Noninvasive Respiratory Therapies

1. OXYGEN THERAPY

Oxygen therapy is the administration of oxygen at a concentration greater than that found in
the environmental atmosphere. At sea level, the concentration of oxygen in room air is 21%. The
goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing
the work of breathing and reducing stress on the myocardium. Oxygen transport to the tissues
depends on factors such as cardiac output, arterial oxygen content, concentration of hemoglobin,
and metabolic requirements. These factors must be kept in mind when oxygen therapy is
considered. Indications A change in the patients respiratory rate or pattern may be one of the
earliest indicators of the need for oxygen therapy. The change in respiratory rate or pattern may
result from hypoxemia or hypoxia. Hypoxemia (a decrease in the arterial oxygen tension in the
blood) is manifested by changes in mental status (progressing through impaired judgment,
agitation, disorientation, confusion, lethargy, and coma), dyspnea, increase in blood pressure,
changes in heart rate, dysrhythmias, central cyanosis (late sign), diaphoresis, and cool
extremities. Hypoxemia usually leads to hypoxia, which is a decrease in oxygen supply to the
tissues. Hypoxia, if severe enough, can be life-threatening. The signs and symptoms signaling
the need for oxygen may depend on how suddenly this need develops. With rapidly developing
hypoxia, changes occur in the central nervous system because the higher neurologic centers are
very sensitive to oxygen deprivation. The clinical picture may resemble that of alcohol intoxication,
with the patient exhibiting lack of coordination and impaired judgment. Longstanding hypoxia (as
seen in chronic obstructive pulmonary disease [COPD] and chronic heart failure) may produce
fatigue, drowsiness, apathy, inattentiveness, and delayed reaction time. The need for oxygen is
assessed by arterial blood gas analysis and pulse oximetry as well as by clinical evaluation.

Cautions in Oxygen Therapy

As with other medications, the nurse administers oxygen with caution and carefully
assesses its effects on each patient. Oxygen is a medication and except in emergency situations
is administered only when prescribed by a physician. In general, patients with respiratory
conditions are given oxygen therapy only to raise the arterial oxygen pressure (PaO2) back to the
patients normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin
dissociation curve the blood at these levels is 80% to 98% saturated with oxygen; higher inspired
oxygen ow (FiO2) values add no further signicant amounts of oxygen to the red blood cells or
plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs
and central nervous system or may depress ventilation (see discussion below).
It is important to observe for subtle indicators of inadequate oxygenation when oxygen is
administered by any method. Therefore, the nurse assesses the patient frequently for confusion,
restlessness progressing to lethargy, diaphoresis, pallor, tachycardia, tachypnea, and
hypertension. Intermittent or continuous pulse oximetry is used to monitor oxygen levels.

Nursing Management PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.

At times oxygen must be administered to the patient at home. The nurse instructs the
patient or family in the methods for administering oxygen and informs the patient and family that
oxygen is available in gas, liquid, and concentrated forms. The gas and liquid forms come in
portable devices so that the patient can leave home while receiving oxygen therapy. Humidity
must be provided while oxygen is used (except with portable devices) to counteract the dry,
irritating effects of compressed oxygen on the airway.
Continuing Care.
Home visits by a home health nurse or respiratory therapist may be arranged based on
the patients status and needs. It is important to assess the patients home environment, the
patients physical and psychological status, and the need for further teaching. The nurse
reinforces the teaching points on how to use oxygen safely and effectively, including re safety
tips because oxygen is ammable. To maintain a consistent quality of care and to maximize the
patients nancial reimbursement for home oxygen therapy, the nurse ensures that the physicians
prescription includes the diagnosis, the prescribed oxygen ow, and conditions for use (eg,
continuous use, nighttime use only). Because oxygen is a medication, the nurse reminds the
patient receiving long-term oxygen therapy and family about the importance of keeping follow-up
appointments with the physician. The patient is instructed to see the physician every 6 months or
more often, if indicated. Blood gas measurements and laboratory tests are repeated annually, or
more often if the patients condition changes.

2. INTERMITTENT POSITIVE-PRESSURE BREATHING

Intermittent positive-pressure breathing (IPPB) is a form of assisted or controlled respiration

produced by a ventilatory apparatus in which compressed gas is delivered under positive pressure
into a persons airways until a preset pressure is reached. Passive exhalation is allowed through
a valve. The specic pressure and volume amounts, along with the use of any nebulizing
medications, are prescribed individually for patients. The nurse should encourage patients to relax
and reassure them that the machine will automatically shut off airow at the end of inspiration.
The IPPB machine may be powered by electricity or gas and may be connected with a
mouthpiece, mask, or tracheostomy adapter.

Indications
General indications for IPPB include difculty in raising respiratory secretions, reduced
vital capacity with ineffective deep breathing and coughing, or unsuccessful trials of simpler and
less costly methods for loosening secretions, delivering aerosol, or expanding the lungs.

Complications
IPPB therapy is used rarely today because of its inherent hazards, which may include
pneumothorax, mucosal drying, increased intracranial pressure, hemoptysis, gastric distention,
vomiting with possible aspiration, psychological dependency (especially with long-term use, as in
COPD patients), hyperventilation, excessive oxygen administration, and cardiovascular
problems.