Classification:

based on FiO2

High flow = fixed Low flow = variable

Very accurate [O2] at flow exceed requirements
PIFR patient > device
deliver a fixed inspired oxygen concentration to the patient,
independent of the PIFR
- No entrainment of room air except venturi mask
20% (environment) + (4 x FR) = FiO2
Relatively stable Fio2 in stable RR
Low flow delivery
PIFR patient < device
Based on patient anatomic reservoir & min ventilation
deliver a variable inspired oxygen concentration to the patient ->
depends on the PIFR.
- on a patient's inspiratory effort (tidal volume, 'speed' of
inspiration and respiratory rate) -> PIFR can often exceed the
flow rate at which oxygen or an oxygen/air mixture is supplied by
the device, meaning that at the time of PIFR more or less
entrainment of room air occurs, altering the resulting FiO2 in an
unpredictable fashion.

0-15L/min
- High flow nasal cannula - Nasal prongs
- Venturi mask - Simple face mask / Hudson mask
- Oxygen tent - Partial breather high flow mask
- Head box
- Non breather high flow mask
- Bag valve mask
 Oxygen therapy

Nasal prong Simple face mask Venturi mask Partial breather Non breather

syn Nasal cannula Hudson mask Ventimask

comp Exhalation port Interchangeable Venturi valve No valve present – Oxygen reservoir bag – must
O2 inlet - mix o2 and ambient air to mixing of inspired and be inflated first 2/3
achieve the desired Fi02 expired in bag
One way flap valve
- Entrainment but at (unidirectional)
constant FiO2 Expirational valve - air out to
environment – no mixing in
Straight – upward to reservoir bag / pre
frontal sinus Inspirational valve – o2 from
Curved – direct O2 bag to patient only.
posteriorly
Flared - increase d at
tip --> reduce velocity - Bernoulli – smaller hole -> low
> comfortable P -> more ambient atm in ->
Curved + flared -> slow low FiO2 O2/ concentration O2
and away frontal sinus

ind Mild hypoxia Moderate Severe

- Tachypneic
- Apneic
- Patient doing the
ventilation
- Must have spontaneous
respiration
->deliver O2 at high
concentration up to 99%
C/I - Mouth breather - Facial injuries - Facial injuries
- Nasal obstruction - - Apnea - Apnea
> nasal polyps/DNS
 - Not in place

adx Can be used in children

-> able to talk, drink,
eat
Used in mouth
breather
FR 1-6 5-10 1-15 10-15 10-15
L/min
(FR<4 – no need to (min FR - 5 to flush
humidifier – nasal hair) out co2)
FiO2 24-44% 40-60% 24-60% 60-75% 80-99%

Techniqu 1. Attach o2 tubing and

e set FR
2. Deflate bag by
occlude the
inspiration valve

1. Attach humidifier
cap and then to
flow meter
2. Adjust flow meter
3. Test leakage
4. Connect nasal
cannula
 5. Place and tighten
Cx - Epistaxis <- dryness Hypercapnia – - Absorption Atelectasis –
- Blocked nasal rebreathing of nitrogen that distended in
prongs due to expired CO2 alveoli being washed out ->
secretions reduction of volume ->
- Gastric distension collapsed -> hypoxemia
- O2 induced
hypoventilation in ill
patient (unable to
compensate)/ hypoxic
drive
- Oxygen toxicity -> long
term -> FRC
spec Variable Variable Fixed Variable Variable
Low flow system ? one way valve -> fixed
performance

Assisted ventilation
-> If O2 therapy fails
Look for obstruction

BVM LMA ETT OPA NPA

->signs of difficult aiway -> intubate Not done
comp

Ind - Failure of O2 therapy Unconscious Conscious/ semi

- Unstable self ventilate Absent of gag
- Use with airway adjunct reflex
C/I - Spontaneous breathing - Cannot open mouth - - Cough/ - Basal skull #
- Complete airway obstruction - Obese vomiting - Nasal #
- Cervical spine injury - 2nd / 3rd trimester pregnancy - Foreign - DNS
- UGIB body
- Need for high airway P
adx Suction and
secretion
Technique 1. Check valve 1. Check air leakage inflate with 1. Check size 1. Check size
2. Supply oxygen 20ml 2. Push 2. Lubricate at tip
3. Put airway 2. Deflate back against hard only
4. C&E technique 3. Use hand on cheek palate – 3. Insert
5. Pull the mandible 4. Open and lubricate twist perpendicularly,
6. Every 5-6s without CPR posteriorly 3. Follow bevel facing
7. 30:2 with CPR 5. Index finger on hard palate curvature septum
Ensure
 - Visible chest rise
- Symmetrical
Misting in mask
No air leak
Equal air enrty ‘aunstcultate
vesicular
Cx - Hyperventilation - - - Gaggling, - Epistaxis
vomiting, - Trauma
aspiration - Exacerbate skull #
- Soft tissue - Stimulate gaga
trauma reflex in sensitive

1. BVM
- Head tilt chin lift (OPA &NPA)
- Jaw thrust
2. LMA
3. ETT – call for help (signs of difficult airway)
4. Surgical airway:
- Tracheostomy
- Cricothyroidotomy

Indications for intubation

In general patient that needed assisted ventilation ->
- Respiratory arrest
- Cardiac arrest
- Complete obstruction of airway about to happen
- Unconcious patient
BURP
- Improve the view of glottis. -> to ease intubation (before insertion of tube)
- If glottic exposure was classified as Cormack–Lehane grade 3 or 4, suggesting difficult laryngoscopy.
backward, upward, rightward, and posterior pressure on the larynx/ thyroid -> causing dorsal displacement of thyroid
contraindication -> not to be used with Sellick because hard to visualize the airway
rightward -> hand position
Adx: no dysphagia, dysphonia
https://epomedicine.com/emergency-medicine/rapid-sequence-intubation-mnemonic/
Sellick / direct cricoid pressure
- Technique during ETT to prevent regurgitation by apply P on cricoid -> by assistant
- direct visualization & occlude esophagus prevent aspiration
- Press above thyroid – press posteriorly
- Cricoid Cartilage -> completely encircles the air path -> strongest part of the airway. -> increases the esophageal opening pressure, making
it harder for air to enter the stomach. -> prevent regurgitation
- Why not trachea? C cartilage posteriorly
*** Don’t say reflux but regurgitation and aspiration
Lehane formack classification
- Operator dependent

-> classifies airway views during direct laryngoscopy based upon the visible anatomical structures.
Grad Approximate Likelihood of difficult
Visible structures
e frequency intubation
1 Full view of glottis 68-74% <1%
2a Partial view of glottis 21-24% 4.3-13.4%
Only posterior extremity of glottis and/or
2b 3.3-6.5% 65-67.4%
arytenoid cartilages
3 Only epiglottis 1.2-1.6% 80-87.5%
4 Neither glottis nor epiglottis very rare very likely

When does oxygen induced hypo occur?

In normal patient with normal lung function, our stimulation to breath is based on PaCO2 -> stimulate the respiratory center in the brain
Ill patient -> hypoxic drive based on PaO2 -
patients with a hypoxic drive are given a high concentration of oxygen -> primary urge to breathe is removed and hypoventilation or apnea
may occur.
- COPD patients -> chronic retention of CO2 -> maintain spo2 88% and 92% in patients with known chronic CO2 retention verified by an ABG.

SPO2
PaO2
Sigmoid curve
Case 1: cardiogenic shock
Cardiogenic shock secondary to MI leading to acute pulmonary edema
A male collapse in ICU with MI -> bradycardia -> going into Vfib

Cardiogenic Shock? Cardiac pump failure leading to systemic hypotension -> global tissue hypoperfusion
- Don’t give fluid
Response
Check patient orientation -> talking -> airway patent
Check pulse

Patient is on nasal prong -> but SPO2 dropping -> adjust FiO2
FiO2

Determine type of hypoxia

A
B
C
j

Case 2: chest tube drainage malfunction

Case 3: AEA/ COPD/ anaphylactic shock – suction -> aspiration due to bag valve mask

CPR
- Patient has to be lfat