NITROUS OXIDE/OXYGEN

SEDATION

MARLENE MELENDEZ, RDH, CDA, BSDH

 OBJECTIVES

1.Physical and chemical properties of N2O-O2

2.Effects of N2O on the systems of the body, potential drug
interactions, and contraindications to N2O-O2 sedation
3.Indications for and steps in the safe administration of N2O-O2
sedation
4.Main components, proper use, and maintenance of N2O-O2
delivery systems
5.Drug calculations and records keeping for N2O-O2 sedation
6.Issues of occupational exposure, abuse, and chemical
dependency
7.Current laws for your jurisdiction as they relate N2O-O2
sedation
 SC STATE LAW

Licensed Dental Hygienists and Expanded Duty Dental Assistants are authorized to
monitor nitrous oxide conscious sedation.

The Board has defined the term “Monitor” to mean carrying out the orders of the
dentist, to include the initiation of the flow of the nitrous oxide component. The
certified auxiliary may then maintain that flow or decrease the level of nitrous oxide
component when oxygenating the patient, without the specific direction of the
dentist. The dentist must determine the need and level of nitrous oxide sedation
regarding a particular patient. The dentist must diagnose the need for a patient to
receive nitrous oxide and may designate the certified auxiliary to place the mask
and set the nitrous oxide component at a level specified for that patient.
 DEFINITION OF SEDATION
SEDATION MAY BE DEFINED AS A STATE OF CALM INDUCED
BY A DRUG OR OTHER TRANQUILIZING SUBSTANCE.
LEVELS OF SEDATION
MINIMAL-A LEVEL OF CONSCIOUSNESS IN WHICH A PATIENT IS ABLE
TO INDEPENDENTLY AND CONTINUOUSLY MAINTAIN AN AIRWAY. THIS
IS THE INTENDED USE OF N2O-O2 SEDATION IN DENTISTRY.

MODERATE-PATIENTS CAN RESPOND PURPOSEFULLY TO VERBAL

COMMANDS.

DEEP SEDATION-PARTIAL OR COMPLETE LOSS OF REFLEXES,

INCLUDING THE INABILITY TO CONTINUALLY MAINTAIN AN AIRWAY
INDEPENDENTLY.

GENERAL- DRUG INDUCED LOSS OF CONSCIOUSNESS. THE PATIENT

IS INCAPABLE OF BEING AROUSED.
OTHER TERM USED FOR NITROUS OXIDE/OXYGEN SEDATION

CONSCIOUS SEDATION
INHALATION SEDATION
NITROUS OXIDE PSYCHOSEDATION
RELATIVE ANALGESIA
LAUGHING GAS
BENEFITS, LIMITATIONS, AND PRECAUTIONS OF
NITROUS OXIDE-OXYGEN SEDATION
ANATOMY, PHYSIOLOGY, AND PHARMACOLOGY

The primary function of the respiratory system is to exchange

oxygen and carbon dioxide across pulmonary/capillary
membranes.

Nitrous oxide exchange uses the same pathways as normal

respiration.

Initial uptake of nitrous oxide occurs most rapidly in the lung

then to the blood stream. Nitrous is also eliminated through the
lungs.
 ANATOMY AND PHYSIOLOGY OF RESPIRATION
Upper Respiratory System
Respiration begins with the nose. Conditions that cause or contribute to
nasal obstructions such as allergic rhinitis, upper respiratory tract infections,
colds, sinusitis, influenza, and deviated septum must be considered before
the administration of nitrous oxide/oxygen sedation.
ANATOMY AND PHYSIOLOGY OF RESPIRATION
LOWER RESPIRATORY SYSTEM
BEGINS AT THE SIXTH CERVICAL VERTEBRA, DIVIDES INTO TWO BRANCHES THE
RIGHT AND LEFT BRONCHI, AND IS SURROUNDED BY CARTILAGINOUS RINGS. THE
LUMEN OF THIS VERY IMPORTANT BREATHING PASSAGEWAY IS MAINTAINED BY
THESE RINGS.
 THE RESPIRATORY PROCESS

Inspiration- When you breathe in, or inhale, your diaphragm

contracts (tightens) and moves downward. This increases the space in
your chest cavity, into which your lungs expand.
Expiration-occurs passively as the chest wall and lungs recoil

These are true statements about N2o-o2 affects on the Respiratory

process
It does not affect mucus production in the lungs
Does not affect pulmonary ciliary production (aids in mucus
formation)
Does not affect pulmonary compliance (lung volume)
 THE RESPIRATORY PROCESS CONT.
TIDAL VOLUME (Adult 6-8liters Child 4-5liters)
THE AMOUNT OF GAS INSPIRED INTO THE LUNGS
THE AVERAGE ADULT TIDAL VOLUME IS 500 CC
MINUTE VOLUME
IS THE AMOUNT OF AIR EXHALED IN ONE MINUTE.
GAS EXCHANGE
OCCURS FROM ALVEOLI TO CAPILLARIES
DIFFUSION HYPOXIA-OCCURS WHEN EXCESS N2O DIFFUSES OUT OF THE
BLOOD.
1. KNOWN AS 2ND GAS EFFECT
2. BEST PREVENTED BY GIVING 100% O2 FOR 3-4 MINUTES
3. HEADACHE IS A SIGN OF DIFFUSION HYPOXIA
EFFECTS OF NITROUS OXIDE-OXYGEN SEDATION

Cardiovascular system
Has no negative effects on the heart
Once in the blood n2o-o2 follows the normal course of
the circulatory system. Nitrous oxide can be beneficial in
the presence of common heart conditions such as
hypertension, angina pectoris, and some congenital
conditions.
 EFFECTS OF NITROUS OXIDE-OXYGEN SEDATION CONT.

CENTRAL NERVOUS SYSTEM

•N2O PRODUCES A DECREASED SENSORY PERCEPTION THAT REDUCES
AN INDIVIDUAL’S ABILITY TO REACT TO PAIN.

•IT TYPICALLY DISTORTS SPATIAL ORIENTATION, MAKING PATIENTS

FEEL HEAVY OR LIGHT, FEELING OF FLOATING, WARM, SLIGHT
TINGLING OR NUMBNESS IN THE LIPS OR EXTREMITIES ARE ALL
NORMAL.

•N2O-O2 MAY HEIGHTEN THE NEGATIVE ASPECTS OF MANY

CONDITIONS SUCH AS SOME PSYCHIATRIC DISORDERS, A HISTORY OF
CHEMICAL DEPENDENCY INCLUDING ALCOHOL AND SUBSTANCE
ABUSE, OR BEING UNDER THE INFLUENCE OF ALCOHOL OR DRUGS AT
THE TIME OF ADMINISTRATION.
 EFFECTS OF NITROUS OXIDE-OXYGEN SEDATION CONT.

OTHER BODY SYSTEMS

NITROUS OXIDE CAN EXPAND AIR SPACES IN THE BODY
RESULTING IN PRESSURE INCREASES IN THE GI SYSTEM
AND SHOULD BE AVOIDED IN PATIENTS WITH
INTESTINAL OBSTRUCTIONS UNTIL RESOLVED.

PATIENTS WHO HAVE HAD RECENT OPHTHALMIC

SURGERY, PARTICULARLY INVOLVING THE RETINA,
MAY HAVE A GAS BUBBLE THAT WAS PLACED IN THE
GLOBE OF THE EYE. NITROUS MAY DIFFUSE INTO THE
BUBBLE, CAUSING EXPANSION AND RESULTING IN
PAIN, DECREASED VISION, OR BLINDNESS
CLINICAL MANIFESTATIONS SUMMARIZED

CARDIOVASCULAR-none to minimal effect on heart

Central nervous system- amnesia, distorted spatial

orientation, sleepiness, may enhance CNS depressant effects

Middle ear- Pressure increase due to expansion of air space

Ophthalmic-expansion of gas bubbles

Reproductive-potential for fetal toxicity exists, caution and

medical consultation are strongly advised.
 ALLERGIES AND NITROUS OXIDE-OXYGEN SEDATION

There are no known allergies to nitrous. Allergies to latex

may pose a problem if equipment contains latex.

Adverse reactions (rare in occurrence)

Dizziness
Increasingly rigid movements
Unresponsiveness
Sweating
Nausea and vomiting (most common)
Dilated pupils
 AVOIDING NAUSEA
• TRY TO KEEP NITROUS LEVELS BELOW 50%; TOO MUCH
N2O-O2

• ASK PATIENTS NOT TO CONSUME A HEAVY MEAL PRIOR

TO TREATMENT- A LIGHT MEAL THAT INCLUDES
CARBOHYDRATES IS APPROPRIATE IF EATEN 2 HOURS
BEFORE THE PROCEDURE
• RECOMMEND TO PARENTS OF CHILDREN TO AVOID
FATTY, FRIED, OR GREASY FOODS JUST BEFORE
SEDATION

• DON’T “SEE-SAW” THE NITROUS LEVELS DURING THE

TITRATION PROCESS- IN OTHER WORDS, GOING UP AND
DOWN WITH THE NITROUS ADMINISTRATION INSTAED
OF AT A CONSISTENT LEVEL
 INDICATIONS OF USE

Apprehensive patients

Restless, anxious, or young children

Long procedures

Hyperactive gag reflexes

Temporomandibular disorders
 CONTRAINDICATIONS

ACTIVE RESPIRATORY INFECTION

DEBILITATING ANGINA
ADVANCED COPD
INTRAOCULAR GAS INJECTION (WITH IN 8-12 WEEKS)
LATEX ALLERGY (EXCEPTION WITH NON-LATEX SYSTEMS)
PREGNANCY MEDICAL CONSULT RECOMMENDED
RECENT TYMPANIC MEMBRANE GRAFT (EAR)
SEVERE PSYCHOSIS (MENTAL DISORDER)
TREATMENT INVOLVING INJECTION OR PATHOLOGY THAT
CAUSES POCKETS OR GASES INTO A BODY CAVITY
 RELATIVE CONTRAINDICATIONS 

psychological disorders Middle ear problem

Claustrophobia PTSD
Contact lenses Pregnancy (2nd trimester)
CNS depressant use Recovering Alcoholic
Cystic fibrosis substance abuse
Dry air induced asthma use of colostomy bag
Vit. B12 deficiency
Latex sensitivity
Bleomycin (antibiotic used
For anticancer treatment)
 CHRONIC EXPOSURE
Reproductive difficulty including the risk of miscarriage,
with the greatest risk occurring during the first
trimester.

Bone marrow depression is irreversible with chronic use.

Neurologic disorder leading to sensory and

proprioceptive impairment that may be permanent.

Hyperreflexia (overactive nervous system) decreased

sensitivity of fingers

Spasticity-certain muscles are continuously contracted.

PRINCIPLES OF NITROUS OXIDE SEDATION
• Non-toxic
• Non-irritating
• Non-flammable
• Organic
• When you increase the concentration of nitrous it
diffuses faster into the blood from the lungs
• Causes a decrease in fine motor control visual acuity
• Causes a decrease in cognitive thinking
• Increase in emotional instability
• Causes amnesia
• May cause patients to dream or fantasize (always have
2 people in the room when you get a patient above
50%)
STRATEGIES TO ENHANCE N2O-O2 SEDATION EFFECTS

• MUSIC
• VIDEO EYEWEAR
• IMAGERY
• HYPNOSIS
• ORAL PREMEDICATION

IN CASE OF DELIRIUM OR EXCITATION

TURN OXYGEN TO 100% & SHUT OFF N20
COMMON SYMPTOMS OF AN ACCEPTABLE LEVEL OF
SEDATION
At approximately 25% concentration of Nitrous Oxide

•Feeling of warmth

•Sense of relaxation or floating

•Feeling of heaviness or tingling of the extremities

•Lessened pain awareness

•Numbness around the lips (circumoral numbness)

During nitrous/oxide administration, at least 25% oxygen at a

flow rate of no less than the patient’s tidal volume per minute
should be maintained at all times.
SYMPTOMS OF EXCESSIVE N2O SEDATION
• Uncontrolled laughter
• Sweating
• Nausea (most common)
• Marked lethargy, closing mouth frequently
• Unresponsiveness, unaware of surroundings, fixed
stare
• Slurring of speech
• Inability to keep mouth open
• Agitation
• Dilated pupils
**Excessive body heat can be lost due to vasodilation
during long appointments using nitrous
oxide/oxygen sedation.
 MANUFACTURING PROCESS
Early nitrous oxide was unsuccessful because it was
contaminated with impurities, used with inadequate oxygen,
and the basic mechanisms of nitrous action were poorly
understood.

Nitrous oxide is manufactured from ammonium nitrate, the

same chemical used to make fertilizers and explosives.

The U.S. Food and drug Administration (FDA) establishes

requirements for manufacturing process and quality control that
must be followed by companies producing nitrous oxide.

The U.S. department of transportation (dot) oversees the

packaging and transportation.
 SEDATION EQUIPMENT COMBUSTION RISKS

Nitrous oxide is a slightly sweet-smelling and colorless gas.

Nitrous oxide and oxygen can form an explosive mixture in the

presence of grease or oil.

Always open nitrous and oxygen tanks slowly to avoid heat of

compression. No combustible materials, such as grease, or
lubricants, should be used on tanks, piping, or regulators
located on or stored near equipment.
 NITROUS OXIDE TANKS
Tanks in the united states are painted BLUE

When the nitrous tank is full, it reads 750 Psi and will go
from 750 to 0 with no reading in between

OXYGEN TANKS

OXYGEN TANKS IN THE UNITED STATES ARE PAINTED

GREEN.

WHEN THE OXYGEN TANK IS FULL IT READS 2,100 PSI AND

WILL READ THE ACCURATE AMOUNT REMAINING
COMPONENTS OF N2O-O2 DELIVERY SYSTEMS
• Manifold
• Copper tubing/hoses
• Pin index safety system
• Regulators
• Flow meters
• Reservoir bag
• Conduction tubing
Safety measures included in delivery units: Pin Index
systems, Automatic shutoff of nitrous tank when oxygen
depleted, Oxygen flush systems & Oxygen flow meters
that automatically come on to 2-3 liters constant flow
****They have a safety mechanism that will not allow
oxygen to drop below 30% and nitrous to go above
70%
continued on next slide
PORTABLE DELIVERY SYSTEM
 PIN INDEX SAFETY SYSTEMS
Regulators
They are found on both portable and central delivery
systems. They reduce gas pressures from tanks before any
gas is delivered into the tubing.
FLOW METERS- THEY ARE VISUAL INDICATORS OF
THE VOLUME OF GASES BEING DELIVERED. THE
OXYGEN SIDE IS GREEN AND THE
NITROUS SIDE IS BLUE.

RESERVOIR BAGS-PROVIDES A VOLUME OF GAS

NECESSARY FOR EACH BREATH.
NASAL HOOD
IS THE BREATHING APPARATUS THAT SITS OVER THE
PATIENT’S NOSE TO FACILITATE THE INHALATION OF GASES.

TUBING
SCAVENGING SYSTEM
REMOVES EXCESS GASES
 EMPLOYEE SAFETY AND HEALTH GUIDELINES
Maximum exposure limit
In 1977 the National Institute for Occupational Safety set the
maximum exposure limit for nitrous concentration to 25 ppm for
dental personal.

Time-weighted dosimetry
This is an inexpensive method for
monitoring individual exposure
to trace gas. The badge is worn
for a specified period of time before
being submitted for analysis.
CALCULATING PERCENTAGES OF GASES
 PATIENT ASSESSMENT
Review medical history

Take vitals: pulse (60-100), respirations (12-16), and blood pressure

(120/80)and pulse oximeter which provides the information of O2
saturation of arterial blood.
Normal oxygen saturation in a healthy adult is 95 or above
O2 sat. Level less than 90% may be an early warning of rapid loss of O2 to
the brain.
Only ASA classification 1 & 2 can have nitrous oxide/oxygen sedation without
medical clearance from their primary physician
It is not required to monitor O2 sat. level for N2O minimal sedation, but it is
required for moderate sedation of 50% N2O or greater.
Therefore, it can be useful in detecting potential problems early.
 TITRATION OF N2O AND O2

• A method of administering a drug in incremental amounts until a

desired level has been reached.
• N2O/O2 is given in incremental doses until a patient has reached
a comfortable, relaxed state of sedation.
• Rapid induction is only used in children under special conditions
by a trained pediatric clinician or extremely knowledgeable in
sedation. This is not recommended in adults.
• This creates a positive experience for the patient.
STEPS FOR ADMINISTERING NITROUS OXIDE-
OXYGEN SEDATION
1. ASSEMBLE ARMAMENTARIUM
2. REVIEW HEALTH HISTORY
3. CHECK VITALS
4. OBTAIN INFORMED CONSENT
5. ESTABLISH TIDAL VOLUME
6. ADMINISTER NITROUS OXIDE AS PRESCRIBED BY THE
DENTIST
7. POSTOPERATIVE OXYGENATION (5 MINUTES)
8. TAKE VITALS (10 BP-10 PULSE-5 RESPIRATIONS)
9. DOCUMENT
10. DISINFECT
 DOCUMENTATION
1. Vital signs (pre and post procedure)
2. How long the nitrous was administered
3. What the tidal volume was
4. Percentage of nitrous administered
5. Ask the patient how they are feeling and put that in the
remarks “patient states they feel fine”

**if the patient’s vital signs are not within 10-10-5 after
administration of nitrous, the patient should stay ON
oxygen for another 5 minutes until the vitals are closer to
10-10-5***
 ETHICAL AND LEGAL ISSUES
• Patient monitoring is mandatory

• Three elements that are always involved in legal cases include,

treating a patient without AN assistant in the room, high
concentrations of nitrous, and failure to titrate the patient to
avoid extension beyond the range of therapeutic sedation.

• If you don’t feel comfortable with how your dentist is

administrating nitrous, please think twice about the
consequences for you and the patient.
BASSETT, K., DIMARCO, A., NAUGHTON, N.,
LOCAL ANESTHESIA FOR DENTAL
PROFESSIONALS: 2ND EDITION