Oxygen Therapy

UKK PGD - IDAI

Goals and Indications

Goals : is to provide tissue oxygenation at the lowest inspired FiO2 Indications :

1. Documented Hypoxemia
Infants & Children : PaO2 < 60 mmHg or SaO2 < 90% (breathing room air) Neonates : PaO2 < 50 mmHg or SaO2 < 88%

Goals and Indications

Indications
2. In Acute care situation in which hypoxemia is suspected :
Shock Severe trauma Short term therapy (during certain medical procedures)

Contraindications
No specific contraindications Nasal cannulas : Nasal Obstruction Nasopharyngeal catheters : Basal skull fracture, Maxillofacial trauma & Nasal obstruction

Hazards, Precautions & Complications

8 7 6 5 4 3 2 1 Pulmonary limits

CNS limits

Several days

Time (hours) Relation between PO2 and exposure time for O2 toxicity
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O2 Toxicity

Increased FiO2

Increased Shunting

Low PaO2
The vicious circle that can occur in managing hypoxemia with High FiO2
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Hazards, Precautions & Complications

Physiologic:
Preterm infants (ROP) Paraquat, bleomycin : pulmonary fibrosis High FiO2 : Absorption atelectasis, BPD, free radicals

Equipment related
Hypoxemia, Hyperoxemia

Overview of the transport of gases

 O2 transported from lungs to tissues. O2 moves down a partial pressure gradient at each interface:
From alveolar gases into blood. From arterial blood into tissues. Into cells and into mitochondria.

CO2 transported from tissues to lungs. CO2 moves down a partial pressure gradient at the same interfaces.

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PO2 = 100 PCO2 = 40

PO2 = 40

PO2 = 100 PCO2 = 40

PCO2 = 40

PO2 = 40 PCO2 = 46
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Oxygenation
FiO2

The key factors which affect adequate oxygenation:

FiO2 (affect Alveolar O2 tension) Alveolar gas exchange The mixed venous oxygen content The distribution of ventilation to perfusion

PAO2

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Alveolar Oxygen Tension

FiO2
FiO2 PAO2 PAO2 = (PB - PH2O)FiO2 - PaCO2/RQ PAO2 = Alveolar O2 tension PB = Barometric pressure (760 mmHg at sea level) FiO2 = fraction of inspired oxygen PaCO2 = arterial CO2 pressure RQ = respiratory quotient = 0.8 PH2O = Water vapor tension (47 mmHg)

PAO2

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Alveolar Oxygen Tension

FiO2
PAO2 = (PB - PH2O)FiO2 - PaCO2/RQ PAO2 = (PB - PH2O)FiO2 - PaCO2/0.8

PAO2

10 years old boy in Surabaya breathing room air PAO2 = (PB - PH2O)FiO2 - PaCO2/0.8 PAO2 = (760- 47)0.21 - 40/1.25 = 100 mmHg

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Oxygen in Blood
O2 is held in 2 compartments in blood
Physically dissolved in plasma Chemically bound on hemoglobin

Solubility of O2 in plasma
= 0.003ml/dl blood/mmHg

The effective carrying capacity of Hb

= 1.34 ml O2/g Hb

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25 20 15

Hb = 15 g/dL

O2 Content (mL/100mL)

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Hb = 8 g/dL

Dissolved O2
0 20 40 60 80 100 120 140 180 200

PO 2

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700 600 500 400

. . V /Q = 1
A

300
200 100

. . VA/Q > 1 . . V /Q << 1

A
0.2
0.4 0.6 0.8 1.0

FiO2
West JB Respir Physiol 1969;7:88
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400

0
300

Arterial PO2

10%

200

25%
100

50%
0.2 0.4 0.6 0.8 1.0

FiO2
Arterial PO2 is plotted as a function of FiO2 for a variety of RL shunts (Benator SR, etal: Br J Anaesthesiol 1973;45:722)
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The Goal of Oxygen therapy

To achieve adequate tissue oxygenation with the lowest fractional concentration of inspired oxygen (FiO2)

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100 80 SaO2 %

B A

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15
CaO2 ml/dl Hb 15gm/dl
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60
10

40
5

20

0 0 20 40

60

80

100

120

140

PaO2 mmHg

1.0 0.9 Risk of clinical oxygen toxicity 0.8 0.7 0.6 Clinically safe 0.5

Fi02

0.4
0.3 0.21 0 1 2

Duration of exposure, days

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Oxygen Administration
Equipment : Smaller versions of the adult devices Low flow (Variable performance oxygen delivery systems) High flow (Fixed performance oxygen delivery systems) Reservoir Enclosure
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Oxygen therapy devices

Low flow
Nasal cannula Nasal catheter

Reservoir
Simple mask Partial rebreathing mask Non rebreathing mask

High flow
Air entraintment mask (Venturi mask)

Enclosure
Oxyhood Incubator O2 Tent

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A = Low flow device B = High flow device C = Reservoir device

Flow

Insp.

Exp.

= Patients flow = Devices flow

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 Advantages

Nasal cannula
A

Easy to use Disposable Useful for moderate O2 need

Disadvantages
Irritating nose and throat (> 6 L/min) Low FiO2 Variability in actual FiO2

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Nasal cannula
FiO2 determined by
Capacity of available O2 reservoir O2 flow Patients breathing pattern

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Nasal cannula
Anatomic reservoir capacity
2/3 ml/kgBW

O2 flow
xL/min = x1000ml/60 sec = 16.7 ml/sec

Breathing pattern
Cycle time I : E ratio The filling time anatomic reservoir
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2L/min O2 nasal cannula provided to a 5 kg infant breathing 40 times/min (assuming I:E ratio of 1:2)
Tidal volume : 6 ml/Kg

Anatomic reservoir : 2/3 ml/Kg O2 flow : Inspir. O2 Volume : Room air (flow) volume : 1L/min = 16.7ml/sec Inspiratory time x flow Tidal volume - (inspir O2 volume + anatomic reservoir volume)

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2L/min O2 nasal cannula provided to a 5 kg infant breathing 40 times/min (assuming I:E ratio of 1:2)
Tidal volume : Anatomic reservoir : Inspir. O2 Volume : Room air (flow) volume : Total O2 volume : FiO2 provided : 3.3 + 16.7 + 2.1 = 22.1 ml Total O2 volume/Tidal volume = 22.1 ml/ 30 ml = 0.74
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30 ml 3.3 ml 16.7 ml 10 ml = 10 ml x 0.21 = 2.1 ml O2

2L/min O2 nasal cannula provided to a 5 kg infant, goes

sleep, breathing 30 times/min (assuming I:E ratio of 1:2)
Tidal volume : 6 ml/Kg

Anatomic reservoir : 2/3 ml/Kg O2 flow : Inspir. O2 Volume : Room air (flow) volume : 1L/min = 16.7ml/sec Inspiratory time x flow Tidal volume - (inspir O2 volume + anatomic reservoir volume)

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2L/min O2 nasal cannula provided to a 5 kg infant, goes sleep, breathing 30 times/min (assuming I:E ratio of 1:2)
Tidal volume : Anatomic reservoir : Inspir. O2 Volume : Room air (flow) volume : Total O2 volume : FiO2 provided : 3.3 + 22.38 + 0.91 = 26.58 ml Total O2 volume/Tidal volume = 26.58 ml/ 30 ml = 0.90
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30 ml 3.3 ml 22.38 ml 4.32 ml = 10 ml x 0.21 = 0.91 ml O2

QuickTime and a TIFF (Un compressed) decompressor are neede d to see this picture.

Recommended Flow meter For newborn

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Masks

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Partial rebreathing mask

Nonrebreathing mask

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High Flow Systems

Air entraintment System Venturi Systems Enclosure Systems

Fixed FiO2 (WYSWYG)

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Air entrainment
Entrainment port

Jet

Jet

Jet

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Venturi (by Giovanni Venturi)

Jet

Entrainment port

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Equation for Computing O2 percentage, Ratio, and Flow

1. To compute O2% of a mixture of Air and O2 % O2 = (Air flow x 21) + (O2 flow x 100) Total flow 2. To compute air-to-O2 ratio needed to obtain O2% Liters air = (100 - %O2) (%O2 - 21) Liters O2
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3. To compute the total output flow from an air entrainment device (given the oxygen input) Compute the air-to-O2 ratio Add the air-to-O2 ratio parts Multiple the sum of the ratio parts by the O2 input flow

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4. To compute the flow of oxygen and air needed to obtain a given O2% at a given total flow

Compute the oxygen flow:

O2 flow = Total flow x (O2% - 21) 79 Compute the air flow: Air flow = Total flow - O2 flow

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TIFF (Uncompressed) decompressor are neede d to see this picture.

Venturi Flow (Salter Lab Ideal)

FiO2 (%%) Red Yellow Blue Orange Green 24 28 31 35 40

O2 Flow (L/min) 3 6 8 10 12

Total Flow (L/min) 105 68 63 56 33

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Venturi Flow (Hudson RCI)

QuickTime and a TIFF (Uncompressed) decompressor are neede d to see this picture.

Color

FiO2 (%)

O2 Flow (L/min)

Total Flow (L/min)

Blue
White Orange Yellow Red Pink

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28 31 35 40 50

3
6 8 12 15 15

78
66 72 72 60 40
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Ventury Systems
Total flow 3 - 4 times minute ventilation A 50 Kg asthmatic patients breathing 40 times per minute ( I:E = 1:3)
Minute volume = 50 x 6 x 40 = 9 Liters Needs total flow = 9 x 4 = 36 L/minute Please be informed about the total flow.

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Oxygen Hood
Advantages
Permit access to the chest, trunk and extremities for continue care Well tolerated by infants

Can deliver up to 100% oxygen (flow 10 - 15 L/min) Disadvantages

Very noisy for the patients Generally not large enough to be used over the age of 1 year
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Low-flow

High-flow

Enclosure systems

FiO2

Variable

Fixed

Variable (depend on devices)

Newborn

Nasal Cannula, Simple oxygen mask

An air entrainment mask (venturi systems)

Oxygen hoods, Closed incubators

Infant & Children

Nasal cannula, An air entrainment mask Nasopharyngeal (venturi systems) catheters, Simple oxygen mask, Reservoir masks

Oxygen hoods, Oxygen tents

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Monitoring
Vital signs O2 monitoring (FiO2) SaO2 Blood gas analysis P(A-a)O2 PaO2/FiO2

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Thanks to Priestley (1774) for discovering oxygen for us