Oxygen Therapy

Physiology of Oxygenation
Alveolar Gas Equation
PAO2=(PB-PH2O)FiO2 PaCO2(FiO2+1-FiO2) R Normal transit time for blood through pulmonary capillary is 0.3 to 0.7 sec Alveolar gas exchange is a major determinant of PAO2

Physiology of Oxygenation
Oxygen delivery to the periphery and its utilization depends on: 1. Oxygen content of arterial blood 2. Amount of blood i.e. cardiac output DO2 = CO X CaO2 X 10 CaO2 = (Hg X 1.34 X SaO2) + (PaO2X0.0031)

Oxygen Cascade
Dry air at sea level : 159 mmHg Trachea : 149 mmHg Alveolus : 101 mmHg Mitochondrion : 3.8 22.5 mmHg Mixed venous blood : 40 mmHg Oxygen consumption per minute at rest is 225 to 250 ml.

Oxyhemoglobin Dissociation Curve

Causes of Hypoxia
A.Hypoxemic Decreased oxygen intake (high altitude) Ventilation-perfusion imbalance (high V/Q) (obstructive airways disease) Shunt (low V/Q) (ASD, pulmonary AV fistula) Diffusion defect (interstitial pneumonitis) Alveolar hypoventilation (COPD) Low mixed venous oxygen

Causes of Hypoxia
B.Impaired Delivery Circulatory (forward flow) (hypovolemia, heart-failure) Distributive (sepsis, arterial insufficiency) Defective blood oxygen transport (inherited abnormal hemoglobin, anemia and acquired abnormal hemoglobin e.g. carbon monoxide poisoning)

Oxygen-tension based gas exchange indices

(A-a)DO2 : normally <15 mmHg in young healthy adults PaO2/PAO2 PaO2/FiO2 P(A-a)O2/PaO2 (Respiratory index)

Indications of Short-Term Oxygen Therapy

Arterial Hypoxemia
1. Hypoxemia with hypercapnia 2. Hypoxemia without hypercapnia

1. 2. 3. 4.

Tissue hypoxia without hypoxemia

Anemic hypoxia Circulatory hypoxia Cyanide poisoning Carbon-monoxide poisoning

Indications of Short-Term Oxygen Therapy

Cardiac failure, trauma and hypovolemic shock Acute myocardial infarction Miscellaneous: sickle cell crisis, acceleration of resorption of air in pneumothorax, relief of dyspnea without hypoxemia

Indications of Long-Term Oxygen Therapy

1.Continous Oxygen
Resting PaO2 < 55 mmHg or SaO2 < 88% Resting PaO2 56-59 mmHg or SaO2 89% in the presence of any of the following indicative of cor-pulmonale
Dependant edema suggesting CHF P-pulmonale on ECG (P wave >3 mm in I,II,aVF)

a) b)

c) d)

Polycythemia (hematocrit > 56%) Resting PaO2>59 mmHg or SaO2>89% justifying that more conservative therapy has failed

Indications of Long-Term Oxygen Therapy

2.Non-continuous Therapy During exercise PaO2 55 mmHg or SaO2 88% with a low level of exertion During sleep : PaO2 55 mmHg or 88% with associated complications like PAH, daytime somnolence and cardiac arrhythmias* *Oxygen flow rate and number of hours per day
must be specified

Goals of Oxygen Therapy

To increase alveolar oxygen tension To decrease the work of breathing required to maintain a given alveolar oxygen tension To decrease myocardial work necessary to maintain a given arterial oxygen tension

Guiding Principles of Oxygen Therapy

Administer minimum therapeutic dose needed to obtain the desired result and no more Prescribe either as percent (e.g. 24%) or a fractional concentration (FiO2 : 0.24) Assess bedside cardiac, pulmonary and neurological status before and beginning oxygen therapy

Evaluation of Oxygen Therapy

Physical examination of cardiopulmonary system: pulse rate and rhythm, blood pressure (systolic and diastolic), perfusion state- skin color, texture and capillary refill Urine output Level of consciousness Ventilatory pattern-respiratory rate, tidal volume and work of breathing Arterial blood gases : PaO2, PaCO2, acid-base status

Oxygen Delivery Equipment

Choice of equipment is based on:
a. b. c. d. 1. 2.
i. ii.

Degree of hypoxemia Requirement for precision of delivery Patient comfort Cost Rebreathing system Non-rebreathing system
Variable performance low flow system Fixed performance high flow system

Types of equipment

Guidelines for Selecting mode of Oxygen

Low flow system is adequate if: Tidal volume is between 300 to 700 ml Ventilatory rate is <25 per minute Ventilatory pattern is regular and consistent

Variable Performance Low Flow System

a. b. c.

Gas flow is not sufficient to meet all inspiratory demands Does not provide consistent and predictable FiO2 Factors affecting FiO2 are:
ventilatory pattern of the patient size of available oxygen reservoir oxygen flow (liters per minute)

Advantages : cheap, comfortable, easy to set up

Variable Performance Low Flow System

For every liter per minute (LPM) change in flow rate, ther is approximately 0.04 (4%) change in FiO2 The larger the tidal volume or faster the respiratory rate, the lower the FiO2 The smaller the tidal volume or slower the respiratory rate, higher the FiO2

Estimation of FiO2 in Low-Flow System

Example: Healthy person with normal ventilatory pattern; tidal volume=500 ml, respiratory rate=20, inspiratory time=1 sec, expiratory time =2 sec, anatomic reservoir=50 ml. 50 ml of 100% O2 from anatomic reservoir 100ml of O2 supplied by cannula flow rate 350 ml of 20% O2 (room air); thus 0.20 x 350 ml=70 ml of 100% O2 Thus 500 ml of inspired gas contains 220 ml of 100% O2 or the FiO2 is 0.44 (44%)

Variable performance Low Flow System

When a constant FiO2 is required, as in chronic carbon-dioxide retention, low-flow systems should not be used A low flow system is not synonymous with a low concentration of oxygen

Guidelines for Estimating FiO2 with Low-Flow Oxygen Devices

100% O2 Flow Rate (LPM) Nasal cannula or catheter 1 2 3 4 5 6 FiO2 0.24 0.28 0.32 0.36 0.40 0.44

Nasal prongs

Guidelines for Estimating FiO2 with Low-Flow Oxygen Devices

100% O2 Flow Rate (LPM) Oxygen mask 5-6 6-7 7-8 Mask with reservoir bag 6 7 8 9 10 FiO2 0.40 0.50 0.60 0.60 0.70 0.80 0.80+ 0.80+

Oxygen Mask

Fixed Performance High Flow System

Gas flow is sufficient to meet all inspiratory demands Provides consistent and predictable FiO2 Patients ventilatory pattern does not affect the FiO2 Based on the principle of air-entrainment and gaseous jet-mixing Better control of humidity and temperature both high and low concentrations can be administered

Air-Oxygen Ratio in High-flow System

Magic-box method 20 30

30 =0.6:1 70 50

100

50

Venturi Device with mask

Oxygen Conserving Devices

Trans-tracheal Oxygen Therapy (TTOT) Reservoir cannula

a. Moustache type b. Pendant type

Demand flow Oxygen Device System

Respiratory Flow Cycle in relation to Continuous Flow supplemental Oxygen

Trans-tracheal Oxygen Therapy

Moustache type & Pendant type Oximizer devices

Moustache type Oximizer Device during expiration & inspiration

Pendant type Oximizer device

Intermittent Flow Oxygen conservation devices

Enclosures
Oxygen Tents Oxyhoods

Oxygen Supply Methods

Home Oxygen is supplied from: Compressed oxygen cylinders Liquid oxygen cylinders Oxygen concentrators and enrichers

Compressed Oxygen Cylinders

Advantages Good for small-volume users no waste or loss, stores oxygen indefinitely, widespread availability Disadvantages Large cylinders are heavy and bulky, high pressures are a safety hazard (2200 psi), provides limited volume of oxygen, frequent deliveries may be necessary

Cylinder Oxygen Systems

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Liquid Oxygen Systems

Advantages Provides large quantities of oxygen, low pressure system, portable units can be refilled from reservoir (up to 8 hours supply at 2 LPM), valuable for rehabilitation Disadvantages Loss of oxygen due to venting when system is not in use, LOX must be delivered as needed, low temperature may be a safety hazard

Liquid oxygen
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Liquid Oxygen Reservoirs (Stationary System)

Portable Liquid Oxygen Unit

Oxygen Concentrator
Advantages No waste or loss, low pressure system (15 psi), cost-effective when continuous supply of oxygen is needed, eliminates need for oxygen delivery Disadvantages Disruption in electrical service renders system inoperable, back-up oxygen is necessary, cannot operate ventilators or other high pressure devices, concentration of oxygen decreases with flow rate, electrical costs for operating system may be substantial

Oxygen Concentrator

Limitations of Oxygen Therapy

Refractory Hypoxemia: *PaO2 < 55 mmHg at FiO2 > 0.35 *PaO2 > 55 mmHg at FiO2 < 0.35 AND response to oxygen challenge of 0.2 FiO2 is less than 10 mmHg Hypoxic Vasoconstrction (HPV) Denitrogenation Absorption Atelectasis (DAA)

Adverse Effects of Oxygen Therapy

Altered physiology *Pulmonary (hypoventilation, absorption atelectasis, pulmonary vasodilatation, decreased mucociliary clearance) *Extra-pulmonary (suppressed (erythropoesis, decreased caediac output, systemic vasoconstriction) Pulmonary Tissue Injury Syndrome (tracheobronchitis, ARDS, Broncho-pulmonary dysplasia) Retinopathy of prematurity

Oxygen is addicting: in its grip are all mitochondria-rich eukaryocytes who learned to depend on it during the past 1.4 billion years. This, the first atmospheric pollutant, is the waste product of Stromatolytes (formation of algal plankton), which excreted it at least 2.3 billion years ago. Since then all sediments have been rusted or oxidised. Oxygen is toxic. It rusts a person in a century or less. With oxygen came the danger and blessing of fire. If introduced today, this gas might have difficulty in getting approved by the Food and Drug administration

Severinghaus JW, astrup PB. History of blood gas analysis; In: Leland Clarks electrode. J Clin Monit 1986;2;125-139

Cellular Mechanisms of Oxygen Toxicity

Step 1 produces superoxide molecule Step 2 produces hydrogen peroxide Step 3 produces hydroxyl ion Step 4 produces water Followed by free radical reactions: lipid peroxidation, enzyme inactivation and nucleic acid damage Cellular defences: superoxide dismutase, glutathione peroxidase, ascorbic acid, alphatocopherol and beta-carotene

Factors that Increase Susceptibility to Oxygen Toxicity

Adrenergic stimulation Corticosteroids Hypothermia Hyperthyroidism Vitamin E deficiency Protein deficiency Premature birth Bleomycin

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