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

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** Agitation Diaphoresis Cyanosis

Tachypnea Dyspnea 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 -170C 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 inside Temperature -170C 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 15C 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

PATIENTS WITH 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 SUPPORTINDICATIONS 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 patients 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 patients 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, its

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 patients 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%