizer
 Because of added humidification and heat
control, airentrainment nebulizers have
been the traditional device of choice for
delivering O2 to patients with artificial
tracheal airways.
 O2 typically is delivered with a T tube or a
tracheostomy mask.
 An alternative is to use an aerosol mask or a
face tent to deliver an O2 mixture via
aerosol to patients with intact upper
airways
Air-Entrainment Nebulizer

 gas-powered nebulizers have a fixed orifice.


 Air-to-O2 ratios can be altered only by varying
entrainment port size.
 Disposable nebulizers usually have a continuous range
of settings from 28% to 100%.
 Less commonly used nondisposable nebulizers have
fixed entrainment settings, such as 100%, 70%, and 40%
Air-Entrainment Nebulizer

 With most nebulizer systems, the extremely small size of the jet needed
for aerosol production limits the maximum O2 input flow to 12 to 15 L/min
at 50 psig.
 For example, the total output flow of an air-entrainment nebulizer set to
deliver 40% O2 ranges from 48 to 60 L/min.
 Although this amount may be adequate for most patients, it is
insufficient for patients with very high inspiratory flow or minute volume
 The actual FiO2 received by patients may be affected by the choice of
airway appliance. The FiO2 delivered by face tent is consistently less
than the set nebulizer concentration, especially at higher level
Air-Entrainment Nebulizer

 There are two ways to assess whether the flow of an airentrainment nebulizer meets
the patient’s needs.
 The first method is simple visual inspection. With this approach (generally used only with
a T tube), the RT sets up the device to deliver the highest possible flow at the
prescribed FiO2. After connecting the system to the patient, the RT observes the mist
output at the expiratory side of the T tube. As long as mist can be seen escaping
throughout inspiration, flow is adequate to meet the patient’s needs, and the
delivered FiO2 is ensured.
 The second way to assess the adequacy of nebulizer flow is to compare it with the
patient’s peak inspiratory flow. A patient’s peak inspiratory flow during tidal breathing
is approximately three times minute volume. As long as the nebulizer flow exceeds this
value, the delivered FiO2 is ensured. If the patient’s peak flow exceeds that provided
by the nebulizer, the device functions as a low-flow system with variable FiO2
Providing Moderate to High FiO2
at High Flow

 The solution is to boost the total output flow. With AEMs, total output flow
can be boosted with a simple increase in input flow. For a 35% AEM (5 : 1
ratio) with an input flow of 8 L/min, the total output flow is 48 L/min. This
flow is insufficient to ensure 35% O2 delivery to all patients.
 Simply increasing the input flow to 12 L/min boosts the output flow of the
AEM by 50%, to 72 L/min. The new high flow ensures delivery of the set O2
concentration to essentially all patients
 This solution is impossible with most air-entrainment nebulizers. Because
the small jets in many of these devices limit O2 flow to 12 to 15 L/min, the
input flow cannot be increased beyond these levels.
Providing Moderate to High FiO2 at
High Flow
alternatives for boosting the FiO2
capabilities in these situations

 First and simpliest approach


a closed reservoir or
nonrebreathing system
These systems combine an inspiratory volume
reservoir (usually a compliant 3- to 5-L anesthesia
bag) with a one-way expiratory valve. Whenever
patient flow exceeds nebulizer flow, the
expiratory valve closes, and the patient draws
additional gas from the reservoir.
Although they can ensure delivery of the set O2
concentration, these systems pose considerable
hazards.
If source flow stops for any reason, the patient
can suffocate.
For this reason, these systems must be equipped
with an emergency inlet valve that allows room
air breathing in the event of source gas failure.
air-entrainment nebulizers is to connect two or
more devices together with a “wye” adapter

 Although a single air-entrainment


nebulizer set at 60% (1 : 1 ratio) with a
maximum input flow of 15 L/min has a
total output flow of only 30 L/min,
connecting two of these devices
together doubles the total output flow
to 60 L/min (the minimum needed for a
high-flow device).
 This approach works well only for
delivery of a concentration of 60% or less
to patients with a minute volume less
than 10 L/min
 set the device to a lower concentration than that prescribed
(to generate high flow) while bleeding supplemental O2 into
the delivery tubing.
 This method increases both FiO2 and total output flow.
 To achieve a specific FiO2 in this type of system, the RT must
analyze the delivered concentration and carefully adjust the
supplemental O2 input flow until the concentration is the
desired value.
 Commercial dual-flow systems entail a similar approach.
 One flow source powers the jet, while another flow
source provides supplemental O2.
 The Misty Ox (Vital Signs, Inc, Totowa, New Jersey) gas
injection nebulizer is an example.
 This system is not an air-entrainment system because it
does not depend on entrainment ports to increase total
flow or O2 concentration to the patient.
 Rather, it uses two flowmeters: one that operates the jet
and one that feeds into the side of the jet manifold.
 The Misty Ox system can provide FiO2 of 0.96 at a flow of
42 L/min and offers O2 concentrations ranging from 0.21
to nearly 1.00.
 If aerosol is not needed, a simple dual-
flow device such as the Downs flow
generator can be used.
 This device is attached to a 50-psig O2
source and provides O2 concentrations
of 30% to 100% at a flow up to 100 L/min.