BASIC PRINCIPLES OF OXYGEN THERAPY

dr. Prabowo Wicaksono Y.P., SpAn Anesthesiology Department UNISSULA Medical Faculty 2012

Why do we need oxygen?

Our organs requires energy to function. Energy is gained from daily food intake and the sugar and fat reserves of the body.

Without energy, cells cannot work Without the burning of nutrient, energy cannot be produced Without oxygen, there is no burning process in the cells Without oxygen, life is not possible. Deprivation for more than a few minutes is fatal Brain Damage !!!!
O2 Alveoli Blood (Hb) Cell Cytochrome C oxidase molecules H2O + energy

Inhaled oxygen will absorbed into bloodstream via alveoli (tiny sacs in lungs). A passing molecules called Hemoglobin (Hb) in the red blood cell will transport the oxygen to the cell. Inside the cell, a protein called Cytochrome C oxidase will make 2 molecules of water out of every molecules of oxygen and an energy is released. The cell use the energy to perform everyday function.

Supply of oxygen to tissue depends on 3 factors: Respiratory system Cardiovascular system Hematological (Hb and its affinity to oxygen)

Respiratory System
Respiratory system is concerned with: Delivery of adequate amount of oxygen and elimination of carbon dioxide from the body Maintenance of normal acid base balance Optimal function of respiratory system depend on function of: Chest wall and respiratory muscles Airways and lungs Central Nervous System (medullary respiratory centre) Spinal Cord Cardiovascular System Endocrine System
Disorder in any portion of these system can lead to respiratory failure

Respiratory Failure (RF)

Inability to keep the arterial blood gases at normal level while breathing air at rest at sea level. The PaO2 < 60 mmHg, with or without PaCO2 > 49 mmHg in arterial blood. Respiratory failure may be acute or chronic. Two basic types of RF: TYPE I RF (Lung Failure): Hypoxemic. Interference with the pulmonary system's ability to adequately oxygenate the blood as is circulates through the alveolar capillaries. PaO2 (room air) < 60 mmHg. (Normal PaO2: 75-100 mmHg). TYPE II RF (Ventilation Failure) : Hypercapnic. Failure to prevent CO2 retention (e.g., severe airflow obstruction, central resp. failure, neuromuscular resp. failure) PaCO2 > 50 mmHg. (Normal PaCO2: 35-45 mmHg) Example: COPD, bronchial asthma, neuromuscular disease, chest wall disorders.

Causes of acute respiratory failure:

A. Defective Ventilation Respiratory centre depression: - Drugs such as narcotics, anesthetics and sedatives - Cerebral infraction - Cerebral Trauma Neuromuscular Disease: Myasthenia Gravis, Guillan Barre syndrome, brain or spinal injuries, polio. Airway Obstruction: COPD, acute severe asthma Restrictive defects: Interstitial lung disease, bilateral diaphragmatic palsy, severe obesity B. Impaired diffusion and gas exchange Pulmonary edema Acute respiratory distress syndrome (ARDS) Pulmonary Fibrosis Pulmonary Thromboembolism C. Ventilation perfusion abnormalities COPD Pulmonary Fibrosis ARDS Pulmonary Thromboembolism

Management of respiratory failure

Objective: achieve and maintain adequate gas exchange and reversal precipitating factor that led to the failure. In type 1 RF high concentration of O2 is given to correct hypoxemia. Should be determined whether the hypoxemia can be relieved by oxygen therapy alone or it needs oxygen and ventilatory intervention. Patient with ARDS do not improve with simple oxygen therapy and they need mechanical ventilation (Positive End Expiratory Pressure- PEEP) . In type 2 RF with previous normal lungs, there is inadequate alveolar ventilation and in these patient ventilatory assistance is needed. In patient with previous lung disease as in acute exacerbation of COPD, controlled oxygen therapy is needed.

Definition of oxygen therapy

Administration of oxygen as medical intervention for a variety of purposes in both chronic and acute patient care. By increasing the supply oxygen to the lungs and thereby increasing the availability of oxygen to the body tissues, especially in patient suffering from hypoxia and or hypoxemia. Hypoxia: Hypoxia: lack of oxygen at the tissue level Hypoxia differs from hypoxemia: the oxygen concentration within the arterial blood is abnormally low (below 85-100 mmHg).

In immediately life threatening situations oxygen should be administered.

When to use oxygen therapy? Hypoxia and or hypoxemia

Acute hypotension.
Breathing inadequacy. Trauma. Acute illness. CO poisoning. Severe anaemia. During the peri-operative period.

Goals of oxygen therapy:

Relieve hypoxemia by increasing alveolar tension Reduce work of breathing Decrease the work of myocardium Maintain PaO2 > 60 mmHg (Blood Gas Analysis): will provide 90% saturation of arterial blood (SpO2 90%), but if acidosis is present, PaO2 more than 80 mmHg is required

Tissue oxygen delivery depends upon: Adequate function of cardiovascular (cardiac output and flow) Hematological (hb and its affinity for oxygen) Respiratory (arterial oxygen pressure) system.

Tissue hypoxia is not relieved by oxygen therapy alone, functioning of all the

three organ systems also needs to be improved

To ensure safe and effective treatment remember: Oxygen is a prescription drug.

Prescriptions should include:

1.
2. 3. 4.

Flow rate.
Delivery system. Duration. Instructions for monitoring.

Delivery Methods
Various devices are used for administration of oxygen.

Sources (Compressed gas storage, high pressure) pressure regulator

flow meter (litres per minute /lpm, range from 0-15 lpm)

Choices of devices dependant on the situation, flow required and patient preference.
Delivery devices: 1.Nasal cannulae (nasal prongs/speculae). 2.Simple facemask. 3.Partial rebreathing mask 4.Non-rebreathing mask. 5.Venturi mask.

1. Nasal Cannulae (NC)

A thin tube with two small nozzels that protude into the patient nostrils. Easy to use. Well tolerated. Comfortable for long periods. Patient can eat and talk easily. Possible to deliver oxygen concentrations of 24-40% at flow rates of 1-6 litres/min. Flow rates in excess of 4 litres/min might cause discomfort and drying of mucous membranes and are best avoided.

2. Simple Face Mask Easy to use. Requires a good fit. Between 6-12 lpm, concentration of oxygen 28-50%

3. Partial Rebreathing Mask Based on a simple face mask, but featuring a reservoir bag which increases the provided oxygen rate to 40-70% oxygen at 5 -15 lpm.

4. Non Rebreathing Mask

Draw oxygen from an attached reservoir bags, with one way valves that direct exhaled air out of the mask. When properly fitted and used at flow rates of 10-15 lpm, they deliver close to 100% oxygen. This type of mask is indicated for acute medical emergencies.

5. Venturi Mask
Also known as an air-entrainment mask is a a type of disposable face mask used to deliver a controlled oxygen concentration to a patient, are considered high-flow oxygen therapy devices. The flow of 100 per cent oxygen through the mask draws in a controlled amount of room air (21 per cent oxygen). Commonly available masks deliver 24, 28, 31, 35, or 40 per cent oxygen. The kits usually include multiple jets in order to set the desired FiO2which are usually color coded. The color of the device reflects the delivered oxygen concentration, for example: blue = 24%; yellow = 28%; white = 31%; green = 35%; pink = 40%; orange = 50%.

Venturi Mask

Humidification
Is recommended if more than 4 litres/min is delivered. Helps prevent drying of mucous membranes. Helps prevent the formation of tenacious sputum.

Monitoring Oxygen Therapy

SpO2 >90% (PaO2 60 mmHg)

When to stop oxygen therapy?

Patient becomes comfortable Underlying disease stabilized Blood pressure, pulse rate, respiratory rate and oxymetry are within normal range

How to assess patient condition in 10 seconds?

1.Stimulate verbal response: good response = airway is clear, breathing and ventilation adequate.

1.No response: Look, listen , feel Look: chest movement, sign of hypoxia (cyanosis), accessory respiratory muscle Listen: snoring, gurgling, stridor, hoarness or no sound (apnea?) Feel : air movement in front of nose.
3. Unconscious patient, Airway obstruction ? Chin lift, jaw thrust (head tilt). 4. Spontaneous breathing or apnea (not breathing?) Still breathing: give oxygen (NRM with 12 lpm) Apnea : positive pressure ventilation with 100% oxygen (10-12 lpm).

A. Inisiasi dan Alur Kebutuhan Terapi Oksigen

Kebutuhan oksigen pada pasien dengan gangguan sirkulasi / nafas akut

Saturasi oksigen >95% Hipoksemia ringan (PaO2 60-79 mmHg dan SaO2 90-94%)

Hipoksemia sedang (PaO2 40-60 mmHg, SaO2 75%-89%)

Hipoksemia berat (PaO2 <40 mmHg dan SaO2 < 75%)

Metode Pemberian Oksigen Sistem aliran rendah Sistem aliran tinggi

Low concentration

Low concentration

High concentration

Kanul binasal 1 6 L/menit Sungkup venturi High concentration 24 44% 48 L/menit Sungkup muka sederhana Sungkup muka kantong rebreathing

Head box

10 12 L/menit Pertimbangkan intubasi ET dan ventilasi dibantu

Sungkup muka kantong non rebreathing PCO2 >50

SpO2 <93% PCO2 <50 58 L/menit 6 10 L/menit

8 12 L/menit

95 100 % FiO2

40 60 % FiO2

95 100 % FiO2 40 60 % FiO2

Thank you