MMPR036 PROCEDURE FOR THE HANDLING AND ADMINISTRATION OF MEDICAL GASES FOR INPATIENT AREAS 1
Table of Contents Introduction... 3 Purpose... 3 Any required definitions/explanations... 3 Management and Administration of Medical Gases in Clinical Areas... 4 Storage and handling of Medical Gas cylinders in clinical areas... 4 Safe transportation and delivery of oxygen from cylinders... 4 Delivery of oxygen from piped oxygen supplies... 5 Delivery of Entonox... 5 Checking of Oxygen Equipment... 5 Checking of oxygen cylinders... 5 Checking and use of piped oxygen outlets... 5 Prescribing, Administering and Monitoring Oxygen Therapy... 6 Prescribing supplementary oxygen... 6 Monitoring and recording oxygen administration... 6 Emergency Situations... 6 Special Circumstances... 7 Care, Transfer and Transportation of Patients Receiving Oxygen... 7 Nebulised Therapy and Oxygen... 8 Entonox Administration... 8 Training... 8 References... 8 Equality considerations... 8 Document control details... 10 Appendix 1 How to Check and Use Oxygen Cylinders... 11 Appendix 2 - Oxygen Administration Devices... 14 Appendix 3 - Target Oxygen Saturation Levels... 21 Appendix 4 - Alternative Administration Devices... 23 Appendix 5 - Contraindications & Cautions... 25 2
Introduction Subordinate to the Medical Gases Operational Policy Northamptonshire Healthcare NHS Foundation Trust issues procedure for the handling and administration of medical gases to ensure patient safety. The Trust is responsible for ensuring that when the administration of medical gas is required for therapeutic reasons, it is done appropriately and safely. Medical gases are legally classified as drugs and therefore require prescription or authority to administer under a Patient Group Direction (PGD) with the exception of oxygen in an emergency. Failure to handle or administer medical gases appropriately can result in serious harm to the patient or others. Purpose The purpose of this procedure is to ensure that: All patients who require medical gases receive therapy that is appropriate to their clinical condition and in line with national guidance and recommendations Medical gases are administered safely to all patients Medical gas cylinders are handled and stored in a safe manner in the clinical area. The Trust complies with the National Patient Safety Agency and Department of Health Estates and Facilities Alerts. Any required definitions/explanations Nitrous oxide: A medical gas used in the induction of anaesthesia, as an analgesic and in some conscious-sedation procedures. It is a prescription only med and is asphyxiant in high concentrations. It can cause nausea and confusion or euphoria. It may be abused. Oxygen concentrator: An electrically powered device designed to separate oxygen from atmospheric air in order to provide a low to medium flow supply (up to 5 8 litres per minute for high flow concentrators) without the need for use of cylinders. Oxygen: A gas given in concentrations of nominally 24 to 100% in order to reverse hypoxia. Legal category General Sales List (GSL) Liquid nitrogen: A cryogenic agent used to burn skin tags, warts and similar dermatological procedures. It presents a cryogenic hazard (cold burns) and is an asphyxiant at high concentrations. Legal category. Prescription only Medicine (PoM) Pipeline: A system designed to deliver medical gases to a ward or department area from a manifold of cylinders remote from the clinical area. The advantage is that it reduces the number of cylinders required on the ward. Manifold: A framework of adaptors, connectors and pipework designed to allow the connection of 2 or more large (usually J size cylinders) to a piped medical gas system. Medical air: Compressed air of medical grade used to power operating and dental equipment, and in some areas via cylinder for nebulisers in routine clinical use. Legal classification GSL/ unclassified. Suction/Vacuum: Installed pipework providing vacuum to power clinical suction equipment. 3
Entonox: A medical gas comprising a premix of 50% oxygen and 50% nitrous oxide, used as an analgesic in pre-hospital, palliative, maternity and other settings. It is a PoM. It can caused nausea and confusion or euphoria. It may be abused. Supplementary oxygen therapy refers to any situation where a patient has been prescribed oxygen in advance for the management of an underlying medical condition. Emergency oxygen administration refers to the administration of oxygen in any situation where an individual s physical health has deteriorated and requires urgent intervention to prevent further deterioration, or cardiac arrest is imminent or has already occurred. Clinical staff are those staff that have direct patient care including qualified and non-qualified staff. Non-clinical staff are those staff that do not have direct patient care. NHFT - Northamptonshire Healthcare NHS Foundation Trust. Management and Administration of Medical Gases in Clinical Areas Storage and handling of Medical Gas cylinders in clinical areas All cylinders will be stored in the nominated location for the clinical area. Appropriate safety signage must be displayed where compressed gas is stored. In all areas, larger oxygen cylinders (Size F and HX) must be stored in areas where patients and public access can be monitored and controlled when not in use. Such areas could comprise locked storage. Within Mental Health / Learning Disability areas, all oxygen equipment must remain locked in the clinic room, unless oxygen is being administered to a patient. All cylinders will be secured and stored as agreed by departmental matrons, Estates and where appropriate, according to the directions of the Resuscitation Service. In order to ensure patient, staff and public safety, no cylinders physically (geometrically) larger than an F / HX size are to be used in clinical areas. Nitrous Oxide. Medical air and Entonox cylinders must be stored so as to be clearly identified as such and not confused with oxygen cylinders. Ideally they should be stored separately. Each cylinder main store should have areas for full cylinders for use to be stored and an area for returns of empty or faulty cylinders. Empty and faulty cylinders should be clearly marked as such. Medical air cylinders should have a collar tag attached when sent to clinical areas making clear tha the cylinder contains MEDICAL AIR. Safe transportation and delivery of oxygen from cylinders When oxygen is to be administered to a patient, the cylinder will be transported in the appropriate trolley or bag. A trained member of staff will administer oxygen. EFA 2010/008 states that cylinders in use must be secured to an immoveable object with a chain or strap. Such mountings are considered to be an appropriate if floor or wall mounted. Clinical areas should seek advice as to what securing methods would be appropriate for the building that they 4
occupy. Anchorages are a potential ligature point and must not be fixed in mental health and learning disability areas. When supplementary oxygen therapy is being delivered the cylinder should be secured to the anchorage by a locally approved means. Where anchorages are not permitted, an individual risk assessment must be completed to determine if it is safe and appropriate for a cylinder and trolley to be left with the patient. Consider placing a member of staff with them for the duration of the oxygen therapy. This risk assessment must be documented in the environmental assessment for the individual patient. If emergency oxygen is being administered, at least one member of staff must remain with the patient at all times to ensure the cylinder trolley is not used as a support or pulled over by the patient Delivery of oxygen from piped oxygen supplies In several clinical areas, piped oxygen is available as an alternative to cylinders. This is a preferable means of delivery owing to decreased handling risks, increased safety of the cylinders in the event of fire and ease of access to staff and patients. In such areas, bayonet flowmeters are supplied (see Appendix 4), and should be used in accordance with Medical Gases training delivered in each clinical area where piped supplies are provided. Oxygen is delivered by a similar means as from a cylinder. Where piped oxygen supplies are provided, cylinders must also be provided to allow for patients to mobilise away from the bedspace whilst receiving oxygen therapy, and also to provide oxygenation in the event of a catastrophic failure of the piped oxygen system. Delivery of Entonox Enotox may be used in any clinical areas an analgesic provided that a) staff are trained in its use, b) the patient is permitted to self-administer under supervision to prevent overdosing by practitioners, and c) it is prescribed or provided under an applicable PGD. Entonox is a powerful analgesic and may be as efficient as low dose morphine. It does however, have a number of contraindications practitioners prescribing and administering Entonox must make themselves aware of the current list of indications and contraindications when they involved with the delivery of this drug. Checking of Oxygen Equipment Checking of oxygen cylinders All oxygen cylinders must be checked daily by unit staff (when unit open) for readiness for use and appropriate documentation completed. If a cylinder requires replacement, this should be arranged at the earliest possible time according to local arrangements. Checking and use of piped oxygen outlets Piped oxygen outlet flowmeters should be checked for operational serviceability and cleanliness daily, or in accordance with local procedures. Medical air outlets must be capped with the flowmeter removed when this is not anticipated to be needed. Oxygen flowmeters should remain connected at all times to allow for delivery of oxygen when needed. 5
Each flowmeter should be checked at least daily, and before use. This includes selecting a set flow rate and occluding the fir tree connector with a thumb. The ball should fall to zero. Failure of the ball indicates a leak at the fir tree. After a short occlusion, it should be released, and oxygen should flow again at the desired rate. The flowmeter should be checked to ensure that it is able to deliver up to the maximum indicated (normally 15 litres per minute). Tubing is connected to the fir tree connector and the desired device connected to the tubing. The desire flow rate should be selected and confirmation that oxygen is flowing to the device should be made. In setting the rate, the centre of the ball is normally used to measure flow, but this must be checked with the manufacturer s instructions, as some devices measure from the top of the ball. Prescribing, Administering and Monitoring Oxygen Therapy Prescribing supplementary oxygen Supplementary oxygen therapy that is planned medical care must be prescribed on the Oxygen Prescription Chart (see Appendix 3.) The prescription should include the target saturation range for the patient, (See Appendix 3) and may include the flow rate, in litres per minute, together with special instructions and which administration device(s) are appropriate as per Appendix 2. Refer to guidelines for administration of oxygen for mental health inpatients, community and hospices have O2 prescriptions embedded into inpatient drug chart. Monitoring and recording oxygen administration The practitioner administering oxygen therapy should sign the Oxygen Prescription Chart when oxygen is administered. Practitioners should monitor all patients receiving oxygen therapy regularly; respiratory rate, pulse oximetry measurement and any change in their physical condition including skin colour (cyanosis) should be recorded. The frequency of observations will depend on the condition being treated and the stability of the patient, and should be specified by the prescriber on an individual basis. For example, unstable patients or those with a new oxygen regime may need continuous or quarter hourly monitoring, whereas patients with stable long term conditions usually need less frequent monitoring. This should be recorded in the clinical notes or NEWS (National Early Warning Score) Observation Chart. (See Resuscitation and related Medical Emergencies Policy for further info) Patients should be monitored for signs of deterioration; unusually low oxygen saturations with or without oxygen, abnormally high or low respiratory rate should be responded to as per the Clinical Response to NEWS as found in the NEWS Chart. Peripheral cyanosis, unusually noisy or laboured breathing should be assessed and responded to in an appropriate manner. Emergency Situations In a medical emergency situation, an oxygen prescription is NOT required. Oxygen should be given to the patient immediately. Any member of clinical staff who has completed oxygen administration training can commence oxygen therapy in an emergency. A subsequent written record must be made in the patient s clinical notes of the oxygen therapy given alongside the recording of any other emergency interventions. All patients who are critically unwell or experiencing a medical emergency should be given 15 litres per minute through a non re-breathe mask whilst awaiting the arrival of the ambulance or doctor review. Patients experiencing a medical emergency should be monitored continuously. 6
All patients in cardiac arrest or are unconscious with an inadequate respiratory rate should be ventilated with a pocket mask or bag-valve mask device connected to 15 litres per minute of oxygen, where possible, along with basic / immediate life support interventions. Special Circumstances Where oxygen concentrators are used, staff should be appropriately trained in their use and local clinical guidelines are included. Concentrators must be serviced in accordance with the manufacturer s instructions, and the instructions of the use of the specific unit must be attached to, or available with the concentrator. On starting the concentrator, the unit must be allowed to warm up, a warning tone will usually sound until the unit is pressurised and delivering oxygen. This may take up to 10 minutes. Oxygen may be delivered from a cylinder whilst this warm up completes. Any safety checks indicated by the manufacturer must be completed and the flowmeter must be checked. This includes selecting a set flow rate and occluding the fir tree connector with a thumb. The ball should fall to zero. Failure of the ball indicates a leak at the fir tree. After a short occlusion an obstruction alarm should sound. This should reset on releasing the occlusion, and oxygen should flow again at the desired rate. The flowmeter should be checked to ensure that it is able to deliver up to the maximum indicated (normally 5 or 8 litres per minute). Domiciliary oxygen is normally managed by General Practitioners; staff involved with the management of home oxygen should refer to the guidance document relating to home oxygen (British Thoracic society guidelines for oxygen use in adults). Care, Transfer and Transportation of Patients Receiving Oxygen Patients receiving long-term oxygen therapy should regularly be checked for signs of infection and pressure sores around the mouth, nose and behind the ears. These checks should be documented in the contact notes and appropriately treated. Patients receiving oxygen therapy are also at risk of drying of the oro-nasal mucosa. Long term oxygen therapy at medium to high flow may best be achieved with humidified oxygen to mitigate this risk. All patients should be monitored and appropriate mouth and nose care given. No paraffin containing moisturisers should be used; instead, water-based emollients should be used with reference to current prescribing guidelines. Patients who are transferred from one clinical area to another must have clear documentation of their ongoing oxygen requirements and documentation of their oxygen saturation levels. Oxygen administration should continue as per the existing prescription until reviewed by the receiving medical team. Patients requiring oxygen therapy whilst being transferred from one area to another or whilst in Trust transport should be accompanied by an appropriately trained member of staff wherever possible. If this does not occur, clear instructions must be provided for personnel involved in the transfer of the patient, which must include delivery advice and flow rate. Cautions to be considered when administering oxygen therapy can be found in Appendix 5. Where it is necessary for oxygen (or other gas) to be transported in a Trust or employee s vehicle, either cylinders between Trust locations, or for a patient in transit requiring continuous oxygen therapy, the following must be adhered to: 7
A green compressed gas diamond must be displayed to the rear of the vehicle The vehicle must hold insurance for business purposes (including the carriage of patients, where appropriate) and the carriage of medical oxygen. The vehicle must carry a Data Card for the gas(es) being carried. The cylinder must be securely stowed to prevent movement in a collision but should be easily accessible to be rapidly removed if needed. It is recommended that a dry powder fire extinguisher is carried Nebulised Therapy and Oxygen Generally, nebulised therapy is given via an air compressor. However, in patients receiving high flow oxygen, the nebuliser mask tubing may be connected to oxygen at a flow rate of 5-8 litres / minute and then oxygen therapy continued once the nebuliser has finished. Patients who are on continuous low flow oxygen therapy via nasal cannulae may receive their oxygen therapy and nebuliser therapy concurrently, with the nebuliser being driven with compressed air. Nebulised therapy should be delivered in accordance of the Marsden Manual of Clinical Nursing. Entonox Administration Entonox should be prescribed or made available under a PGD For analgesia, as needed. Equipment should be checked before use and a new delivery device (mouthpiece or mask filter) should be provided to each patient. The device may be used by the patient several times, but must be clean and must be replaced in a timeframe as specified by the supplier. Equipment is checked by operating the cylinder main valve and checking contents, then turning off again. The pipes and delivery mechanism and delivery device must be in date and clean/ in good condition. Training Training will be delivered by each area according to local policy. References British Thoracic Society 2017; Guidelines for Oxygen use in adults in healthcare and emergency settings available at www.brit-thoracic.org.uk Resuscitation Council (UK) Guidelines 2015; available at www.resus.org.uk National Patient Safety Agency Rapid Response Report: Oxygen safety in hospitals, September 2009, NPSA/2009/RRR006 Equality considerations The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact of Policy changes for different groups within the community. In particular, the Trust is required to assess the impact (both positive and negative) for a number of protected characteristics including: Age; Disability; Gender reassignment; 8
Marriage and civil partnership; Race; Religion or belief; Sexual orientation; Pregnancy and maternity; and Other excluded groups and/or those with multiple and social deprivation (for example carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless people). The author has considered the impact on these groups of the adoption of this Procedure. It is unlikely that the operation of this procedure and associated policies and protocols will lead to unlawful discrimination. The appropriate and reasonable adjustments will be made if required to support the administration of gas where a service user has a physical impairment. 9
Document control details Paul Marlow- Sessional Resuscitation Officer Author: Suzanne Richardson Resuscitation Officer Approved by and date: 19 th September 2017 Responsible committee: Medicines Management Committee Any other linked Policies: MMP020 Medical Gases Operational Procedure CLP002 Resuscitation and Related Medical Emergencies Policy CRM002 Incident Policy (Including near miss incidents) HSC010 Moving and Handling Policy Procedure number: MMPR036 Version control: Version 1 Version No. Date Ratified/ Amended Date of Implementation Next Review Date Reason for Change (eg. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) 1 19.09.17 19.09.17 30.09.19 Review 10
Appendix 1 How to Check and Use Oxygen Cylinders Daily checks on the cylinder The expiry date may be identified from the Batch Label fitted to every cylinder this should be checked to confirm that the cylinder is in date. If the cylinder is due to expire within one calendar month, the appropriate department must be contacted to arrange its replacement. The cylinder is fitted with an Integrated Valve containing a Live Contents Gauge this gauge should be checked. For the CD size cylinder, the needle should be pointing anywhere within the green section - this means the cylinder is over ¾ full. For the HX size cylinder, it must be greater than ¼ full. Below these acceptable levels, the cylinder must be replaced. DO NOT TURN THESE CYLINDERS ON AS PART OF THE DAILY CHECK. Where an E or F size cylinder is used, the main cylinder valve must be turned on with the key prior to reading the gauge as above. The main valve must then be closed following the check and the oxygen in the flowmeter released. 11
How to use the Oxygen Cylinder Tear off strip on red / grey round seal and remove seal from cylinder. Remove red seal or pull down grey flap over oxygen port. 12
Open hand wheel fully in direction shown, then back off by ¼ turn. Connect oxygen device tubing to the fir tree connector, then turn dial to number of litres per minute required. Where an E or F size cylinder is used, the cylinder is opened with the key and the dial flowmeter (if fitted) used as above, or a ball flowmeter used as at Appendix 4. 13
Appendix 2 - Oxygen Administration Devices Variable Concentration devices: Variable concentration devices do not deliver a reliable concentration of inspired oxygen (FiO 2 ) and therefore must be used with care in use for patients with specific oxygen requirements (e.g. new therapy for COPD patients and/or patients with known CO 2 retention etc.) Many factors including mask seal efficiency, breathing pattern and rate, tidal volume, and mouth or nose breathing dominance will have an effect on the actual FiO 2 achieved for each patient. Flow rate range Achievable FiO 2 Device 0 4 litres / min 25 34% Nasal Cannulae 5 10 litres / min > 35% Simple Face Mask (Medium concentration mask) 10 15 litres / min ~85% Non re-breathe Mask Nasal Cannulae Nasal cannulae consist of a pair of tubes each about 2cm long, each projecting into the nostril and stemming from a tube which passes over the ears and which is therefore self-retaining. Cannulae have the advantage of not interfering with feeding and are not as inconvenient as masks during coughing and sneezing. Action: Position the tips of the cannula in the patient s nose so that the tips do not extend more than 1.5cm into the nose. Place the tubing over the ears and under the chin. Adjust the flow rate to the indicated flow rate / range. 14
Simple Face Mask (Medium Concentration Mask) The simple face mask has a soft plastic face piece with vent holes provided to allow exhaled air to escape. The oxygen concentration delivered is influenced by leakage between the mask and face, as well as the patient s tidal volume and respiratory rate. This mask should not therefore be used for patients known to retain carbon dioxide. Simple Face Mask when taken out of packet Action: Gently place the mask over the patient s face, position the strap behind the head, then carefully pull both ends of the elastic through the front of the mask until secure. Ensure a comfortable fit for the patient. Check that the strap is not across the ears to prevent irritation. Adjust the flow rate to the prescribed amount. The flow rate must never be below 5 litres / min. 15
Non Re-Breathe Mask (Reservoir Mask) The non re-breathe mask has a plastic face piece with a one-way exhalation port. There is a one-way valve between the reservoir bag and the face mask. In the non re-breathing system, oxygen flows into the reservoir bag and into the mask through the one-way valve. On exhalation air is vented through the exhalation port in the mask. The one-way valve between the bag and mask closes and prevents rebreathing of exhaled air. High concentrations of oxygen around 85% can be achieved. This mask MUST NOT be used for supplementary oxygen therapy for patients known to retain carbon dioxide EXCEPT in medical emergency situations when the treatment and prevention of hypoxia is the priority whilst awaiting the ambulance. Action: Ensure the reservoir bag is fully inflated before placing the mask on the patient using 15 litres per minute of oxygen. In a medical emergency situation, ALL patients should be administered oxygen at 15 litres per minute through the non re-breathe mask whether prescribed or not. 16
Fixed concentration devices Venturi mask A mask incorporating an air entrainment device to enable a fixed concentration of oxygen to be delivered, independent of patient factors, fit to the face or flow rate. Oxygen is forced out through a small hole causing a Venturi effect which draws in air to mix in a specific concentration with oxygen. Blue 24% White 28% Yellow 35% Red 40% Green 60% Venturi mask in place (above) and venture (left) Venturi may be fitted direct to the mask as above, or in specialist settings, with an intermediate tube of 25mm link tubing ( elephant tubing) as left. Action: Select correct venturi device for the required inspired percentage (FiO 2 ). The venturi may be changed for one at a lower or higher percentage to keep the patient s oxygen saturations within the target range. Gently place the mask over the patient s face, position the strap behind the head, and pull both ends of the elastic through the front of the mask until secure. Ensure a comfortable fit for the patient. Check that the strap is not across the ears. Adjust the flow rate to the indicated flow rate on the venturi (This figure is the minimum flow rate for the venturi.) The flow rate may be doubled if the patient has a respiratory rate above 30 per minute, to ensure adequate oxygenation. 17
Other Devices Tracheostomy Mask The tracheostomy mask is designed for patients who neck breathe with a tracheostomy or laryngectomy. The mask fits comfortably over the tracheostomy and has an exhalation port on the front of the mask. Action: Gently place the mask over the patient s airway, position the strap behind the head then carefully pull both ends through the front of the mask until secure. Ensure a comfortable fit for the patient. Administer oxygen therapy as prescribed most neck-breathing patients will receive humidified oxygen therapy. Venturi devices, tubing connectors or nebuliser acorns may be attached to the tracheostomy mask. 18
Bag-Valve-Mask The bag-valve-mask device is designed to administer oxygen to a patient during resuscitation who has no or inadequate breathing. The device generally requires a 2 person technique to be used effectively in order to deliver artificial ventilations to the patient. Bag-Valve-Mask device when taken out of packaging Bag-Valve-Mask device assembled ready for use Action: Place the patient supine with the head in a sniffing position, i.e. neck slightly flexed with the head tilted backwards on the neck. Connect the oxygen tubing to 15 litres per minute of oxygen and allow the reservoir bag to inflate. Apply the mask over the patient s nose and mouth using the thumbs of both hands. Lift the jaw into the mask with the remaining fingers by exerting pressure behind the angles of the jaw. At the same time, press the mask onto the face with the thumbs to make a tight seal. 19
A second person should squeeze the self-inflating bag for 1 second, ensuring the patient s chest rises and falls as in normal breathing. Reduce any leaks between the face and mask by adjusting the contact pressure, altering the position of the fingers and thumbs or increasing jaw thrust. 20
Appendix 3 - Target Oxygen Saturation Levels Critical illness requiring high levels of supplemental oxygen Initial oxygen therapy is a non-rebreathe mask at 15Lpm Once stable reduce oxygen dose (and change delivery device as needed)- aim for target saturation of 94-98% Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients. Serious illness requiring moderate levels of supplemental oxygen if the patient is hypoxaemic Initial oxygen therapy is nasal cannula at 2-4 Lpm; simple face mask at 5-10 Lpm or an appropriate Venturi mask The recommended initial oxygen saturation target range is 94-98% If patient has co-existing COPD and known to retain carbon dioxide or other risk factors for hypercapnic respiratory failure aim at saturation of 88-92%. If oximetry is not available continue with oxygen as above until it is available Change to reservoir mask if the desired saturation range cannot be maintained with nasal cannula or simple face mask COPD and other conditions requiring controlled or low dose oxygen therapy Use either a 24% or 28% Venturi mask - aiming for oxygen saturation of 88-92%. The inspired flow rate and percentage (FiO 2 ) may need to be increased if no improvement in saturations is seen. If saturations remain below 88%, consider using an alternative device. Targeted Oxygen Saturations are the recommended means of prescribing oxygen in the majority of patients. They should be used as the means for prescribing and for ongoing oxygen. The regime assists in reducing damage caused by long term hyperoxaemia and can reduce muscle damage in acute cardiac patients. However, there are some situations where this may not be appropriate; for example, with long term stable patients receiving regular a flow rate of oxygen titrated for respiratory disease, in palliative care, and the initial phase of emergency care. Refer to Guidelines for the Administration of Oxygen in a Medical Emergency. 21
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Appendix 4 - Alternative Administration Devices Ball Flowmeter (Also referred to as a bayonet flowmeter) DESCRIPTION Device to allow the patient to receive an accurate flow of oxygen, usually between 1 and 15 litres per minute. PURPOSE To ensure that the patient receives the correct flow rate of oxygen. May be wall-mounted or on a cylinder. 3 2 3 2 1 1 Normal correct setting for 2 Lpm OPERATION Attach the oxygen tubing to the fir-tree connector on the flow meter. Turn the finger-valve to obtain the desired flow rate. The centre of the ball USUALLY shows the correct flow rate. The diagrams show the correct setting to deliver 2 Lpm. Checking procedure Ensure the flowmeter is clean, free from damage and firmly connected to the cylinder or wall outlet. On each check, before each use, and at least every 24 hours in continuous use, the fir tree connector on the bayonet flowmeter must be checked for an adequate seat onto the flowmeter body. This is achieved by turning on the oxygen supply at 15 litres per minute (Lpm) and then occluding the fir-tree outlet with a thumb. The ball should drop to 0 Lpm at this point, and return to 15 Lpm when the fir tree is uncovered. If the ball does not drop to 0 or if leakage is heard, remedial action is required as the fir tree is leaking owing to an ineffective seat or damage. 23
Humidification This should only be used if specifically requested by the doctor or physiotherapist and be administered by appropriately trained personnel. Humidification equipment should be changed at least every 7 days and the water in a refillable container replaced every 24 hours according to the recommendations of the Marsden Manual of Clinical Nursing Procedures. Humidified oxygen may be considered in the following circumstances: 1. If the flow rate required by the patient exceeds 4 litres per minute for several days 2. Tracheotomy or tracheostomy patients 3. Cystic Fibrosis patients 4. Bronchiectasis patients 5. Patients with a chest infection retaining secretions 6. Patients within a palliative care environment 24
Appendix 5 - Contraindications & Cautions There are no absolute contraindications for the administration of oxygen. Cautions Oxygen administration and carbon dioxide retention In patients with chronic carbon dioxide retention, oxygen administration may cause further increases in carbon dioxide and respiratory acidosis. This may occur in patients with COPD, neuromuscular disorders, morbid obesity or musculoskeletal disorders. There are several factors which lead to the rise in CO 2 with oxygen therapy in patients with hypercapnic respiratory failure and details are in the BTS guideline. Other precautions/ Hazards/ Complications of oxygen therapy Avoid contact of apparatus with grease or oil Avoid contact of apparatus with alcohol based products. Ensure alcohol hand rubs are fully evaporated before using or handling oxygen equipment Oxygen must only be used in a no smoking designated area Drying of nasal and pharyngeal mucosa avoid use of petroleum jelly based products Oxygen toxicity Absorption atelectasis Skin irritation Fire hazard Potentially inadequate flow resulting in lower FiO 2 than intended due to high inspiratory demand, inappropriate oxygen delivery device or equipment faults 25