OXYGEN THERAPY

&
DEVICES

CO-ORDINATED BY : DR. AMIT CHAUDHARY

PRESENTED BY : DR. ASLAM AZIZ RIZVI
Why Oxygen is required for survival?
Aerobic Metabolism
Oxidative phosphorylation
Glucose → CO2+H2O+ 38ATP
Anaerobic Metabolism
Glucose→ Lactic Acid + 2ATP

Deprivation of Oxygen leads to death most rapidly.

Therapy with oxygen is useful or necessary for life in
several diseases and intoxications which interfere with
normal oxygenation
FiO2: fraction of conc of O2 in inspired air
P(A-a)O2: alveolar arterial gradient
SpO2: % of O2 saturation with Hb
SaO2: arterial O2 saturation
SvO2: venous O2 saturation
PaO2: PP of O2 in arterial blood
CaO2: O2 content of arterial blood
Oxygen Cascade

pO2 (mmHg) O2 content

Inspired air 159 21ml%
Alveolar air 101-104 13-14ml%
Arterial Blood 98-100 19ml
Mitochondrial 5-10
Venous Blood 40 14ml%

Pasteur Point
Normal Oxygenation
Oxygen Hb
Plasma

O2 capacity of Hb - 1.34 ml/gm

O2 saturation of arterial blood - 97%
Solubility in plasma - 0.003ml O2/dl of blood/mmHg
CaO2 = (1.34 x Hb Conc. x SpO2) +(0.003ml x
PaO2) = 19.8ml/dl blood
CvO2= 0.003x 40 + o.75 x 15x 1.31 = 14.8ml/dl blood
CaO2-CvO2 = 5 ml/dl blood
Oxygen Deprivation
Hypoxia is the term used to denote insufficient
oxygenation of the tissues.
Types :
1. Hypoxic Hypoxia
2. Anemic Hypoxia
3. Stagnant Hypoxia
4. Histotoxic Hypoxia
O2 Flux
DO2= CaO2 x Q
= 20ml O2/dl blood x 50dl blood/min
= 1000 mlO2/min
So, depends on Cardiac output, PaO2, Hb. Conc

VO2= Q x CaO2-CvO2 = 250ml/min

O2 extraction = (CaO2- CvO2)/ CaO2= 25%
Oxygen therapy
Administration of oxygen in concentration more than
ambient air
Oxygen therapy is must whenever PaO2< 60mmHg or
SpO2< 90%
Goals of oxygen therapy
Treatment/Prevention of hypoxemia.
Decrease myocardial work
Decrease work of breathing

Increased metabolic demand

Oxygen Delivery Systems
With the exception of anaesthesia circuits, virtually all O2
delivery systems are non rebreathing
In these circuits, exhaled VT does not form part of the
inspiratory gas and the only CO2 inhaled is that which
exists in any entrained room air
To avoid rebreathing, exhaled gases must be sequestered by
one way valves and inspired gases must be presented in
sufficient volume & flow to allow high peak flow rates and
MV demonstrated in critically ill pts.
Inspiratory entrainment of room air OR the use of
inspiratory reservoirs and one-way valves typifies non-
rebreathing systems & defines them into two groups:-

Low Flow Systems/ Variable Performance System

 Depend on inspiration of room air to meet inspiratory flow &
vol demands

High Flow Systems/ Fixed Performance System

 Provide the entire inspiratory atmosphere
 They use reservoirs or very high flow rates to meet large peak
inspiratory flow demands & exaggerated MV of critically ill pts
Low Flow Systems/
Variable Performance System
 Depend on inspiration of room air to meet the pts peak
inspiratory flow & minute vol demands that are not met by
inspiratory gas flow or O2 reservoir alone

 Nasal cannulas,
 simple face mask,
 partial rebreathing masks,
 non rebreathing masks,
 tracheostomy collars
Criteria:
 VT 300-700ml
 RR <25/min
 Regular & consistent ventilatory pattern

Produce FiO2 values from 21- 80%

FiO2 may vary with size of O2 reservoir, O2 flow & pts
ventilatory pattern

Low flow sys do not mean low FiO2 values

Example 1:
 Normal pt
 Anatomic reservoir for
nasal cannula ~ 1/3 of
anatomical dead space
=150/3= 50ml
 Flow rate:
6l/min=100ml/sec
 I:E= 1:2
 If the terminal o.5 sec of
2sec exp time has
negligible flow, anatomic
reservoir completely fills
with 100% O2, if flow
rate 100ml/sec
 Calculate FiO2
Thus,
Larger the VT or faster the
RR LOWER the FiO2

Smaller the VT or lower the

RR HIGHER the FiO2
High Flow/ Fixed Performance Systems
Are non rebreathing systems that Provide the entire inspiratory
atmosphere needed to meet the peak inspiratory flow & minute
ventilatory demands of pt

 Venturi masks
 Aerosol masks

 Adv:
 Ability to deliver predictable, consistent and measureable high & low FiO2,
despite pts ventilatory pattern
 Ability to control the humidity & temp of delivered gases
 Limitations:
 Cost, bulkiness, pts tolerance
High Flow/ Fixed Performance Systems
2 primary indications:

Pts who require a consistent, predictable, minimal FiO2

to reverse hypoxemia YET prevent hypoventilation
because of a dependence on hypoxic ventilatory drive

Pts with inc MV & abnormal respiratory pattern who

needs predictable & consistent high FiO2
Nasal Cannula
FiO2 – 24%-44%
Adults- 4-6ltr/min
Newborn- .1-.9 l/min
Add moisture above
4ltr/min
FiO2 varies with pt.
respiratory rate and
volumes
For each 1 l/min ↑ in
flow, FiO2 ↑ by 4%
Simple Face mask
To provide a higher FiO2, size of
O2 reservoir must inc.
Consists of 2 side ports
They allow air entrainment & exit
for exhaled gases.
Mask serves as an additional 100-
200ml reservoir.
Has no valves
FiO2 – 40-60%
Gas flow> 8l/min do not
significantly ↑ FiO2 above 0.60 as
the O2 reservoir is filled
At least 5L/min to flush out CO2
 Partial Rebreathing Mask
To deliver FiO2 >60% with low flow system, O2 reservoir must
be inc
Adds a reservoir bag with 600-1000ml
Side ports allow entrainment of air & exit of exhaled gases
1st 33% of pts exhaled VT fills the reservoir bag. This vol is from
the anatomic DS & contains little CO2.
During inspiration the bag should not collapse or it will l/t
↓FiO2 coz of entrained air
With the next breath, the 1st exhaled gas(in reservoir bag) &
fresh gas are inhaled→ Partial rebreather
Fresh gas flows ≥8L/min &
reservoir bag must remain
inflated during entire ventilatory
cycle to ensure highest FiO2 &
adequate CO2 evacuation
FiO2 0.60-0.80+ can be delivered
Allows O2 conservation, so maybe
useful during transportation.
Non Rebreathing Mask
Similar but adds 3 unidirectional valves
One way vlaves located on each side to vent exhaled gases
3rd unidirectional valve situated b/w mask & reservoir bag.
Prevents exhaled gases from entering into bag
Bag must be kept inflated
fiO2 0.80-0.90
Fgf 15l/min
Safety valve: spring valve that permits entrainment if
reservoir is evacuated. Is needed to meet demand of critically
ill pts
If total ventilatory needs are met without entraiment, the
rebreathing mask performs like a high flow system
Mask should fit snugly to avoid entrainment
Problems:
Gastric distention, cutaneous irritation
Tracheal Collars
Used to deliver humidity to pts with artificial airways
fiO2 is unpredictable, inconsistent & dependent on
ventilatory pattern
Venturi Masks (High Flow Devices)
Fixed performance device
Also k/a High Air Flow Oxygen Enrichment (HAFOE)
Entrain air by bernoulli principle & constant jet pressure
mixing
As gas flows under pressure at a rapid flow rate through a
narrowed orifice, an area of subatmospheric pressure
develops lateral to small opening→ creates a ‘jet drag’
This causes air entrainment until pressures are equalized
Altering the gas orifice OR entrainment port size causes
FiO2 to vary
Provides predictable & reliable FiO2 values 0.24-0.50
independent of pts ventilatory pattern

 Fixed FiO2 model: requires special inspiratoy attachments

that are color coded & have labelled jets that produce a
known FiO2 with a given flow

 Variable FiO2 model: which has a graded adjustment of air

entrainment port that can be set to allow variation in
delivered FiO2
Standard air –oxygen entrainment ratios & minimum
recommended flows for a given FiO2 must be used
Min total flow requirement equals 3-4 times MV, i.e. reqd
to meet pts peak inspiratory flow demands

Special Concerns:
 Obstructions distal to the jet orifice can produce back
pressure & an effect k/a “Venturi stall” → entrainment is
compromised → ↓ total gas flow & ↑FiO2.
 Aerosol devices should not be used. Water droplets can
occlude the oxygen injector
Color Coding
Blue 24% 4l/min
White 28% 6
Orange 31%
Yellow 35% 8
Red 40% 8
Green 60% 12
Aerosol Masks & T Pieces with Nebulizers or
Air-Oxygen Blenders
Deliver consistent & predictable FiO2 regardless….
T Piece c/b used for pts with artificial airway
Deliver FiO2 0.35-1.00
Max gas flow 14-16l
Air is entrained at higher FiO2 → total flow ↓ at high FiO2
To meet ventilatory demands, 2 nebulizers may feed a
single mask to inc total flow and a short length of
corrugated tubing m/b added to aerosol mask side ports to
inc reservoir capacity
Circuit resistance may inc as a result of kinking of
aerosol tubing→↑pr at venturi device →↓air
entrainment, ↑FiO2, ↓total gas flow.
So, an air-oxygen blender s/b used for FiO2>0.40
These can deliver consistent & accurate FiO2 from
0.21-1.0 & flows upto 100l/min
Recommended for pts with inc MV who require high
FiO2 & in whom bronchospasm m/b precipitated by
nebulized water aerosol
Oxygen Blender
Manual Resuscitation Bags
Used for resuscitation & manual ventilation of ventilator
dependent pts
Can deliver FiO2> 0.90, VT upto 800ml,O2 flows 10-15 ml/min
PEEP valves s/b used for pts who require >5cm H2O PEEP
Complications
Normobaric O2 inhalation for
6-8 hrs reduced tracheal mucous velocity
12 hrs retrosternal burning
chest tightness
fatigue
24 hrs anorexia
nausea / vomiting
malaise
cough
hiccups
grunting sensation
24-48 hrs reduced FVC
reduced gaseous exchange
72-96 hrs pulmonary oedema
Respiratory
Hypoventilation.
Absorption atelectasis.
Tracheobronchitis.
Bronchopneumonia.
Pulmonary toxicity.
Bronchopulmonary dysplasia in newborn.
Non Respiratory
CVS – HR
CO
Diastolic BP
Pulmonary artery pressure
CNS – Behavior changes
Depression / euphoria
Vertigo
Tinnitus & muscular toxicity
Seizures
Non Respiratory
Eye – Retinopathy of prematurity
Visual Toxicity – progressive myopia
cataract
Middle ear – TM rupture
Serous otitis media
Compression arthralgia.
Claustrophobia.
Fire hazards.
Complications
Hypoventilation

 Pts with COPD who depend on hypoxic ventilatory drive

 So have a chronically elevated PaCO2, Normal pH, PaO2<60mmHg
 ↑PaCO2 compensated by inc HCO3 in arterial blood & CSF→ pt
becomes desensitized to ventilatory stimulation to changes in
PaCO2.
 Here, chemoreceptors in aortic & carotid bodies control ventilation
(sensitive PaO2<60mHg)
 Goal is to raise the PaO2 just to pts chronic level
 If it raises PaO2 above this level, pts hypoxic drive is blunted &
hypoventilation results→ Respiratory failure
Absorption Atelectasis

 N2 already at equlibrium remains within alveoli & splints alveoli

open
 At high FiO2→ N2 is washed out of alveoli → now filled with O2.
 In areas of lungs with reduced V/Q ratios, O2 is absorbed into
blood faster than ventilation can replace it.
 The affected alcveoli become smaller until ST becomes so great that
they collapse
 FiO2>o.50 may ppt this in pts with dec V/Q ratios
Oxygen Toxicity

 After 8-12hrs of exposure to high fiO2

 Higher production of O2 free radicals i.e. O2-, OH-, H2O2 & O. this
affects cell func by:
 Inactivating sulfhydrl enzymes, disrupting DNA synthesis &

disrupting cell membrane integrity

 Vit E, superoxide dismutase promote protective free radical
scavenging within lungs.
 During lung hyperoxia, these protective mech are overwhelmed &
toxicity results
 Cough, substernal pain, dyspnoea, rales, pul edema, arterial
hypoxemia, b/l pul infiltrates, atelectasis
2 types:
Chronic
Acute
2 phases:
Early/exudative phase: 24-48hrs
Late/proliferative phase: > 72hrs

Use only min FiO2 to obtain SaO2>90%

 Retrolental fibroplasia

 vascular proliferation, fibrosis, RD

 Neonates < 36wks gestation inc risk
PaO2 < 140mmHg → Safe
Hyperbaric O2 Therapy
O2 therapy at greater than 1 atm pressure
Usually at 2-3 atm pressure.
It leads to inc. in dissolved content of O2 in plasma,
along with inc. of O2 bound to Hb (≈1%).
1 atm pressure – 0.3 ml O2
2 atm pressure – 4.038 ml O2
3 atm pressure – 6.072 ml O2
Hyperbaric Oxygen Therapy:
At sea level barometric pr is 760mmHg/1 atm pr
Arterial pCO2 40mmHg & pH20 is 47mmHg
Thus, inhalation of 100% O2 at 1 atm pr ↑es the art pO2 to a max of 760-
(40+47)= 673mmHg
(O2 content= Hbx1.34x SaO2+0.003XPaO2)

Thus at 1atm pr, level of dissolved O2 can only be ↑ed to (673x0.003) =

2ml/100ml of blood
But this is not sufficient to meet the resting tissue O2 demand of
5ml/100ml of blood
So, pt is asked to breathe 100% O2 in a chamber at high pr
At 2atm pr → 2x673x0.003= 4.038ml/100ml blood
At 3atm pr → 3x673x0.003= 6.057ml/100ml blood
Indications for HBO
Decompression sickness
Diver with the ‘bends’
Gas gangrene
Reduces the size of the bubbles
Carbon monoxide and Cyanide poisoning
Decreases half life of CO bond
Severe anemia (blood loss)
Wound healing
Ischemic skin grafts, flaps, burns
Acute ischemic vasculitis
Hyperbaric O2 Toxicity
Convulsions & coma- Paul Bert Effect
Cardiac Failure
Hemolytic anemia
Subcutaneous emphysema.
Organ damage- thyroid, adrenal, kidney
Inflammation of lungs- Lorraine Smith Effect
Helium O2 Therapy
Advantages – turbulence
viscosity
density
Leads to gaseous exchange, viscosity of secretion
which leads to clearance.
Mixture: 80% / 20% or 70% / 30%
Densities: 1.803 & 1.586 times less.
Indications Helium O2 Therapy
Pt. with acute distress from upper airway obstruction.
Driving gas for small vol. nebulizers and
bronchodilators therapy in acute severe asthma.
COPD.
Pneumothorax.
Carbogen Therapy
Usually 95% oxygen and 5% carbon dioxide.
Treats singulitus (hiccups).
Provides a challenge to stimulate breathing in some
patients.
 Extracorporeal membrane oxygenation (ECMO) is an
extracorporeal technique of providing both cardiac and respiratory
support oxygen to patients whose heart and lungs are so severely
diseased or damaged that they can no longer serve their function.
 Most commonly used in NICUs for newborns in pulmonary distress
 Similar to a heart-lung machine. To initiate ECMO, cannulae are
placed in large blood vessels to provide access to the patient's blood.
Heparin is given to prevent blood clotting.
 The ECMO machine continuously pumps blood from the patient
through a "membrane oxygenator" that imitates the gas exchange
process of the lungs, i.e. it removes carbon dioxide and adds oxygen.
Oxygenated blood is then returned to the patient
 Two types:
 veno-arterial (VA) and
 veno-venous (VV).

 In both modalities, blood drained from the venous system is

oxygenated outside of the body.
 In VA ECMO, this blood is returned to the arterial system and in VV
ECMO the blood is returned to the venous system
 Due to the high technical demands, cost, and risk of complications,
ECMO is usually only considered as a last resort therapy.
Oxygen delivery devices
T-piece
Face Tent
Ideal for post anesthesia.
Not enclosed and
claustrophobic.
Only for low oxygen
concentrations.
Head Hood Pendant Reservoir
Reservoir Cannula
Nasal Biflow Tracheal Catheter
Tracheal Mask
Oxygen (Croup) Tent
Incubator
Monoplace HBO Chamber
Multiplace HBO Chamber
Multiplace HBO Chamber
Monitoring
Clinically:
Consciousness level.
Respiratory rate.
Heart rate.
Blood Pressure.
Peripheral Circulation.
Cyanosis.
ABG.
Pulse Oximetry.
THANK YOU