Getting ready for use Cracking the tank
Contents
1. tube ETT or tracheostomy Remove the mask from the bag and the adapter should be universal and fit onto the patients ETT or the tracheostomy When an advanced airway is in place there is no interruption in bagging for chest compressions and the breaths are given at a rate of 1 every 6 seconds look for patient efforts and match their spontaneous rate Be CS to look for chest wall rise and cyclical fogging of the KEA Rey ti z eo oe N i g o SaN gt A Advanced Airways REMEMBER do not put excess tension or pressure on advanced airways as this may alter their position and result in accidental extubation est Me hihi yo A What questions do I need to ask before choosing a bronchial hygiene therapy o Tey a Does the patient have excessive mucus production Does the patient have a weak ineffective cough Is the patient able to follow directions Does the patient have a caregiver that can help administer therapy Is the patient able to ambulate and or change positions easily What outcomes will be used to assess effectiveness of therapy If the patient is currently receiving bronchial hygiene when was the last time the appropriateness of the therapy was evaluated Has anything in the patient s condition changed since the last evaluation oo pen T GS ro iba o Traditional Bronchial Hygiene amp Directed Cough Postural Drainage amp External manipulation of t2. a NC Note when putting in the nose make sure the prongs curve down wr a r al Tank transport amp Tanks should be secured into an approved carrier during use You should always pull the tank behind you never push it ee Device limitations Nasal Cannula The flow should never go above 6L e The tubing cannot handle the increase in flow and it is damaging drying to the patients nasal membranes Simple mask The flow should never go below 6L e There has to be enough continuous flow to flush out the patients CO2 so they don t suffocate Trach collar Requires modification to use You need to remove the adapter from the simple mask and insert it into the gas inlet tube on the collar The flow should never go below 6L e There has to be enough continuous flow to flush out the patients CO2 so they don t suffocate Wall source Oxygen flow meters i The flow rate is read at the center of the round ball thee ct l aAa 5 A Tank storage E Turning off the tank When finished take the patients delivery device off the tank and attach it to the wall flow meter ensuring accurate flow rate Close the tank and let the remaining gas bleed out of the regulator until the tank PSI reads zero you will hear the flow stop Close the flow regulator and remove the regulators if required e You must bleed off the gas or it will damage the tanks regulator and ca
3. d turn until you just hear the hiss of the gas escaping and then close This is to blow any debris out of the tank connections that could damage the equipment or harm the patient DD P Applying the regulator Pi The regulator should fit over the top of the tank and have two pins that will fit into receptacles on the tank Position the regulator with the pins in the receptacles and tighten down manually Then use the wrench to open the tank by turning at least two full turns and listen for a leak If you hear feel a leak make sure the flow regulator is closed and listen again If the tank is still leaking close the tank bleed out the gas in the regulator by turning the flow on until the PSI reaches zero turn off the __ flow remove the regulator and try again or get a different regulator that one may be broken New grab and go tanks are available that you simply turn off and on oe Applying an oxygen device amp Most devices now have quick connect ends to that you can attach them to threads or a Christmas tree If your device doesn t you may need to make sure your regulator has a Christmas tree screwed onto the flow regulator or has the nipple style gas outlet Your patient may have a prescribed amount of flow required during exercise check their orders and set the flow If they have no orders you can check what their flow rate is on their wall flow meter and set it based on that Nasal Cannul
4. ee Fe i Oxygen Delivery Positive Pressure 3 Breathing Airway Clearance and Bronchial Hygiene Shawna Strickland MEd RRT NPS AE C University of Missouri Columbia Respiratory Therapy Program sie Lae EA ia SEED EES ON a Getting ready for use amp Applying regulator Opening the tank amp Checking PSI st Applying oxygen device amp Storage and Transport Vm a a ttm A Regulators eal amp Regulators have two functions show PSI and control the flow of gas delivered to the patient Every kind of compressed gas has it s own regulator that will only fit that particular kind of gas tank Ifit doesn t fit don t force it it probably is for a different gas amp Every hospital will have its own standard for tank PSI requirements prior to use for therapy transport Always check your tank PSI prior to use nooo e gt socal nt Oxygen tanks ow amp Gas tanks are made from steel or aluminum They have a standard color coding system Caution this system is different in other countries always check the label to be sure of the gas and its concentration Oxygen tanks are green Aluminum tanks are lighter and imprinted at the top near the collar 3AL Steel tanks are much heavier and imprinted at the top near the collar with 3AA or 3A Compressed Medical Gas Oxygen is 99 pure oxygen tank Apply the specialized wrench to the tank an
5. elp Perform a head tilt chin lift and look listen and feel for breathing Get ambu bag and mask and hook up oxygen if available at 10 15 L flush it if you have to Mask positioning Mask are shaped like a teardrop and have a soft air filled cushion The point of the mask should hit the bridge of the nose and the base fit between the lower lip and chin Check for chest wall rise to ensure air movement Reposition if needed i e large resistance is met not an adequate seal Do not completely empty the bag as you may over inflate and cause trauma to the lungs Follow BLS guidelines 2 breathes every 30 cycles of chest compressions If respiratory arrest only then 1 breath every 5 6 seconds or when patients has an effort Head tilt chin lift This is done by placing one hand on the forehead and another on the lower jaw and gently flexing the neck and lifting the chin This opens the airway and allows for adequate ventilation In order to ventilate you must maintain a tight seal around the patients nose and mouth This is done using the E C technique Use the thumb and forefinger to make a C with the thumb on the apex of the mask and the forefinger at the base Make and E with the remaining 3 fingers placed on the jaw line and thrust the jaw forward to keep the airway open Advanced airways An advanced airway is an oral nasal endotracheal
6. he thorax Chest wall percussion Chest wall vibration Irritation Inspiration Compression Expulsion Copyright 2002 Elsevier Science USA All rights reserved Postural Drainage Positioning Coppi 200 Dibran Sconce LIGA Ad pii rv Use gravity to move secretions to the Copyright 2002 Elsevier Science USA All rights reserved large airways so the patient can cough them out New Methods of Bronchial Hygiene Positive expiratory pressure PEP Acapella Flutter valve therapy Intrapulmonary percussive ventilation IPV High frequency chest wall oscillation HFCWO PEP Therapy This can be used with or without regular nebulizer therapy eUsing it with nebulizer therapy achieves two goals at once When the patient exhales positive pressure is created in the lungs This pressure allows air to enter behind areas of mucus obstruction and keeps the airways open during exhalation During exhalation mucus is now able to move the mucus toward the larger airways and the patient can cough it out Flutter Valve Cost of device 50 60 Copyright 2002 Elsevier Science USA All rights reserved Contraindications to PEP Patients who are Recent facial oral or unable to tolerate the skull surgery or t in work of breathing trauma 2 ICP gt 20 mm Hg Esophageal surgery Hemodynamic Active hemoptysis instability Nausea Epistaxis Known or sus
7. ng Definition The removal of tracheobronchial and upper airway secretions Purpose To clear the airways of obstructions for improved gas exchange and prevent aspiration W Important to remember This is always a sterile procedure when the patient has an endotracheal tube or tracheostomy tube Closed Circuit Catheters a Common features Endotracheal or tracheostomy tube adaptor Suction catheter inside sterile sheath Thumb port Lavage port Popular because No disconnection from the ventilator decreased VAP Reduced cost Reduced exposure of HCP to infectious materials One Use Sterile Catheters Sized in French typically 6 14 Fr Most catheters are 56 cm long 3 Common features Thumb port to apply suction Side holes in the distal tip for plugging Distal tip is blunt and open Flexible Some have markings for length cm Complications of Suctioning amp Hypoxemia Cardiac arrhythmias Trauma to airway mucosa Atelectasis Contamination of lower airway Contamination of caregivers Increased intracranial pressure Positive Pressure Breathing Manual Ventilation Indications Respiratory arrest or insufficient effort Back up for patient on mechanical ventilators with an advanced airway Spontaneous Ventilation Ribs expand and diaphragm drops to create a negative pressure inside the thoracic cavity amp The l
8. pected Untreated tympanic rupture or pneumothorax other middle ear problem Flutter Valve Therapy When correctly the effect is 3 fold Vibrations applied to the airway facilitate the loosening of secretions The increase in bronchial pressure helps avoid air trapping Expiratory air flows are accelerated and facilitate the upward movement of mucus 2 Stages of Flutter Technique Stage 1 Stage 2 Loosening and Eliminating mucus mobilizing mucus Cough or huff Using flutter will maneuver follows the increase the pressure flutter to help expel the on exhalation and secretions recruit lung units similar to the PEP device Acapella Similar to PEP but adds vibration therapy as well Can be delivered with aerosol therapy Who can use the IPV amp Patients who can breathe on their own with a mouthpiece or mask Patients who are intubated and on a mechanical ventilator Patients who have a tracheostomy and may or may not be on a ventilator Flutter Tips Tilt is important With the mouthpiece horizontal to the floor e Tilt cone up or down to get maximal effect Feel the patient s chest and back for vibrations Clean the device on a regular basis by disassembling and soaking Delivers rapid high flow bursts of air or oxygen into the lungs At the same time it delivers therapeutic aerosols medications that might open the air
9. ungs fill with air because the atmospheric pressure greater than the intrathoracic pressure Exhalation is passive relying on chest recoil SSS Ss R REC Scr ae DWS as n Pa T Manual Resuscitators Three sizes eAdult 25 kg and larger ePediatric 10 25 kg eNeonatal less than 10 kg a g SV K e z Resuscitation bags Self inflating bags are most common and have a one way valve that allows for exhalation while separating the exhaled gas from the oxygen reservoir They are referred to as bag valve mask BVM or ambu bags When entering a patients room you should always be aware of where their ambu bag is located or where to get one quickly in case of an emergency Positive Pressure Ventilation E Concept External pressure applied to the lung to move air Exhalation is still passive Advantages Provide ventilation and oxygen for those who can t for whatever reason do it themselves Disadvantages Over inflation can cause many pulmonary and hemodynamic complications Under inflation doesn t allow adequate ventilation and oxygenation Features of Manual Ventilators Oxygen tubing Oxygen reservoir to provide more than 0 40 FiO Body of bag Lots of one way valves to direct air flow Patient adaptor to mask or tube Exhalation port do not occlude this Optional PEEP valve Shake their shoulder yell their name Call for h
10. use inaccurate readings Tank storage Tanks should be stored in approved storage racks or secured upright against the wall If there is no rack place the tank gently on its side out of the way against the wall and find out where the tank should be placed Never leave a tank lying against the wall or propped up against anything as this is unstable if the tank falls it can cause serious damage injury even death If a tank is empty it must be labeled as EMPTY TANK DO NOT USE with a tag prior to being put up Cylinder Duration Equation Your patient is wearing a nasal cannula with oxygen flowing at 2 LPM He is using an E cylinder and it is full 2200 psig tf Equation 0 28 x 2200 2 LPM This tank will last 308 minutes 5 hours and 8 minutes Oxygen Orders amp Remember that oxygen is a drug It must be prescribed by a physician PRN 3 Oxygen saturations via pulse oximeter How long does the tank last Every size tank holds a different amount of gas obviously bigger tanks last longer than smaller tanks What do I need to figure out the duration Cylinder factor e E cylinder factor 0 28 Flow rate of oxygen to the patient How full is the tank Try one on your own Your patient is wearing a nasal cannula with oxygen flowing at 5 LPM He is using an E cylinder and it is half full 1100 psig How long will this tank last Suctioning Suctioni
11. ways like Albuterol Requires compressed gas to work Clinical Indications 2 Treatments typically Bronchiolitis last for about 15 20 Cystic fibrosis minutes depending on Chronic bronchitis the individual patient 2 B Gachiectasis and the medications CNeuromastabir that need to be given disorders Emphysema se Tee AY g T E ee HFCWO The Vest HFCWO The Vest oe Patient wears vest and Pieces and parts Treatments are usually vest is secured with Foot pedal makes it about 30 minutes long clasps or velcro hi nee go Most aerosolized gd Ol Patient vest is chosen me and the air is vibrated ii oe medications can be e os asea on patient Size ste UDI SSS aL E P administered at the the patient s chest which ZAN p Air pulse generator ise tine will loosen the mucus e We can adjust ventilator Designed for patient flow and speed of self administration home vibrations Coursey Jcheanced Faapito Si Pad Wore j De eee heria he AF Bnjiii Keerd o n a 5 PR g Cr p How do we know that this worked See Increased sputum production amp Improved breath sounds amp Improved chest x ray amp Improved arterial blood gases Improved oxygenation SpO or SaO amp Patient subjective response Do you feel better
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