Skill Building

Is your patient getting enough oxygen?

SUSAN K. SMITH, RN,C, BS, MS
SK Smith Consulting • Warriors Mark, Pa.

OXYGEN THERAPY CAN be confusing

for any nurse. If your facility’s policy per-
mits licensed practical nurses to initiate
oxygen therapy, you’ll need to know when
to give patients supplemental oxygen and
what delivery system to use. And regardless
of whether you’re in a decision-making sit-
uation, you should understand the mechan-
ics of oxygen delivery.
In this article, I’ll explain the indications
for oxygen therapy, the types of oxygen
delivery systems, and how to select the best
system for a given patient.

Why it’s used

Oxygen is a drug, and its primary indica-
tion is acute or chronic hypoxemia. Hypox-
emia occurs when the oxygen saturation in
the arterial blood is less than 90%. Even if
the patient’s oxygen level isn’t that low,
supplemental oxygen can help treat or re-
lieve various conditions that increase oxy-
gen demand, such as chest pain, fever, sep-
sis, shortness of breath, and acute and
chronic respiratory problems. In these
cases, oxygen therapy enhances oxygen de-
livery to the tissues and prevents hypoxia, a
decrease of oxygenation at the tissue level.
Administration of oxygen is an important interven- Depending on where you work, the preferred oxy-
tion for reversing and preventing complications from gen source may be a concentrator, a wall unit, or an
hypoxemia. National guidelines say that oxygen therapy oxygen tank. Compressed gas in a green oxygen tank
should be used: is the most common oxygen source. The large H
• in acute-care patients suspected of having hypoxemia cylinder is used when the patient is going to stay in
• in severe trauma his room; in other words, it’s a stationary oxygen
• in acute myocardial infarction (heart attack) source. The smaller E tank is available for times when
• for short-term therapy you need to transport the patient to another depart-
• during surgical interventions, postanesthesia, and re- ment, such as radiology. So it’s a portable oxygen
covery. source.
An oxygen concentrator is a machine that removes
Go to the source nitrogen, water vapor, and hydrocarbons from room
Before you can administer supplemental oxygen to a air. Oxygen is concentrated from room air and is
patient, you need an oxygen source and an oxygen delivered at more than 90%. The concentrator is the
delivery system that suits the patient’s needs and least expensive type of system, but it’s not portable
therapeutic goals. and it’s often noisy.

10 LPN2005 l Volume 1, Number 2

Special delivery soluble gel to lubricate
Oxygen delivery systems are classified according to the the nares. Correct appli- Applying a nasal
amount of oxygen that flows through them for deliv- cation of the nasal can- cannula
When using a nasal cannula,
ery to the patient. A low-flow system provides variable nula ensures the highest
follow these steps to apply it:
oxygen concentrations, but not enough oxygen flow to level of oxygen delivery • Connect the nasal cannula
meet the patient’s total breathing effort. This is be- (see Applying a nasal can- to the oxygen source.
cause part of the volume is supplied by the room air nula). • Gently insert the nasal
the patient inhales with each breath. prongs into the patient’s
In contrast, a high-flow system delivers a concentra- NASAL CATHETER nares.
tion of oxygen that’s greater than the patient’s require- An uncommon • Loop the tubing over the
ments. High-flow systems are used for patients who option patient’s ears, being careful
require precise concentrations of oxygen (see Methods of Probably less familiar to not to pull on the prongs.
oxygen delivery). you, a nasal catheter sys- • Slide the fastener snugly
under the patient’s chin.
Let’s take a closer look at the various ways that oxy- tem is a soft tube con-
• Turn on the oxygen to the
gen can be delivered. taining openings in the
ordered flow rate.
distal portion, allowing
NASAL CANNULA low concentrations of
Effective and inexpensive oxygen to flow from the supply tubing to the patient’s
Chances are you’re familiar oropharynx. This catheter is lubricated with water-sol-
with the nasal cannula. It’s uble gel and then inserted gently into the patient’s
the most popular low-flow nose. Again, the patient’s FiO2 varies with his breath-
oxygen delivery system, and ing effort.
the least expensive. The advantages and disadvantages of this infrequent-
Most nasal cannulas are ly used method are the same as the nasal cannula.
lightweight green, clear, or However, the catheter must be changed every 8 hours
light blue tubes with two because it can clog easily with dried secretions.
prongs, each about 1 cm long. The prongs fit into the
patient’s nares (nostrils) and the tubing is secured FACE MASK
around his ears and face. Oxygen then flows from the A simple solution
oxygen source, through the tubing, and into the prongs Low-flow oxygen may also be delivered through vari-
in the patient’s nasopharynx at a rate of 1 to 6 L/min. ous types of masks. The simple face mask covers the
The percentage of oxygen (known as FiO2) delivered patient’s nose and mouth. This lightweight mask has
by the nasal cannula depends on the patient’s breathing numerous holes in its sides that allow room air to en-
effort and the amount of room air inhaled with each ter and exit. When the patient breathes at a faster rate,
breath. An FiO2 of room air has a value of 0.21. the FiO2 is lower than when he’s breathing at a lower
Cannulas can usually deliver 24% to 40% of oxygen volume or lower rate.
and up to 6 L/min. The oxygen supply can be humidi- A face mask provides approximately 35% to 50% of
fied by attaching a container of sterile water to decrease oxygen per liter and should be maintained at a flow rate
nasal dryness. of 5 L/min to prevent the patient from rebreathing
When using a nasal cannula, mouth-breathing exhaled air. This type of mask is often used for short-
doesn’t interfere with oxygen delivery. Make sure, how- term therapy or in emergency situations. See Applying a
ever, that the nares aren’t obstructed with secretions, as mask to ensure the patient receives optimal oxygen
this will greatly decrease oxygen delivery. Continuous delivery.
use of a nasal cannula allows the patient to eat and drink
without removing the oxygen. PARTIAL REBREATHER MASK
Nasal cannula use may have some adverse effects, Mixing oxygen and room air
such as nasal stuffiness or dryness, runny nose (rhinitis), A partial rebreather mask is a form of low-flow oxygen
and skin irritation over the ears, or under the chin, delivery that can deliver higher concentrations of oxy-
nose, and across the face where the tubing lies. You can gen. A partial rebreather mask looks like a simple face
help guard against skin irritation by padding the areas mask with a reservoir bag. Oxygen flows through the
under the elastic strap with soft gauze and using water- supply tubing into the reservoir bag, allowing the pa-

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 Skill Building

tient to breathe oxygen-rich air from the bag and a

small amount of room air through the exhalation ports Methods of oxygen delivery
in the sides of the mask. When the patient exhales, a Delivery Liter % oxygen
small portion of oxygen-rich air reenters the bag. system flow delivered
Oxygen flow of 6 to 10 L/min is needed to provide Nasal cannula 1 to 6 L/min 24% to 40%
an oxygen concentration of 40% to 70% and to prevent Nasal catheter 1 to 6 L/min 24% to 44%
excessive carbon dioxide buildup. The reservoir bag Simple mask 5 to 10 L/min 35% to 50%
Partial rebreather mask 6 to 10 L/min 40% to 70%
should remain at least partially inflated at all times.
Nonrebreather mask 10 L/min minimum 60% to 80%
This type of mask is ideal for patients who require
Venturi mask 4 to 10 L/min 24% to 55%
short-term high FiO2 oxygen supplementation.

NONREBREATHER MASK This type of mask supplies 24% to 55% oxygen

No room air allowed
The highest concentration of
low-flow oxygen can be given
through a nonrebreather
mask. Because it allows for a
tight seal over the nose and
mouth, a nonrebreather mask
delivers 60% to 80% oxygen
at a minimum flow of 10 L/
min. Nonrebreather masks look similar to partial re-
breather masks, with a couple of important exceptions.
First, a nonrebreather mask has a one-way valve that
prevents exhaled air from reentering the reservoir bag.
Second, it also has one or more valves covering the air
holes in the face mask. This prevents the patient from
breathing in room air, but allows exhaled air to flow
out. That way, exhaled gases don’t mix with the fresh
oxygen delivered.
VENTURI MASK
High-velocity oxygen
delivery
A Venturi mask, also known
as a VentiMask, is one of the
best methods for delivering a
specific and consistent per-
centage of oxygen to a patient
who needs consistent FiO2.
through a narrow opening. The high velocity of oxy-
gen delivered through the constricted opening regu-
lates the percentage of oxygen. Placing an adaptor be-
tween the bottom of the Venturi mask and the oxygen
source alters the size of the opening, allowing various
oxygen concentrations to be delivered. The patient’s
respiratory rate and pattern don’t affect the oxygen
concentration. Flow rates of 4 to 10 L/min provide
oxygen concentrations of 24% to 55%.
Mask versus cannula
So, why would you use a mask instead of the more
comfortable cannula delivery system? The main rea-
son is because the amount of humidity you can add to
a nasal cannula isn’t as great as what you can add to a
mask. Most patients on long-term oxygen therapy
with a nasal cannula complain of dryness in the mu-
cous membranes of the nose and mouth. Humidity
moistens these membranes and helps thin the patient’s
respiratory secretions. The mask may also be used if
the patient needs a higher concentration of oxygen, if
he’s severely congested, or if his breathing is erratic.
Masks have some disadvantages, though. For exam-
ple, patients complain that masks are less comfortable,
cause heat buildup, and feel confining. Claustrophobic
patients are especially sensitive to feeling confined.
Because the mask covers the nose and mouth, you
have to remove it so that the patient can eat, drink,

Matching the delivery system to the oxygen saturation level

Respiratory condition Oxygen saturation Treatment
Normal respiration 95% – 100% No treatment
Mild hypoxemia 91% – 94% Use nasal cannula or simple mask
Moderate hypoxemia 86% – 91% Use partial rebreather, nonrebreather, or Venturi mask
Severe hypoxemia < 85% Use partial rebreather or nonrebreather mask. Prepare for possible intubation
if these methods are not successful.

12 LPN2005 l Volume 1, Number 2

expectorate, and take medications. Masks can also be oxygen can be delivered in many ways. Make sure you
displaced easily; it’s not unusual for you to find that the understand each method’s indications, advantages, and
patient’s mask has migrated to his forehead, chin, or disadvantages. Using this equipment properly helps
neck, limiting oxygen delivery. Some patients develop your patient receive optimal oxygen therapy. LPN
skin irritation where the elastic straps rub on the ears.
Selected References
Carter R, Tiep B. Oxygen-delivery systems. Respiratory Therapist. 16(7):36,
Prescription for oxygen 38, 40, December 2003.
Now that you know the basics, let’s discuss when to King JE. How do I choose a supplemental oxygen delivery device?
use oxygen. Nursing2003. 33(12):32, December 2003.
Suppose your patient is having trouble breathing but
his oxygen saturation is in the normal range (95% to
100%). He won’t need any treatment. But what if he’s On the Web
showing signs of mild hypoxemia, with an oxygen satu-
ration of 91% to 95%? Then he’ll need supplemental National Institutes of Health Clinical Center
oxygen, which can be given by way of a nasal cannula or http://www.cc.nih.gov/ccmd/html.pg/cctrcs/
simple mask. cctrcsproc.html
If he deteriorates to moderate hypoxemia (86% to
91% oxygen saturation) or severe hypoxemia (oxygen
saturation below 85%), you’ll give him oxygen through
a partial rebreather or nonrebreather mask. A patient
with severe hypoxemia may have to be intubated if
these oxygen delivery methods don’t help (see Matching
the delivery system to the oxygen saturation level).
Always remember to treat the whole patient; don’t
rely on saturation values alone. Be sure to check the
patient’s vital signs, especially his respiration, and then
check the color of his
Applying a mask nail beds, lips, and ears
When using a mask to
for signs of cyanosis. If
deliver oxygen, follow these
he isn’t getting enough
steps to apply it:
• Connect the mask to an
oxygen, you’ll see a
oxygen source. bluish discoloration.
• Turn on the oxygen to the Also, look for respiratory
ordered flow rate and fill the retraction and nasal flar-
reservoir bag. ing. If you note these
• Place the mask under the problems, try reposition-
chin and then up and on the ing the patient to a sit-
nose. ting position, with the
• Mold the flexible metal head of the bed elevated.
device over the bridge of
Keep in mind that you
the nose.
might get a false or low
• Holding the mask in place
with one hand, pull the elas-
oxygen saturation read-
tic strap over the head so ing if the patient has cold
that it rests above the ears. extremities or fingers, or
• Make sure the elastic if he has hypothermia or
straps fit snugly. hypovolemia. Falsely
• Adjust the oxygen flow high readings occur in
rate to meet the patient’s cases of anemia and car-
needs. bon monoxide poison-
ing.
You’ve learned that

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