Function/Information Advantages/Disadvantages What Would Sam Do?

(WWSD)
Hand Hygiene before and after
PPE Don: Gown, mask, eye wear, gloves
Doff: Gloves, eye wear, gown, mask
Medical Gas Supply Equipment
Measurement of Gas Pressure

Mercury Barometer: uses column of Hg as an opposing force of atm to measure

Pressure measured for gas in a container= usually psi
Barometers atm pressure
Aneroid Barometer: Uses evacuated metal container, spring, and pointer Bourdon gauge found in ambulances bc it is gravity
independent
Manometers Mechanical Manometer: Similar to an aneroid but uses a diaphragm or
evacuated container 1 atm= 760 mmHg or torr OR 1034 cmH2O OR 33 ftH2O OR
Bourdon Gauge Bourdon Gauge: Hollow coiled metal tube with eliptical cross section; commonly
14.7 psi
found on medical gas cylinders

Physics of the Principles

Kinetic Theory: Gases are composed of discrete molecules that are in random
motion, with molecular collisions that are elastic (no energy lost), that depend on
Kinetic Theory temperature, and have no physical attraction bt themselves

Gas Pressure Gas Pressure: force per unit area (psi)

Caused by molecular collisions with themselves and walls of container
Pascal's Law Temperature effects velocity (increased KE)

Pascal's law: fluid in a container transmit pressure equally in all directions

Rate (velocity) depends on:

Gas Flow Driving pressure (directly related to velocity)
Size of opening (inversely related to diameter)
Bernoulli's Principle
Bernoulli's principle: As velocity increases, lateral pressure decreases

Viscous shearing: a high-velocity jet injected into a quiescent (stationary) gas

Vorticity: tendency of velocity of jet gas to decrease due to "swirling" mixture of

Viscous Shearing, Vorticity, and
Ejectors
2 gases
Ducted ejectors: uses nozzle, viscous shearing, and vorticity to increase total flow A: Ducted ejectors increase pressure downstream and has Stationary gas reduces high velocity jet stream causing
less effect on entrainment vortices
Similar to venturi except:
Tube diameter doesn't change
Purpose: maintain high velocity (not restore lateral pressure)
Velocity remains high and pressure remains constant
Used in nebulizers

Expanded on Bernoulli's
Tube with increased radius (angle must be <15 degrees) A: Delivers a fixed flow (know exactly what the pt is receiving)
High velocity of source gas causes ambient air entrainment Not dependent on anatomy and breathing mechanics
Venturi's Principle
HAFOE (high air flow with O2 enrichment mask) = venturi mask D: Kinks can cause a problem with the entrainment
Increased pressure downstream will decrease ambient air entrainment (decreased flow, increased O2 to pt)
resulting in a higher FiO2

Velocity of gas increase with pressure upstream (max. velocity)

Choked (compressible) Flow When Pressure= 1.893x that of atm => velocity is no longer increased, but is
choked
Nebulizers become choked @26 psi driving pressure

Reynolds: no units; 2000

Determines if gas flow through a tube in laminar or turbulent
Reynold's Number Laminar: smooth, uniform flow; less energy to sustain (<2000)
Turbulent: erratic, irregular flow; requires more energy (>2000)
Formula: R= (velocity x density x diameter)/(viscosity)
Poiseuille's Law
Poiseuille's Law: Describes Resistance when flow is laminar
As the radius of a tube is halved, resistance to flow increases by a factor of 16
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Boyles Law: Pressure is inversely related with Volume

Charles Law: Volume is directly related with Temperature (in Kelvin)

Gay-Lussac's Law: Pressure is directly related with Temperature

Other Gas Laws 0 C= 273 K
Dalton's Law: Pressure of gas mixture = sum of the partial pressure of the
component gases (partial pressure of each is proportional to its volumetric
percentage)

Combined Gas Law: (PV)/(T)

Fick's Law: Rate of gas diffusion into another is directly related to it's
concentration (diffusion)

Henry's Law: Rate of gas diffusion into liquid is directly related to it's partial
Gas Diffusion:
pressure of the gas @a given temperature (solubility)
Fick's Law ex. Opening a coke can
Henry's Law
Graham's Law
Graham's Law: Rate of gas diffusion through liquid is directly related to the gas
solubility & inversely related to MW
Why CO2 and O2 diffuse at ~same rate; CO2 is 19x faster in liquid and O2 is
faster in gas & has a larger [O2] gradient

Compressors

Piston: Uses a piston driven by an electric motor

Diaphragm: Uses a flexible diaphragm driven by electric motor Must be an oil-free environment (oil + O2 => fire)
Piston
Diaphragm Typically used in small nebulizers No vaseline is used in hospitals
Centrifugal
Centrifugal: Uses electrically powered impeller (like a fan) O2 is not combustible but will aid it
May produce large volumes of air (power an entire hospital)
A flow driven device and is the most efficient

Liquid reservoir systems

Bulk Supply Systems
Holds liquid O2 in bulk (hospitals) and warms up naturally when traveling
A: Liquid O2 takes up less space
Held @ -183 C through the pipes

Holds portable liquid O2 (homecare)

Portable Reservoirs
Stationary home models: 20-43 L
1lb liq. O2 = 343 L O2
Ambulatory versions: 0.6-1.23 L

Piping Systems

Supply: Manifold, bulk liquid, or both

24 hour reserve supply required
Copper pipes (compressible) used and tested to 1.5x working pressure

Safety Features: Alarms will ring when there is a drop in system pressure
Construction Zone Valves: emergency shutoffs (in case of fire)
Pressure Sensors: ensure 50 psi

Station Outlets: (safety)

DISS= Diameter index safety system; Gas specific threading and diameter (<200
psi)
PISS= Quick connect

Main Supply: on ground floor; seals off whole building

Zone Valves Riser: seals off floor above
Zone: Seals off a unit/ward
Cylinders
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Regulated by DOT
3AA: Made of steel
3AL: Aluminum alloy is ligher and stronger
3A: Aluminum with carbon fiber wrap (<70% steel and <30% aluminum; fill to A: non-steel cylinders can be used near MRI
Construction and Markings 3000 psi) usually found in ambulances If there is more than 1 date, look at the most recent one
D: 3AL and 3A's cost
Cylinder markings: Initial, passed inspection (+), date tested, next inspection in
10 years (*), construction material, approved filling pressure (up to 10%>
working pressure), serial number, and owner's stamp

q5 or 10 years
Difficult with carbon fiber tanks
Involves measuring a cylinder's expansion characteristics when its filled to 5/3 of
working pressure A: must contain a pressure relief mechanism to prevent
Hydrostatic Testing
explosion
Permanent expansion = volume of water displaced when pressure is released
Elastic expansion = decreased wall thickness (happens when cylinder is physically
damaged or subject to corrosion)

Largest to Smallest: H, G, M, E, D, B
H & E: most common in hospitals
Cylinder Sizes H: 244 ft3 of O2 "O-rings" prevent leakage
E: 22 ft3 of O2
D: most common on ambulances

O2: green
CO2: gray
N2O: light blue If the label and color code DO NOT match = DO NOT USE
Color Coding
C3H6: orange (extremely reactive; propene) CYLINDER
He: brown
Air: yellow

1 E cylinder typically lasts ~30 minutes @15 LPM

Full cylinder: 2200psi or 2100 psi
Crack cylinders before use with tank key (make sure outlet is
Safety Index: 500 psi is considered empty in hospitals (use when transporting a
Safety Rules for Cylinder Use away from people and that they are warned)
cylinder) 1600psi is a full cylinder Make sure all cylinders are secured (cap for H cylinder should
H= 3.14 L/psi be on except during use)
Transport calculation:
E= 0.28 L/psi 1) How much O2 flow? (psi tank x conversion factor) When you're done with the cylinder, turn flowmeter off and
use tank key to cut off flow, then "bleed" pressure from
2) How much is pt using? (trip time x O2 used by pt in LPM)
flowmeter by turning it back on and pressure returns to zero,
then turn off

O2 Regulation Devices

Direct Acting Cylinder Valve: Opens and closes valve directly

D & E cylinders
Cylinder Valves
Diaphragm Cylinder Valve: "indirect acting"
Diaphragm opens and closes valve
H cylinder

American Standard Safety System (ASSS): uses varient of threading to prevent

attachment of wrong equipment
Found on large cylinders (H)

Pin Index Safety System (PISS): Uses varients in pin placement to prevent
Cylinder Valve Safety Features attachment of wrong equipment DISS: screws into the wall
Found on small cylinders (D & E)

Pressure Release Devices: frangible disk and fusible plug

Frangible disk: thin metal disk that ruptures if pressure is too high
Fusible plug: melts @ temperature > 208-220 F

Regulators A reducing valve + flowmeter (control pressure and flow of gas)

Reducing Valves
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Single-stage: Uses 2 opposing forces (Spring tension and gas pressure)

Single-stage Modified single-stage: has an additional spring that allows >flow rates
Most common
Modified Single-stage Multistage is the most accurate but most expensive All reducing valves will bring pressure to 50psi
Multistage: allows >flow & more precise pressure
Multistage 2 or more single stage combined; first drops to 200 psi and second drops to 50
psi
Usually in bulk systems

Pressure Relief Valves: safety or pop-off valves; 1 per stage

Safety Features Indexing of inlet and outlet:

Inlet utilizes ASSS or PISS
Outless utilizes DISS

Ranges:
Typically: 0-15 LPM
Low Range: 0-3 LPM Controls gas flow to pt
O2 Flowmeters
(Pediatrics/Neonates and COPD) If back pressure exceeds source gas pressure gas flow stops
High Range: 0-75 LPM (CPAP or BiPAP
and Vapotherm)

Sets flow by adjusting orfice size A: Gravity independent

Fixed Orifice Common E cylinder flowmeter Regulator with knob and #'s
D: Uncompensated for back pressure
Commonly used with heliox

Bourdon gauge + adjustable reducing valve A: Gravity independent and lightweight

Reads pressure but indicates flow
Bourdon Gauge Can't tell of O2 is flowing just by looking @gauge D: Back pressure DOES effect read out because valve is
proximal to source
Back pressure causes HIGHER read out Accurate only @ambient temperature

D: Back pressure DOES effect read out because valve is

Uncompensated Thorpe Tube Back pressure causes LOWER read out proximal to source Ball does not move when plugging into source
and Gravity dependent

A: Back pressure does NOT effect read out because valve is

The type of thrope tube used in hospitals
Compensated Thorpe Tube proximal to patient Ball jumps when attached to gas source
Ball jumps when plugging into source D: Gravity dependent

Other Medical Gas Supply Equipment

Delivers a mixture of Air and O2

Proportioners (blenders) Built in alarm senses a decrease in pressure (squeling noise)
100%: shuts off air Used a lot in NICUs A: Delivers precise concentrations
21%: shuts off O2
Too much O2 to babies can cause ROP (blindness)

A: Reduces oxygenation of anatomical VD, No need for

Only delivers O2 during inspiration humidity, and O2 isn't wasted
Oxygen Conserving device (OCD) Seen more in home care
REQUIRES EXERCISE OXIMETRY STUDY
D: Time to set up and for treatment and Cost

Production of O2
Fractional Distillation Air is liquified and cooled
Nitrogen & trace gases have lower boiling point
99.5% pure O2

Molecular Sieve: uses Zeolite

Concentrators
Membrane Enricher: semipermeable polymer only lets O2 through (Size:
Nitrogen > Oxygen) Molecular Sieve is more effective than Enricher
Sieve: 50-90% FiO2
Enricher: 40% FiO2 @ 1-10 LPM
Rare in hospitals but seen more in home care

Gas Densities
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Matters bc gases will layer based on density

Specific gravity: density according to standard (air)

O2: 1.429 g/L

Different Gas Densities Air: 1.29 g/L
CO2: 1.98 g/L
He: 0.1785 g/L
N2O: 1.98 g/L
NO: 1.34 g/L

Time constants: each is 0.5 seconds

TCT= 60/TCT 1: 63% filling
Other Math For First Test Ve= Vt x RR 2: 86.5% filling
Demand= Ve x 5 3: 95% filling
4: 97% filling

Medical Gas Therapy Equipment

Indications for O2 Therapy Increased WOB, Cardiac problems, Hypoxemia

In Acute Care Setting: PaO2 less than or equal to 60 mmHg or SaO2 less than or
equal to 90%
Goal of O2 therapy is to reduce morbidity and mortality
Hypoxemia
In Sub-acute or Home Care Setting: PaO2 less than or equal to 55 mmHg or SaO2 associated with hypoxia
less than or equal to 88%
Associated with Cor pulmonale, CHF, and erythrocythemia with Hct>56

Set up:
Anatomic reservoir (space in naso- & Low flow= variable D: FiO2 depends on: Attach regulator to O2 source, attach tubing, adjust flow,
Low Flow O2 Devices
oropharynx): 50 mL Provides part of pt's inspiratory gas flow needs Anatomy and Breathing mechanics (Vt & RR) place on pt and verify comfort (if there is a reservoir bag
make sure it doesn't collapse)

Nasal Cannula (NC)

For patients who are stable A: Patient can use their mouth (eating, talking, etc.), Comfort, If pt needs more O2 => pendant cannula
Always use with bubbler (capped @6LPM) won't rebreathe CO2 If pt needs more flow => HFNC
Up to 44%
1-6 LPM
First 50 mL @100%, then air entrainment D: Nasal Irritation Make sure pt is wearing the device properly
Rule of 4's starting from 20%

Invasive but similar to a NC

Rests in oropharynx @ uvula
Nasal Catheter D: Invasive
Available in 8-10 french: kids
12-14 french: adults
French: method of sizing catheters (each unit= 0.33mm)

Reservoir Cannula/Pendant Cannula Maintain FiO2 @ lower flow

A: ability to conserve gas flow
Also called an oxymizer
Holds 100% FiO2

A: Has Murphy's eyes (holes) for cross ventilation and Avoids

Continous long term O2 nasal irritation
Transtracheal Catheter
Direct delivery of O2 into trachea (reduces dilution with RA=less entrainment) D: INFECTION, Subq emphysema (air trapped in subq; feels Trach is better; lower chance of infection
Uses 59% less flow than a NC like rice crispies), and hemoptysis.
Surgically inserted bt 2nd-3rd cartilage ring Complications from minor surgery and Mucus obstruction can
occur

Simple O2 Mask
Used in OR
Adds reservoir space (fills during pause)?? D: Chance of rebreathing CO2 if flow rate is set below 5 LPM
35-55% FiO2 Confining and must be removed to use mouth
Minimum rate: 5 LPM
If mask fogs up = flow is too low
Maximum rate: 12 LPM

Partial Rebreather (reservoir mask) Additional O2 fills bag during pause

Reservoir should NOT collapse; pt rebreathes some exhaled gas
No valves= cross communication D: Pt rebreaths some exhaled gas Not enough flow=> becomes an simple O2 mask
Up to 70% FiO2
15 LPM
First 1/3 of expiration is anatomic dead space
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Nonrebreather (reservoir mask) Patients in respiratory distress A: Has 3 one-way valves:

Effective for delivering high FiO2 for short periods of time One bt mask and bag (prevents rebreathing; closes on
Up to 100% FiO2 Prolonged use: associated with valve malfunctions expiration) If any valves are taken off it becomes a partial rebreather
Range: 8-12 LPM Two bt mask and RA (reduces entrainment and lets out CO2;
Minimum rate: 10 LPM Bag should not collapse closes on inspiration)

A: Better than a nonrebreather because it has a better seal

and a bigger reservoir (750 mL)
HiOx80 Designed for high FiO2 with less entrainment
Has ports on mask that nebulizers can be attached to
D: No entrainment ports mean high FiO2 can be achived but
Up to 80% FiO2 only @ 8 LPM Nebulizer can be added
can't get more flow
Expensive, rare in hospitals

Bypasses upper airways

Vapotherm 2000i
Up to 40 LPM via NC
20 LPM via transtracheal catheter A: Rain out is minimized In hospitals it is considered a high flow device
Up to 95% RH (55mg/L @41 C)
5-40 LPM Water bag used to provide heat and humidity (bc it can get to high flows)

High flow = fixed FiO2 does NOT depend on anatomy and breathing mechanics Hypoxic Drive: too much O2 => decreases ventilatory drive
High Flow O2 Devices => pt hypoventilates or stops breathing
Meets all of pt's demands (Vt and RR) Caution for COPD pts

Venturi Mask Air: O2= (100-FiO2)/(FiO2-21) D: Protective covering over entrainment port needed Use venturi mask for COPD for fixed flows, never a
Ratio x LPM => added together to find total flow nonrebreather

High Flow Nasal Cannula (NFNC) A: Provides high flow and high FiO2
Hooked up to a blender and Heater/humidifier (bypasses nose) Nasal prongs and tubing are bigger than NC
Up to 100% FiO2 D: Can't use if pt is a mouth breather (use CPAP or BiPAP
Up to 50 LPM instead)

Used in Pediatrics and OR A: 100% FiO2. Can feel lung compliance and resistance
Anesthesia Bag mask (flow-inflating)
Self-inflating mask: ambu bag (doesn't require flow) D: Can't bag sans gas source
Used for infants A: Controls environment (temp. & FiO2)
Incubator
Infants have brown fat to insulate but can not regulate body temperature D: Frequent hands on care can reduce efficiency of O2
O2 measured @ bottom/near head
(shivering) regulation

Encloses infant's head D: Must haves:

Head Box or Oxyhood
Gas is premixed (blender), heated, and humidified Adequate flow to wash out CO2
Blended correctly
5-10 LPM to wash out CO2
Often used with an incubator O2 measured @ head

Primarily used for aerosol therapy for pediatric pts (cool mist aerosol)
[O2], humidity, and temp. controlled (sort of, because of opening and closing of
tent & difficult to seal)

Croupettes: commonly used for pediatric aerosol treatment

A: Goes over bed/crib if pt refuses to wear a mask
Mist Tents (Croupettes)
Other types:
Ohmeda Pediatric Aerosol Tent: Self contained refrigerated aerosol generator D: Difficult to seal
(keeps tent cool)

Mistogen Child Adult Mist (CAM) Tent: Chills and circulates H2O to cool tent;
incorporates a Mistogen HV-12 Neb
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Monoplace (most are mounted on wheels= portability) and Multiplace chambers

(provide 2 gas sources; 1 for compression and 1 for respiration)

Drives O2 @high pressure into the body

Supersaturates plasma with O2 @ up to 1500 mg

Increased elimination of other gases: N & CO

Hyperbaric Chamber A: Increased ability for WBCs to fight infections,
Conditions that can benefit:
Gas gangrene Neovascularization to poorly perfused tissues, and Lethal to Uses Boyles Law
100% FiO2 Radiation necrosis anaerobic microorganisms
CO/cyanide poisoning
Ischemic tissue transplant
Necrotizing soft tissue infections
Decompression sickness
Severe acute anemia/hemmorhage
Crush injuries/trauma
Refractory osteomyelitis or anaerobic infections

Other Types of Gas Therapies

Set up: O2 flow meter, nebulizer, large bore tubing, drainage

bag, and appropriate interface
Used for edema; causes vasocontriction Attach flowmeter to outlet and assemble neb with
appropriate amount of saline and medication (based on
Cool Mist Aerosol Bad case: OR calculation)
Mild case: Racemic Epinephrine (quicker) or Cool Mist Attach large bore tubing to ned and position drainage bag so
Longer term: Steroids that it is @lowest position
Attach pt interface and turn on (enough aerosol= doesn't
disappear during inspiration)

For treatment of obstructive diseases bc gases of lesser density can more easily
bypass the obstruction
A: works well for providing flow for pts with some kind of
Heliox (He/O2) Flowmeter x conversion factor OR obstruction (asthma, post extubation stridor, etc)
LPM / conversion factor
Only a heliox thorpe tube provides accurate measurements
80/20: 1.8 Do not give through NC (ineffective bc of leakage) D: The difference in density means pt is receiving a different
70/30: 1.6 amount than the read out states (calculations done to find Fixed orifice usually used for heliox therapy
For nonintubated pts use well fitted nonrebreather
60/40: 1.4 actual)
A 80/20 means the pt could become hypoxemic
Intubated pts: deliver with positive intermittent pressure device
Nonintubated pts: well-fitted nonrebreather attached to a reservoir bag
Nasal cannula: cannot be used (ineffective)

A: Can also be used for CO poisoning as a

Carbogen (CO2/O2) stimulant/depressant of ventilation and prevent complete
Used to treat various disorders like singultus washout of CO2
Available in: Administered by nonrebreather with reservoir bag
5/95 and 7/93 mixtures D: Toxicity: flushed skin, full, bounding pulse, hypertension,
and muscle twitching

A: Short acting and delivered directly to lungs

Used to treat persistent pulmonary hypertension in newborns (vasodilator)
Can also be used for burn pts who have a hypermetabolism
Nitric Oxide (NO)
Administered by: I-Novent machine D: Need a constant gas flow to work OR: uses single limb (should be a dual limb)
General starting point: 20 PPM Need doctor's order Highly reactive and can form:
Wean by halfing the dose each time (ie. MetHb: oxidizes Fe receptors
20 to 10 to 5 etc.) FDA approved for neonates; off label for adult use Nitrogen dioxide (NO2), Nitric acid (HNO3), and MetHb
Rebound vasoconstriction:
Viagra has the same effect systemically
Lungs will collapse if pt isn't weaned off of NO (wean slowly)

Humidity and Aerosol Therapy

Aerosol and Humidity
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Humidity Water in a gaseous state

Behaves like other gases (exerts p and is in constant, random motion)
Some indications for humidity:
Capacity: @37C holds 44 mg/L of H2O
When calculating partial pressure of a gas containing humidity take into account presence of an artifical AW
water vapor pressure (Dalton's Law) Dehydration
Water Vapor Pressure: @37C exerts 47
Fever
mmHg (constant, regardless of Hygrometer: used to measure humidity Breathing of anhydrous gases
Barometric p but depends on Temp. RH 100%= fully saturated
and RH)

Water content (absolute humidity): Measured in g or mg of H2O; Fully saturated

= max capacity/absolute humidity

Relative Humidity (RH): % of H2O capacity

Formula: (Actual humidity/Capacity) Latent Heat of Vaporization: energy required to vaporize a
D: Large humidity deficits lead to:
liquid
Humidity: Measurements Evaporation: Liq. H2O to Gas H2O Retained secretions, Mucus plugging, Obstructions, and Evaporation occurs when liquid molecules @surface contain
infections (mucocilliary elevator disrupted)
More Liq. Molecules escape to gas as temp. increases (overall energy lvl decrease enough KE to break free
and Temp declines)

Humidity deficit: Difference bt inspired gas content and gas content @BTPS
(37C, 44 mg/L, and 47 mmHg) effects mucocilliary elevator

Particulate matter suspended in gas

Proper instruction => better deposition

Size and Mass: (R, V, and M direct relationship w/ each other) Decrease = gravity
has less effect and is suspended longer and travels farther down
tracheobronchial tree
Aerosol: Physical Characterisitics and
Deposition
Hygroscopic: absorbs water and falls out of suspension
Particle size: 1-5 microns
Tonicity: Hypertonic (3% or 7%), Isotonic (0.9% saline), Hypotonic
Electrical Charge: No physiological effects but may effect equipments (EKG)
A: Hypertonic solutions increase the gel layer and are irritants
that can cause coughing and expulsion of excessive mucus
6 ft distance bt TB= minimal chance of contraction
Effective dose for HIV is high and chance of contraction from
D: Larger particles have inertia (impacts oropharynx)
accidental stick is <1%
Respiratory pattern MATTERS (slow, deep inspiration WITH a
hold= keeps airways open)

Temperature and Humidity: Increased temp = increased humidity = higher

deposition

Application of choked flow:

Nozzle => choked flow => jet stream => hits liquid that the capillary tube drew Medical aerosol generators:
up from reservoir => viscous shearing => hits baffle (only allows small particles A: Larger particles with inertia, hit baffle and falls back down Atomizer
Aerosol Production through) to reservoir Nebulizer
Inhaler
Atomizer has no baffle to stabilize particle size

Humidity Therapy Equipment Simple reservoir, wick, or membrane devices (water is separated from gas
stream by hydrophobic membrane; only water passes through)

Adds water vapor to gas

AARC: Should provide a minimum of 30 mg/L H2O @30C (All humidifiers and if
airways are bypassed) Probes should be pushed all the way in to obtain correct
temperature
Humidifiers D: if gas is in contact with liquid = contamination (Humidifiers
Efficiency of Humidifiers: If tubing were upside down, condensation would be on
High temperatures (more molecules in gaseous state and holds more water) are warm and wet = perfect for microbes) probes and wrong temperature would be obtained
Set temp @40C and when it reaches pt If there's condensation on probe = reads a lower temp than
Large Surface Area (more humidity)
it is 37C actual and will keep increasing temp = overheats
Increased time for contact (more humidity; can't slow flow if pt needs it) VD is a problem in single-limbed circuits (CO2 may or may
not be cleared)
Passive Humidifier: HME; everything else on list is an active humidifier
Circuits: Inspiratory limb has probes and both limbs can have wires to prevent
rainout
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A: Moves large amounts of air

Is actually an aerosol generator
Room humidifier
D: Large potential for infection (large H2O reservoir is a good
Clean every week with acetic acid
place for bacterial growth); must be kept clean

Gas passes over H2O reservoir as water evaporates into gas

Pass-Over Humidifier D: Not a lot of contact time Seen in CPAP and mechanical vents.
Higher temp = ability to hold more H2O

L flow, ambient temperature, and time of operation In hospitals if >4LPM = use humidity
Diffuser breaks gas into small bubbles (smaller the bubble= greater the ratio of Because it does not bypass the upper airways, it provides
Bubble Humidifier
water to SA) even more humidity
Gas directed into bottom of reservoir A: Built in pop-off valve: >2 psi, obstruction, and leaks =
33-40% RH @ 37C whistle alarm
Capped @6 LPM Set up:
Water column height above gas outlet = increased humidity content of bubbles Attaches to nasal cannula tube and thorpe tube without
by allowing longer contact time nipple attached

Has a venturi device (can entrain)

Misty-Ox Laminar Diffuser Humidifier High flow= high output
Water trap bag added because of rain out A: may be used with turbo heater
Looks similar to a bubbler but has entrainment ports
High humidity @high flows (up to 80 If 1 source isn't enough, a 2nd can be added Can deliver cool mist treatment for upper AW edema
LPM)
If mist can't be seen= not enough, turn up flow

Cascade & Cascade II Humidifier A: Servo-controlled, diffusion grid increases surface area, and
efficient
Heating element is NOT in direct contact with water= no contamination
100% RH @37C @ 10 LPM D: Won't function unless it's connected properly and cost

A: Wick = increased surface area (bc of honey comb pattern)

May utilize a heated-wire circuit
A wick type humidifier
Hudson RCI ConchaTherm Humidifier Metal plate around heats Yellow machine in lab
D: have to purchase their circuit (expensive) and gas is in
contact with water

Fisher & Pakel Humdifier A wick type humidifier (modified) A: Servo-controlled White machine in lab
Commonly seen in hospitals Heated wire compatible Used with sterile water irrigation bag
Delivers gas @29-40C

Heated wick type humidifier A: Can be used for both infants & adults and is servo-
controlled
Bear VH-820 Humidifier Has 3 temperature probes:
Proximal AW, Heater rod, and Humidifier outlet D: Outdated

A: gas nor water are in contact with heater = no

Pegasus Thera-Mist Humidifier A wick type humidifier with a standardized 38mm top contamination
Good for pts that are immunocompromised and is small
Delivers up to 20 LPM @body humidity Temperature varies with gas flow
D: cost

A: Bacterial filter can be attached

D: increases VD because it goes between Y and pt

Absorbs heat & moisture from exhaled gas & returns it to inhaled gas Contraindications:
Has a port cap for excretions (Better to just switch out for a new HME if Frank bloody or thick, copious secretions
condensation or secretions are noticied) Expired Vt <70% of delivered
Pt receiving humidification with low Vt (lung protective
Use if: strategies like a pt with ARDs) bc it increases VD, CO2, and
Heat & Moisture Exchanger (HME or Short term use (<96 hours) vent. Requirement Goes between Y and pt= increases VD= harms pts
Artificial Nose) For medical gas equipment Removal from circuit of pt receiving lung protective stratedies
No air leaks decrease VD, CO2, and increase pH Bc of water absorption, HME flow increases resistance after
70-90% RH @30-31C No thick, bloody secretions Acute respiratory failure (increases Ve, vent. drive, and WOB) several hours of use
Minute volume is not high Low body temp (<32C)
In OR High spontaneous VE (>10 L/min)
Must be switched to aerosol bypass mode or remove
Can NOT be used WITHOUT an artificial AW (contamination) if nebulizer is placed for aerosol treatment
Know Contraindications R and VD may negate effects of positive pressure and increase
WOB and may increase requirements for mech. vent.
NIV with large mask leaks mean pt doesn't exhale enough
volume

Aerosol Therapy Equipment
AARC Indications for Aerosol Therapy
Nebulizers
Small Volume Nebulizers
3 mL < x <30 mL
6-10 LPM
Particle size: 1.5-7 microns
Respigard II SVN
<2 microns
Nebutech HDN
80% of delivery is <5 microns
Monaghan AeroEclipse Breath-
Actuated Nebulizer
Small-Particle Aerosol Generator
(SPAG)
Mean diameter: 1.3 microns
Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
When selecting appropriate aerosol device:
Available drug formulation Cool bland aerosol: Upper AW
Desired site of deposition Hypertonic or hypotonic saline for inducing sputum
Pt condition/characterisitics Heated bland aerosol: minimizing humidity deficit; when
Pt availability to use device properly upper AW is bypassed
Pt's preference
Interfaces for aerosol therapy: face tent, aerosol mask,
Acute situations with high or multiple doses or unable to follow directions => tracheostomy collar, and Briggs adaptor
SVN or LVN
Bland Aerosol (BUS; no medication):
Bypassed upper AW, Upper AW edema, and sputum specimen/secretion
mobilization
Medication for systemic absorption: Oral or IV would be
better
Aerosol to Upper AW:
Rhinitis, Upper AW inflammation, Systemic dz. (inhaled insulin), and Anesthesia
Devices used to generate bland aerosols:
Aerosol to Lung Parenchyma: LVN and Ultrasonic nebulizers
To deliver a topical medication that has its site of action in parenchyma or for
systemic absorption
Produces particulate matter delivered into a gas stream
2 types:
Mainstream: baffle sits in tube going directly to pt
Side-stream: baffle sits in reservoir (medication not wasted) produces smaller
sized particles
Types of SVNs:
Disposable gas-powered: Updraft, choked flow, sear forces, and vorticity
Bulb-type SVNs: Coordination is key and no longer common in the US
Set Up: Briggs, neb, 6 inch tubing (enough to clear CO2 and
provides a reservoir for medication on next breath= greater
Indications: unable to follow directions, poor VC, unable to perform inspiratory
hold maneuver, tachypnea, medication only available as a solution drug depostion), and mouthpiece
Nebulizer should NOT be cleaned with tap water bc of
Divided into 3 categories: possible contamination of Legionella
Jet neb (JN), USN, and vibrating mesh
Any nebulizer that holds <30 mL = SVN
A: Can be used to deliver drugs with many side effects
(protects provider)
Set Up: mouthpiece, Y piece attached to 1-way valve and
An SVN that utilizes an expiratory filter 2 one way valves; one at expiration limb with filter and
Used to administer Pentamidine (for PCP; HIV pts) another at inspiration limb filter (expiration) and briggs (Inspiration) that is attached to
the neb and tubing (reservoir) that is capped
D: cost
An SVN
A: medication is not lost during expiration
Enhances delivery during inspiration via one way valves
A: less medication wasted and smaller doses can be effective
An SVN (superior drug deposition)
Nebulizes on on inspiration (based on pressure)
D: takes too much time
A SVN D: Ribavirin is toxic and not used anymore
Designed to deliver Ribavirin as treatment for RSV pts Instead an AW is maintained, suctioned, and left alone to give
Ribavirin is administered via tent or hood time to recover
Toxic effects: Conjunctivitis, rash, bronchospasm, no
Is a reusable unit pregnant/nursin exposure
2 gas supplies: 26 psi to create aerosol and second supply is for drying chamber Precautions: Negative pressure room, HEPA mask, gloves,
to further reduce diameter gown, goggles

Large Volume Nebulizers
8-15 LPM
HEART Nebulizers
2.2-3.5 microns
240 mL reservoir
Vibrating Mesh (Aerogen)
Can deliver 1 micron particles
Ultrasonic Nebulizers (USN)
Small Volume Ultrasonic Nebulizers
<10 mL
Good positioning is key to lung expansion and proper instruction is important for
Meter Dose Inhaler (MDI)
Function/Information
Any nebulizer that holds >30 mL
Used to provide continuous aerosol therapy
Large bore aerosol tubing maximizes delivery
Types: HEART and Babbington (expensive but has 2 reservoirs)
May deliver: Bland aerosol, Cool/warm Mist OR Aerosolized medication
Low flow: smaller particles and higher mist density
High flow: larger particles and less density
A LVN
Intended for continous therapy
High output
Mini HEARTs: holds 30 mL but has no cap
GREATEST DRUG DEPOSITION
Not a SVN or LVN; categorized on its own (depends)
Uses an IV pump
Timed and controlled intermittent or continuous treatment
Utilizes high frequency sound waves (Hz and amplitude)
Frequency controls particle size (1-10 microns)
Amplitude controls output
Types: DeVilbiss and Timeter CompuNeb
Reusable
Components: Generator, cabel, pizoelectric crystal, reservoir, and fan
Small volume ultrasonic nebs: Usually for delivery of inhaled medications
Large volume ultrasonic nebs: Usually for delivery of hypertonic saline
Internal battery (12v and 120v adapters)
Smaller particles than conventional gas-powered nebs
Types: DeVilbiss Pulmosonic and Microstat
Also called puffers
greater drug deposition
Pressurized cannister contains drug in a volatile propellant (active drug <1% or
less of mixture
Indications: oriented, cooperative, coordinated pt, adequate VC, RR<25, and if
drug is only available in MDI form
Holding Chamber: should always be used with an MDI
Allows propellant to evaporate/slows delivery, larger particles fall out of
suspension, and coordination not needed bc there's a 1-way valve
Has a built in alarm that sounds if inspiration is too fast
If holding chamber isn't available, use a spacer
Advantages/Disadvantages
D: mini HEART: can be knocked over; secure as best as you can
A: fine particles, low residual volume, more efficient than jet
neb, fast, quiet, and portable
D: Cost
D: hazards include: electrical shock and nosocomial infections
D: If medication is a steroid, pt must rinse out mouth after
treatment
Cleaning: Disinfect mouthpiece assembly in a solution of 1/2
white vinegar and 1/2 water for 20-30 minutes; rinse and let
and liquid detergent, rinsed, and air dried in vertical position
What Would Sam Do? (WWSD)
Connects directly to thorpe tube (won't get knocked over)
Drug calculations:
1) Dosage and LPM given (LPM=> given mL/hr= total)
2)2.5 mg => dosage =>amount
3) Subtract amount from total
Albuterol: 2.5 mg = 0.5 mL
8 LPM = 20 mL/hr (Mini HEART)
10 LPM = 25 mL/hr
15 LPM = 40 mL/hr
Tandem set up: 2 LVNs with 2 flowmeters connected to a
source. "WYE" adaptor connects to both LVNs and is
connected to a Briggs and reservoir tubing
No baffle bc mesh acts as physical barrier bt drug reservoir
and body of neb= Less condensation, secretions, or
contamination
No propellant needed
Frequency is like RR
Amplitude is like Vt
Seen in homecare and shakes/vibrates
Instruction:
If new or it has been a long time since use: Always prime,
rock, and check cannister (Is it the right medication?)
Every time it's used: Rock and check expiration date
Instruct pt to take deep breaths in & out before
MDI mouthpiece in mouth, pump, and when ready, deep
inspiration with 5-10 sec hold, and exhale
If a second dose is needed: wait >30 seconds
air dry
Holding chamber should be cleaned with lukewarm water
 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)

Prime with every use

Eliminates the need for chambers or spacers
Respimat Only for maintainence drugs Hold breath after inspiration (5-10 seconds)
Produces steam and moves slow; fine particles
Usually steroids (rinse out mouth after use)

Aerosol in dry powder form (no propellant needed)

Air drawn through a small dose D: If pt is too weak to create high inspiratory flow, it should
Dry Powder Inhaler (DPI) not be used
Indications: Poor MDI coordination, sensitive to propellant, inspiratory Gravity dependent Dot on R = correct position
Flow atleast 30 LPM flow>60LPM, and drug availability If medication is a steroid: pt must rinse out mouth after
treatment
Types of DPI: Diskhaler, Diskus, and Turbuhaler

Aerosol Administration Devices

Not used for LVN or when medication is being delivered
Drainage Bag
Utilized when using aerosol delivery devices and cool mist

Also called an aerosol T

Briggs Adapter
Has Two 22 mm ports and One 15 mm port
Use with 6 inch aerosol tubing as a reservoir

Aerosol Mask Similar to simple mask but inlet is for large bore (blue) tubing (22mm)
Fits over a tracheostomy tube; 22 mm large bore inlet
Trach Mask
Secured with elastic strap

Face Tent Straps under chin, enclosing only lower part of face
Used in recover and for facial burns
Hyperinflation Therapy Equipment Goal: Recruit
Incentive Spirometry (IS)

Indications: (CTUPP)
COPD and surgery
Thoracic surgery
Upper abdominal surgery
Predisposed/presence of atelectasis
Incentive Spirometry AARC Presence of restrictive lung defect with quadraplegia/disfunctional diaphragm Let pt recover bt breaths to prevent hyperinflation and bc it
is tiring
Contraindications: (VIP)
VC < 10 mL/kg, IC <1/3 of predicted
Inability of pt to use device properly
Pt can't be supervised or instructed

Measurement of inspired volumes; IS relies on voluntary effort to perform a Pt's max. INSPIRATION
hyperinflation manuever Can help prevent pneumonia (alveoli stay dry and open)
Goal: Used to prevent atelectasis and for cough promotion (Hyperinflation/lung
expansion) If measurement is in:
mL= volume displacement device
Use chart to find pt's predicted volume based on age, gender, and height A: IS activity mimics natural sighing and yawning mL/sec= flow dependent device
Improves FRC (reserve)
Incentive Spirometry Methods: If there is an O2 port, it can be utilized during treatment so pt Track the TOP of the float/diaphragm when measuring and
Flow dependent: has a scale and ball(s) that pt rise using negative pressure does not desaturate after reaching goal, HOLD BREATH UNTIL IT REACHES THE
(Triflo II) RT doesn't have to be present for pt to perform BOTTOM (or 5-10 seconds)
Volume displacement: has a volume and coach indicator, corrugated tubing,
piston, and mouthpiece (Voldyne) Adult IS: Stay between Better and best
Photoelectric measurement: has a turbine, light sensor/emitter, and microchip Pediatric IS: Stay at smiley face
(Monaghan Spirocare)
10 breaths q hr

Disposable and volume displacement IS device In better-best range

Voldyne (Hudson RCI) Set up: Slide pointer to prescribed volume level, pt should
Applies sub-ambient pressure above a piston inhale slowly to raise piston and maintain flow at "best"
Converts flow to volume; marker on side sets goal for pt
range, hold until it reaches the bottom, and exhale normally
 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)

Disposable and flow dependent

Goal is 3 floats in 3 seconds

Triflo II (Hudson RCI)
1 float= 800 mL/sec
2 float = 1000 mL/sec
3 float = 1200 mL/sec

Disposable; Operates using true volume displacement

Volurex (DHD Medical) D: rare
Uses a flexible bellow that fills as pt inspires

2 models (battery powered or 110 volt)

Operates using photoelectric principle
Monaghan Spirocare
Spinning turbine interrupts flow of light; speed of turbine is converted into
inspiratory flow which is converted into volume

Positive Airway Pressure (PAP) Includes CPAP, PEP, EPAP, and IPAP

Positive AW pressure adjuncts to bronchial hygiene therapy (CPAP, PEP, EPAP,

and IPAP)

Indications: (rPHO)
Reduce air trapping (asthma or COPD)
Prevent/reverse atelectasis
Helps mobilize secretions
Optimize delivery of bronchodilators

Contraindications: No absolute
Positive Airway Pressure (PAP) AARC Unable to tolerate increased WOB
ICP >20 mmHg
Hemodynamic instability
Facial, oral, skull surgery or trauma
Acute sinitis
Epitaxis
Esophageal surgery
Active hemopytsis
Nausea
Tympanic membrane issues
Untreated pneumothorax

CPAP: Bias flow (AW stays open on inspiration and expiration) Inspiratory Positive Airway Pressure (IPAP): PAP only on
Can only be set to a single pressure; most popular treatment for OSA Inspiration; set higher
Continous Positive Airway Pressure Maintained at 5-20 cmH2O during both I and E
(CPAP) and Bilevel Positive Airway Expiratory Positive Airway Pressure (EPAP): PAP only on
Pressure (BiPAP) BiPAP: IPAP + EPAP Expiration; Like PEEP (end expiration)
Bilevel Positive Airway Pressure; can be set to include a breath timing feature Can be set @10-20 cmH2O
Providing two pressure settings: inspiratory p and expiratory p

Bias flow; expiration from pt creates back pressure
Adjusted by diameter or resistance valve
Pt must be encouraged to reach flows high enough to maintain an expiratory
pressure @10-20 cmH2O
Positive Expiratory Pressure (PEP) Thera-PEP: outdated (2 pieces)
Oscillating PEP: (for retained secretion)
Flutter: steel metal ball inside (looks like an MDI)
Acapella: Has a rubber band inside (magnet adjusts resistance)
Blue= low flow (weak pts) and Green = high flow
Aerobica
Proximity of magnet to lever adjusts resistance
Set Up: Mouthpiece (or mask if they can't follow directions),
A: Acapella is gravity independent (pt can be laying down)
1-way valve, Briggs, manometer, adjustable resistance valve
PEP is less cumberson and more manageable than CPAP or
EPAP (neb and reservoir is optional), and noseclips
D: Ball in flutter valve gets dirty and must be performed Nebulizer should be placed after mouthpiece
Clean with sterile water
sitting up or standing
Method: Slow, deep breath and exhaled actively (10-20x)
with FORCEFUL COUGH

Strengthens inspiratory muscles by providing variable resistance to gas flow

during inspiration
Inspiratory Muscle Training Devices Nose clips discourages cheating

Varies size of orfice to vary resistance to flow

 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
Intermittent Positive Pressure Breathing
(IPPB)

Indications: LIPS PFT

Lung expansion
Inability to clear secretions
Presence of atelectasis where other devices had been utilized but insatisfactory
(IC, PEP, etc)
Short term ventilatory support Critical care setting: IPPB can be used every 1-6hrs
Pt who is weak, fatigued, or has severe hyperinflation Order reevaluated daily
For aerosol medication delivery General care setting: ordered ~2-4x daily, determined based
Treating severe bronchospasm A: can be administered with any device that delivers on pt's response to therapy
IPPB AARC intermittent positive pressure to AWs (Mech. Vent. Or manual Reevaluated every 72 hrs with changes to pt's condition
Contraindications: (no absolute): Heard Sam Has Uncontrollable FARTs resuscitation)
Hemodynamic instability Begins inspiration when negative pressure is generated by pt
Untreated pneumothorax and terminated for passive exhalation (this is for
High ICP spontaneously breathing pts and those with artifical AWs)
Facial, oral, skull surgery
Active Hemoptysis
Radiographic evidence of bleb (tissue destruction => air pockets)
Tracheoesophageal fistula
Singulitus (hiccups)

Low Pressure Reducing Valve (short term therapeutic modality)

Puritan Bennett; utilizes spring tension and diaphragm
0-45 cmH2O
IPPB Vents (Gas Pressure Regulations)
Magnetic attraction opposing gas pressure
Bird IPPB vent
Pressure control moves magnet closer/farther from metal clutch plate, varying
magnetic attraction

Pneumatically powered
IS w/ a motor; manually recruits for pt
Pressure Knob: controls volume (8 mL/kg; based on weight in kg)
Controls cycle (cuts off flow and pressure for passive exhalation) If a pt is in distress and you don't know what to do, start by
Sensitivity knob: Triggers breath according to how hard the pt pulls; green to red increasing flow
(5=>40=> -1=> -14) Sensitive to least sensitive
IPPB (BIRD) A: Can be used as an emergency ventilator
Flow knob: up to 40; changes time (how quickly/slowly a pt receives breath) Mark 8 has the PEEP knob on the top (bias flow => PEP or
Increase flow = decreases I time CPAP)
Air Entrainment knob: can increase flow (~50-60 LPM if pulled out) and change Circuit comes with a nebulizer
FiO2 Triggers a breath on negative pressure
Apnea Knob: nullifies sensitivity; triggers a breath after a certain amount of time Bird mark 7 and 7A do not have PEEP valve
has passed (can set RR => becomes a short term ventilator)

A pancreatic disorder that effects multiple body systems

Causes secretions to become thick and copious
Protein indigestion, fluids harden and thicken => repeated infections (tissue Huff Cough: cough keeping mouth and glottis open
Don't stand downstream
destruction) => eventually leads to a lung transplant 1) deep breath in
2) cough @50%
Cystic Fibrosis First treatment:
3) cough @75%
Bronchodilator given bc bronchospasm is going to be induced with hypertonic 4) cough @max velocity
saline
Vest put on and hypertonic saline given
On set 2: Pulmozyme (orphan drug) that cuts through consolidations is given Pulmozyme is for children and Mucamist is for adults
On last set (out of 3) give aerosolized antibiotics (for pseudomona)

Tolerance is key
Avoid bony prominences and leads
Bronchial Hygiene Techniques to clear AW secretions and improve distribution of ventilation
Chest Physiotherapy (CPT): Postural Drainage, Chest
percussion, and expiratory vibration

Vibramatic Precussor
Flimm Fighter
MJ Percussor
Manual Percussor
High Frequency Chest Wall Oscillation
(HFCWO) Therapy
High Frequency Chest Compressions
High frequency pulsed gas delivery in small bursts, in combination with delivery
Intrapulmonary Percussive Ventilator
(IPV)
Emerson CoughAssist MI_E Device
Indication: neuromuscular disorders, quadriplegia, respiratory muscle weakness,
Emergency Resuscitation Equipment
Physics Of The Principles
Function/Information
Electrically powered; called the vibrator
Usually for neonates and infants
Timer/frequency controls allow for variations in pt tolerance
Electrically powered and mostly for home care
Pneumatically powered off of 50 psi (45-55 psi)
Air is recommended
Palm cups: 4 sizes that are soft vinyl rubber
Adds consistency to technique for manual CPT
Ballard (neonates): soft vinyl on plastic wand; alleviates fatigue
Make your own with tongue blade
Includes: IPV, Vibratory PEP, and High frequency Chest compressions (Vest)
Application of external CW compression using a self-inflating/deflating
pneumatic vest
Pneumatically powered
Pt controls Frequency, Amplitude, and time control for
Components: Air-pulse generator, 2 hoses, and vest that pt applies
Frequencies: 5-25 per second
Indications: Mucus plugging, retained secretions, and disease
Contraindication: unstable thoracic cage injuries
of a dense aerosol (Acapella w/ motor)
Usually used for kids
Types: IPV-2 and IPV-1C
Electrically powered pneumatic insufflation/exsufflation device
Assists with providing inspired volumes and expiratory flows, generates
pressures +/- 60 cmH2O
Maximum flow of 10 LPS
Timing is IMPORTANT; place on end of expiration
Place expiration a little higher than inspiration
and paralysis
Advantages/Disadvantages What Would Sam Do? (WWSD)
Produces 2 directional forces:
Perpendicular to CW: loosens mucus
Parallel to CW: moves mucus toward central AWs
A: Suitable for self therapy (vest, velcro)
D: Limited controls: On/Off only
Pneumatically powered= use of gas or pressurized air
Moves up and down; mimics hands
Cup hands when providing chest PT
Avoid buttons, zippers, bony prominences, spine, clavicles,
A: Effective scapulae, breasts, any surgical incisions, areas with rib
D: Tiring for therapist fractures, and below the rib margins
Do NOT percuss on bare skin
Vest or wrap can be utilized
External vibrations
Start with high frequency and low amplitude
Increase/decrease amplitude by 1 and frequency by 2
A: servo controlled
10 minute intervals for 3 sets and pt should cough after each
set
comfort/effectiveness
On the third set: amp= freq and deliver antibiotics
Foot pedal can control on/off function
Hose goes toward bag/sac bc it needs to expand
Should not be too snug bc it needs to expand
Pressures range from 25-40 mmHg
Frequency ranges from 5-25 Hertz
Internal vibrations
Works with saline and aerosol
Drives pressure in and can be hooked up to a ventilator
Inspiration can be triggered manually by selecting a push
button control on neb (trigger I by pushing button down for
5-10 seconds and E by releasing the button)
This is a positive pressure device
Drives flow in and sucks it back out, inducing a cough
If placed on pt during inspiration=> collapses lungs
A: Has a port for O2
Administered via facemask or tracheal AW
Ask pt to coordinate breath with machine; "take breath in
when it's placed on you"
D: Dangerous if not placed on at the right time
Was originally used for Polio and now for Duchenne
Muscular dystrophy and Spinal Muscular dystrophy

Artificial Airway Cuffs
Cuff Pressure Manometers and
Techniques
Keep <20 torr
Cuff Repair: Respironics PressureEasy
Resuscitator Valve Types
C/E Technique
Poiseuille's Law
Tubing Size
Securement & Positioning
For children: (age in yrs + 16)/4 = size of
ETT
(Does NOT take into account abnormal
AWs)
A good starting spot for securement =
size of tube x 3
Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
P=F/A
High-volume and low-pressure cuff A: The cuff can prevent pneumonia (ventilatory associated
More volume= more SA = less P to seal against tracheal wall pneumonia = VAP; now called NAE)
The cuff protects airways because the epiglottis is bypassed (for ETT and trachs)
D: If cuff is not deflated before placing in/taking out or it's
Cuff leak test: helps identify pts at risk for developing post extubation edema; being manipulated => can cause trauma
listening for flow going through (a leak) Cuff should also be deflated before using any one-way valve
or speaking device
Age cutoff for cuffs is 8 yrs old (not absolute) Cuffs do not always work and sometimes things do get
Better to use cuff to protect airways and gives the option to inflate cuff or leave through
deflated
Measures P in cuff used to seal off trachea; calibrated to atm p
Manometers: (attached to pilot balloon to read pressure in cuff)
Mechanical Manometer & 3-way stop cock: use if there is no cufflator; stop cock
allows for 3 way communication
Posey Cufflator: Reads pressure when attached to pilot balloon (~20= green
zone) Keep in mind that Esophageal opening p is ~20-25 mmHg
DHD Cuff-Mate2
Strain-gauge cuff manometer
Techniques:
Minimal leak volume (MLV): Inflate cuff until trachea is occluded (MOV) and
then deflate a little bit until a leak is heard
Minimal occlusive volume (MOV): Inflate cuff until a leak is not heard
Ensures there is integrity in balloon
Helps with tubes having a leaky cuff
D: cost
Adds pressure to cuff during inspiration (when it's needed most)
Cuff pressure reduced during exhalation (bc it's passive)
One-way valves that sit inside resuscitative bagging equipment and will open or
close when inspiration or exhalation occurs
The different types:
Diaphragm (leaf): Made of flexible plastic that will distort as P is applied & allow
flow through (similar to duck bill)
Spring &Disk/Spring &Ball: Spring is compressed as bag is squeezed, allowing
flow to pt
Duck bill valve: Made of flexible plastic that distorts with P (similar to diaphragm)
Never push mask to mandible because it will occlude the airway; Always lift
mandible to mask
"C" @mask
"E" @mandible
As radius decreases 1/2 = Resistance increases 16x
Smaller AW = Increased WOB
Position check:
For this reason, small artificial AWs make weaning from Mech. Vent. more
1. If there are equal, bilateral lung sounds and movement
difficult 2. Colormetric ET => yellow
Always bring different sizes to be prepared
3. CHEST X-RAY
ETT/trachs: Artificial AW's that provide ventilation for pt D: If pt is obese, has a short and thick neck, or
If pt's chest doesn't rise with bagging => reposition AW with
Should sit 3-4 cm above carina underdeveloped mandible/chin = difficult intubation
head tilt or jaw thrust
Need a fixed, anatomical landmark (gums or teeth) to secure tube
Cricoid cartilage: ~C6 in adults and ~C4 in infants and
children
Without calculations (in practice): Narrowest portion in pediatric AW until age 6 (cuffs are
Men: start with 8 (7.5-8.5)
optional kids under 8)
Women: start with 7 (6.5-7.5)
 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)

Supply lines are bt 400-600 mmHg If suctioning in GI track: -40 mmHg

and must be reduced to -20 to
Vacuum Regulation
-120 mmHg Vacuum systems utilize single-stage reducing valves
Maximum for adult NT suctioning: -120
NEGATIVE PRESSURE => NEGATIVE NUMBERS EVAC (special ETT that can be connected to suction with
mmHg
Only suction on withdrawal and intermittently bc tissue may be grabbed subglottic ports called Murphy's Eyes that are right above
the cuff)
Neonates: -60 to -80 mmHg
Pediatric: -80 to -100 mmHg Do NOT:
Adults: -100 to -120 mmHg Apply suction on way down Use with suction cannister (tube connected to suction
Suction >10 seconds (TOTAL) catheter should be connected to the port in the middle on
Exceed -120 mmHg the cap of the cannister; where the filter is)

Upper AW Obstructions

Indications: Causes of upper AW obstruction; pt loses patency, can't protect

their AW, or quit breathing
(DECAF Coffee Slows down Sam's Lean Legs)
Drug OD
Edema
CNS depression
AW examination: obtain an AW Hx (known history of difficult
Anesthesia intubation, presence of OSA, temperomandibular joint
Indications/ Contraindications Foreign body aspiration disease, previous AW surgery, anatomical abnormalities of
Cardiac Arrest
head or neck, small mouth opening, and significant overbite
Space-occupying lesion
Mallampati scoring
Soft tissue obstruction
Laryngeal obstruction
Loss of Consciousness

Contraindication: pt's desire to not be resuscitated that is clearly expressed and

documented

Use positional maneuvers to open the AW:

Head Tilt: "sniffing position"
Do not hyperextend
One hand on forehead & head tilted backward Anything that relaxes the body can cause pt to lose tone
Positional Manuvers to Open AWs
Anterior Mandibular Displacement (Jaw thrust): Opens AW sans spinal cord Edema and Foreign body aspirations will cause stridor
manipulation; Raises mandible by grabbing both sides of ramus

Never manipulate neck if pt was involved in a MVC => perform a jaw thrust

Use sissor technique to open mouth

Artificial AWs
Always keep back up AWs at bedside in same and smaller
sizes and a bagging system

Designed to relieve obstructions caused by tongue or other soft tissue and

separates the tongue from posterior wall of pharynx if properly placed

Indication: nonresponsive
Contraindications: Conscious pt (bc of gag reflex) and Hx of seizures (use NPA
Oropharyngeal Airway (OPA) instead) A: Channel runs down the middle so a catheter can be used to Should be inserted upside down and turned over
suction or pt can be bagged If placed straight in, it will push the tongue back
Size matters: measure from edge of mandible to corner of mouth
Too small: pushes tongue posteriorly (continued obstruction)
Too large: Epiglottis held shut
Right size: Posterior tip of AW @ base of tongue

Nasopharyngeal Airway (NPA)
Men: 8-10 french
Women: 6-7 french
Diameter of pinky is fairly close
Laryngeal Mask Airway (LMA)
Combitube Airway
Mouth-to-Mask Ventilation Devices
Manual Resuscitators
Flow-Inflating Manual Resuscitator
Set thorpe tube to highest setting and
adjust flow with valve on device
Natural PEEP= 5cmH2O
Self-Inflating Manual Resuscitator
Holds 1 Liter
Function/Information
Also called a Nasal Trumpet; Separates tongue from soft palate
Made of silicon material = more pliable compared to an OPA
Indications: Hx of seizures, conscious pt (the contraindications of OPA) and if pt
needs repeated nasal suctioning
Contraindication: If resistance is met in both nostrils or pt has any kind of nasal
condition
Size matters: measure from tragus of ear to tip of nose
Too small: continued obstruction
Too large: epiglottis held shut
Right size: tip rests bt tongue and soft palate
Tip rests against upper esophageal sphincter
Sides face pyriform fossae, lying just under base of tongue
Seals off the esophagus so air goes into the trachea
Indications: OR, ED, and short term ventilation (bc it moves)
Never seen in ICU
Black line should ALWAYS face the upper lip (@teeth)
Confirm placement with BS, ETCO2, and CXR
2 cuffs and 2 ports, one that sits higher up and the other that sits at the bottom
Inflate both cuffs and ventilate through either port
Confirm which produces chest rise & adequate ventilation
Double lumen device: Esophageal/gastric AW and ETT (seals esophagus and
pharynx)
Not for long term use (if seen in the ED => reintubate with a ETT)
Contraindicated for pts with vigorous gag reflex, esophageal disease, or after the
digestion of caustic substances; also not for pediatric use
Soft-seal mask + one-way valve (and/or filter) to separate pt & practitioner
May have valve for supplemental O2 which can increase FiO2 to 70%
If not, use a NC
Secure mask with both hands because a tight seal is important
Any resuscitation device is a HIGH flow device
"Anesthesia bag"
Indication: neonate or pediatric pt (NICU, OR, pediatrics)
Contraindication: no gas source
Always use a blender with this device
Opening the port will let more air out and decrease pressure and flow getting to
the pt
Used to deliver 21% O2 in absence of supplemental O2 and has a valve
Mostly used for adults
Types: Ambu, BagEasy, and Pulmanex
Ambu: have bags attached that act as O2 reservoirs and can connect to blenders
so pt can receive a fixed flow
Most also have a PEEP valve that adds resistance
Indication: No gas flow
Advantages/Disadvantages
A: Ends are flared to prevent the tube from falling back into
AW and being lost in pt
D: According to diameter, there is usually a preset length
(If it is too long, pull it out a little)
Nasal bleedng and aspiration can occur
A: Good for difficult Aws/emergency situations and short
term intubation (blind)
Doesn't require AW manipulation with extreme head
positioning
A: Emergency out in the field; EMS use this (blind intubation)
D: Complications include: dysphagia, sore throat, injury to
pyriform sinus and esophageal wall
D: Other, better devices can be used
A: Can deliver a precise flow, can feel resistance and lung
compliance (prevents hyperinflation)
Can create CPAP (PEEP) if you squeeze and hold bc it creates
bias flow
D:MUST HAVE A GAS SOURCE TO USE
Advantage: Do NOT need a gas source
Disadvantage: Can hyperinflate pt's lungs bc device is high in
elastance and stiff so lung compliance is harder to feel
(if it gets harder and harder to bag, the pt could be air
trapping)
What Would Sam Do? (WWSD)
Use a lot of lubrication for comfort of pt; thread up for adults
and thread down for kids
Bevel should face away from septum (lots of capillaries here)
If resistance is met, try 1 churn and push, if it doesn't work
try the other nare
If pt has Hx of seizures= keep a couple @bedside
Coude tip (bent) helps identify that the device is in the
trachea (clicks if moved across the tracheal rings)
Cuff pressure <60 cmH2O
When replacing with ETT:
Use a bougie, run down, take off LMA after marking, run
down ETT
"King's AW"
Changed out in hospitals bc can't suction through it and
causes occlusion problems
37 or 41 French (41 is for pts over 60 inches in height)
These are adjunctive devices used to support short-term
artificial ventilation
Has no valves; cross communication
Consists of: O2 line, manometer, mask, and bag system
Port closer to pt is O2
Port closer to bag is where the manometer goes
Valve on system has holes that will let air out (decreased
flow & pressure to pt)
Will be asked to bag at a certain rate (use TCT formula)
Avoid >30 mmHg
Always be on lookout for hyperinflation
With O2 reservoir, can ensure pt receives 100% FiO2
PEP = non-continuous
PEEP= continuous
Can be non-disposable and reused after it is autoclaved but
most will be disposable

Uses spring tension to maintain a set pressure in lungs, even at end-exhalation
PEEP Valves
Need to confirm with a manometer to avoid barotrauma (may use manometer
Intubation Equipment
Miller Laryngoscope Blade
Macintosh Laryngoscope Blade
Magill Forceps
Stylet
Yankauer Suction (tonsil tip)
End Tidal CO2 Detection
Endotracheal Tube Exchanger
Endotracheal Tubes (ETT)
Cuffed and Uncuffed
Has a high sub-glottic port that sits above the cuff and allows for intermittent
Hooks up to a Ballard (closed suctioning system; remember ranges for vacuuming
Hi-Lo EVAC
Contraindication: Pt has AW that is difficult to intubate bc diameter is usually
Wire Reinforced
Oral & Nasal RAE Tubes
Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
Added to resuscitators to provide resistance
Placed where exhalation valve sits
D: Too much PEEP can be dangerous (be careful)
May be necessary for critically ill pts
alone to try and maintain PEEP without a valve)
DO NOT ROCK HANDLE => knocks out teeth
Move arm, not wrist (beer-toasts)
Straight blade
Directly lifts the epiglottis to see cords
DO NOT ROCK HANDLE
Wider, curved blade
Indirectly lifts epiglottis by inserting into and lifting vallecula A: Need less strength to use
DO NOT ROCK HANDLE
Assist in intubation
Helps clear debris in upper AW and can be used for nasal intubations
Assist in intubation
Wire placed in ETT for structure/rigidity
Manipulates shape
Remove once ETT is placed in
Assist in intubation
HARD, suction catheter
A: Good for suctioning oral cavity
Thumb port: if tissue is suctioned, it can be let go (intermittent) Has a curved tip
No thumb port: continuous suctioning
Also called a Colorimetric ET
D: Just bc it is reading CO2 does not always mean that the ETT
One of the ways to check if artificial AW is place in correct position
is correctly positioned
Blue/purple = bad
Yellow = good (reading CO2)
Can connect to O2 if you are worried about pt desaturating
Facilitates removal and replacement of an ETT
Don't forget to mark the length of previous ETT A: quick replacement of ETT if there is a problem that cannot Match up numbers for correct placement
be fixed by an RT
Changing out ETT: take off cap and off vent. Circuit when
Indication: If tube must be replaced (i.e.. Cuff problem)
changing, replace tube, place cap back on and attach it to
vent. Circuit, thread down to correct position
Placed with laryngoscopes to allow ventilation with high levels of positive
pressure and direct access to lower AWs to remove secretions and for drug Have connectors that can come off it you churn and twist
delivery
Cuff sits inferior to cords; Murphy's eyes opposite of bevel, and has a pilot
D: If you have to keep inflating with air, it may be in the
balloon wrong place (sitting @cords instead of inferior) and causing Mark by the gum or teeth, not the lips (can swell and move)
Radio-opaque blue line: to assist with identification on X-ray damage
Left Facing bevel: improves view of cords and makes it easier to thread
suctioning
A: can suction out any debris on top of the cuff Special ETT
pressure)
bigger
A: works well
Used to prevent kinking D: cost
Right angled tube Keeps artificial AW out of the way during surgery
Indication: OR
 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)

Types:
Carlen's Tube: 2 cuffs, intubate L mainstem
The lower cuff seals off LMB and higher cuff seals off RMB to ventilate
Robertshaw Tube: 2 cuffs, intubate R OR L mainstem A: Ventilate each lung based on their needs and conditions The two Ballard's must synch up "master & slave"; one sets
Endobronchial
D: Have to bring 2 of everything the pace, the other must keep up
Requires a bronchoscope (RT's cannot perform this procedure)
Volumes to both lungs can be delivered together or on every other breath
(together is preferred bc the latter will cause a constant increase in thoracic
pressure)

Suctioning should be done based on recommendation (by

Bypass entire upper AW doctor) and prn
Incision usually made bt 2nd & 3rd tracheal rings A: better than an ETT bc less chance of infection and more
Tracheostomy Tubes (TT) Either in OR or @Bedside (percutaneous approach) comfortable If clear, bilateral breath sounds are heard= don't suction (or
Good for long-term ventilation damage can be done)
Obturators: help with trach insertion and limits trauma If a new trach is put in an the pt presents with increased
WOB and SOB => could be subq emphysema

D: No disposable inner cannula; entire trach must be changed

Most common
Cuffed and Disposable AW with a cuff and pilot balloon periodically Changed every 7 days
Made of PVC (plastic) and biofilm can be an issue

A: inner cannula is disposable; entire trach does not need to Changed 2x a day (at least once a shift)
Cuffed with a Disposable Inner Cannula
be changed out unless there is a cuff problem Make sure the cannula locks in

Locate where kink is:

A: More flexible Run catheter down tube
Silicon, flexible trach usually for kids If there is resistance right off the bat =>obstruction
Bibonna
Cuff is injected with water/fluid instead of air D: No disposable inner cannula If it runs down => its in pt (auscultate)
Kinking is a problem Rhonchi => suction
Wheezing => bronchodilator

Good to use during weaning process

A: pt can speak and has a removable inner cannula
Fenestrated When inner cannula is removed & balloon is deflated, pt may breathe through
upper AW D: rare in hospital bc deflating cuff provides the same thing
With cuff inflated & inner cannula inserted, mechanical ventilation is possible

A: antimicrobial (limits bacterial infection)

Has an adaptor with a rounded tip so tissue damage is limited
Silver Jackson Made of stainless steel and is cuffless; can be used as a permanent trach when inserted

D: Cost

A: pt can speak without using their own expiratory gas flow

Has fenestrations; used for weaning
Only use if pt can protect their AW; if they have a strong
Communi-Trach Facilitates speech with an inflated cuff
D: difficult for pt to coordinate and speech is not normal cough reflex
Also called the Pitt Speaking Tube sounding

Longer trach.
XLT XLT proximal: for overweight pts
XLT distal: for pts with long necks

Assess pt => strong cough? => place on pt

Specialized Weaning Devices Maintains patency of stoma during weaning Let the pt build up using a speaking device with small
increments (and depending on how long it is used for, it can
promote failure, so be careful)

Made of Teflon; devices can be attached to it like a French catheter for suction
Never stand downstream of a trach pt
Consists of :
Trach Button Inner cannula Do not place straight in (can cause subq emphysema)
Plug: closes stoma so pt can breathe through upper AW
IPPB adapter: allows mechanical ventilation (no cuff) Usually kept capped/plugged unless AW access is needed
Spacers: adapt to varying neck thickness

Kistner Button
Olympic Trach-Talk
Passy-Muir Tracheostomy Valve
Secretion Evacuation Devices
Suction Regulators
Suction catheters
(AW size x 2) + 2 = suction catheter size
Physiological Measurement & Monitoring
Devices
Pulmonary Measurement Devices
Volume Displacement Devices
Body Plethysmographs (body box)
Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
A: Facilitates for speech and allows for a more effective cough
One-way valve forces pt to exhale through upper AW (seals on expiration)
D: Can't use with mechanical ventilation
Speaking device; not common
Allows pt to inspire through trach but must expire through upper AW so, TRACH
CUFF MUST BE DEFLATED (or pt can't exhale)
Speaking device; common and is the gold standard for speaking valves
Small one-way valve that facilitates for speech
TRACH CUFF MUST BE DEFLATED (or pt can't exhale)
Remember AARC guidelines for suctioning
These plug into vacuum
OCCLUDE PORT TO CHECK ACTUAL PRESSURE
And never use max (only for oral cavity)
Uses a single-stage regulator to reduce the high negative pressures from the
Actual practice: ~160 mmHg used
supply line to safe physiological levels
Set up, 2 hoses:
Generally, don’t need to go >120 mmHg
1 on regulator to cannister (to collect suction)
Types: Puritan Bennett 1 on hole in middle, connected to catheter
Don't connect Ballard to tandem bc then there is
communication bt AWs and oral cavity
Long, narrow catheters designed to remove secretions, blood, or vomit from a
pt's Aws
Whistle Tip
Argyle Aeroflow (rounded tip)
Coude tip (curved)
Ballard Closed Suction System (catheter stays in bag & never in touch with
A: Lukens Trap ("Sputum trap" can be attached to a suction
external environment)
catheter or Ballard) for collection of samples to send to lab
Caution:
Before/after have the pt hyperventilate and hyperoxygenate
Never use catheter with diameter >1/2 the diameter of pt's AW
Insert and apply suction on withdrawal and intermittently (when in pt's AW; can
continuously suction if it is an artificial AW)
Total suction time can not be for more than 10 seconds
Spirometers measure volume or flow changes
Water seal spirometer: Also called a Collins spirometer; air displaces water =>
volume
Industry standard for years
Exhaled gas enters a counterweighted, metal bell
Has a CO2 absorber and one way valves to minimize VD
Measurements should be accurate (can be based on
Other types: Stead-Wells (uses a plastic ball)
cooperation) and precise (repeatability)
Dry rolling seal spirometer: “a frictionless piston” (that is displaced)
Oriented horizontally
Plastic instead of metal
Bellows spirometer: Gas entering bellows causes it to expand
Measures volume and flow
Uses Boyle’s Law(changes in pressure) to measure changes in thoracic volume
P in box changes w/ increase or decrease in volume Measures anything that is on PFT chart
Pneumotachometer measures Pressure, volume, and flow Measure flow with pneumotachometer
Most commonly measured: AW resistance and FRC
 Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)

Used to measure PEFR @bedside (breath out fast & hard)

AW collapses if there's an obstructive disease
Types: Obtain baseline (@home 3 PEFR maneuvers, pick the highest,
SensorMedics Mass Flow Sensor: changes in temperature when they are healthy)
Pneumotachometers
Fleisch: on pressure gradients (most accurate when gas flow is laminar) Red= danger take inhaler and get to hospital
Venturi: difference bt P1 and P2 as air mixes Yellow= inhaler
Pilot Tube Green= Good
Vortex Sensor

Attached to IPPB and records volumes

Vane-Type Respirometers
Most accurate b/t 10-20 LPM
Flow > 300 LPM may damage vane
Wright respirometer: Portable As flow goes through, it spins and tracks volume
Uses rotating vanes & a gear mechanism D: If flow is too fast= doesn't work Track VC (max I and E)
Inertia may have some effect; Newton’s 1st Law
Take deep breath in and out (not too fast)

Types:
Green set @80-100% of baseline
Wright: Permanent/reusable (used for pediatric and adult pts)
Peak Flowmeters Mini-Wright: cheaper, lighter, plastic Red set @50% and below
Assess: Disposable, common, and vertical Asthmatics and COPD pts use this daily
Quick burst of air (should be done every morning)

O2 Analyzers

O2 is a paramagnetic gas (attracted to magnetic field) D: Cannot continuously measure

Change in magnetic field causes “dumbbell” to rotate
Physical Gas must be anhydrous
Delicate & expensive to repair
Shows both partial P & FiO2

Utilizes thermoconductivity to measure FiO2

Electrical Uses a device called a Wheatstone Bridge D: Not suitable for flammable environment (OR)
More O2 = greater heat transfer
Change in current is proportional to change in FiO2

A: may measure a moving gas

Types: Can be used intermittently, continuously, in OR, etc.
Galvanic: Electrical current is proportional to Partial pressure of O2 (scale is set
to FiO2) Has a fuel cell Polarographic is most effective
Compares [O2] of unknown gas with ambient air (responsive Fuel cell undergoes chemical rxn
Does not need to be turned on (constantly reading FiO2 of RA, so keep capped to
Electrochemical to changes in percentage of O2 instead of partial pressure of
prolong its life)
O2) To calibrate, check if probe is reading 21% on RA
Polarographic: Similar to galvanic except:
Composition of electrodes and Battery power speeds up rxn (Has a fuel cell +
D: Galvanic: fuel cells need replacing
battery)
Polarographic: fuel cells and battery needs replacing

Blood Gas Analyzers

Reference electrodes ("reference cell"): provide a constant reference

Electrochemical results must be: Reversible, Reproducible, and Stable
As blood passes through system; need to reference it to something

pH glass: Permeable to H+ ions

Electrodes:
Voltage is produced by placing solutions of varying pH on opposite sides and can
Reference pH, PCO2, PO2, electrolytes (need from venous after it has
pH Glass be used to determine pH of one of the solutions, if it is unknown gone through tissues), MetHB
pH system (cell)
pH system (or cell): Composed of one reference electrode & one sample
electrode placed on opposite sides of pH glass (to measure the pH of a solution)
Measuring cell has known solution on one side/unknown (blood) on the other
Potential difference b/t known & unknown is proportional to pH of the blood

PCO2 system: pH system modified to measure PCO2

CO2 diffuses across membrane to react w/ sodium bicarb and water to produce
H ions; Voltage change is measured; proportional to CO2 dissolved in blood
Electrodes: Severinghaus electrode= measuring CO2
PCO2 System Clarke reads flow which is proportional to PO2 (also called a
PO2 System PO2 system: O2 diffuses from blood to react w/ buffer & form OH- (yields polarographic electrode)
current flow); Flow is proportional to PO2
Tip is covered w/ semi-permeable membrane
Clarke electrode= measuring PO2

Blood Gas Sensor Blocks
Calibration & Quality Control of Blood
Gas Systems
Trend vs Shift
Transcutaneous Electrodes
PCO2 System
Heater maintains electrode @ 440C
Q30 or more (set the timer)
PO2 System
Heating element raises skin T0 to 440C
Q30 or more (set the timer)
O2 Saturation Measurement
Hb and Its Variants
CO-Oximetry
Pulse Oximetry
End Tidal CO2 Monitoring
Function/Information
Conventional electrodes are much smaller
Service life is longer 20 to sealed systems
Calibration: comparing a measuring device with a known physical standard
(periodically to ensure accuracy)
Done w/ gases known to be within 0.05%
Quality control: Application of statistical analysis with standardized control
samples
Differentiates b/t random analytical errors & systematic technical errors
Terms used in statistical analysis of blood gas machine testing
Trend: 6 or more results that show an increasing or decreasing pattern (pattern
that increases or decreases)
Shift: 6 or more results falling on the same side of the mean value (everything is
on one side or another; above or below)
Allows real-time monitoring sans repeated blood samples
2 types: PCO2 System and PO2 System
A modified Severinghaus electrode
Must be periodically remembraned
Airtight seal @ base of electrode prevents ambient air from entering
Calibrated by exposure to a gas w/ known CO2 concentration (5% or 10%)
Essentially a modified Clarke electrode
Must be periodically remembraned
Airtight seal @ base seals out ambient air
Calibrated by exposure to a zero solution & room air (2-point calibration)
Hb reversibly binds with O2 (HbO2 and RHb)
Carboxyhemoglobin (COHb): bound to CO
Affinity= 200-250x
Methemoglobin (MetHb): cannot bind with O2; brown in color
Principle of operation
Determines fractional Hb
Uses spectrophotometry: RBC’s are hemolyzed to release Hb
Isobestic point: wavelength where 2 or more variants (Hb, HbO2, HbCO) absorb
same amount of light
By knowing amount of light absorbed, concentration can be determined
Principle of operation
Principle of Operation
Continuous measurement of [CO2] @AW opening during respiration
Capnography= continuous [CO2] displayed in wave form (each wave form is
expiration)
Sensor Position: Mainstream, Sidestream, and Proximal diverting
Colorimetric End Tidal CO2 Determination
Advantages/Disadvantages
A: Good to use as trending devices
Noninvasive trending device
D: expensive and can burn the pt
D: Must be moved frequently to prevent burns
D: Must be moved frequently to prevent burns
D: any cane= topical anesthetic and nitric oxide= by product is
methb
What Would Sam Do? (WWSD)
Sensor blocks are labeled (twice)
Every hospitals has its own policies
Timer to run quality control already set for each day
Erroneous result= need to calibrate
Solution that is run through should come out within 0.05%
Point of Care: I-STAT
Point of care= can run at bedside(results in 2 minutes)
Place on solid surface bc it is expensive and shouldn't be
shaken
IF a shift is consistent it can be used to trend
Not going to match ABG exactly
Sits on skin and requires certain temp to work; move it every
4hrs bc the electrodes run hot
Calibrate Clarke by exposing to RA
Servinghouse by sticking into machine (reference cell inside
machine)
To trend correctly = need an ABG (can be used for venous
sample for kids (no ABG for kids) but shift CO2 by 6)
Remembrane and move every 4hrs and calibrate every 8 hrs
Add solution before placing it as a buffer bt it and pt's skin
q4 bc we see pt's q4
Needs to be airtight and sealed= why membrane solution is
important
Same procedure as above but calibration is different
zero out = atm
Infrared- all RBCs that pass through light is read to see what
is attached
RHb= reduced Hb
Brown blood=> run through co-ox (methylene blue or
vitamin C (citric acid, ascorbic acid) to reverse chemical rxn)
Reads fraction of Hb that has Met, O2, and CO
Can't trust it until it has been run through a real co-ox and
then it can be used to trend
Is a trending device
Methods of measuring CO2: IR spec., Mass spec.(can sample
10-12 pts), Raman spec.
Can be preformed invasively and noninvasively
Can be used for Conscious sedation, during an entire code
(measures vent. and for tracking tissue perfusion)

Measurement of O2 Consumption and CO2 Production: Ve, Vt, and REE
Indirect Calorimetry
Apnea & Home Sleep Monitors
Function/Information Advantages/Disadvantages What Would Sam Do? (WWSD)
2 Methods:
Closed circuit: pt breathes into and out of a container
To estimate a pt's energy requirements prefilled with O2 (CO2 consumption measured by O2 volume
In steady state: relaxed used by pts)
Open circuit: volume inspired and expired gases measured as
well fractional [O2] in each
Nutritional Assessment:
Ventilator weaning When pt is in steady state you can track metabolism
Diet/exercise prescription
Nutritional support for COPD: Low carb, fat diet and high
protein
Apnea Monitor Types:
Inductive plethysmography Apnea Monitor: Premature babies with apnea (monitor's
breathing and alerts parents; agitate fingers and toes)
Impedance plethysmography
Home Sleep Monitors: (measures Pulse ox, air flow, and HR) Home sleep monitors: For OSA
Plethysmograph (measures breathing mechanics while
Impedance channel sleeping)
SpO2 channel For adults
Heart rate channel
CPAP will stent anatomic AW open
Airflow channel