Oxygen therapy

Oxygen is a treatment for hypoxaemia, not

breathlessness.
By : Alyssa Aldilla (406152080)

Bagian Anestesiologi RSUD Cibinong, Bogor

Periode 5 Juni 2017 14 Juli 2017
Fakultas Kedokteran Universitas Tarumanagara
Indications for Oxygen Therapy

Documented hypoxemia, defined as a decreased PaO2 in the blood below

normal range. PaO2 of < 60 torr or SaO2 of < 90% in patients breathing room
air, or with PaO2 and/or SaO2 below desirable range for specific clinical
situation.
An acute situation in which hypoxemia is suspected. Substantiation of
hypoxemia is required within an appropriate period of time following initiation
of therapy.
Severe trauma.
Short-term therapy (e.g., carbon monoxide poisoning) or surgical intervention
(e.g., post-anesthesia recovery).
Pneumothorax absorption.
Hypoxia

Hypoxia refers to a condition where the amount of oxygen available to

the cells is not adequate to meet metabolic need.
The causes of hypoxia are :
Hypoxemia (e.g., at high altitudes).
Anemic hypoxemia (e.g., reduced hematocrit or
carbon monoxide poisoning).
Stagnant hypoxemia (e.g., shock, ischemia).
Histotoxic hypoxia/dysoxia (e.g., cyanide poisoning).
Hypoxemia

If the partial pressure of O2 (PaO2) is less than the level predicted for
the individuals age, hypoxemia is said to be present.
Some of the causes of hypoxemia are:
Low Pinspired O2 (e.g., at high altitude).
Hypoventilation, V/Q mismatch (e.g., COPD).
Anatomical Shunt (e.g., cardiac anomalies).
Physiological Shunt (e.g., atelectasis).
Diffusion deficit (e.g., interstitial lung disease).
Hemoglobin deficiencies.
Oxygen Hemoglobin
Dissociation Curve
Oxygen transport can
be explained and
depicted by the
oxygen-hemoglobin
dissociation curve.
factors affecting the loading and
unloading of oxygen are:
Blood pH (Bohr effect)
Body temperature
Erythrocyte concentration of certain organic phosphates (e.g., 2,3
diphosphoglycerate)
Variation to the structure of the hemoglobin (Hb) molecules (e.g.,
sickle cells, methemoglobin (metHb) and fetal hemoglobin (HbF))
Chemical combinations of Hb with other substances (e.g., carbon
monoxide)
Oxygen Delivery Device

Low Flow O2 Therapy

High Flow O2 Therapy
+/- Humidity Therapy
Low Flow Oxygen Delivery
Devices
Low flow oxygen delivery devices provide a variable FiO2 depending
on the patients/clients inspiratory demands. As the inspiratory
demands increase, ambient air is entrained and the FiO2 is diluted.
Examples of low flow devices include:
Nasal Cannula
Nasal Catheter
Transtracheal Catheter Simple Mask
Partial Rebreather Mask Non-Rebreather Mask
High Flow Oxygen Delivery
Devices
High flow oxygen delivery devices will provide a fixed FiO2 (0.24 - 1.0)
regardless of the patients/clients inspiratory demands.
Some examples of high flow devices include:
Air Entrainment Mask (Venturi);
Air Entrainment Nebulizer;
Nasal High Flow Oxygen Therapy;
Mechanical Ventilators (invasive Non-invasive); CPAP/APAP
Machines;
Resuscitation Bags; and
Hyperbaric Oxygen Chambers.
Humidity

Humidity refers to the water vapour content of a gas. In a healthy

individual air is delivered to the alveoli at Body Temperature and
Pressure Saturated (BTPS)
Humidification of the air we inspire normally takes place via the nasal
passages and upper airway. with supplemental medical gas (generally
cool and dry) can cause drying of the secretions and mucosa
potentially leading to airway obstruction and tissue injury
Clinical Signs and Symptoms of Inadequate Airway
Humidification

Atelectasis
Dry, non-productive cough
Increased airway resistance
Increased incidence of infection
Increased work of breathing
Substernal pain
Thick dehydrated secretions
 Ventilatory support:
1. In patients with hypercapnic respiratory failure, in whom an ABG
measurement shows a pH <7.35 and
PaCO2 >45 mmHg, NIV or invasive ventilation should be considered.49-53
[Grade A] COPD patients with a pH
<7.26 managed with NIV require more intensive monitoring with a low
threshold for intubation.52 [Grade A]
2. In patients in whom oxygen-induced hypercapnia is suspected, oxygen
therapy should be titrated to
maintain the 88-92% target oxygen saturation range and not be abruptly
stopped due to the risk of profound
rebound hypoxaemia.54-56 [Grade C]
 3. In patients with severe cardiogenic pulmonary oedema continuous positive
airway pressure (CPAP) should
be considered.57 [Grade A]
4. NIV is not routinely recommended in acute hypoxaemic respiratory failure, as
results from clinical trials
and observational studies have provided mixed results for various patient
groups,50, 58-61 however there is
some evidence of benefit in certain patients with immunosuppression.50, 59, 61-
63
5. It is recommended that patients receiving ventilatory support are located in a
ward area such as an HDU,
ICU, a close observation unit or monitored bed unit, where there are adequate
numbers of staff experienced
in ventilatory support to provide an appropriate level of monitoring and titration of
therapy.49 [Grade D]
Assessment of Oxygen Therapy
Oximetry
measurement of blood hemoglobin (Hb) saturations using
spectrophotometry:
Hemoximetry (also called CO-oximetry) performed in arterial
blood gas analysis.
Pulse Oximetry - portable, noninvasive monitoring technique
Blood gases indication
All critically ill patients
Unexpected or inappropriate fall in SpO2 below 94% in patients breathing air or oxygen or any
patient requiring oxygen to achieve the above target range (Allowance should be made for
transient dips in saturation to 90% or less in normal participants during sleep.)
Deteriorating oxygen saturation (fall of 3%) or increasing breathlessness in a patient with
previously stable chronic hypoxaemia (eg, severe COPD)
Most previously stable patients who deteriorate clinically and require increased FiO2 to maintain
a constant oxygen saturation
Any patient with risk factors for hypercapnic respiratory failure who develops acute
breathlessness, deteriorating oxygen saturation, drowsiness or other features of carbon dioxide
retention
Patients with breathlessness who are thought to be at risk of metabolic conditions such as
diabetic ketoacidosis or metabolic acidosis due to renal failure
Any other evidence from the patients medical condition that would indicate that blood gas
results would be useful in the patients management (eg, an unexpected change in track and
Target therapy
There have been no randomised trials comparing different oxygen
saturation levels for patients not at risk of hypercapnic respiratory failure.
Expert opinion (based on physiology and observational studies)
recommends maintaining normal or near-normal oxygen saturation of 94
98% for these patients
The target saturation in patients with COPD who are at risk of hypercapnia
is 8892%
The target saturation for patients with other risk factors for hypercapnia
(eg, morbid obesity, chest wall deformities on neuromuscular disorders) is
8892% based on expert opinion which is extrapolated from observational
studies
THANK YOU
Reference
This College of Respiratory Therapists of Ontario (CRTO). 2013.
Oxygen Therapy Clinical Best Practice Guideline. P 5-43.
ODriscoll B R, Howard L, Earis J, Mak V, Bajwah S, Beasley R, et al.
British Thoracic Society. BTS guideline for oxygen use in adults in
healthcare and emergency settings. 2017. THORAX an international
journal of respiratory medicine vol 72 supp 1.