Oxygen & Medical Gas Therapy • High-pressure storage system

Liquid Oxygen Cylinders

Physical Characteristics of Medical Gases:
• Categorize according to fire risk • Practical when large amounts of oxygen are needed or
• Flammable when oxygen is running at a constant high-liter flow
o Most anesthetic gasses • Stored in cryogenic, insulated, vacuumized thermal
• Nonflammable containers
o Carbon dioxide - (CO2) is a gas that is colorless, • Filled to a filling density.
odorless, nonflammable, and will not support
Bulk Storage Systems
combustion.
o Nitrogen • Stored in either liquid or gaseous form
o Helium - (He) is an odorless, tasteless, • Liquid storage is more commonly used.
nonflammable gas, and it has therapeutic uses. – Convenient
• Support combustion – Operate at lower pressures
o Oxygen (O2) - is a colorless, odorless, tasteless, and
Central Piping Systems
transparent gas.
o Air - is a gas mixture composed of nitrogen, oxygen, • Delivers gas from the bulk storage area to its various
carbon dioxide, argon, and trace gases. points of use
o Nitrous oxide - (N2O) is nonflammable, supports • Pressure sensors are placed at various locations in piping
combustion, and is used as an anesthetic agent. system to monitor pressure.
o Oxygen-nitrogen • Zone valves enable gas to be shut off to certain areas in
o Oxygen-carbon event of a fire.
o Nitric oxide (NO) is nonflammable & supports
Connector Systems
combustion.
• Pin Index Safety System was designed for the valve outlet
Production & Regulation of Medical Gases
of small cylinders.
• Gases used for medical purposes must meet high • Diameter-Index Safety System prevents the interchange
standards of production & stricter regulations. of medical gas connectors.
• FDA requires O2 purity of at least 99.0%. • Quick-connect systems are designed for low-pressure
• Oxygen is commercially produced for medical purposes connectors.
by two main methods:
Oxygen Regulation Devices
− Fractional distillation
− Physical separation • Cylinder valves and reducing valves are necessary to
• Physical separation methods regulate gas pressure and for the safe attachment of
− Molecular sieve pneumatic equipment.
− Permeable plastic membrane • Specialized regulations are needed to control gas flow
• Medical-grade air is produced by filtering & compressing and oxygen concentration.
atmospheric air.
Therapeutic & Diagnostic Uses of Oxygen
• Air-compressor types: piston, diaphragm, centrifugal
compressors. • The respiratory therapist must be well versed in both the
therapeutic and diagnostic uses of oxygen.
Regulation of Medical Gas Safety • Monitoring the patient during therapy and assessing the
• Involves various governmental and nongovernmental outcome of therapy
agencies Goals and Objectives of Oxygen Therapy
• Responsibilities of agencies
• To correct acute hypoxemia
− Regulate production of compressed gas cylinders
• To alleviate the symptoms associated with chronic
and bulk systems
hypoxemia
− Handling, storage, and labeling of medical gases
• To decrease the workload of the cardiopulmonary system
Storage & Distribution of Medical Gases
Causes of Hypoxemia
• Distribution involves central piping and connector
• Must be differentiated from hypoxia
systems, and oxygen regulation devices.
• Four major causes
• Stored in one of three types of containers:
– Low alveolar PO2 (PAO2 )
– Compressed gas cylinder
– Diffusion impairment
– Liquid oxygen cylinders
– Ventilation/perfusion mismatch
– Bulk storage systems
– True shunt
Compressed Gas Cylinders
Assessment of Hypoxemia
• Convenient method for storage and delivery of oxygen • Accomplished by a thorough patient assessment
• Cylinders manufactured in various sizes combined with laboratory data indicating hypoxemia
 Indications for Oxygen Therapy Oxygen Therapy Protocols

• Documented hypoxemia • Protocols ensure

• Acute myocardial infarction, trauma, postoperative – Immediate changes
recovery, and any condition in which hypoxemia is – Bedside assessments for patient
suspected – Individual treatment based on need
– Timely discontinuance of therapy when no longer
Hazards of Oxygen Therapy
needed
• Four major hazards
Analyzing Oxygen Concentrations
– Absorption atelectasis
– Ventilatory depression • Verify if desired F1O2 is being delivered
– Oxygen toxicity • Physical oxygen analyzers
– Retinopathy of prematurity • Electrochemical oxygen analyzers
Oxygen Delivery Systems • Electrical oxygen analyzers

• High-flow systems Therapeutic Use of Gas Mixtures

– Aerosol masks • Certain gases can be combined with oxygen to treat a
– Trach collars variety of conditions.
– Trach tubes • Gas mixtures
– Mist tents • Carbon dioxide-oxygen
• Low-flow systems • Helium-oxygen
– Nasal cannulas • Nitric oxide therapy
– Simple O2 masks • Carbon dioxide and oxygen (carbogen) – Increase
– Partial rebreathing masks cerebral blood flow
– Nonrebreathing masks o Treatment of central retinal artery occlusion
• Reservoir systems o Side effects include headache, hypertension,
– Reservoir cannulas and pendants dizziness, muscle tremors, and mental depression.
– Simple masks • Helium and oxygen (heliox)
– Partial and nonrebreathing masks – Low density
• Oxygen enclosures – Reduce a patient’s work of breathing
– Incubators – Effective where turbulent flow exists
– Oxyhoods – Side effects: directly related to low density
– Mist tents • Nitric oxide therapy
Oxygen-Conserving Devices – FDA approval in December 1999
– Extensive clinical trails have been performed with
• Treats hypoxemia
success.
• Portable concentrators
− Allow freedom to travel Hyperinflation Therapy
− Patients can manage their power options.
Key Definitions, Concepts, & Professional Standards
• PDOD and DODS
• Total lung capacity (TLC)
− Electronic or pneumatic devices
• Functional residual capacity (FRC)
− Extend the time of the cylinder or vessel
• Elastic recoil
Hyperbaric Oxygen Therapy • Pleural pressure
• American Association for Respiratory Care clinical
• Exposure of a patient to a pressure greater than 1
practice guidelines
atmosphere while breathing 100% oxygen either
o Developed statement to help practitioners deliver
continuously or intermittently.
appropriate care in specific clinical circumstances
Monitoring Oxygen Therapy o Improve consistency & appropriateness
• Can be accomplished by both invasive and noninvasive Historical Perspectives
methods
• Rebreathing of carbon dioxide
• Invasive methods
• Breathing of gas mixtures
– Arterial blood gas analysis
• Resistive breathing devices
– Co-oximetry
• Intermittent positive pressure breathing
– Arterial line (A-line)
• Prevention & treatment of pulmonary atelectasis
• Noninvasive methods
• Collateral channels—collateral ventilation
• Comfort
• Physiologic basis
• Risks are minimal.
o Deep, prolonged inspiratory effort
• Continuous display of status
o Depends on relationship between distending
pressure and resulting change in lung volume
 Deep-Breathing Techniques ● Four common characteristics of centenarians
− Optimism
• Prevention or resolution of pulmonary atelectasis
• Sustained inspiratory efforts − Flexibility
• Spontaneous deep breathing using the diaphragm and − Commitment
chest wall − Engagement in activity

Sustained Maximal Inflation ● Morbidity and mortality

(Incentive Spirometry) ● Wellness
● Improve patient success in accomplishing the maneuver − “an approach to personal health that emphasizes
● Specific indications individual responsibility for wellbeing through the
– Presence of any condition that would predispose practice of health-promoting lifestyle behaviors”
a patient to development of atelectasis
– Presence of atelectasis
● Contraindications Models of Health
● Hazards and complications ● Differently underlying beliefs and attitudes
– Patient observations ● Medical model – Based almost exclusively on biological
– Coached not to maintain the hyperinflation explanations of illness and disease
Positive Airway Pressure ● Environmental model – Includes effects on personal
health, focused on conditions outside of the individual
• Reduction in functional residual capacity
● Holistic model – Comprehensive approach
• Methods of application
− Entails the community, focuses on optimal
− Positive expiratory pressure therapy
health, prevention of disease, positive mental
− Expiratory positive airway pressure therapy
and emotional health
− Continuous positive airway pressure therapy
− Criticized for being too idealistic
● Procedure
● Contraindications Dimensions of Health
● Hazards and complications
● Six dimensions of wellness
● Limitations
o Physical - Functional operation of the body and how
Intermittent Positive Pressure Breathing it responds to damage and disease
o Physical fitness and medical care
● Modality used to provide short-term ventilatory support
o Occupational - Deriving satisfaction and pleasure in
● Passive or active administrations
one’s job
● Active therapy sessions appear to result in the greatest
o Intellectual - The use of one’s mind and Attainment
posttreatment inspiratory capacity (IC)
of knowledge, education, and experiences on a
● Procedure
lifelong basis
● Specific indications
o Social - One’s ability to fulfill one’s role and Certain
– Other methods of lung expansion not effective in
expectations and give-and-take
preventing or correcting atelectasis
o Spiritual - Not always synonymous with religion and
● Contraindications
One’s inner belief and interpretation of the meaning
● Hazards and complications
and purpose of one’s existence
● Limitations
o Emotional - Understanding and accepting of
Outcomes Assessment feelings and One’s capabilities and limitations

• Therapy session Philosophy of Holistic Health

• Posttreatment data collected and evaluated
● Disease prevention
Health Promotion − People exposed to a health threat
− Primary prevention
• Health promotion is a concept, a process, a way of life
− Secondary prevention
that has become popular.
− Tertiary prevention
• Reduction of morbidity and mortality and in the
● Health promotion
enhancement in longevity and quality of life
– People who are healthy and seek development of
• Professionals need to understand life expectancy.
community and individual measures
General Principles and Concepts of Health – Notion of individual responsibility for one’s actions—
four components.
• Many people have considered health as the absence of – Locus of control: internal and external – Influence of
disease. cultural norms
• Health has become redefined and reevaluated. • Power in the peer group
• Life expectancy
● Infant mortality
● Maximum or optimum life span and the average life span ● Continuous decline in the death rate
 Factors Affecting Health Care in the United States in – Traditional view is limited to a health care
system that activates resources.
the 20th Century
– Wellness model: awareness, education,
● Era of public health improvements motivation, behavior change, high-level
– Deaths from infectious disease and infant mortality wellness
– Greater attention to personal hygiene and nutrition
● Era of drug and chemical discoveries Health Promotion Process
– Efforts directed at identifying chemical agents that ● Individual or personal wellness
could be used to combat presence of infectious – Making choices about health
diseases – Systematic strategy
● Era of medical and technological advances – Having the individual take the time to identify
– Heart transplants, coronary artery surgery, open- personal health practices
heart surgery – Commit, assess, act
● Era of lifestyle ● Community or organizational wellness
– Obsession about health and fitness – Health promotion programs
– Tremendous interest in caring for one’s body – PRECEDE-PROCEED model
Leading Causes of Death – 4Ds model

o Infectious diseases
Role of the Federal Government
o Heart disease ● Healthy People: The Surgeon General’s Report of Health
o Cancer Promotion and Disease Prevention
o Strokes – Raised consciousness of the nation to the notion
o HIV/AIDS, suicide, and homicide have dropped off the that we need to exercise the personal discipline
list. – Simple measurements
o Environment and lifestyle factors ● Promoting Health/Preventing Disease: Objectives for the
o Essential that individuals have responsibility for day- Nation
to-day activities and better control risk factors – 15 priority areas
o Respiratory therapist should recognize leading ● Healthy People 2000
causes of death. – 3 broad goals, 22 priority areas, 319 national
Behavioral Causes of Death objectives
● Healthy People 2010
• Tobacco products ● Healthy People 2020
• Drug and alcohol misuse and abuse – Designed to be highly inclusive and collaborative
• Microbial and toxic agents
• Motor vehicles
Role of Respiratory Therapist in Health Promotion
• Firearms • Technician, diagnostician, and clinician
• Sexual behavior • Must possess superior clinical assessment skills to
Determinants of Health Status practice in today’s health care environment
• Health care educator
● Inadequacies in the existing health care system • Involved in health promotion and disease prevention
● Behavior factors or unhealthy lifestyles movement
● Environmental hazards • Provide leadership in determining health promotion and
● Human biological factors disease prevention activities for students, faculty,
● Framingham Heart Study practitioners, patients, and the general public
● Heredity
– Genetic inheritance Fundamentals of Patient Education
– Aging process • Individuals taking on the process of education and
– Metabolic processes training must realize that what may appear as a complex
– Overall processes of maturation situation can be placed into a simple format.
● Environment • Building blocks can be manipulated to obtain specific set
● Health care system goals and objectives.
– Ability to access health care
– Ability to purchase appropriate health care benefits The Educational Process
● Lifestyle ● Modalities of learning
– Daily living, day-to-day routines or habits – Sensation, perception, and memory
Continuums – Most educational programs designed include at least
two modalities.
• Health continuum – Understand patient’s needs and abilities
• Illness and wellness continuum – Develop educational program
● Goals, objectives, and outcomes – Dedication to professional ideals and patients
– Goals are general statements of purpose. – Health fairs
– Objectives are declarative statements that direct
Departmental Structure
the learner’s action toward a specific goal.
– Outcomes are the end product. ● Vertical management structure
● Communication skills ● Centralized
– Attending behavior, active listening, reflection and ● Quasi-decentralized
inventory questioning, and encouraging alternative ● Decentralized
behaviors ● Communications department
– Verbal and nonverbal cues
● Patient readiness Diversity of Respiratory Care Services
– Change is a process and a personal experience.
● Expanding roles
– Predischarge process
● Various procedures: ventilator management,
● Patient compliance
oxygen, hyperinflation
– Patient does as instructed
● Cardiopulmonary designation
The Respiratory Therapist as the Educator ● Sleep medicine
● Home activities
● Research is required to determine the patient education
site, resources, and the actual ability to perform and Operational Issues
succeed.
● Daily work assignment
● Patient sites – Varies on the clientele, can be adapted
– Manual paper systems
● Within the community – Educational programs
– Automated information systems
● In the health care facility
● Planning the manual system
– Typically responsible for the development and
– Legitimize staffing and productivity levels
administration of educational programs
– Maximal productive work time
– Reading level
● Automated information systems assignment
– Design
development
– Illustrations
– Time-saving tool
– Content
– Printing new assignments or setting up alert systems
– Patient management
– Balance Fiscal Issues
– Source
• Operating budget – All categories of expenses that are for
● In-service education
non depreciable items
● Patient education resources
• Capital budget – Health care organizations will want to
Management of Respiratory Care Services capitalize as much equipment possible for finance
purposes
● Human resource management – Creates the manpower
resource that provides direct and indirect patient care in Reimbursement
the profession
● Medical direction or medical director – Individual(s) with ● Diagnosis-related groups and resource utilization
whom direct responsibility for the quality of patient care groups – Payment systems for inpatient activities
resides ● Managed care
● Clinical time standards – Health maintenance organizations
– Uniform reporting standards – Common methods to control expenditures
– Normal timed work units assigned to activities Human Resource Management
performed by respiratory departments
● Performance improvement – Quality measures used to ● Recruitment
track consistency and quality – Staffing trends for pay rates and benefits
● Interdisciplinary – Use of professional and – Keeping active in professional activities
nonprofessional stakeholders in teams to make an ● Selection and placement – Selection of an individual by
impact on systems and practice the position being recruited for using the job description
● American Association for Respiratory Care and needs of each particular position
● Clinical practice guidelines ● Orientation – Mandatory programs
– Introduction of new employee
History, Professional, & Community
● Compensation – All benefits that cause an employee to
Involvement in Respiratory Care desire to stay at an individual work site
● AARC has provided leadership, guidance, and public ● Training and development
forum. – Periodic orientation
● Community involvement – Learning new procedures
– Inservice education
 – Input from presenters – Presence of atelectasis, suspected of being caused
● Performance appraisal by mucous plugging
– Fair treatment – Diagnosis of diseases such as cystic fibrosis,
– Consistency of appraisal from employee to employee bronchiectasis, or cavitating lung disease
● Employee discipline
– Reinforces need to follow standards and the Assessment of Pulmonary Hygiene
concepts of quality and conformity for all employees • Ability of patient to cough effectively and expectorate
– Competency based secretions
Manager Accountability • Factors that alter effectiveness
o Characteristics of mucus
● Administrative accountability o Breathing pattern
– Decentralization of the respiratory care departments o Mechanics of the cough
into service lines • Mucus
– Matrix form of evaluation o Ciliary activity and production of mucus
– Resides partially with finance and information o Mucus rheology
systems administrative personnel • Breathing pattern
● Medical direction o Retention of secretions
– Consultation and professional input for other o Alveolar collapse
operations of the department • Effectiveness of cough
– Main professional entity responsible for quality care • Alterations in physical properties of mucus
outcomes o Mucus transport
● Staffing accountability o Viscosity, elasticity, spinnability
– Direct involvement in patient care • Improving pulmonary hygiene
Computer Applications o Altering the physical properties of mucus
o Improving the distribution of air in the lungs
• Usually involves financial and quality functions • Coughing – Essential for clearing mucus from airway
• Add-on information systems specific for activities • Alterations in airflow and air distribution
• Measurement of outcomes o Retention of secretions
• Vendor-specific application example o Effective air distribution is essential.
Pulmonary Hygiene and Chest Physical Therapy
Chest Physical Therapy
• Chest physical therapy (CPT) – Postural drainage,
percussion, vibration (PDPV)
• Guidelines with application to bronchial hygiene ● Generally accepted procedures to improve airflow and
distribution of air in the lungs
Goals and Objectives of Pulmonary Hygiene ● Breathing retraining
& Chest Physical Therapy – Diaphragmatic breathing
– Patient initiates inspiration by sniffing – Observation
• Improve clearance of secretions
of patient needed
• Decreasing obstruction of the airways
● Postural drainage, chest wall percussion, chest wall
• Hope of improving distribution of ventilation and gas
vibration
exchange
– Improve mucociliary clearance
Normal Mucociliary Clearance – Increase expectorated sputum volume – Improve
airway functions
● Mucociliary escalator
– Uses gravity and mechanical energy
● Mucostasis
● Forced exhalation technique
● Functions of airway mucus
● Vibration – Stimulate the movement of secretions
● Characteristics of mucus
● Percussion – Loosens and mobilizes secretions that are
– Glycoproteins, proteoglycans, lipids, other proteins,
adhering to the bronchial walls
sometimes DNA
● Active cycle breathing – FET and thoracic expansion
– Mucous blanket
exercises and diaphragmatic breathing
● Cough
● Autogenic draining – Improves airflow in the small
– Important defense mechanism
airways
– Four phases
● Mechanical adjuncts to chest physical therapy
– Hazards and complications
● Positive airway pressure adjuncts to bronchial hygiene
Diseases and Conditions Associated therapy
with Abnormal Mucus Clearance – Mobilize secretions and treat atelectasis
– Continuo us positive airway pressure and positive
● Indications for CPT and PDPV expiratory pressure
– Difficulty with secretion clearance
● Combined mechanical, acoustical vibration – Digitally ● Reducing resistive inspiratory work of breathing through
controlled electro-acoustical transducer device endotracheal tube for spontaneous breathing
● Intrapulmonary percussive ventilation therapy – – Automatic tube compensation (ATC)
Administered to the airways by a pneumatic device – Tube compensation (TC)
● Continuous lateral rotation (kinetic) therapy ● Neurally adjusted ventilatory assist (NAVA)
● Selection of mucociliary clearance techniques – Applies pressure in proportion to strength of a
● Complications and adverse effects of chest physical diaphragmatic contraction
therapy – Improves patient-ventilator synchronicity
o Bronchospasm – Has potential to reduce work of breathing
o Transient hypoxemia
Summary of Initiating Mechanical Ventilation
o Increased intracranial pressure
o Hypotension o Verify ventilator function
o Pain o Connect humidification system
o Vomiting o Calibrate sensors
o Dysrhythmias o Set patient parameters
Initiation, Monitoring, and Discontinuing Mechanical o Set alarms
o Connect ventilator to the patient
Ventilation
o Perform a ventilator check
● Indications for Mechanical Ventilation:
● Initiate in cases of: Patient Monitoring
o Apnea • Determine appropriateness of ventilator settings.
o Acute ventilatory failure • Airway pressure provides measure of the overall effect of
o Oxygenation failure the ventilator settings on oxygenation.
o Impending ventilatory failure • Capnogram’s shape provides information.
● Apnea or acute ventilatory failure – Impairment of
physiologic pathway of breathing Ventilator Check
● Oxygenation failure
o Patient values
– Failure of the lungs to provide gas exchange
o Lung compliance values
– Pulmonary shunting
o Alarms set appropriately
– Alveolar recruitment
o Apnea ventilation
● Impending ventilatory failure
o Low inspiratory pressure alarms
– Physiologic function measured
o High airway pressure alarms
– Chronic airflow obstruction (CAO)
– Noninvasive ventilation Waveforms
Initiation of Mechanical Ventilation • Quality of breathing
• Graphic representation of pressure, flow, and volume over
● Guidelines to follow
time
● Ventilator check
• Help detect problems
– Vary in operation verification procedures
• Air-trapping
– Checking ventilator function
– Older ventilators Work of Breathing
• Check for leaks
• Respiratory muscle energy or force used to move a tidal
Initial Ventilator Settings volume of air
• Force times distance
● Adjust control settings based on patient’s ideal or
• Measured in terms of pressure times volume
predicted body weight
o Kilogram-meters or joules
● Ramp waveform—provides highest mean airway
pressure at the lowest peak pressure Humidification of Mechanical Ventilation
● Pressure control mode versus volume control mode
● Inspiratory time • Gas delivered by a ventilator must be monitored for
● Normal compliance adequate humidity.
o Assist-control (AC) • Not useful to measure inspiratory temperatures when
o Synchronized intermittent mandatory using HMEs or HCHs
ventilation (SIMV) • Heated-wire ventilators circuits carry added responsibility
● Bilevel ventilation of monitoring the relative humidity (RH).
– Severe reduced compliance
Humidification of Mechanical Ventilation
– High and low CPAP setting
● Adaptive support ventilation (ASV) – Prevents apnea, • Patient
volutrauma, PEEPi, or rapid shallow breathing – Delivery of positive pressure
• Patient-ventilator interface – At-risk patients: head or neck surgery, smoke injury
– Use of endotracheal or tracheostomy tubes – Extubations should be performed by clinicians
• Ventilator complications capable of providing masks and bag ventilation.
– Extubations should be considered when indication for
– Inadequate humidification leading to mucous
mechanical ventilation is no longer present.
plugging and airway obstruction
● Long-term discontinuance
– Ventilator malfunction – Weaning process
– Operator error – Daily screening of patient respiratory function
– Ventilator-induced injury – Proportional assist ventilation (PAV)

Ventilator Management

● Initiated from the moment the patient is placed on

mechanical ventilation
● Management priorities
● Pulmonary function of patients
– Restrictive
– Obstructive
– Relatively normal

Mechanical Ventilation in Oxygenation Failure

• Therapeutic objectives for patients with ARDS are to

promote alveolar recruitment to prevent alveolar
overinflation.
• Increase alveolar pressure; then provide PEEP to maintain
alveolar expansion.

Mechanical Ventilation in
Chronic Airflow Obstruction (CAO)

• Noninvasive positive pressure ventilation provides

effective treatment and reduces need for intubation
• Least amount of ventilation provided
• Low levels of PEEP/CPAP
• Sedations may be required.
• Work of breathing considered
• Pressure support will increase breathing.
• Helium-oxygen mixtures

Mechanical Ventilation in Neuromuscular Disease

• Normal lung compliance

• Results in respiratory muscle weakness
• Management should include:
o Larger tidal volumes
o Higher inspiratory flow rates
o Aggressive management of secretions

Independent Lung Ventilation

• Indicated when the pulmonary problem is primarily

unilateral
• Large bronchopleural fistulas or air leaks
• Seesaw ventilatory pattern

Ventilator Discontinuance

● Short-term
– Most do not require weaning postoperatively.
– Factors affecting
• Medical condition
• Airway anatomy
• Neurologic function
– NIF is the peak negative pressure measured.