2) an acute situation in which hypoxemia is suspected.

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1 I. Subject: Oxygen Therapy II. Policy: Oxygen therapy shall be initiated upon a physician's order by health care professionals trained in the set-up and principles of safe oxygen administration. Oxygen therapy may be initiated by nursing personnel or respiratory therapy personnel in the following situations: 1) Oxygen administration is included in an approved written treatment protocol, or 2) A clinical emergency in which a profound hypoxia is determined to be present. Oxygen delivery to adults by nasal cannula devices will require supplemental humidification only when the flow rate exceeds three (3) liters per minute. Oxygen administration by all other devices with the exception of venturi masks and non-rebreathing masks will require supplemental humidification. Oxygen administration to pediatric patients and neonates will always require supplemental humidification. III. Indications: A. Hypoxemia 1) Documented hypoxemia- a) arterial oxygen tension (PaO2) of less than 60 mmhg or arterial oxygen saturation (SaO2) of less than 90% in subjects breathing room air b) in neonates, PaO2 less than 60 mmhg and/or SaO2 less than 90% or capillary oxygen tension (PaO2) < 40 mmhg. 2) an acute situation in which hypoxemia is suspected. B. Severe trauma 1

2 C. Excessive myocardial work in the presence of ischemia or failure D. Certain categories of anemic hypoxia with or without hypoxemia, including: 1) Carbon monoxide poisoning 2) Methemoglobinemia and other dyshemoglobinemias 2) Shifts of the oxygen dissociation curve to the right. IV. Contraindications: There are no specific contraindications for oxygen administration when indications are judged to be present. V. Hazards: A. Oxygen induced hypoventilation, especially in patients with COPD. B. Absorption atelectasis caused by an increased partial pressure of oxygen accompanied by a decreased partial pressure of nitrogen. C. Oxygen toxicity caused by inspiring a high concentration of oxygen over an extended period of time. D. In newborns: 1) in premature infants PaO2 of > 80 mmhg should be avoided because of the possibility of retinopathy of prematurity. 2) increased PaO2 can contribute to closure or constriction of the ductus arteriosus which is a possible concern in infants with ductus-dependent heart lesions. E. Supplemental oxygen should be administered with caution to patients suffering from paraquat poisoning and to patients receiving bleomycin. F. During laser bronchoscopy, minimal levels of supplemental oxygen should be used to avoid intra-tracheal ignition. 2

3 G. Fire hazard is increased in the presence of increased oxygen concentrations. H. Bacterial contamination associated with certain nebulization and humidification systems is a possible hazard. I. Ischemia-reperfusion or re-oxygenation injury J. Mucosal dryness The concentration and duration of oxygen should be closely monitored because of these potential hazards of oxygen therapy, and the lowest concentration /flowrate should be used to achieve the desired outcome VI. Rationale: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. The direct effect of breathing increased oxygen concentration is to increase alveolar oxygen tensions, thus increasing the pressure gradient for oxygen diffusion into the blood system. These increased alveolar oxygen concentrations may result in less pulmonary work needed to maintain a given alveolar oxygen tension and/or less myocardial work. Oxygen can be administered in concentrations up to 100%. The specific concentration prescribed depends on the patient's condition and the therapeutic goal. There are two (2) types of oxygen delivery systems, high-flow and low-flow. A high flow system provides the entire gas flow inspired by the patient, while a low-flow system does not. A high flow apparatus pre-mixes oxygen and room air prior to the delivery of the patient. Not only must the flow rate be great enough to exceed the patient's minute ventilation requirements, it must also be fast enough to provide a peak flow rate consistent with the patient's ventilatory pattern. A low-flow system utilizes room air to supplement the gas supplied by the system. There are several different devices available for delivering supplemental oxygen with each system. Selection of the proper system and device depends on the need and condition of the patients. Whenever a consistent and predictable FIO2 is required, a high-flow system should be utilized. A low-flow system provides a relatively stable FIO2 if the patient's ventilatory pattern is stable and consistent, the patient's tidal volume is between ml (adult) and the respiratory rate is less than 25 bpm (adult). 3

4 VII. Methods of Administration: A. Oxygen Nasal Cannula- This is the most popular method for delivering low concentrations of oxygen due to its economy and patient comfort. This is an example of a low-flow system of oxygen therapy. The oxygen cannula is a lightweight plastic tube with two short flexible outlets that permit insertion into the nares. The use of this device is dependent upon one characteristic, this being that the nasal passages are patent. As long as the nasal passages are clear, the patient need not breathe through the nose to receive consistent oxygen therapy. The nasal and oral cavities serve as an anatomic reservoir for oxygen, and the FIO2 delivered depends upon the size of this reservoir, the flow rate of oxygen and the patient's respiratory rate, tidal volume and minute volume. 1) Indication and contraindications for oxygen therapy are listed under the title heading. 2) The equipment necessary for assembly of nasal cannula are: a) Nasal cannula b) Oxygen flowmeter c) Humidifier (flowrate greater than 3 L/min d) Oxygen tubing (if necessary for longer length) The flow rates and the approximate corresponding FIO2 for adults are listed as: Oxygen Cannula FIO2 1 L/min 24% 2 L/min 28% 3 L/min 32% 4 L/min 36% 5 L/min 40% 6 L/min 44% 4

5 3) The procedure for applying a nasal cannula on a patient is as follows: a) Check for a physician order for the device, percentage of oxygen and/or flow rate. b) Greet the patient and explain to the patient the procedure and therapeutic objectives of oxygen nasal cannula as well as the safety precautions including prohibition of smoking, open flames, or devices that may spark c) Remove smoking materials and other fire hazards from the room. d) Check for nasal patency of the patient. Have the patient occlude each nostril alternately during inspiration with mouth closed. Patient should have no difficulty inspiring through each nostril. If a difficulty is encountered, notify the patient's nurse and physician. e) Place oxygen flowmeter in the wall-outlet. f) Attach the humidifier to the flowmeter. g) Insert the cannula's prongs into each nostril so that their curve follows the natural contour of the nostril. h) Pass the cannula tubing over both ears and position under the chin on the neck. i) Slide adaptor cinch up tubing to adjust for comfort and fit. j) Turn on flowmeter to the ordered flow rate. k) Observe patient for tolerance of the cannula. 4) Documentation of the nasal cannula on the Respiratory Therapy Oxygen Rounds flowsheet should include the date, time, flowrate, and device ordered. At initial placement of nasal cannula the documentation of patient understanding of the therapeutic objectives is required. This 5

6 device should be checked once every 12 hours with the date, time, flow rate, whether the device is in use or not, and the device itself. 5) Complications associated with a nasal cannula could include the following: Complication: Obstructed nostril Nasal trauma (bleeding) Remedy: Change oxygen device type Change oxygen device type Mucosal irritation Increased amount of nasal secretions Change, and if necessary, replace humidifier. Use of non-petroleum based lubricant (K-Y, or CANN-EASE) Change to another oxygen device B. Venturi Mask- This device consists of a simple venturi jet incorporated into a face mask. The venturi device determines the degree of air mixing as well as oxygen concentration. Because of air entrainment, this mask provides a high flow of gas while maintaining a known oxygen percentage. There are two (2) variables that affect the delivered FIO2 of the venturi mask device: a) The size of the jet orifice b) The size of the air entrainment port There are primarily two (2) types of venturi masks. The first is a mask with a variable air entrainment port so that the same mask can be used to deliver different concentrations. The second approach is to have fixed air entrainment ports with different sized jet orifices. This type of venturi mask requires a different attachment 6

7 (which is color coded) for each concentration. Standard FIO2 are 24%, 28%, 31%, 35%, 40%, 50%. The recommended flow rate for each corresponding FIO2 is found on the jet orifice itself. Total gas flow may be calculated by the following equation: Total flow= (flowrate of oxygen source) (1-FIO2) + flow rate of oxygen source FIO Total gas flow should be at least three (3) times the patient's minute ventilation. 1) The indications and contraindications for oxygen therapy are listed under the heading. 2) The necessary equipment for assembly of a venturi mask is as follows: a) Oxygen flowmeter b) Venturi Mask (with adaptors) and oxygen tubing 3) The procedure for applying a venturi mask is as follows: a) Check for physician's order. b) Greet the patient and explain to the patient the procedure and therapeutic objectives as well as the safety precautions including prohibition of smoking, open flames, or devices that may spark. c) Remove smoking materials and other fire hazards from the room. d) Place the oxygen flowmeter in the wall outlet. e) Select the appropriate venturi mask; assemble (including the venturiinlet protection cone) and connect it to the flowmeter. f) Apply mask to patient's face, then secure the elastic strap around the head, whichever is more comfortable. 7

8 g) Adjust the nose clip and strap so that the face mask fits snugly but not tightly. h) Observe the patient for tolerance of the mask. i) Be sure the venturi adaptor is not obstructed or covered by blankets, sheets, etc. 4) Documentation of the venturi mask on the Respiratory Therapy Oxygen flowsheet should include upon initiation the date, time, flowrate, device ordered, percentage of oxygen, and the patient's understanding of the procedure and its therapeutic objectives. This device should be checked every 12 hours and the date, time, flowrate, device ordered, percentage of oxygen, and whether it is in use or not should be documented. 5) Complications associated with a venturi mask could include the following: Venturi Mask Complications: Poor tolerance Mucosal irritation Pressure sores Remedy: Adjust mask for comfort or change device Add, check or replace Humidifier. Use of nonpetroleum based lubricant (K-Y, or CANN-EASE) Pad areas of irritation with gauze or duoderm and if possible, change to a different oxygen device type. C. Simple Oxygen Mask- The simple oxygen mask is designed to deliver oxygen concentrations in the range 8

9 of 40-60%. An oxygen mask is a plastic device designed to fit closely to the patient's face and comfortably approximate the contours of the patient's nose, cheeks and chin. Holes are present in the sides of the mask to allow free entry or exit of room air. FIO2 delivered depends upon the liter flow and the patient's ventilatory pattern. The corresponding flow rates and approximate FIO2 for adults are as follows: Simple Oxygen Mask Oxygen FIO2 5 L/min.40 6 L/min L/min.60 1) The indications and contraindications for oxygen therapy are listed under the title heading. 2) The necessary equipment for assembly of a simple oxygen mask is as follows: a) Oxygen flowmeter b) Simple mask (with attached tubing) c) Humidifier 3) The procedure for applying a simple oxygen mask is as follows: a) Check for physician's order b) Greet the patient and explain to the patient the procedure and therapeutic objectives of a simple oxygen mask as well as safety precautions including prohibition of smoking, open flames, or 9

10 devices that may spark. c) Remove smoking materials and other fire hazards from the room. d) Place the flowmeter into wall outlet. e) Attach the humidifier to the flowmeter. f) Attach the simple oxygen mask to the humidifier. g) Adjust the flowmeter flow to the corresponding FIO2 ordered by the physician. Must be set to at least 5 L/min. h) Apply the mask to the patient's face, then secure elastic strap around the neck at the level of the tragus of the ear, or around the head above the ears, whichever is more comfortable. i) Adjust the nose clip and strap so that the face mask fits snugly but not too tightly. 4) Documentation of the simple oxygen mask on the Respiratory Therapy Oxygen flowsheet should include the date, time, flowrate, device ordered, and the patient's understanding of the usage and therapeutic objectives. This device should be checked once every 12 hours with the date, time, flowrate, the device and whether it is in use or not. 5. Complications associated with a simple oxygen mask could include the following: Complication: Poor tolerance Remedy: Adjust oxygen device for comfort. Pressure sores Pad area of irritation with gauze or duoderm. 10

11 Mucosal irritation Hypercarbia D. Partial Rebreathing Mask- Add, check or replace humidifier. Use of non-petroleum based lubricant (K-Y, or CANN-EASE) Increase flowrate to improve flushing. The partial rebreathing mask is designed to deliver concentrations of oxygen in excess of 60% using an oxygen reservoir bag attached to the plastic mask. The patient should deflate the reservoir gas about one third during inspiration. There must be high enough flow rate entering the system to ensure that the reservoir bag will never completely empty during an inspiratory cycle. The delivered FIO2 depends upon the oxygen flowrate and the patient's ventilatory pattern. The corresponding flow rates and approximate FIO2 are as follows: Partial Rebreathing Mask Oxygen FIO2 6 L/min 60% 7 L/min 70% 8 L/min 80% 1) The indication and contraindications for oxygen therapy are listed under the heading. 2) The necessary equipment for assembly of a partial rebreathing mask is as follows: a) High-flow oxygen flow meter. b) Partial rebreathing mask (with reservoir bag and oxygen tubing). 11

12 c) Humidifier. 3) The procedure for applying a partial rebreathing mask is as follows: a) Check for physician' order. b) Greet the patient and explain to the patient the procedure and therapeutic objectives of a partial rebreathing mask as well as the safety precautions including prohibition of smoking, open flames, or devices that may spark. c) Remove smoking materials and other fire hazards from the room. d) Place the oxygen flowmeter in the wall outlet. e) Attach the humidifier to the flowmeter. f) Attach the partial rebreathing mask to the humidifier. g) Adjust the flowmeter to the desired flowrate for the corresponding FIO2. h) Check flow of gas into reservoir, occlude the exit port of the bag and allow the bag to completely fill. i) Apply the mask to the patient's face, and then secure the elastic strap around the neck at the level of the tragus of the ear, or around the head above the ears, whichever is more comfortable. j) Adjust the nose cup and strap so that the face mask fits snugly but not tightly. k) Readjust the flowrate if necessary, so that the bag does not completely collapse during inspiration. l) Be sure that the reservoir bag is not obstructed by blankets, sheets, 12

13 etc. m) Observe patient tolerance of mask. 4) Documentation of the partial rebreathing mask on the Respiratory Therapy Oxygen flowsheet should include the date, time, flowrate, device ordered, and the patient's understanding of the usage and therapeutic objectives. This device should be checked once every 12 hours with date, time, flowrate, device and whether it is in use or not. 5) Complications associated with a partial rebreathing mask could include the following: Complication: Pressure sores Poor tolerance Mucosal irritation Remedy: Pad areas of irritation with gauze or duoderm. Adjust oxygen device for comfort, add, check or replace humidifier. Add, check or replace humidifier. Use nonpetroleum based lubricant (K-Y or CANN-EASE) Hypercarbia Increase flow rate to increase flushing. E. Non-Rebreathing Mask- The non-rebreathing mask is a mask with a reservoir bag and set of 1-way valves. A 1-way flutter valve is inserted at the point of connection between the reservoir bag 13

14 and mask. This allows gas to flow from the reservoir bag to the mask only. Also, 1- way valves are added to the holes in the sides of the mask to allow gas flow from inside the mask to the atmosphere and prevents the entrainment of room air. This type of mask with reservoir bag will allow high concentrations of oxygen to be inspired. The FIO2 delivered depends on the fit of the mask, the O2 flowrate, and the patient's ventilatory pattern. The corresponding flow rates and approximate FIO2 are as follows: Oxygen FIO L/min % 1) The indications and contraindications for oxygen therapy are listed under the heading. 2) The necessary equipment for assembly of a non-rebreathing mask is as follows: a) Oxygen flowmeter b) Non-rebreathing mask (with reservoir bag and oxygen tubing) c) Humidifier (if applicable) 3) The procedure for applying a non-rebreathing mask is as follows: a) Check the physician's order b) Greet the patient and explain to the patient the procedure and therapeutic objectives of a non-rebreathing mask as well as the safety precautions including prohibition of smoking, open flames, or devices that may spark. c) Remove smoking materials and other fire hazards from the room. d) Place the oxygen flowmeter in the wall outlet. 14

15 e) Attach the non-rebreathing mask to the humidifier or flowmeter. f) Adjust the flowmeter to the desired flowrate for the proper FIO2. g) Attach the mask to the face of the patient with the reservoir partially inflated. Place the elastic straps around the neck at the level of the tragus of the ear or around the head above the ear, whichever is more comfortable. h) Adjust the nose clip and strap so that the face mask fits snugly but not tightly. i) Readjust the flowmeter, if necessary, so that the reservoir is nearly full (does not empty) at all times during the patient's respiratory cycle. j) Be sure that the reservoir bag is not obstructed by objects such as blankets, sheets, etc. k) Observe the patient tolerance of the mask. 4) Documentation of a non-rebreathing mask on the Respiratory Therapy Oxygen flowsheet should include the date, time, flowrate, device ordered, and the patient understanding of the usage and therapeutic objectives. This device should be checked once every 12 hours with the date, time, flowrate, device and whether it is in use or not. 5) Complications associated with a non-rebreathing mask could include the following: Complications: Poor tolerance Pressure sores. 15 Remedy: Adjust oxygen device for comfort. Pad areas of irritation with gauze or

16 Mucosal irritation Malfunction of 1-way valve duoderm. Add, check or replace humidifier. Use nonpetroleum based lubricant (K-Y, CANN EASE) Replace mask or valve. VIII. Hypercarbia Special Considerations Increase flowrate to improve flushing. A. It may be necessary at times when a patient must be maintained on high concentrations of oxygen and may not be removed to administer aerosol medications with compressed medical air. In this case, oxygen will be used as the nebulizer driving gas. 1. Use a separate oxygen oxygen outlet and flowmeter to deliver aerosol therapy. Use a double outlet Y device if necessary. 16

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