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Course: Medical Surgical Nursing

Topic: Respiratory Care Modalities Part-I

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learner should be able to:

Describe the types of respiratory care modalities.
Describe the indications for various respiratory care modalities.
Discuss the nursing management of various respiratory care modalities:

Preparation of Client
Preparation of Equipment
Expected Outcomes
Assessment of Outcomes
Considerations for the Gerontologic Client
Client Education

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Respiratory Care Modalities

Therapies used for clients with various respiratory conditions.

The type of therapy is based on the oxygenation disorder.

Therapies may be noninvasive to highly invasive.

Smeltzer et al., 2010

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Respiratory Care Modalities (Continued)

Categories

Oxygen therapy
Aerosol therapy
Physical therapy
Mechanical aids to lung inflation

Used in all patient care settings

Princeton University, 2017

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Oxygen Therapy

Provides extra oxygen to breathe (supplemental oxygen)
Requires a prescription from the health care provider
Short term or long-term use
Available in liquid or gas form
Multiple devices
Invasive and non-invasive

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

What is oxygen therapy?

Oxygen therapy is a treatment that provides individual with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. It is available in the hospital, another medical setting, or at home. Some individuals only need it for a short period of time. Others will need long-term oxygen therapy.

There are different types of devices that are used to give oxygen. Some use tanks of liquid or gas oxygen. Others use an oxygen concentrator, which pulls oxygen out of the air. A nose tube (cannula), a mask, or a tent can be used. The extra oxygen is breathed in along with normal air.

There are portable versions of the tanks and oxygen concentrators. They can make it easier for to move around while using the therapy.

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Oxygenation Process

Atmospheric Oxygen- 21%
Oxygen is inhaled and carbon dioxide is exhaled
Effective Oxygenation process requires:

Unobstructed airway
Chest and lung synchronization
Unobstructed bronchial airway
Effective Cardiac functioning
Adequate hemoglobin level

Impaired due to medical conditions

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

The air we breathe contains 21% oxygen and is crucial for life. Several body systems must work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately oxygenate tissues. First, the airway must be open and clear. The chest and lungs must mechanically move air in and out of the lungs. The bronchial airways must be open and clear so that air can reach the alveoli, where oxygen is absorbed into the bloodstream and carbon dioxide is released during exhalation. The heart must effectively pump this oxygenated blood to and from the lungs and through the systemic arteries. The hemoglobin in the blood must be in adequate amounts to sufficiently carry the oxygen to the tissues, where it is released and carbon dioxide is absorbed and carried back to the lungs.

Several medical conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart disease, and anemia can impair an individual’s ability to sufficiently complete this oxygenation process, thus requiring the administration of supplemental oxygen.

Note: Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use.

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Who Needs Oxygen Therapy?

Individuals with conditions that cause low blood oxygen

COPD (chronic obstructive pulmonary disease)
Pneumonia
COVID-19
A severe asthma attack
Late-stage heart failure
Cystic fibrosis
Sleep apnea

Doyle & McCutcheon, 2015

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Oxygen Delivery System

Doyle & McCutcheon, 2015

Low-Flow Delivery Systems	High-Flow Delivery Systems
Client breathes some room air along with the oxygen	Provides the total inspired air
Does not provide a constant or known concentration of inspired oxygen	A specific percentage of oxygen is delivered independent of the client’s breathing
Examples: nasal cannula, oropharyngeal catheter, simple mask, partial-rebreather, and non-rebreather masks	Examples: transtracheal catheters, Venturi masks, aerosol masks, tracheostomy collars, T-pieces, and face tents

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Oxygen Therapy Delivery Methods

Invasive Oxygen Therapy

Endotracheal intubation
Tracheostomy
Nasotracheal
Mechanical Ventilator

Ernstmeyer & Christman, 2021

Smeltzer et al., 2010

Non-Invasive Oxygen Therapy:

Nasal cannula
Face mask, Face tents, Venturi mask, Rebreather, partial Rebreather
Bag Valve Mask /Ambu bag
Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure (Bi-PAP)

To know more about Invasive Oxygen Therapy Please refer to slide deck Airway Management

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Flow Rates and Oxygen Percentages

Nursing Skills by Chippewa Valley Technical College, Table 11.3a Settings of Oxygenation Devices, Chapter 11.3

Device	Flow Rates and Oxygen Percentages
Nasal Cannula	Flow rate: 1-6 L/min FiO2: 24% to 44%
High-Flow Nasal Cannula	Flow rate: up to 60 L/min FiO2: Up to 100%
Simple Mask	Flow rate: 6-10 L/min FiO2: 28% to 50%

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Flow Rates and Oxygen Percentages

Nursing Skills by Chippewa Valley Technical College, Table 11.3a Settings of

Oxygenation Devices, Chapter 11.3

Device	Flow Rates and Oxygen Percentages
Non-Rebreather Mask	Flow rate: 10 to 15 L/min FiO2: 60-80% Safety Note: The reservoir bag should always be partially inflated.
CPAP, BiPAP, Venturi Mask, Mechanical Ventilator	Use the settings provided by the respiratory therapist and/or provider order.
Bag Valve Mask	Flow rate: 15 L/min FiO2: 100% Squeeze the bag once every 5 to 6 seconds for an adult or once every 3 seconds for an infant or child.

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Critical Thinking Question

State the major differences between low-flow and high flow oxygen delivery systems.

Give examples of devices in each category.

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Nasal Cannula

Small bore tube connected to two short prongs.
Supplies oxygen directly from a flow meter or through humidified air
Effective for short- or long-term therapy

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Nasal Cannula (Continued)

Advantages:

Provides 24% to 40% O₂ concentration
Delivers oxygen (O₂ ) at 1 to 6 litres per minute (L/min)
Convenient to talk and eat while receiving O₂
May be drying to nares if above 4 L/min
Easy to use, low cost, and disposable

Limitations:

Easily dislodged
Ineffective with blocked nostrils, deviated septum, polyps

Doyle & McCutcheon, 2015

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Simple Face Mask

Fits over the mouth and nose

Exhalation ports should always remain open.

An elastic secures the mask around the the head.

Metal piece over the nose allows for a custom mask fit.

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

A mask fits over the mouth and nose of the client and consists of exhalation ports (holes on the side of the mask) through which the client exhales CO₂ (carbon dioxide). These holes should always remain open. The mask is held in place by an elastic around the back of the head, and it has a metal piece to shape over the nose to allow for a better mask fit for the client. Humidified air may be attached if concentrations are drying for the client. It is used in the clients who cannot tolerate nasal cannula for medium dose of delivery, intended for short term use like post-op recovery, and also appropriate at times where high levels of oxygen are required.

Advantages: Can provide 40% to 60% O₂ concentration. Flow meter should be set to deliver O₂ at 6 to 10 L/min. Used to provide moderate oxygen concentrations. Efficiency depends on how well mask fits and the client’s respiratory demands. Readily available on most hospital units. Provides higher oxygen for clients.

Disadvantages: Difficult to eat with mask on. Mask may be confining for some clients, who may feel claustrophobic with the mask on.

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Simple Face Mask (Continued)

Advantages:

Can provide 40% to 60% O₂ concentration
Can deliver oxygen 6 to 10 L/min
Readily available on most hospital units
Provides moderate to higher oxygen

Disadvantages:

Difficult to eat with mask on
Difficult for claustrophobic clients

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Non Re-Breather Mask (Low-Flow System)

Simple mask with a reservoir bag attached.
No re-breathing of exhaled air.
Series of one-way valves between mask, bag and on the exhalation ports.
The client only breathes in from the reservoir bag.
On exhalation, gases are are directed out through the exhalation ports.

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Non Re-Breather Mask (Continued)

Advantages:

Delivers between 60% and 80% FiO₂
Delivers O₂ at 10 to 15 L/min

Disadvantages:

Risk of suffocation
Used only for short-term high oxygen requirements
Risk of hyperoxygenation
Requires a tight seal
May be hot and confining for the client
Interferes with talking and eating

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

Advantages: With a good fit, the mask can deliver between 60% and 80% FiO₂ (fraction of inspired oxygen). The flow meter should be set to deliver O₂ at 10 to 15 L/min. Flow rate must be high enough to ensure that the reservoir bag remains partially inflated during inspiration.

Disadvantages: These masks have a risk of suffocation if the gas flow is interrupted. The bag should never totally deflate. The client should never be left alone unless the one-way valves on the exhalation ports are removed. This equipment is used by respiratory therapists for specific short-term, high oxygen requirements such as pre-intubation and client transport. They are not available on general wards due to: 1. the risk of suffocation, 2. the chance of hyper-oxygenation, and 3. their possible lack of humidity. The mask also requires a tight seal and may be hot and confining for the client. The mask will interfere with talking and eating.

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Face Tent (Low-Flow System)

The mask covers nose and mouth
Does not create a seal around the nose

Advantages:

Can provide 28% to 100% O₂
Deliver O₂ at a minimum of 15 L/min
Used when facial burn, broken nose, or claustrophobic is an issue
Disadvantages: Difficult to achieve high levels of oxygenation

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Critical Thinking Question

The client has been diagnosed with COPD, the O𝟸 saturation level is at 89%. Supplemental O𝟸 has been prescribed.

Identify the type of oxygen delivery system depicted in this picture

How does this device work on inspiration and expiration?

How many L/m can be delivered through this device?

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High Flow Nasal Cannula

Delivers up to 100% humidified and heated oxygen with flow rate of up to 60 L/min.
Used with clients with critical condition and requires advanced monitoring.
Set up by a respiratory therapist and then maintained by a nurse.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Supplemental oxygen therapy is one of the more commonly prescribed interventions used by physicians when caring for hypoxic patients acutely. This supplementation often takes the form of a low-flow nasal cannula. However, there are limitations to this supplemental oxygen intervention.

In low-flow nasal cannula therapy, FiO2 delivery is directly tied to flow rate. For increased FiO2, the rate must be increased. The low-flow nasal cannula is an open system of supplementation with high levels of leaking air around the oxygen source. As such, the efficacy of treatment for the low-flow nasal cannula is limited. High-flow nasal cannula therapy is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute.

High Flow nasal cannula has many clinical applications. Some of the potential areas of clinical application where there is evolving evidence is listed below:

Acute hypoxemic respiratory failure
Post-surgical respiratory failure
Acute heart failure/pulmonary edema
Hypercapnic respiratory failure, COPD
Pre and post-extubation oxygenation
Obstructive sleep apnea
Use in the emergency department
Do not intubate the patient

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Partial Re-Breather Mask (High-Flow System)

Bag should always remain partially inflated.

Flow rate should be high enough to keep the bag partially inflated.

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Partial Re-Breather Mask (High-Flow System)

Advantages:

Delivers 10 to 12 L/min for an O₂ concentration of 80% to 90%
Used short term for clients who require high levels of oxygen

Disadvantages:

Expired air mixes with the inhaled air
May be hot and confining
Interferes with eating and talking

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Venturi Mask (High Flow System)

Consists of a bottle of sterile water, corrugated tubing, a drainage bag, air/oxygen ratio nebulizer system.

The mask may be an aerosol face mask, tracheostomy mask, a T-piece, or a face tent.

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

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Venturi Mask (High Flow System)

Advantages:

Provides 24% to 60% O₂ at 4 to 12 L/min
Base of the mask regulates the oxygen concentration
Promotes comfort by delivering humidified oxygen

Disadvantages:

May be warm and confining
Interferes with talking and eating
Requires expertise to set up system

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

Venturi mask is indicated for the clients with respiratory distress or other acute or chronic indicators and contraindicated for the patient with facial injuries.

Advantages: The system can provide 24% to 60% O₂ at 4 to 12 L/min. Delivers a more precise level of oxygen by controlling the specific amounts of oxygen delivered. The port on the corrugated tubing (base of the mask) sets the oxygen concentration. Delivers humidified oxygen for client comfort. It does not dry mucous membranes.

Disadvantages: The mask may be hot and confining for some clients, and it interferes with talking and eating. Need a properly fitting mask. Nurses may be asked to set up a high-flow system. In other instances, respiratory therapists may be responsible for regulating and monitoring the high-flow systems.

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Critical Thinking Question

State the advantages and disadvantages of the Venturi mask.

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Continuous Positive Airway Pressure (CPAP)

Mask covers nose, or nose and mouth, attached to a machine that applies continuous mild air pressure to keep the client’s airways from collapsing.

Experts set the system and a prescription is required.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Continuous Positive Airway Pressure (CPAP)

A continuous positive airway pressure (CPAP) device is used for individual who are able to breathe spontaneously on their own but need help in keeping their airway unobstructed, such as those with obstructive sleep apnea. The CPAP device consists of a special mask that covers the client’s nose, or nose and mouth, and is attached to a machine that continuously applies mild air pressure to keep the client’s airways from collapsing.

A prescription is required for a CPAP device in the hospital or client’s home environment. In the hospital, the FiO₂ is set up with the CPAP mask by the respiratory therapist. In a home setting, an adapter is added so that oxygen is attached using a flowmeter with pre-programmed settings so the client and/or nurse are only required to turn the machine on before sleeping and off upon awakening. It is important to keep the mask and tubing clean to prevent infection, so be sure to follow agency policy for cleaning the equipment regularly. If a humidifier is attached, distilled water or sterile water should be used to fill it.

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Bilevel Positive Airway Pressure (BiPAP)

Device has two pressure settings.
A higher setting during inhalation and a lower setting during exhalation.
Used for obstructive sleep apnea, acute respiratory distress.
Noninvasive alternative to intubation and mechanical ventilation.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Bag Valve Mask (Ambu Bag)

Handheld device used in emergency situations during respiratory arrest or failure.
Supplies oxygen at 15 L/minute, FiO₂ of 100%.
Different sizes for infants, children, and adults.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Flow rate: The flow rate for a bag valve mask attached to an oxygen source should be set to 15 L/minute, resulting in FiO₂ of 100%.

Advantages: A bag valve mask is portable and provides immediate assistance to clients in respiratory failure or respiratory arrest. It also can be used to hyperoxygenate clients before procedures that can cause hypoxia, such as tracheal suctioning.

Disadvantages: The rate and depth of compression of the bag must be closely monitored to prevent injury to the client. In the event of respiratory failure when the client is still breathing, the bag compressions must be coordinated with the client’s inhalations to ensure that oxygen is delivered and asynchrony of breaths is prevented. Complications may also result from overinflating or overpressurizing the client. Complications include lung injury or the inflation of the stomach that can lead to aspiration of stomach contents. Additionally, rescuers may tire after a few minutes of manually compressing the bag, resulting in less than optimal ventilation. Alternatively, an endotracheal tube (ET) can be inserted by an advanced practitioner to substitute for the mask portion of this device. See more information about endotracheal tubes below.

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Critical Thinking Question

Indicate whether the following statements are true (T) or false (F)

The BiPAP is an invasive alternative to intubation and mechanical ventilation.
A medical prescription is needed for oxygen administration through a CPAP device/
Ambu bags supply oxygen at 5L/min.
BiPAP devices are used to prevent airways from collapsing.

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Nurses Role During Oxygen Therapy

Prepare the Client

Confirm patient ID
Obtain care provider’s order
Explain the procedure to the client and family
Ensure patient’s privacy
Perform respiratory assessment
Monitor respiratory rate, pulse oximetry, lung sounds
Employ safety measures: hand hygiene, connecting equipment
Position patient: as per medical condition
Evaluate patient’s response

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Nurses Role During Oxygen Therapy

Prepare Equipment

Gather supplies: pulse oximeter, oxygen delivery device, tubing
Connect flow meter to oxygen supply source
Apply adapter for tubing
Connect nasal cannula tubing to flow meter
Set oxygen flow rate
Ensure appropriate positioning of oxygen delivery device
Introduce other oxygen delivery devices, such as masks and non-rebreather masks if needed.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Nursing Process During Oxygen Therapy

Assessment:

Obtain history
Asses current symptoms for shortness of breath (SOB)
If SOB is associated with chest pain, or respiratory failure, obtain emergency assistance
Note presence of cough (productive and non-productive)
Note medication use
Assess respiratory status for airway clearance, respiratory rate, SPO₂, and lung sounds.
Note signs of cyanosis,

Obtain serial ABG if necessary

Close monitoring of skin breakdown at pressure points

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Prior to initiating therapy, obtain a history of respiratory conditions and current symptoms of shortness of breath. The duration of this focused assessment should be modified based on the severity of the client’s dyspnea. See Table 11.4 for focused interview questions related to oxygen therapy. This information is used to customize the oxygen delivery device and flow rate for the client. For example, supplemental oxygen is typically initiated in non-emergency situations with a nasal cannula at 1-2 liters per minute (L/min), but a client with a history of chronic obstructive pulmonary disease (COPD) may require a different device such as a Venturi mask.

Providing a physical presence is an important intervention for the associated anxiety that accompanies dyspnea. Consider asking a team member for assistance.

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Nurses Role: Safety and Oxygen Therapy

Monitor Client and asses at regular intervals
Administor/adjust oxygen with consultation
Store O2 cylinders upright, chained in appropriate holders
Store full oxygen, partially-full or empty oxygen tanks separately
Never place 02 tanks on the client’s bed
No smoking around oxygen delivery devices
Keep oxygen 5 feets away from heat source
Check for electrical hazards before use
Check portable tank levels before use
Flowmeters free of oil or grease

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Remember that oxygen is a medication.

Oxygen is a medication and should not be adjusted without consultation with a physician or respiratory therapist.

Store oxygen cylinders correctly.

When using oxygen cylinders, store them upright, chained, or in appropriate holders so that they will not fall. Full oxygen tanks should be stored separately from partially-full or empty oxygen tanks.

Use tank holders appropriately.

When transporting a client, proper tank holders must be used per Joint Commission guidelines. Tanks should never be placed on the client’s bed.

Do not allow smoking near the oxygen devices.

Oxygen supports combustion. No smoking is permitted around any oxygen delivery devices in the hospital or home environment.

Keep oxygen cylinders away from heat sources.

Keep oxygen delivery systems at least 5 feet from any heat source.

Check for electrical hazards in the home or hospital prior to use.

Determine that electrical equipment in the room or home is in safe working condition. A small electrical spark in the presence of oxygen will result in a serious fire. The use of a gas stove, kerosene space heater, or smoker is unsafe in the presence of oxygen. Avoid items that may create a spark (e.g., electrical razor, hair dryer, synthetic fabrics that cause static electricity, or mechanical toys) with nasal cannula in use. Petroleum-based lubricants should not be used on the lips or around the nasal cannula.

Check levels of oxygen in portable tanks.

Check oxygen levels of portable tanks before transporting a client to ensure that there is enough oxygen in the tank.

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Oxygen Therapy: Gerontologic Consideration

Respiratory changes occur throughout aging process.

Respiratory muscles weaken.
Large bronchi and alveoli enlarge.
The available surface area of lungs decreases; reduced ventilation and gas exchange.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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Oxygen Therapy: Gerontologic Consideration (Continued)

Decrease in ciliary action.
Decrease cough reflex.
Decreased costal cartilage and chest wall compliance.
Increased chest rigidity, respiratory rate, and decreased PaO₂.
Risk of aspiration and infection related to these changes.
Education: Adequate nutrition helps to excrete excess CO₂ and maintain optimal respiratory rate.

Ernstmeyer & Christman, 2021

Image by: Pxhere

Contact info: info@nursesinternational.org

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Client Education

Safety considerations with oxygen.
Breathing: Inhale through the nose with slow, deep breaths and to breathe out through the mouth.
Seek medical help for difficulty breathing and shortness of breath.

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

The nurse is preparing the client for oxygen administration with a high-flow nasal cannula. Which of the following interventions should the nurse take into consideration? (Select all that apply).

Obtain informed consent
Explain the procedure to the client and the family
Discuss the mode of administration
If tracheostomy, suction adequately before therapy
Correct positioning per medical condition
Ensure comfort

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Red Flags

Shortness of breath associated with chest pain
Respiratory arrest
Respiratory distress
Oxygen saturation below 92%

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Doyle, G. R., McCutcheon, J. A. (2015). Clinical procedures for safer patient care. BCcampus. https://opentextbc.ca/clinicalskills/

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Skills. Creative Commons.

Princeton University. (2017). Assessing Selected Respiratory Therapy Modalities: Trends and . https://www.princeton.edu/~ota/disk3/1981/8102/810205.PDF

Smeltzer, S. C., Hinkle, J. L., Cheever, K. H., Bare, B. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Edition 12.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Contact info: info@nursesinternational.org

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