Oxygen Therapy

Maj/Capt Win Ye Htut

M.B.,B.S, M.Med.Sc(Anaesthesiology)
Outlines

• Oxygen transport and tissue oxygenation

• Assessment of hypoxia

• Indications for oxygen therapy

• Oxygen delivery devices

Oxygen Transport and tissue oxygenation

Gas Echange
•1 atm = 760 mmHg = 100 Kpa
•Dry atmospheric air gas – 21% of 100KPa
(21 KPa or 160mmHg)

•As gas is inspired it is diluted by water vapour

•Water vapour – 6.3 Kpa=47mmHg
•PiO2 = 0.21 x (760-47)= 149mmHg
•PiO2 = 0.21 x (100-6.3) = 19.8KPa
• PAO2 = PiO2 - PACO2/RQ
• PAO2 = 0.21 x (100-6.3) - 5/0.8 = 14KPa

• Oxygen transport
• Oxygen is carried in 2 forms in the blood:
• Flux = (CO X Hb x Saturation X Huffners constant(1.34)) +
(0.0031 X PaO2)

• Tissue oxygenation
• Depends on oxygen delivery and utilization by tissue
• Oxygen delivery – integrated function of Pulmonary, CVS
and Hematological systems
Assessment of hypoxia
• decreased oxygen intake

• ventilation – perfusion imbalance

• reduced oxygen delivery

• circulatory hypoxia (low cardiac output/ hypovolemia)

• abnormal blood oxygen transport ( anemia/

hemoglobinopathies / CO poisoning)

• Excessive or dysfunctional tissue utilization

• inhibition of intracellular enzymes (cyanide – cytochrome

oxidase)
Symptoms of Hypoxemia and Hypoxia

• Dyspnea, tachypnea. Hyperventilation

• +/- Cyanosis

• Impaired mental performance

• Seizures, permanent brain injury

• Tachycardia/Tachypnoea/Hypertension –

• Bradycardia/Hypotension

• Lactic acidosis
PULSE OXIMETER
• Noninvasive measurement of ratio of oxy-Hb to deoxy-Hb
(uses spectrophotometry based on the Beer-Lambert law)
• Differentiates oxy- from deoxyhemoglobin by the differences
in absorption at 660nm and 940nm
• Estimates heart rate by measuring cyclic changes in light
transmission and functional hemoglobin saturation:
oxyhemoglobin/deoxy + oxy
• The relationship between the arterial partial pressure of
oxygen(PaO2) and the oxygen saturation is described by the
oxyhaemoglobin dissociation curve.
The oxyhaemoglobin dissociation curve showing the relation between partial pressure of oxygen
and haemoglobin saturation

Currie, G. P et al. BMJ 2006;333:34-36

Copyright ©2006 BMJ Publishing Group Ltd.

Low false reading
• Nail polish
• Poor perfusion state - severe vasoconstriction, hypothermia
with shivering or excessive movement)
• Malposition -(Excessive movement)
• peripheral vascular disease
• ambient light,
• Met-Hb (prilocaine overdose)
• Methylene blue
• Indocyanine green
• Malposition
• (Pulse oximetry is not affected by jaundice, HbF, dark skin
or anaemia.)
Indications for Oxygen therapy
• Cardiac and respiratory arrest
• Respiratory failure Type 1 and type 2
- Hypoxemia (PaO2 < 60 mmHg, Sat<90%), hypercapnia
PaCo2 >50mmHg
• Hypotension ( Systolic BP < 100 mmHg)
• Shock (any causes)
• Low Cardiac Output and Metabolic Acidosis ( bicarbonate
<18 mmol/l)
• Respiratory distress ( RR>24/minute)
• During anaesthesia
• Post-operative period
• Anaemia
Choice of delivery system is based upon:
• 1. Degree of hypoxemia
• 2. Requirement for precision of delivery
• 3. Patient comfort
• 4. Cost
Classification of the oxygen delivery systems

Variable performance devices

• Nasal cannulae (prongs or • Venturi-operated devices
Fixed performance devices

spectacles) • Anaesthetic breathing

• Nasal catheters systems with a suitably large
• Hudson face masks and reservoir
• Partial rebreathing masks
• Non rebreathing masks
Common Low flow devices
• Nasal cannula (prongs or spectacles)
• Nasal catheters
• Transtracheal catheter
• Face mask
• Partial rebreathing mask
• Non rebreathing mask
• Tracheostomy mask
NASAL CANNULA

• Flow rate - 2–4 L/min delivers an FiO2 of 28–36%

• FiO2 = 20% + (4 × oxygen litre flow)
• No increase in FiO2 if flow is more than 6L/min
• Nasopharynx acts as a reservoir
• If patient breaths through mouth, air flow produces a Venturi
effect in the posterior pharynx entraining oxygen from the
nose
• Available in different sizes and different prong shapes
NASAL CANNULA

Advantages:
•Ideal for patients on long-term oxygen therapy
•Light weight and comfortable
•The patient is able to speak, eat and drink
•Humidification not required
Disadvantages:
•Can not provide high flow O2
•Irritation and can not be used in nasal obstruction
•FiO2 varies with respiratory efforts
•High flow rates are uncomfortable
NASAL CATHETER

• Single lumen catheter

• inserted to just above the uvula

• Oxygen flows - 2–3 L/min can be used. FiO2 35-40%

• It should not be used when a nasal mucosal tear is suspected

• No advantages over nasal cannula

 SIMPLE FACE MASK

• Transparent mask provided with side holes

• Reservoir capacity 100–250 ml

• Different oxygen flow rates result in a highly variable and

unpredictable FiO2

• Rebreathing of CO2 can occur with O2 flow rates of less than

2 L O2 l/min

• 4 L/min of oxygen flow delivers an FiO2 of about 35–40% •

Flow rates greater than 8L/min do not increase FiO2
Simple Face Mask (“Hudson”)
PARTIAL REBREATHING MASK

• Mask with reservoir bag of capacity 1lit

• Oxygen flows directly into the reservoir bag, which fills

during exhalation

• Deliver an FiO2 between 60% and 80%

• A minimum of 8L/min should enter the mask to remove

exhaled CO2 and to refill oxygen reservoir

• Flow rate must be sufficient to keep bag

PARTIAL REBREATHING MASK

Advantage:

•Inspired gas not mixed with room air

•Patient can breath room air through exhalation

Disadvantage

•More oxygen flow does not increase FiO2

•Interfere with eating and drinking

NON REBREATHING MASK

• Provided with one way valves between mask and bag,

exhalation ports

• FiO2 of 95% can be achieved with an oxygen flow rates of

10 to 15 L/min

• Ideally NRM should not allow entrainment of air, but

because of safety concerns one of the two exhalation ports is
not provided with valve
NON REBREATHING MASK
NON REBREATHING MASK

Advantage:
•Highest possible FiO2 without intubation
•Suitable for spontaneously breathing patients with severe
hypoxia
Disadvantage
•Expensive
•Require tight seal, Uncomfortable
•Interfere with eating and drinking
•Not suitable for long term use
•Malfunction can cause CO2 buildup, suffocation
VENTURI MASK
• Advantage
• Fine control of FiO2 at fixed flow
• Fixed, reliable, and precise FiO2
• High flow comes from the air, saving the oxygen cost
• Can be used for low FiO2 also
• Helps in deciding whether the oxygen requirement is
increasing or decreasing
Disadvantage
• Uncomfortable
• Cannot deliver high FiO2
• Interfere with eating and drinking
HIGH FLOW NASAL CANNULA

• Delivers heated and humidified oxygen via special devices

(eg,Vapotherm®).

• Rates up to 8 L/min in infants and up to 60 L/min in children

and adults.

• In patients with respiratory distress or failure, oxygen by

humidified high-flow nasal cannula may be better tolerated

than by face mask

HIGH FLOW NASAL CANNULA
HIGH FLOW NASAL CANNULA
• High flow washes out carbon dioxide in anatomical dead
space.

• Creates positive nasopharyngeal pressure.

• FiO2 remains relatively constant.

• Because gas is generally warmed to 37°C and completely

humidified, mucociliary functions remain good and little
discomfort is reported
Self-inflating resuscitation bags with oxygen
reservoirs
Self-inflating bag
•Compact, portable, self-
inflating bag with a one-way
valve.
•Oxygen reservoir can be
added to increase FiO2.
•Paediatric version exists.
Mechanical Ventilation

• Non Invasive Ventilation

• Invasive Ventilation
Non Invasive Positive Pressure Ventilation
(NIPPV)
Mode of NIV
•NIV mode
•PSV
•CPAP
•BiPAP
Indication for NIV
• OSA
• Mild ARDS
• Mild COAD
• Mild pulmonary oedema
• Neuromuscular transient desease and drugs
• Weaning difficulties
Contraindications
Relative Contraindications

Respiratory arrest Extreme anxiety

Unstable cardiorespiratory status Massive obesity
Uncooperative patients Copious secretions
Unable to protect airway- impaired Need for continuous or nearly
swallowing and cough continuous ventilatory assistance
Facial Oesophageal or gastric
surgery
Craniofacial trauma/burn
Anatomic lesions of upper airway
Extracorporeal membrane oxygenation
(ECMO)
• Extracorporeal membrane oxygenation (ECMO), also
known as extracorporeal life support (ECLS), is an
extracorporeal technique of providing prolonged cardiac and
respiratory support to persons whose heart and lungs are
unable to provide an adequate amount of gas exchange or
perfusion to sustain life.
• The technology for ECMO is largely derived from
cardiopulmonary bypass, which provides shorter-term
support with arrested native circulation. The device used is a
membrane oxygenator, also known as an artificial lung.
HAZARDS OF OXYGEN THERAPY
• Respiratory toxicity
• 1.hypoventilation
• 2.absorption atelectasis
• 3.pulmonary oxygen toxicity

• Retinopathy of prematurity

• Hyperbaric oxygen toxicity

• Fire hazard

• Depressed haemopoiesis
Take home message
 Acute empiric oxygen treatment is ok but hypoxemia
should be verified with pulse oximetry and /or ABG’s when
situation more stable.

 Oxygen is a drug and should be ordered as such: mode of

administration, flow rate, FiO2 (venturi), treatment goal,
monitoring, when to stop.

 Avoid overzealous treatment- Adequate saturation for the

patient - COPD 88-90%
Thank You