TERAPI OKSIGEN

Basic : Binasal & Facemask

Pelatihan Critical Care Management in COVID-19
WISMA ATLET
JCCA – PERDATIN JAYA
WHY OXYGEN ?
 AIRWAY
MANAGEMENT

TERAPI
OKSIGEN
 Oxygenation

UDARA BEBAS:
PiO2 : 21% x 760 = 160 mmHg
PiCO2 : 0.04 % x 760 = 0.3 mmHg
PiN2 : 78.6 % x 760 = 597mmHg
ALVEOLUS
PiH2O : 0.46 % x 760 = 3.5 mmHg
N2 H2O
PAN2:
573 mmHg
PAH2O:
47 mmHg
KAPILER
PROSES PARU
PAO2: PACO2:
DIFUSI 104 mmHg 40 mmHg PaO2
O2 O2 CO2 O2
Pulmonary Artery Pulmonary Vein
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg PcO2: 100 mmHg
mmHg
\ PAO2  PcO2
WHAT IS HAPPENING
IN COVID-19 ???
 Oxygenation is disrupted

PROSES N2 H2O
PAN2: PAH2O:
DIFUSI 573 mmHg 47 mmHg

terganggu PAO2: PACO2:

104 mmHg 40 mmHg PaO2
O2 O2 CO2 O2
Pulmonary Artery Pulmonary Vein
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg PcO2: 100 mmHg
TROMBUS mmHg
 Oxygenation

UDARA BEBAS:
PiO2 : 40% x 760 = 160 mmHg
PiCO2 : 0.04 % x 760 = 0.3 mmHg
PiN2 : 58,6% x 760 = 420mmHg
ALVEOLUS
PiH2O : 0.46 % x 760 = 3.5 mmHg
N2 H2O
PAN2:
420 mmHg
PAH2O:
47 mmHg
KAPILER
PROSES PARU
PAO2: PACO2:
DIFUSI 140 mmHg 40 mmHg PaO2
TERGANGGU O2 O2 CO2 O2
Pulmonary Artery Pulmonary Vein
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg PcO2: 100 mmHg
mmHg
\ PAO2  PcO2
 BEWARE OF
SILENT HYPOXEMIA
TERAPI OKSIGEN
SECARA UMUM
TERAPI OKSIGEN
PADA COVID - 19
No EVIDENCE
•To date, no evidence of optimal
oxygen treatment for COVID-19
patients is known, neither in
terms of a method for
administration nor for target
saturation (SpO2).
BUT THERE ARE
RECOMMENDATIONS
WHO RECOMMENDATION in COVID-19
•in adult, non-pregnant patients with COVID-
19,
•target SpO2 should be >90% when the
patient is stabilized,
•while in critically ill patients (with shock,
coma, seizures, risk of respiratory arrest), an
SpO2 > 94% should be the target
Surviving Sepsis Campaign: Guidelines on the
Management of Critically Ill Adults with COVID-19
23.In adults with COVID-19, we suggest starting
supplemental oxygen if the peripheral oxygen
saturation (SPO2) is < 92% (weak
recommendation, low quality evidence), and
recommend starting supplemental oxygen if
SPO2 is < 90% (strong recommendation,
moderate quality evidence).
24.In adults with COVID-19 and acute
hypoxemic respiratory failure on oxygen,
we recommend that SPO2 be maintained
no higher than 96% (strong
recommendation, moderate quality
evidence).
SSC in COVID-19
•reasonable SPO2 range for
patients receiving oxygen
is 92% to 96%
COPD ?
•That target SpO2 in COVID-19
patients without known chronic lung
disease should be 92–96%
•That target SpO2 in COVID-19
patients with known chronic lung
disease (COPD) should be 88–92%
JADI… KITE PAKE YANG MANE ?
WHICH oxygen therapy?

Supplementation of
O2
10-15 Lpm
2-5 Lpm
60-100%
24-44%

6-10 Lpm 0.5-60 Lpm

40-60% 20-100%

Increased FiO2
 NASAL KANUL

• 1 LPM – FiO2 24%

• 2 LPM – FiO2 28%
• 3 LPM – FiO2 32%
• 4 LPM – FiO2 36%
• 5 LPM – FiO2 40%
6-10 Lpm
40-60%
10-15 Lpm
60-100%
NO HUMIDIFICATION
WHICH oxygen therapy?

Supplementation of
O2
10-15 Lpm
2-5 Lpm
60-100%
24-44%

6-10 Lpm 0.5-60 Lpm

40-60% 20-100%

Increased Only
Increased FiO2 Blood Oxygen !
TAMBAHKAN
PRONE POSITION
We’re learning proning
Case Gender Age SAPS II score Ventilatory support BMI Duration of PaO2/FiO2 PaO2/FiO2 Intubation
−2
no. (years) at admission (kg.m ) prone before after
positioning prone prone
(hours) position position

1 Male 60 27 HFNO 50 L/min 27 7 144 254 Yes

2 Male 54 32 COT 6 L/min 27 1 215 147 No

HFNO 50 L/min 1 129 156

3 Male 55 26 HFNO 50 L/min 26 16 126 194 No

HFNO 50 L/min 16 183 162

4 Male 66 37 COT 5 L/min 31 4 150 242 Yes

5 Male 61 28 COT 3 L/min 21 1 274 225 Yes
COT 3 L/min 2 193 124
6 Male 64 36 COT 5 L/min 27 2 212 168 No
• For adults with COVID-19 who are receiving supplemental
oxygen, recommends close monitoring for worsening
respiratory status and that intubation, if it becomes
necessary, be performed by an experienced practitioner in a
controlled setting (AII).
• For patients with persistent hypoxemia despite increasing
supplemental oxygen requirements in whom endotracheal
intubation is not otherwise indicated, the Panel recommends
considering a trial of awake prone positioning to improve
oxygenation (CIII).
•The Panel recommends against using
awake prone positioning as a rescue
therapy for refractory hypoxemia to
avoid intubation in patients who
otherwise require intubation and
mechanical ventilation (AIII).
TAMBAHKAN
DEXAMETHASONE
TAMBAHKAN
PROFILAKSIS
ANTIKOAGULAN
Bagaimana kalau…
Sesak nafas /
SpO2 <93%
 PPPASIEN POSITIF / PDP COVID-19

GANGGUAN SESAK HIPOKSEMIA,

HENTI JANTUNG JALAN NAFAS
RR >30/MENIT
NAFAS SpO2 <93% (FiO2 21%),
PaO2/FiO2 <300 mmHg

TIDAK NRM 15 lpm

1. Apakah kondisi sedang memburuk progresif?
Titrasi dan
2. Apakah diyakini akan memburuk? Evaluasi per 1 jam
YA
1. Compos Mentis, komunikasi lancar, DAN HFNC 30-60 LPM atau NIV
2. RR 20-30/menit, DAN YA FiO2 100%
3. SpO2 >90%, DAN dan POSISI TELUNGKUP
4. Tidak syok Titrasi dan Evaluasi dalam 1 jam

TIDAK EVALUASI, Apakah:

1. Penurunan kesadaran, ATAU
Lanjutkah HFNC / NIV 2. RR >30/MENIT, ATAU
3. SpO2 <92% (<95% bila komorbid), ATAU
Evaluasi per 2 jam 4. Peningkatan kerja otot napas bantu, ATAU
5. Nadi >120/menit, ATAU
6. ROX index <3,85
TIDAK
YA
INTUBASI → VENTILATOR

- PaO2/FiO2 <60 mmhg selama >6 jam

Pertimbangkan ECMO bila tidak ada
- PaO2/FiO2 <50 mmhg selama >3 jam
- pH <7,2 dan PaCO2 >80 mmHg >6 jam kontraindikasi dan faskes memadai
TERIMA KASIH