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Respiratory Devices

Dell Children’s Medical Center

Revised June 2019

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Oxygen Delivery Devices

Respiratory Devices

Low Flow

These devices do not supply all of the patient’s inspiratory demand, causing room air to mix with the oxygen being administered. The FIO2 then becomes dependent on the patient’s ventilatory pattern.

Nasal Cannula
Simple Mask

High Flow

These devices can potentially supply all the patient’s inspiratory demand and are not affected by changes in the patient’s ventilatory pattern.

Venti-Mask
Partial Non-Rebreather/Non-Rebreather
High Flow Nasal Cannula

Aerosol Devices

These devices provide aerosol particles to the patient . This helps with keeping the airways hydrated. These devices can be heated or cool in delivery.

Cool Mist Aerosol
Heated Mist Aerosol

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Nasal Cannula

Appropriate settings

The nasal cannula can be run from 0.03 lpm – 2 lpm (ALL patient populations)
All nasal cannulas should be humidified with a bubble humidifier
FIO2 up to approximately 28% at 2 lpm (dependent on the fit and ventilatory pattern)

Advantages

Patient comfort, patient can eat and talk without disruption of oxygenation
Able to wean easily to room air

Disadvantages

Uncomfortable for some patients
Hard to initiate on a reluctant patient
Needs a securing device
Only able to deliver low percentages of oxygen

Low Flow Devices

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Simple Mask

Appropriate Settings

Should be run from 5-10 lpm
FIO2 range from 35-50% (dependent on flow, “fit” of the mask and ventilatory pattern)

Advantages

Ease of application, tolerated better than nasal cannula by some patients
Can give higher FiO2 than the nasal cannula

Disadvantages

Uncomfortable for some patients
Must be removed for eating, etc.
May cause CO2 rebreathing if not set at a minimum of 5lpm.
Cannot be used with bubble humidifier, which can lead to drying of the mucosa.

Low Flow Devices

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Venturi Mask

Appropriate Settings

FiO2 ranges from 24-60% adjust flow according to FIO2 dialed in.

Advantages

Provides a precise Oxygen concentration
Can be weaned to lower FiO2 than a simple mask

Disadvantages

Noisy
Several adapters to keep up with to adjust FIO2

High Flow Devices

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Non-Rebreather

Appropriate Settings

Should be run at 10 lpm or higher to ensure that the reservoir bag stays at least 1/3 to 1/2 full during inspiration
FIO2 range is 55-70% on a partial non-rebreather and 70-100% on a non-rebreather

Advantages

Ease of application
Delivers high FIO2 percentage

Disadvantages

Patient must take device off to eat
Risk of CO2 re-breathing if flow is not adequate
Risk of O2 toxicity
Cannot be weaned to lower FiO2

High Flow Devices

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High Flow NC

Appropriate Settings (Opti Flow)

Flow rates based on cannula size

Premature/ Neonatal 1-8 lpm
Infant 1-20 lpm
Pediatric 1-25 lpm
Adult 1-60 lpm

FiO2 21-100% via blender

Advantages

Can deliver precise FiO2 at both low and high percentages.
FiO2 is independent of flow
Helps to wash out CO2 in the nasal cavity and oropharynx to prevent re-breathing
May help with work of breathing
Decreased risk of mucosal damage due to high flow rates.

Disadvantages

More observation needed by staff
Risk of overheating
May increase work of breathing if flow is set inappropriately high
Risk of water rainout being delivered to the nares if not properly drained.

High Flow Trach Adapter

Runs at 10 lpm, can deliver 21-100% FIO2 @ 100% relative humidity

High Flow Devices

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High Flow NC Continued

Acute Care Guidelines

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Cool Mist Aerosol

Appropriate Settings

Between 5-10 lpm of flow based on the FIO2 setting that can range from 28-98%
Used with either the aerosol mask or trach collar

Advantages

Can deliver cool humidity to the airways for patients with croup or upper airway edema
Bronchial hygiene, hydrate secretions

Disadvantages

Wheezing or bronchospasm
Overhydration of secretions
Alterations in patient temperature
Bacterial contamination

Aerosol Devices

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Heated Mist Aerosol

Appropriate Settings

Between 5-10 lpm of flow based on the FIO2 setting that can range from 28-98%
Used with either the aerosol mask or trach collar

Advantages

To maintain humidity in airways that have bypassed the upper airway
Bronchial hygiene, hydrate secretions

Disadvantages

Wheezing or bronchospasm
Overhydration of secretions
Alterations in patient temperature
Bacterial contamination

Aerosol Devices

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Heliox

Low density gas mixture of helium and oxygen that can reduce air flow resistance, work of breathing and improve gas exchange in patients with upper airway obstructions.

Indications

Upper airway obstructions (ie. caused by extubation swelling, croup, asthma, etc.)

Delivery Methods

Non-rebreather (preferred)
Cool mist aerosol mask
High flow nasal cannula
Servo-i ventilator

80/20 mixture tank

Can be blended with O2 to make a 70/30 and a 60/40 mixture
Anything above 40% O2/60% He

Specialty Gases

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Nitric

Pulmonary vasodilator that plays a major role in regulating vascular muscle tone.

Indications

Treatment of hypoxic respiratory failure associated with pulmonary hypertension

Contraindications/Hazards
Delivery Methods

Nasal cannula
High flow nasal cannula
Dual limb ventilator circuit

Use INO weaning protocol to avoid rebound

Specialty Gases

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INO weaning protocol

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Metered Dose Inhaler (MDI)

Always used with a spacer
Common Canister Protocol utilized when appropriate

Included Medications: Advair and Flovent MDI

Medication Delivery

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Nebulizers

Small-volume nebulizer (SVN)

Hudson nebs run at 7-10 lpm
Only used with bronchodilators (2.5-10mg single dose Albuterol, Atrovent, Racemic Epi, etc.)

Large-volume nebulizer (LVN)

Hudson Green Neb: Output 15 ml/hr

Used for 1 hr Albuterol administration

Purple Heart Neb:

Output 30 ml/hr at 10 lpm
Delivered with blended O2 via mask
Used for multiple hrs of Albuterol administration

Vibrating Mesh (Aerogen Nebulizer)

Output 12mls/hr
Used in–line with ventilators, BIPAP and HFNC
Used in conjunction with a syringe pump when delivering respiratory medication continuously

Medication Delivery

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Nebulizers (cont.)

Small Particle Aerosol Generator (SPAG)

Used with Ribavirin
Output 16mL/hr
Used when treating RSV in immunocompromised patients
Used with Demistifier tent and negative pressure room
Special Precautions: Pregnancy and anyone wearing contact lenses

Filtered Nebulizer

Used with Pentamidine and Amphotericin-B
Used with Demistifier tent and negative pressure room

Medication Delivery

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Chest Physiotherapy (CPT)

Therapy Vest-needs specific order

Wrap inflates with air and creates high frequency chest wall oscillation
Settings include: Hz (frequency), pressure, time limit

Cupped hand/hand percussor or Pneumatic Percussor

Percussion-device chosen by RT (unless otherwise specified)
Rhythmically percussing with chosen device to all available lung fields (unless specified region is given)
Postural Drainage should be used with this method

Neocussor-needs specific order

Gentle vibration over all available lung fields (unless specified region is given)
Used only for neonates/infants
Postural drainage should be used with this method

Postural Drainage

Is the movement of the patient in order to drain secretions from the lung segments to the central airway by using gravity
Trendelenberg is only used with a specific physician order

Secretion Clearance

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Intrapulmonary Percussive Ventilation (IPV)

Delivery Method

Mask, Mouthpiece, artificial airway, in-line with ventilator

Devices

1C (red)
2C (blue)

Allows for more ventilation options (demand CPAP function-for increased WOB)
Pt on > 60% O2
Pt needs baseline PEEP to sustain SpO2 requirements; on </=7cmH2O of PEEP

Can only deliver 15ml NS or 3% HTS in nebulizer cup, due to large particle size and poor deposition of medications

Secretion Clearance

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Cough Assist

Delivery Method

Mask and artificial airway
Simulates a cough for those who have a weak cough or no cough

Uses positive pressure forced into the airways followed by negative pressure applied to the airway to help remove secretions (simulates cough)

Devices

Digital machine allows for the addition of O2
Analog machine does not allow for the addition of O2

3 cycles of 10 breaths

Secretion Clearance

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Acapella

Delivery Method

Mouthpiece and Mask
Hand held device-uses magnet and counter weighted lever to produce positive expiratory pressure and oscillations when pt exhales into the device

Devices

Green-high flow (>/=15 lpm)
Blue-low flow (</=15 lpm)

Actively exhale 3-4 seconds; 10-12 breaths

Secretion Clearance

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Suctioning

Nasotracheal Suction

Requires a specific order for NTS due to its more invasive technique
Devices: single use suction catheter

Oropharyngeal/Nasopharyngeal Suction

Does not need an order, suction as needed or in compliance with the VAP protocol
Devices: yaunker, nasal aspirator

Artificial Airway Suction

Does not need an order, suction as needed/clinically indicated and at least q12 on mechanically ventilated patients per policy
Suction catheter should not exceed half the diameter of the airway
Suction regulator pressure should be between 0-120 mmHg-dependent on patient size
Devices: single use suction catheter, in-line suction catheter (ventilated patients only)

Secretion Clearance

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EZPAP

Delivery Method

Mouthpiece and Mask
Delivers positive expiratory pressure using back flow
Delivers pressures of 5-20 cmH2O, should adjust flow and patient position to achieve 10-15 cmH2O
Do NOT exceed 20 cmH20

3 cycles of 10 breaths

Lung Recruitment

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Oropharyngeal Airway

Indicated for use with patients at risk for airway obstruction due to relaxed upper airway muscles or blockage of the airway by the tongue
Only to be used on an unconscious patient with an inactive gag reflex
Measure from the corner of mouth to the angle of the mandible
Insertion:

clear the mouth of secretions/vomit/blood/sputum using a suction catheter
Place the oral airway in the mouth using a tongue depressor to push down on the tongue while you place the OPA following the natural curve of the airway

Always remove airway once patient becomes conscious

Airway

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Nasopharyngeal Airway

Used to keep the airway open in conscious or unconscious patients (bypasses gag reflex). Especially helpful in semi-conscious patients and patients who need frequent nasal-tracheal suctioning
Should not be used on patients with suspected head trauma or skull fracture
Measure from nare to the angle of the mandible
Insertion:

Apply a water-soluble lubricant, with the bevel toward the septum, advance gently

Airway

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Tracheostomy Tube

Indicated for prolonged ventilation or severe upper airway obstruction
Types of Tracheostomy tubes:

Bivona:

Cuff Status: Cuff inflated with sterile H20 (clear pilot balloon) or air (blue pilot balloon)
TTS or flextend
Sizes: Neo 2.5-4.0; Pedi 2.5-5.5

Shiley:

Cuff status: Cuff inflated with air
Sizes: Neo 3.0-4.5; Pedi 3.0-5.5

Same size and one size smaller trachs and obturator kept at patient bedside for emergency use

**Airway cards kept at bedside for trach/ETT patients (red card-critical airway; yellow card-stable airway**

Airway

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Endotracheal Tubes (ETT) and Laryngeal Mask Airway (LMA)

Endotracheal Tubes

Indicated for ventilated patients
Sizes: 2.5-8.0 cm (cuffed and uncuffed)
Size Calculation: (16+age)/4
Depth of insertion at lip: 3X tube size (estimation-check with x-ray)

Laryngeal Mask Airway

Supraglottic airway used to keep patent airway; typically used for shorter duration or until ETT can be placed

Airway

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Self Inflating and Flow Inflating Bags

Self Inflating Bags (Ambu Bag)

Can be used for providing rescue breaths or ventilation for a child in respiratory failure
Can deliver with or without a gas source
Can NOT provide CPAP or blowby O2

Flow Inflating Bags (Anesthesia Bag)

Can be used for providing rescue breaths or ventilation to a child in respiratory failure
Can provide CPAP support for a child in respiratory distress
Can be used for short term blowby O2
Can only deliver with a gas source

Manual Ventilation

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Non-Invasive

Hospital Ventilators – use dual limb circuits, requires closed mask
CPAP/NCPAP

One continuous pressure maintained throughout the respiratory cycle
Devices: Hospital vent, home device (CPAP or Ventilator)
Used with Nasal Prongs and Mask

PS/CPAP

Inspiratory and expiratory pressures (2 separate pressures set)
Devices: Hospital vent, home device (Ventilator or BIPAP)

NIV NAVA

Delivers assisted pressure in proportion to and in synchrony with the patient’s respiratory efforts. The EDI catheter allows patient effort to be seen via the EDI signal which represents the electrical activity of the diaphragm.

**Must have proper sizing of mask/nasal prongs to maintain airway pressures in all modes**

Mechanical Ventilation

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Home Devices

Non-Invasive - uses single limb circuits, requiring an open mask (valve/port for exhalation)
Depending on home device there are many different options for modes in NIV and invasive ventilation.
Invasive ventilation has both single limb circuits (requires a exhalation valve) and dual limb circuits available.
These vents can be rented by RT in the event of improper mask fit on dual limb circuits

Mechanical Ventilation

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HFNC with positive pressure- RAM or F&P HFNC

Used to deliver positive pressure through a high flow nasal cannula attached to a ventilator or positive pressure device.
Interface device selected based on achieving 80% occlusion of the nares
F & P or RAM cannula will be selected to create the 80% occlusion of the nares.
RAM cannot be used as a HFNC device due to equipment compatibility.

Bubble CPAP – selected for pressure without a rate

Considerations:

Limited Flow – may have to increase pressure to increase flow
Pressure readings will not likely be what is delivered. According to the majority of studies it is about ½ set pressure

NIV NAVA- selected for anything needing more support
Considerations

New device – not much literature

Non-Invasive Continued

F & P HFNC with vent adapter

RAM Cannula

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Invasive

Conventional Ventilation – Servo-i

Modes include:

Pressure Regulated Volume Control (PRVC)
Pressure Support (PS)/CPAP (Continuous Positive Airway Pressure)
Volume Control (VC)
Pressure Control (PC)
Synchronized Intermittent Mandatory Ventilation (SIMV) – used in conjunction with PC, VC or PRVC

Mechanical Ventilation

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Invasive

Conventional Ventilation- Servo-i (cont.)

Specialty modes include:

Bi-Vent / APRV

Is a pressure controlled breathing mode giving the patient the opportunity for unrestricted spontaneous breathing. In this mode the ventilator uses two shifting pressure levels and the patient can breathe spontaneously at both these levels.

Volume Support (VS)

Is a spontaneous mode; the patient has to initiate the breath and the ventilator delivers support in proportion to the inspiratory effort and the target volume.

Auto Mode

Auto mode helps your patients' transition into spontaneous breathing with less need for staff intervention. It is an interactive mode that switches between controlled and supported ventilation conditional to patient effort.

NAVA

Neurally Adjusted Ventilatory Assist (NAVA) promotes lung protective spontaneous breathing with higher diaphragmatic efficiency, and fewer periods of over- and under-assist. This can help you reduce sedation with higher comfort scores and improved sleep quality.

Mechanical Ventilation

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Invasive

High Frequency Oscillatory Ventilator (HFOV)

3100 A

Used for pediatric and neonate population

3100 B

Used for the large child or adult population

Mechanical Ventilation

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Invasive

Volumetric Diffusive Resuscitator (VDR):

Uses a phasitron that delivers high flow mini-bursts of air into the lungs at rates from 100-1000 times each minute. During the delivery of percussive bursts of air into the lungs, a continued wedge pressure is maintained, while a high velocity flow opens the airways and enhances intrabronchial secretion mobilization.

Operational Pressure – psi pressure setting from the wall to the ventilator
Pulsatile Flowrate – inspiratory flow set to achieve desired peak inspiratory pressure (PIP) gradient
Convective Rate – breaths (cycles) per minute delivered from oscillatory (baseline) CPAP to pulsatile flowrate (PIP)
Percussive Rate / Pulse Frequency – percussion breaths (cycles) per minute
“Big” I:E Ratio – inspiratory : expiratory time ratio for convective rate
“Little” i:e Ratio – inspiratory : expiratory time ratio for percussive rate
Oscillatory PEEP / CPAP – oscillatory baseline positive end expiratory pressure / continuous positive airway pressure
Demand PEEP / CPAP – PEEP/CPAP added above oscillatory CPAP to meet pt’s increased flow demand
Convective Pressure Rise – additional pressure gradient applied to convective rate above pulsatile flowrate (PIP)

Mechanical Ventilation

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Invasive

Volumetric Diffusive Resuscitator (VDR) continued

Recommendations for Treatment of Hypoxemia – increase the MAP

1. Increase OCPAP

2. Increase Pulsatile Flowrate

3. Increase Pulse Frequency (may also increase CO2)

Recommendations for Treatment of Hypercarbia – increase ventilation

1. Increase Pulsatile Flowrate

2. Decrease Pulse Frequency (may also decrease SpO2)

Recommendations for Treatment of Hypocarbia – decrease ventilation

1. Increase Pulse Frequency

2. Decrease Pulsatile Flowrate

Mechanical Ventilation

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Skin Care Guidelines

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