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May.27.2021

Oxygen Therapy and Oxygen Delivery (Respiratory Therapy) - INACTIVE

ALERT

Administration of oxygen to some patients may result in hypoventilation, further hypercapnia, hypoxia, and apnea.

Patients with sudden changes in their vital signs, level of consciousness (LOC), or behavior may be experiencing profound hypoxia or hypercapnia.undefined#ref3">3

Verify that the tubing is connected to the oxygen and not to air or another gas. Connecting the tubing to a gas other than oxygen can have fatal consequences.

OVERVIEW

Supplemental oxygen is defined as delivery of oxygen in a concentration greater than room air, which has an oxygen concentration of 21% or a fraction of inspired oxygen (FIO2) of 0.21.4

Supplemental oxygen is provided mainly to patients with adequate spontaneous respirations (ventilation) but inadequate oxygenation. Supplemental oxygen can also be used with emergency devices such as manual resuscitation and positive pressure devices. The need for supplemental oxygen may be determined by clinical assessment of the patient, pulse oximetry, and arterial blood gas (ABG) or venous blood gas analysis, when indicated. In ill or injured patients who do not have chronic lung disease, oxygen is never contraindicated. Insufficient oxygen administration may lead to hypoxia, which is a significant risk to the patient.

The provision of supplemental oxygen should be treated with the same respect and caution that is used when administering any medication. Oxygen delivery has safe dosing ranges, but it may produce adverse effects; toxic effects are possible, especially with delivery of high concentrations or with prolonged use. Supplemental oxygen administration is subject to federal, state, and local laws and regulations.1

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain to the patient and family that if an oxygen face mask is in use, it should be removed only to eat, drink, blow the nose, cough, expectorate, or vomit, and then it should be replaced immediately. Explain that the mask may be replaced with a nasal cannula while eating.
  • Discuss safety precautions for oxygen use in the home.
  • Educate the patient and family regarding the application and assembly of oxygen devices and equipment as assigned and ordered for the patient.
  • Instruct the patient and family not to smoke while supplemental oxygen is in use.
  • Instruct the patient and family on proper mask positioning and the importance of a snug fit. Explain that both prongs of the cannula must be in the nose.
  • Explain that assistance in comforting a child while administering oxygen may be needed.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient's vital signs, heart rate, respiratory rate and effort, peripheral oxygen saturation (SpO2), LOC, and breath sounds.

Preparation

  1. Review the practitioner's order for oxygen to determine the delivery method, flow rate, and duration of oxygen therapy.
  2. Ensure that the room is clear of potentially flammable and spark-producing items.
    Rationale: Fire is a significant physical hazard of oxygen therapy.
    Do not allow smoking and remove spark-producing items and flammable and volatile substances.

PROCEDURE

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Attach the flowmeter or regulator to the oxygen source.
  6. Attach the oxygen connector to the flowmeter. If humidified oxygen is required, attach the humidifier to the flowmeter.
  7. Attach the flared vinyl tip of the oxygen tubing to the tailpiece or humidifier.
  8. Verify that the tubing is connected to the oxygen and not to air or another gas.
    Connecting the tubing to a gas other than oxygen can have fatal consequences.
  9. Adjust the oxygen to the flow rate ordered and medically indicated by the equipment manufacturer's recommendations to deliver the prescribed amount of oxygen. The float ball in the flowmeter should be positioned so that the flow rate line is in the middle of the ball.
  10. Ensure that oxygen is flowing through the cannula or mask.
  11. For a nonrebreather mask (Figure 1)Figure 1, ensure that the reservoir bag is filled with oxygen before applying it to the patient.
    1. To deliver the highest concentration of oxygen, ensure that the nonrebreather mask has a tight seal.
    2. If the tight seal causes discomfort or feelings of claustrophobia or of "being smothered," consider changing to another appropriate oxygen delivery device.
  12. When using a partial rebreather oxygen mask with a reservoir bag (Figure 2)Figure 2, adjust the flow rate so that the bag collapses by no more than one third, even with a deep inspiration.2
  13. Consider using an air entrainment (Venturi) mask (Figure 3)Figure 3 for a patient with chronic hypercapnia because it will deliver a precise percentage of oxygen, which is needed for this patient population.
  14. Place the cannula prongs into the patient's nares (Figure 4)Figure 4 or apply the mask to the patient's face.
    1. If the patient is restless or has a head dressing that prevents secure placement of the cannula tubing, secure it to the face with transparent dressing or tape to keep the prongs from slipping away from the nares.
    2. For oxygen masks (Figure 5)Figure 5, adjust the malleable metal nose strip for a better and more comfortable fit.
  15. Pad the straps with gauze or cotton, if needed, to help prevent irritation and discomfort.
    1. Oxygen masks may impede care in patients with facial burns or trauma or in patients who need frequent facial care.
    2. Gastric tubes may interfere with obtaining an adequate seal.
  16. If humidification (e.g., a large-volume nebulizer with corrugated tubing) is being used, periodically check the tubing and drain it of excess water, as needed (Figure 6)Figure 6.
  17. Discard supplies, remove gloves, and perform hand hygiene.
  18. Document the procedure in the patient's record.

MONITORING AND CARE

  1. Monitor the patient and oxygen device to ensure that the side ports of a simple oxygen mask do not become blocked.
  2. Monitor for oxygen-induced hypoventilation (caused by suppression of the hypoxic respiratory drive), which can lead to further hypercapnia, hypoxia, and apnea.
    Aggressively monitor patients who have underlying chronic obstructive pulmonary disease (COPD), cystic fibrosis, sedation from medications, neuromuscular disease, morbid obesity, or extensive previous chest disease.
    1. Titrate the oxygen delivery to maintain an SpO2 between 88% and 92% in patients at greater risk for complications.5
    2. If hypoxia persists, notify the authorized practitioner, who may consider invasive or noninvasive mechanical ventilation.
  3. Monitor all oxygen delivery devices (Table 1)Table 1 to ensure that they are functioning correctly and delivering the desired concentrations of oxygen.
    Rationale: Oxygen concentration delivery is highly variable, and factors such as oxygen flow rate, ventilatory rate and depth, mask seal, and anatomic dead space all contribute to this variability.
  4. If the patient is not tolerating a mask and has high-flow or oxygen requirements, consult the authorized practitioner. A special high-flow oxygen cannula system with warming and humidification may be more suitable.
  5. When administering oxygen to a young child, ask the parent or caregiver to help comfort the child, as needed.
  6. Remove the mask while the patient is eating, drinking, coughing, expectorating, blowing the nose, or vomiting. The patient may wear a nasal cannula while eating if vital signs remain stable (with no increase in the patient's work of breathing).
    Rationale: Masks interfere with the patient's speech. Aspiration is a potential hazard when an oxygen delivery mask is in use. Elevating the head of the bed may reduce this risk.
  7. Monitor the oral and airway mucosa for excessive dryness.
    Rationale: Compressed air is dry, and standard humidification equipment delivers only a fraction of the needed humidity to the patient. The mucosa must be kept moist to prevent excessive dryness and nosebleeds.
  8. Observe the patient for signs or symptoms of pain. If pain is suspected, report it to the authorized practitioner.

EXPECTED OUTCOMES

  • Improved oxygenation with the prescribed or medically indicated oxygen
  • Signs of hypoxia improved or eliminated
  • Vital signs stabilized or returned to baseline
  • ABG values or SpO2 improved or returned to baseline
  • Decreased work of breathing
  • LOC returned to baseline

UNEXPECTED OUTCOMES

  • Aspiration due to vomiting with oxygen face mask on the patient
  • Excessively dry airway or oral mucosa
  • Mask or cannula disconnected or removed without discontinuation order from authorized practitioner
  • Ill-fitting mask
    • Facial irritation and skin breakdown
    • Poor tolerance of a tight-fitting mask
  • Oxygen-induced hypoventilation
  • Pathologic lung tissue changes
  • Absorption atelectasis

DOCUMENTATION

  • Delivery device and related supplies
  • Oxygen flow rate
  • SpO2 (and capnography if applicable) postintervention; document any changes in these values that occur with activity change
  • Respiratory assessment findings
  • Vital signs
  • Education
  • Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

  • An older adult patient may be neglectful of the delivery device’s position, be more easily annoyed, or have “picking” behavior, such as pushing aside or removing the device. Frequently reorienting the patient, encouraging the presence of a family member, and securing the tubing to the patient’s cheek may help.

REFERENCES

  1. American Association of Respiratory Care (AARC). (2007). AARC clinical practice guidelines: Oxygen therapy in the home or alternate site health care facility—2007 revision & update. Respiratory Care, 52(1), 1063-1068. (classic reference)* (Level VII)
  2. Heuer, A.J., Hilse, A.M. (2021). Chapter 42: Medical gas therapy. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 906-935). St. Louis: Elsevier.
  3. Kallet, R.H. (2021). Chapter 16: Bedside assessment of the patient. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 317-341). St. Louis: Elsevier.
  4. O'Connor, R.E. and others. (2015). Part 9: Acute coronary syndromes: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 Suppl. 2), S483-S500. doi:10.1161/CIR.0000000000000263 (Level VII)
  5. Rolfe, S., Paul, F. (2018). Oxygen therapy in adult patients. Part 1: Understanding the relevant physiology and pathophysiology. British Journal of Nursing, 27(14), 798-804. 8 doi:10.12968/bjon.2018.27.14.798

ADDITIONAL READINGS

Albert, R.K. and others. (2016). A randomized trial of long-term oxygen for COPD with moderate desaturation. The New England Journal of Medicine, 375(17), 1617-1627. doi:10.1056/NEJMoa1604344

Haynes, J.M., Ruppel, G.L. (2016). Pulse oximetry in acute respiratory failure: What should be expected? Respiratory Care, 61(8), 1135-1136. doi:10.4187/respcare.04965

Iliaz, S. and others. (2015). Does the 6-minute walk test predict nocturnal oxygen desaturation in patients with moderate to severe COPD? Chronic Respiratory Disease, 12(1), 61-68. doi:10.1177/1479972314562406

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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