‫بسم هللا الرحمن الرحيم‬

Oxygen Therapy

Dr. mahmoud omar

 Oxygen therapy

• Oxygen therapy is defined as the

administration of oxygen at
concentrations greater than those found
in ambient air.
• Oxygen is a treatment for hypoxaemia,
not breathlessness.
• The recommended target saturation range for
acutely ill patients not at risk of hypercapnic
respiratory failure is 94-98 %.
• Some normal subjects, especially people aged
> 70 years, may have oxygen saturation
measurements below 94% and do not require
oxygen therapy when clinically stable.
• For most patients with known COPD or other
known risk factors for hypercapnic respiratory
failure (eg, morbid obesity, chest wall
deformities or neuromuscular disorders), a
target saturation range of 88-92 % is suggested
pending the availability of blood gas results.
Oxygen therapy in non-hypoxaemic
patients

1. Carbon monoxide (CO) poisoning

Higher affinity for the haemoglobin molecule
giving rise to carboxyhaemoglobin (COHb). The
half-life of COHb is about 4–5 h when breathing
air but is reduced to about 40 min when
breathing 100% oxygen.
2. Pneumothorax
• High flow oxygen reduce the total pressure of
gases in pleural capillaries by reducing the
partial pressure of nitrogen.
• This should increase the pressure gradient
between the pleural capillaries and the pleural
cavity, thereby increasing absorption of air from
the pleural cavity.
3. During cardiopulmonary resuscitation
4. Short-term postoperative (for 2 h)
5. Improve anastomotic surgery
6. Cluster headache
 Oxygen therapy during nebulised
treatments
• For patients with asthma, nebulisers should be
driven by piped oxygen or from an oxygen
cylinder fitted with a highflow regulator capable
of delivering a flow rate of > 6 l/min.
• If the cylinder does not produce this flow rate,
an air-driven nebuliser (with electrical
compressor) should be used with
supplemental oxygen by nasal cannulae at 2–
6 l/min to maintain an appropriate oxygen
saturation level.
• When nebulised bronchodilators are given to
patients with hypercapnic acidosis, they should
be driven by compressed air and, if necessary,
supplementary oxygen should be given
concurrently by nasal cannulae at 2–4 l/min to
maintain an oxygen saturation of 88–92%.
 long-term oxygen therapy
(LTOT)
• Long-term oxygen therapy (LTOT) is the
administration of low-flow supplemental oxygen
that traditionally is administered at doses of 1–4
L/min.
• In terms of maximum benefit, oxygen should be
continous at least 15 h/days
Indications for long-term oxygen therapy
(LTOT)

• PaO2 ≤ 55 mmHg(7.3 kPa), or SaO2 ≤ 88 %

• PaO2 ≤ 59 mmHg(7.8 kPa), or SaO2 ≤ to 89
%, if there is evidence of:-
- cor pulmonale / right heart failure
- erythrocytosis (hematocrit >55%)
• LTOT is traditionally provided using one of 2
types of large stationary system:
1. Oxygen concentrator
2. Liquid-oxygen (LOX) system
 Oxygen during sleep
1. PaO2 ≤ 55 mmHg, SaO2 ≤ 88 %
2. Fall of PaO2 > 10 mmHg
and/or
3. Fall of SaO2 > 5 % during sleep with signs or
symptoms of nocturnal hypoxemia (eg,
impaired cognitive process, restlessness, or
insomnia).
 Oxygen during exercise
1. PaO2 ≤ 55 mmHg, SaO2 ≤ 88 %
2. In patients who do not significantly
desaturate during exercise, if they
have dyspnea and ventilatory
abnormalities during exercise that
suggest supplemental oxygen may
permit greater exertion
 Oxygen conserving devices

Oxygen conserving devices have been introduced as a

means of making oxygen therapy more efficient, more
portable, and less intrusive
 Nasal Cannula
• Nasal cannula can be used to deliver low and medium-
dose oxygen concentrations.
• Comfortable and easily tolerated, patient can eat, talk
• Flow rate should never exceed 6 L/min as this would
cause rapid drying and dehydration of the nasal mucosa.
• Rates higher than 6 L/min will not cause a significant
increase in FIO2 and therefore result in a waste of
oxygen.
Nasal Cannula Flow Rates
• For every liter per minute of flow delivered, the
oxygen concentration the patient inhales increases
by 4%
• Room air = 21%
• 1 liters/min. = 24%
• 2 liters/min. = 28%
• 3 liters/min. = 32%
• 4 liters/min. = 36%
• 5 liters/min. = 40%
• 6 liters/min. = 44%
Relation between oxygen flow rate via nasal cannula and FiO2.
Each additional L/min in oxygen flow increases the FiO2
by about 4 percent
 Simple Face Mask

• The flow rate from simple

face masks should be adjusted
between 5 and 10 L/min
to achieve the desired target
saturation (40-60 %)
• Flow rates below 5 l/min may cause carbon
dioxide rebreathing and increased resistance
to inspiration
• So, this mask is suitable for patients with
hypoxaemic respiratory failure (type 1) but is
not suitable for patients with hypercapnic
(type 2) respiratory failure.
 Partial rebreather mask
• O2 directed into reservoir Exhalation
• Insp: draw gas from bag & ports
room air
• Exp: first 1/3 of exhaled gas
goes into bag
• Dead space gas mixes with
‘new’ O2 going into bag
• Delivers 35-60% Oxygen at O2
6-10 L/min flow rate

Reservoir
 non-rebreather mask
• Oxygen tubing and a face mask with attached
reservoir bag, two air inlet/outlet ports on
mask, covered with thin, one way rubber flaps
to allow exhalation
• This type of mask delivers oxygen at
concentrations between 60-90% when used
at a flow rate of 10-15 l/min
 One-way valves

• Valve prevents exhaled gas

flow into reservoir bag
• Valve over exhalation ports
prevents air entrainment
O2

Reservoir
 One-way valves

• Valve prevents exhaled gas

flow into reservoir bag
• Valve over exhalation ports
prevents air entrainment
O2

inspiration
Reservoir
 One-way valves

• Valve prevents exhaled gas

flow into reservoir bag
• Valve over exhalation ports
prevents air entrainment
O2

inspiration
Reservoir
 One-way valves

• Valve prevents exhaled gas

flow into reservoir bag
• Valve over exhalation ports
prevents air entrainment
O2

expiration
Reservoir
 Venturi mask
• A Venturi mask gives an accurate concentration of
oxygen to the patient regardless of oxygen flow rate.
• The gas flow into the mask is diluted with air which is
entrained via the cage on the Venturi adaptor.
• The amount of air sucked into the cage is related to
the flow of oxygen into the Venturi system. The higher
the flow the more air is sucked in.
• Therefore the Venturi mask delivers the same
concentration of oxygen as the flow rate is increased.
• Venturi masks are available in the following
concentrations: 24%, 28%, 35%, 40% and 60%.
• They are suitable for all patients needing a known
concentration of oxygen, but 24% and 28% Venturi
masks are particularly suited to those at risk of carbon
dioxide retention.
Venturi masks
 Tracheostomy masks
• These devices are designed to allow oxygen to be
given via a tracheostomy tube or to patients with
previous laryngectomy (ie, ‘‘neck breathing
patients’’).
• Oxygen given in this way for prolonged periods
needs constant humidification and patients may
need suction to remove mucus from the airway.
Reservoir cannulas
Transtracheal oxygen
 Oxygen storage
1- Cylinders (compressed gas)
• Cylinders contain compressed gas held under a very
high pressure.
• These can be used for
bedside administration
where piped oxygen is not
available or can be the
supply for a piped system.
2- Liquid oxygen (LOX)
Liquid oxygen does not require high pressure containers
for oxygen storage; rather, a thermos. One liquid liter of
oxygen expands to nearly 1000 liters of gaseous oxygen.
 3- Portable oxygen concentrators (POCs)
• Portable concentrators make use of improved
battery technology and size and power of
pumps and motors to provide battery-powered
concentrators ranging from 2.5 to 10 hours.
• POCs that can deliver oxygen only in:
1. pulse-dose mode
2. continuous-flow
Demand oxygen pulsing devices
 Humidification
• Humidification is not required for the delivery of low-
flow oxygen or for the short-term use of high-flow
oxygen.
• Humidified oxygen should be used for patients who
require high-flow oxygen systems for more than 24 h
or who report upper airway discomfort due to
dryness.
Oxygen Flow Meter
.The centre of the ball indicates the correct flow rate

3 3

2 2

1 1

This diagram illustrates the correct

setting of the flow meter to deliver
a flow of 2 litres per minute
Oxygen during Air Travel
“We live submerged at the bottom of an ocean of
the element air, which by unquestioned
experiments is known to have weight”

Evangelista Torricelli
(1608 –1647)
Physiologic Divisions of the Atmosphere

1. Physiologic Zone
2. Physiologically Deficient Zone
3. Partial Space Equivalent Zone
4. Space Equivalent Zone
 Physiologic Zone

• Sea level to approximately 10,000 feet

• Some references state 12,000 feet
• The human body is adapted in this zone
• Barometric pressure drops from
approximately 760 mm Hg to 485 mm Hg
in this zone
• Zone where non-pressurized aircraft
operate safely
10,000 FT MSL

MSL - mean sea level

 Physiologically Deficient Zone

• 10,000 to 50,000 feet

• Most commercial aviation occurs in this zone
• Human survival in this zone depends on
pressurized cabins and/or supplemental
oxygen
• Barometric pressure drops to 87 mm Hg in this
zone
• Because of the reducing atmospheric
pressure, hypoxia is a problem during ascent
without artificial atmosphere
Partial Space Equivalent Zone

• 50,000 feet to 120 miles

• Similar to space
• Pressurized suits required
• Changes in gravity affect the body
Space Equivalent Zone

• Above 120 miles

• Artificial atmosphere/pressure suits
mandatory for life
• Weightlessness effects
• “Outer space”
Barometric Pressure and Inspired Po2
at Various Altitudes
 Cabin altitude
• Pressurization of the cabin within commercial
airlines limits the fall of air pressure, allowing the
airplane to cruise at altitudes up to 40,000 feet
without inducing extreme hypobaric stress.

• The altitude within the cabin (called cabin altitude)

must be maintained below 8,000 feet, allowing
only brief diversions to 10,000 feet cabin altitude
for safety (eg, to avoid adverse weather)
Physiological effects of exposure to altitude

• Breathing air at 2438 m (8000 ft) is equivalent

to breathing 15.1% oxygen at sea level. In
healthy subjects exposed to these conditions,
their PaO2 will be influenced by their age and
minute ventilation, but the PaO2 is likely to fall
to between 7.0-8.5 kPa (53-64 mmHg, SpO2
85-91%).
• However, healthy passengers do not
generally experience symptoms.
Initial assessment

BTS Recommendations Managing Passengers with

Respiratory Disease Planning Air Travel 2004
 Additional risk factors

1. Hypercapnia
2. FEV1 <50% predicted
3. Lung cancer
4. Restrictive lung disease involving the
parenchyma (fibrosis,) chest wall
(kyphoscoliosis) or respiratory muscles,
ventilator support
5. Cerebrovascular or cardiac disease
6. Within six weeks of discharge for an
exacerbation of chronic lung or cardiac
disease.
 Hypoxic challenge test

• The ideal test, which is to expose a subject to

hypoxia in a hypobaric chamber, is not widely
available. The hypoxic challenge test described
by Gong is therefore often used.
• The maximum cabin altitude of 2438 m (8000 ft)
can be simulated at sea level with a gas mixture
containing 15% oxygen in nitrogen for 20
minutes or until equilibration. Spo2 is monitored
throughout, and ABG measured before and after
the test.
Results of hypoxic challenge test
 The 50 metres walk

• The ability to walk 50 metres without distress has the

merit of being simple.
• Failure to complete the task (in terms of distance or
time) or moderate to severe respiratory distress will
alert physician and the patient to the possible need
for in-flight oxygen
 Predicting hypoxaemia from equations

 For Obstructive lung diseases:

• PaO2 at 8000 feet (mmHg) = [0.238 x (PaO2 at
sea level)] + [20.098 x (FEV1/FVC)] + 22.258

 For restrictive lung diseases:

• PaO2 at 8000 feet (kPa) = 0.74 + [0.39 x PaO2
at sea level (kPa)] + [0.033 x DLCO (%
predicted)]
• No guidelines currently exist for patients
already requiring supplemental oxygen
at sea level.
• In general, patients who use LTOT
should increase their oxygen flow while
at cruising altitude.
Predictive Calculation of the Arterial Gasometric
Variables during the Transfer of Respiratory Patients
by Air RTO-MP-HFM-109.
 Example
• Pt is using 2 L/m oxygen by nasal canula to get
Po2 60 PCo2 40
• Aa grad O2 = FiO2 (BP – PH2O) – (PaCO2/0,8) –
PaO2.
• Aa grad O2= 0.28(760-47)-50-60=89.64
• Fio2= (89.64+50+60) /(537-0.061Χ537)=
199.64/504.24=0.39
 Oxygen Adjustment Calculation

Fio2 required at altitude =

Fio2 Χ BP1 / BP2
• Where
• BP1 = barometric pressure prior to ascent
• BP2 = barometric pressure at altitude
• Fio2 = inspired O2
 Oxygen Adjustment Calculation

Example
• A patient on 28 % Fio2 is flown from sea level
(760 mm Hg) to 10,000 feet (537 mm Hg)
• Required Fio2 = 28 % Χ 760 / 537 = 40 %
 Hyperbaric oxygen therapy
(HBOT)

Hyperbaric oxygen therapy (HBOT) is breathing

100% oxygen while under increased atmospheric
pressure.
Chamber pressure is usually maintained
between2.5 -3.0 atm, with treatment lasting 45 to
300 minutes depending upon the indication.
Pressures exceeding 2.8 to 3.0 atm, particularly
over prolonged exposure hyperbaric periods,
dramatically increase the risk of oxygen toxicity
 :Clinical uses

1. Carbon monoxide poisoning

2. Decompression sickness and
air embolism
3. Gas embolism
4. Acute traumatic or thermal injury
5. Radiation injury
6. Nonhealing ulcers
7. Compromised skin grafts and flaps
8. Actinomycotic brain abscesses
9. Gas gangrene
 Contraindications
 Absolute contraindication
- untreated pneumothorax.
 Relative contraindications include
- obstructive lung disease
- upper respiratory or sinus infections
- recent ear surgery or injury
- fever
- claustrophobia
• NB. Pregnancy was once believed to represent a
contraindication to HBO, but now is considered an impetus to
pursue HBO therapy among patients with CO intoxication
 Complications
• Most side effects are mild and reversible,
1. Reversible myopia
2. Otic barotrauma
3. Middle ear effusions and tympanic membrane
rupture
4. Pulmonary barotrauma
5. Pulmonary oxygen toxicity
6. Seizures
 Ozone therapy
• The FDA recently approved ozone’s use
as a disinfectant in the food processing
industry
• Ozone therapy still under
research as a treatment for
cancer and as antiviral.
 Heliox
Helium is an odorless, colorless, monoatomic,
noble gas. Being an inert gas, helium is
nonreactive with body tissues and has no
bronchodilating or anti-inflammatory properties.
• Because 70% helium/30% oxygen has less
than half of the density of air or 100%
oxygen, it provides higher flows for a given
pressure difference when compared with air
or oxygen.

• This property of higher flows occurs for

turbulent or near-turbulent flows, which are
typically present in the portion of the airway
tree that contribute the most resistance
during ventilation. Heliox also provides higher
flows through partial airway obstruction
 Uses in children
1. Postextubation stridor
2. Croup
3. Bronchiolitis
4. Status asthmaticus
5. Respiratory distress syndrome
6. Bronchopulmonary dysplasia
 Uses in adults
1. Severe asthma
2. COPD
 Carbogen

• Mixture of 95% oxygen and 5% carbon dioxide

• Uses:
1. added to a number of anaesthetic and
oxygenation mixtures used under special
conditions such as cardio-pulmonary bypass
surgery and the management of renal dialysis.
2. Acute hearing loss.
3. Central retinal artery occlusion
Oxygen toxicity
Pulmonary consequences:

1-Increased intrapulmonary right-to-left shunt fraction

2-diminished lung volumes due to:
A. absorptive atelectasis(due to washout of alveolar
nitrogen )
B. accentuation of hypercapnia
C. damage to airways and pulmonary parenchyma.
D. Bronchopulmonary dysplasia (BPD)
 :Extrapulmonary consequences

• The retinopathy of prematurity (retrolental

fibroplasia)
• CNS symptoms, including generalized tonic-
clonic seizures.
• alter CVS function
- Local coronary vasoconstriction,
- ↓ stroke volume and cardiac output

- relative bradycardia,
:Oxygen with hypercapnea

 Traditional teaching emphasizes that

hypercapnia results from suppression of
hypoxic ventilatory drive.

 The major processes which contribute to

worsening hypercapnia are:
1. Worsened V/Q matching due to attenuation of
hypoxic pulmonary vasoconstriction
2. Decreased binding affinity of hemoglobin for
carbon dioxide
3. Decreased minute ventilation
What
is
this?

Chest radiograph in a patient with ARDS.

The patient was treated with perflubron,
which is used for partial liquid ventilation
 Liquid ventilation
• the lungs are partially filled with perfluorocarbon
(PFC), a clear inert liquid, in which both oxygen
and carbon dioxide are highly soluble to serve as a
respiratory medium
Thank
you