Housemanship Training Programme

Department of Anaesthesiology and Intensive Care

OXYGEN
THERAPY
INTRODUCTION

•Oxygen is a drug

• Has a Drug Identification Number (DIN)

• Colorless, odorless, tasteless gas
• Makes up 21% of room air
• Is NOT flammable but does support combustion
AIR ATMOSPHERE
•NITROGEN ( N2 ) 78.08 %
•OXYGEN ( O2 ) 20.95 %
•ARGON ( Ar ) 0.99 %
•CARBON DIOXIDE ( CO2 ) 0.03 %
OXYGEN THERAPY BACKGROUND
INFORMATION

HYPOXIA :

•Decrease in actual content of O2 in the blood

•Inadequate supply of O2 for cell function
•Each cell requires O2 to fuel normal metabolic
processes
 5

HYPOXEMIA
Definition :

Low levels of oxygen in the blood

• PaO2 of less than 60 mmHg (moderate)

• SpO2 of less than 90%
HYPOXIA

vs

HYPOXAEMIA
 “Most commonly
prescribed drug in
pre hospital and
hospital setting”
 DEFINITION
RX > 21% O2

To treat or prevent
- symptoms & manifestations

of hypoxia
 Indications
for
oxygen therapy
 “Oxygen therapy is
indicated

whenever

tissue oxygenation is
impaired !”
 INDICATIONS:

• Cardiac and respiratory arrest

• Hypoxaemia (PaO2<60mmHg, SaO2<90%)
• Hypotension (systolic blood pressure <100 mm Hg)
• Low cardiac output and metabolic acidosis
(bicarbonate<18 mmol/l)
• Respiratory distress (respiratory rate >24/min)

(American College of Chest Physicians and National Heart

Lung and Blood Institute recommendations for instituting
oxygen therapy)
HYPOXIA
!!!
WHAT CAUSES
HYPOXIA ?
•Inadequate O2 in the lungs

•Abnormality in the hemoglobin

•Impaired diffusion of O2

•Abnormality in the balance between the amount of air

moving into the lungs & the amount of blood circulating
through the lungs ( V/Q mismatch)

•Chemical interference
HYPOXEMIA-
GRADING
•Mild- SpO2 < 97% ( PaO2-75mmHg)
•Moderate- SpO2 < 90%( PaO2 - 60mmHg)
•Severe- SpO2<75%( PaO2 - 30mmHg)
A PaO2 of <20
mmHg for significant length of time produces brain death
EFFECTS OF
HYPOXIA
• Respiration: increase ventilation via peripheral
chemoreceptors
• CNS: drowsiness, disorientation, reduced pain
sensibility, emotional outbursts, tremors, cheyne-stoke
respiration, death (when %O2 falls below 60)
• CVS: increase HR and BP
SYMPTOMS OF
HYPOXIA
•
TACHYCARDIA** • Tachypnea
• AGITATION
• DIAPHORESIS • Dyspnea
• CYANOSIS
• Use of accessory
muscles

**Adult response – pediatric and neonatal

patients experience bradycardia
HOW IS HYPOXIA TREATED ?

The obvious need in hypoxia

is OXYGEN, to preserve the life of
body cells. Supplemental oxygen
is administered to treat hypoxia
 SUPPLEMENTAL O2
THERAPY

What is supplemental O2 therapy :

•to administer O2 at concentration greater

than 21%
•to raise the level of O2 entering the lungs
with each breath
CONSIDERATIONS IN
OXYGEN THERAPY
Does the patient have a normally sensitive respiratory center
and a normal control over respiration
BENEFICIAL EFFECTS
OF OXYGEN
THERAPY
•Improvement in cell function involving various organ
systems
•Decrease in the work of breathing
•Decreased in the myocardial work
HOW IS SUPPLEMENTAL O2
ADMINISTERED

•Patient receives supplemental O2 in excess of 21

% from O2 sources such as piped O2 system, a
compressed gas cylinder or O2 concentrator
•Patient also requires a pressure and flow
regulating device, humidifier, connecting tubing,
and device that fits in the nose and on the face
through which O2 can be breathed
Vacuum Insulated Evaporator
Vacuum Insulated Evaporator (VIE). A VIE is a container designed
to store liquid oxygen. It has to be designed to allow the liquid
oxygen inside to remain very cold. It consists of two layers,
where the outer carbon steel shell is separated by a vacuum
from an inner stainless steel shell, which contains the oxygen (figure 1).
The oxygen temperature inside is about -170°C and the container is
pressurised to 10.5 atmospheres (10.5 bar). Gaseous oxygen above
the liquid is passed through the superheater to raise the temperature
to ambient (outside) levels. It then flows into the hospital pipeline
Temperature -170°C inside
system giving a continuous supply of piped oxygen to outlets on the
Pressurised to 10.5 atmosphere
wards and in theatre. Heat is always able to get into the container
and provides the energy to evaporate the liquid oxygen, changing it
into oxygen gas which is continuously drawn off into the pipeline
system. This escape of gas into the pipeline system prevents the
pressure inside the container from rising. If the pressure rises
too much (above 17 bar), oxygen is allowed to escape via a safety superheater
valve into the atmosphere.
• Oxygen cylinders: come in several sizes.
• : colour coding

• In Malaysia oxygen cylinders are black

• with white shoulders. ( UK)

• The pressure inside at 15°C is 137 bar.

OXYGEN CONCENTRATOR

• Electric oxygen system

• Provides oxygen by extracting it
from the air
• Generally use pressure swing
•adsorption with zeolites
• Unlimited oxygen supply while
connected to power source
• No refilling needed
PATIENTS WITH
NORMALLY SENSITIVE
RESPIRATORY CENTER
Can tolerate high concentration of oxygen at a
flow rate of 6-8 liters per minute
No risk of CO2 retention
Conditions: Severe Interstitial Lung Disease
Pneumonia
Pulmonary edema
Atelectesis
Acute hypoventilation
of any cause
Acute severe asthma
ABNORMAL CONTROL
OVER RESPIRATORY
CENTER
Respiratory center comparatively
insensitive to increasing pCO2 and
dependant hypoxic stimulus
High concentration of oxygen will improve
O2 saturation but will will result in
hypoventilation and dangerous rise in
pCO2
O2 therapy-Pink but obtunded, drowsy or
even comatose patient
 CONDITIONS WITH ABNORMAL
RESPIRATORY DRIVE

•Severe chronic obstructive pulmonary disease

•Chronic hypoventilation syndromes
•Some elderly patients with asthma
OXYGEN THERAPY
METHODS
•Routine oxygen therapy using low flow O2 delivery devices
•Controlled O2 therapy
ROUTINE O2
THERAPY
•Sufficient to relieve moderate hypoxia
•Can achieve oxygen concentration (FIO2) of about 40% at a
flow rate of 6-8 liters per minute
•Patients usually do not tolerate high flow rates with these
devices
ROUTINE O2
THERAPY
•Nasal catheters and prongs
•Face mask
•Face mask with reservoir bags
•Face mask with reservoir bags and directional valves
NASAL PRONGS
NASAL CATHETERS
AND PRONGS
•O2 concentration is about 24% at flow rate of 1liter /minute
•At 6-8 liter per minute O2 concentration is about 40%
•Actual O2 delivered to lung also depends on tidal volume
and minute ventilation
•Precise regulation of therapy is not possible
NASAL CATHETERS
AND PRONGS-USE
•Nasal catheter-tip should be advanced to the fold of soft
palate, too far advancement may cause abdominal distention
•Catheter should be lubricated by xylocaine jelly
•Catheter should be changed from one nostril to other every
4 hourly
FACE MASK
FACE MASK
•Mask forms a small O2 reservoir at nasal opening
• the Inspired O2 concentration depends on the size of mask
and flow rate of oxygen
•Higher flow rates up to 10 liter / minute can be tolerated
( SpO2 – 55%)
FACE MASK WITH
RESERVOIR BAGS
FACE MASK WITH
RESERVOIR BAGS
•Reservoir bag increases the potential reservoir of oxygen
and , allows a further increase in ventilation
•Sufficiently high flow rates should be maintained (8-12
liter/minute)
•Can increase the FIO2 to 50-80%
•Directional valve: FIO2-90-95%
CONTROLLED O2
THERAPY
•Necessary in all patients who show a hypercapnic response
to unlimited or uncontrolled oxygen administration
•In severely hypoxic patients even a small rise in PaO2 will
produce a significant greater rise in the oxygen saturation of
arterial blood
CONTROLLED O2
THERAPY
•It is best to start with an inspired oxygen concentration of
24% and watch for rise in PCo2
•If increase in PCO2 is less than 10mmHg then increase FIO2
to 28-30%
•Maximal permissible limit of rise in PCO2 is 20mmHg and p
H < 7.25
 MECHANICAL RESPIRATORY
SUPPORT-INDICATIONS

•Refractory hypoxemia unresponsive to supplemental

oxygen
•Excessive work of breathing: RR>35/ mt Minute
ventilation> 12 liter/minute
•Hemodynamic instability
•Inability to protect airway
•Anticipated rapid clinical deterioration
NON- INVASIVE
VENTILATOR SUPPORT
•Effective in a very small subset of minor Acute
lung Injury
•C-PAP:
Levels: 10-12 Cm H2O
Very high Flow rate:>70 liter/ minute
•Bi- PAP:

I-PAP-15cm H2O E-PAP-7-10cm H2O

•Aim –SpO2_ >90%
INVASIVE
VENTILATION
•fundamental concepts: Low tidal
volume
PEEP to prevent collapse of alveoli
Avoidance of O2 toxicity Prevention of
hemodynamic instability
OXYGEN
CANNULA
Low flow device - patients inhale room air along w/ O2
Recommended flow rate-1/2 LPM to 6 LPM
Deliver O2 concentrations 24% - 44%
1 LPM change in O2 flow, approx 4% change in inspired O2
e.g 1 LPM = 24%, 2 LPM = 28%
NASAL CANNULAS
OXYGEN MEDIUM
CONCENTRATION MASK
Low flow devices - do not supply all inspiratory
gases. Patient inhales some room air along with
O2
Recommended flow rate : 5- 10 LPM
Do not use at flow rates less than 5 LPM, as flow
rates may not flush exhaled CO2 from the mask
Deliver O2 concentration : 40% - 60%
Inspired FIO2 will change with patient’s
ventilatory pattern
 OXYGEN MEDIUM
CONCENTRATION MASK
OXYGEN HIGH
CONCENTRATION MASK
Low flow device - may not supply all
inspiratory gases, so patient inhales some
room air along with O2 if the flow is not
adequate
A 750 ml reservoir bag has been added to
the system to increase supply of 100%
Oxygen available to the patient
Recommended flow rates : 8-12 LPM
Use the suitable flow rate necessary to keep
reservoir bag well inflated and to prevent the bag
from deflating more than 1/3 when the patient
inhales. If patient is extremely short of breath,
this may require flow rates greater than 10 LPM
Delivered O2 concentration : 60 - 80 %
 NON-REBREATHING
MASKS
Low flow device - if flow through the device is
not adequate, the system will not supply
sufficient gas to meet the patient’s inspiratory
needs
Valves added to the system to control the O2
flow and the path of inspiration & exhalation
Recommended flow rates : 10 -12 LPM
Use the flow rate necessary to keep the
reservoir bag from collapsing during
inspiration. If 3 valves are in place, it’s
CLOSED SYSTEM. The flow through the
mask must be adequate since the patient
cannot inhale room air
Delivered O2 concentration : 80 -100 %
With 3 valves in place, and proper setup, the
mask may deliver up to 100 % oxygen
 MULTI-VENT MASK
High-flow device - large amounts of room air can be entrained
through the mask, in addition to the O2, the total flow through
the mask (41-79 LPM) can exceed the patient’s respiratory
requirement
Recommended flow rates : 3 - 15 LPM
Delivered O2 concentration - precise O2 concentration can be
selected at: 24%, 26%, 28%, 30%, 35%, 40%, and 50%
MULTI-VENT MASK
SELECT-A-VENT

High flow device - total flow through mask

(40 - 78 LPM)
Recommended flow rates : 3 -15 LPM
Recommended flow is indicated on the diluter
Delivered O2 concentration - 6 precise O2
concentration : 24%, 28%, 31%, 35%, 40% and
50%