ACUTE CARE COURSE 2019-2020

OXYGEN THERAPY

DR. JAAFAR AL-JAZAERI (M.B.CH.B)

AHA-CERTIFIED BLS & ACLS PROVIDER
 TOPICS
• Introduction
• Indications of Oxygen Therapy
• Contraindications of Oxygen Therapy
• Adverse Effects of Oxygen Therapy
• Selection of Oxygen Delivery System
• Oxygen Delivery Devices
• Safe Oxygen Therapy in Acute Hypercapnic Respiratory Failure
INTRODUCTION
• This lecture will review various devices that are available to continuously
deliver oxygen to spontaneously breathing infants, children, and adults. The
amount of oxygen that each continuous system can deliver and the
advantages and disadvantages of each method are discussed.
• Oxygen Therapy is usually defined as the administration of oxygen at
concentrations greater than those found in ambient air.
• The main goal of oxygen therapy is: “To treat or prevent hypoxemia thereby
preventing tissue hypoxia which may result in tissue injury or even cell
death”
INTRODUCTION
• Oxygen is a drug. Has indiction and contraindication
Fraction of Inspired Oxygen

• Supplemental O2 is an FIO2 > 21%.

• The body does not store oxygen.
• FIO2 is the same at all altitudes.
• High FIO2 doesn’t affect COPD hypoxic drive.
• A given liter flow rate of nasal O2 does not equal any specific FIO2.
• Face masks cannot deliver 100% oxygen unless there is a tight seal.
Liters Per Minute

• No need to humidify if flow of 4 LPM or less.

INDICATIONS OF OXYGEN THERAPY
(1) Hypoxia
(2) Pre-oxygenation
(3) Postoperative Oxygenation
(4) Hyperbaric Oxygen Therapy
INDICATIONS OF OXYGEN THERAPY
(1) Hypoxia:
• Hypoxia is a deficiency of oxygen at the tissue level.
• Hypoxemia is deficiency of oxygen in arterial blood (PaO2 < 60 mmHg).
• Hypoxia can be divided into 4 types:
a. Hypoxic hypoxia: oxygen tension of arterial blood is reduced, eg. altitude,
equipment error, drug overdose, asthma.
b. Anaemic hypoxia: arterial oxygen tension is normal. However, amount of
Hb available to carry oxygen or Hb function is reduced, eg. anaemia,
carboxyhemoglobinemia, methemoglobinemia.
c. Ischemic hypoxia: arterial oxygen tension and Hb concentration are
normal. Blood flow to the tissues is reduced and oxygen cannot be
delivered to the tissues, eg. congestive heart failure, dehydration.
d. Histotoxic hypoxia: all above factors are normal, however a toxic agent
prevents the cells from using oxygen although oxygen is delivered to the
tissues, eg. cyanide toxicity.
INDICATIONS OF OXYGEN THERAPY
(2) Pre-oxygenation:
• If the patient is breathing room air, the oxygen store in functional residual
capacity (FRC) is approximately 450 ml and it can be increased to 3000 ml
with breathing 100% oxygen. As a result, there will be a rapid fall in oxygen
saturation during apnea (e.g. following induction of anesthesia) if breathing
room air.
• Pre-oxygenation means breathing 100% oxygen for three to five minutes
through an anesthetic circuit with a face mask firmly applied to the face.
This will replace the nitrogen in the FRC with oxygen and also referred to as
denitrogenation. The extra oxygen in the FRC can provide an essential store
of oxygen for period of apnea after induction.
• Pre-oxygenation is particularly essential for rapid sequence induction and
difficult intubation.
INDICATIONS OF OXYGEN THERAPY
(3) Postoperative Oxygenation:
• Additional oxygen should be given to all patients for the first 10 min after
general anesthesia, as a result of hypoxemia during the early recovery
period.
• Postoperative hypoventilation is common due to the residual effect of
anesthesia, opioid analgesia, pain or airway obstruction.
• Prolonged oxygen therapy is required after operation in certain conditions
such as hypotension, ischemic heart disease, anaemia, obesity and
shivering.
INDICATIONS OF OXYGEN THERAPY
(4) Hyperbaric Oxygen Therapy:
• Hyperbaric oxygen therapy means the patient is exposed to oxygen tension
exceeding ambient barometric pressure.
• It is indicated in decompression sickness, air embolism, gas gangrene and
carbon monoxide poisoning.
CONTRAINDICATIONS OF OXYGEN THERAPY
(1) Patients with chronic hypercarbia e.g. COPD.
(2) Inappropriate use of O2 delivery devices (e.g. nasal cannulas and
nasopharyngeal catheters in neonates and pediatric patients that have
nasal obstructions).
(3) Patient's refusal to receive oxygen.
ADVERSE EFFECTS OF OXYGEN THERAPY
• There are both respiratory and non-respiratory toxicity due to the effects of
oxygen therapy (especially if prolonged and high pressure). It depends on
patient susceptibility, FiO2 and duration of therapy.
(1) Fire hazard
(2) Absorption atelectasis
(3) Pulmonary toxicity
(4) Hypoventilation
(5) Neonatal complications: Retinopathy of prematurity (ROP),
Bronchopulmonary dysplasia (BPD)
(6) Hyperbaric oxygen toxicity
(7) Physical effects: dryness/crusting of nose or mouth, nasal bleeding,
barotrauma (simple or tension pneumothorax)
(8) Others: morning headaches, fatigue
ADVERSE EFFECTS OF OXYGEN THERAPY
(1) Fire hazard:
• Oxygen supports combustion of other fuels.
• You should never smoke or use flammable materials when using oxygen.3m distance from fire
(2) Absorption atelectasis:
• High concentrations of oxygen can cause atelectasis especially in dependant
areas of the lungs.
• When oxygen is the only gas being given, it is rapidly and completely
absorbed from the alveoli and results in collapse (absorption
atelectasis).
• Nitrogen present in the air is absorbed more slowly and prevents the
alveolus from collapsing.
ADVERSE EFFECTS OF OXYGEN THERAPY
(3) Pulmonary toxicity:
• Patients exposed to high oxygen levels for a prolonged period of time have
lung damage. It depends on FiO2 and duration of exposure.
• It is due to intracellular generation of reactive O2 metabolites (free radicals)
such as superoxide and activated hydroxyl ions, singlet O2 and hydrogen
peroxide, which can damage alveolar-capillary membrane. Pulmonary
capillary permeability increases and leading to edema, thickened
membranes and finally to pulmonary fibrosis.
• Pulmonary fibrosis may occur after exposure to high concentration of
oxygen for a week.
ADVERSE EFFECTS OF OXYGEN THERAPY
(4) Hypoventilation:
• It is seen in COPD patients with chronic CO2 retention who have hypoxic
respiratory drive to breath.
• Increased arterial tension to normal can lose the hypercapnoeic stimulus
to maintain ventilation resulting in hypoventilation in these patients.
ADVERSE EFFECTS OF OXYGEN THERAPY
(5) Neonatal complications:
➢ Retinopathy of prematurity (ROP):
• It is a neovascular retinal disorder and formerly termed retrolental
fibroplasia.
• It is caused by vascular proliferation followed by fibrosis and retinal
detachment leads to blindness.
• The low birth weight, very premature infant is at risk.
• It is resolved in 80% of cases without visual loss.
• PaO2 of 50-80 mmHg is recommended in premature infants receiving
oxygen.
ADVERSE EFFECTS OF OXYGEN THERAPY
➢ Bronchopulmonary dysplasia (BPD):
• This is a form of chronic lung disease that develops in preterm neonates
treated with oxygen and positive-pressure ventilation.
• The pathogenesis of this condition remains complex and poorly understood;
however various factors can not only injure small airways but also interfere
with alveolarization (alveolar septation), leading to alveolar simplification
with a reduction in the overall surface area for gas exchange. The developing
pulmonary microvasculature can also be injured.
ADVERSE EFFECTS OF OXYGEN THERAPY
(6) Hyperbaric oxygen toxicity:
• Prolonged exposure of hyperbaric O2 therapy can lead to pulmonary, optic
and CNS toxicity.
• Symptoms of pulmonary toxicity include retrosternal burning, cough and
chest tightness. It can cause narrowing of the visual fields and myopia in
adults.
• Signs and symptoms of CNS toxicity include behavior changes, nausea,
vertigo, facial twitching and tonic-clonic seizures.
SELECTION OF OXYGEN DELIVERY SYSTEM
• Rapid and effective oxygen delivery is an essential component of the care of
critically ill or injured patients.
• A variety of systems are available to deliver oxygen to spontaneously
breathing patients. Factors that influence the appropriate choice for any
given situation include the dose of oxygen required and how well the patient
tolerates the device.
• For patients who require assisted ventilation, oxygen can be initially
delivered with either a self-inflating or flow-inflating ventilation bag.
SELECTION OF OXYGEN DELIVERY SYSTEM
• General principles regarding oxygen delivery include:
➢ The choice of system will depend upon the clinical status of the patient and the
desired dose of oxygen, which is a function of the fraction of inspired oxygen
(FiO2 or concentration) and rate of oxygen gas flow. For example, a low-flow
blow-by system may be suitable for an alert infant or child in moderate
respiratory distress who requires a low dose of oxygen. By contrast, an obtunded
patient with irregular respirations needs bag-mask ventilation with a high
concentration and a high flow of oxygen (eg, 100% FiO2 at a flow of 10 L/minute
or greater).
➢ When oxygen delivery is anticipated to be prolonged, it should be humidified,
whenever possible, to prevent dried secretions from obstructing smaller airways.
➢ The effectiveness of oxygen delivery should be monitored with pulse oximetry.
SELECTION OF OXYGEN DELIVERY SYSTEM
• Key patient considerations include:
➢ Young children in respiratory distress may become frightened or agitated
when oxygen is administered, causing their clinical conditions to deteriorate.
Therefore, they should remain in a position of comfort whenever possible. A
parent or caregiver can often hold the oxygen source in proximity to or over
the child's face.
➢ As long as oxygenation is adequately maintained, a nasal cannula may be
preferable to a face mask for delivering oxygen to confused or delirious
adults.
➢ Uncontrolled oxygen delivery may promote hypercapnia in adults with
chronic obstructive pulmonary disease.
Oxygen Flowmeter
OXYGEN DELIVERY DEVICES
(1) BLOW-BY OXYGEN
‫نسمة‬
• Blowing (or wafting) oxygen past a patient's face is not a reliable means of
oxygen delivery and is not used in adults. However, this method may
temporarily provide oxygen to infants and toddlers who become agitated
and more distressed with other methods of oxygen delivery, particularly
during the initial evaluation and treatment of a reversible cause of
respiratory distress such as croup or bronchospasm.
• Limited evidence suggests that only low concentrations of oxygen (<30%
FiO2) can typically be provided using these systems.
(1) BLOW-BY OXYGEN
• The following points should be considered when providing blow-by oxygen
to children:
✓ Oxygen can be best delivered at a flow rate of at least 10 L/minute through a
reservoir (ie, a simple mask or large cup).
✓ The reservoir must remain in proximity to the child's face.
✓ Oxygen saturation should be monitored.
✓ Alternative oxygen delivery systems are warranted for children who require
>30% oxygen or prolonged oxygen therapy.
(2) NASAL CANNULA
• Oxygen flows from the cannula into the patient's nasopharynx, where it
mixes with room air.
• It does not increase dead space and there is no rebreathing.
• It is ideal for long term oxygen therapy.
• Components of nasal cannula:
- Adjustable head strap
- Two prongs
- Plastic oxygen tubing
• The concentration of oxygen that can be delivered by nasal cannula varies
depending upon factors such as the patient's respiratory rate, tidal volume,
oxygen flow rate, and extent of mouth breathing.
• Oxygen can be delivered by simple nasal cannula using either low- or high-
flow rates.
Advantages & Disadvantages of Nasal Cannula
(2) NASAL CANNULA
Low flow nasal cannula:
• 100% oxygen is typically run through a bubbler humidifier at a rate of 1 to 4
L/minute. The oxygen concentration that is delivered varies from 25 to 40%,
depending upon factors such as the patient's respiratory rate, tidal volume,
and extent of mouth breathing.
• Flow rates greater than 2 L/minute are irritating to the nares, unless the
oxygen is heated and humidified.
• Flow rates greater than 2 L/minute are not recommended for routine use in
careless
newborns and infants because inadvertent administration of positive airway
pressure may occur at higher flow rates.
• Low-flow nasal cannulae are used to deliver oxygen to an adult with a low
oxygen requirement or to an infant or child with patent nares who requires
low levels of supplemental oxygen and does not tolerate a simple mask.
• However, low-flow nasal cannulae are of limited use as the primary system
of oxygen delivery during the stabilization of acutely ill patients because
they cannot reliably deliver high concentrations of oxygen.
(2) NASAL CANNULA
High flow nasal cannula:
• High-flow nasal cannula oxygen therapy involves delivery of heated and
humidified oxygen via special devices initiated at rates up to 8 L/minute in
infants and up to 60 L/minute in children and adults.
• In patients with respiratory distress or failure, humidified high-flow nasal
cannulae may be better tolerated than oxygen by face mask in terms of
comfort.
• High-flow nasal cannula can be used in patients of all ages and with a variety
of conditions, including premature infants with respiratory distress
syndrome, infants with bronchiolitis, and adults with hypoxemic respiratory
failure.
• In adults with acute hypoxemic respiratory failure without hypercapnia,
high-flow oxygen therapy by nasal cannula is a reasonable alternative to
standard oxygen therapy or noninvasive positive pressure ventilation.
Types of FACE MASKS
(3) SIMPLE FACE MASK
• Simple masks fit loosely over the nose and mouth. It is made of transparent
plastic.
• With oxygen flow rates between 6 and 10 L/minute, simple masks can
provide concentrations of oxygen between 35 and 50%, depending on the
patient's respiratory rate and the mask fit.
• Various sizes are available from pediatric to adult.
• Components of simple face mask:
- Body
- Vent holes
- Elastic band
• Body of the mask serves as a reservoir for both oxygen and expired CO2.
(3) SIMPLE FACE MASK
• It has a small dead space and can result in a small amount of
rebreathing. Dead space depends on oxygen flow and patient’s minute
ventilation.
• An oxygen flow rate greater than 5 L/minute is recommended to prevent
rebreathing of CO2.
• A simple mask is useful for patients who need moderate amounts of oxygen
to maintain acceptable oxygen saturation.
• It can provide higher concentrations of oxygen than a nasal cannula.
However, precise concentrations of oxygen cannot be reliably delivered.
• Disadvantages of using simple face mask:
- Patient complains of feeling of suffocation and poorly tolerated.
- Speech is muffled, eating and drinking are difficult.
(4) PARTIAL REBREATHING MASKS
• A partial rebreathing mask consists of a simple mask with an attached
reservoir bag to increase the capacity of O2 reservoir by 600 ml.
• Oxygen concentrations from 50 to 60% can be achieved with oxygen flow
rates between 10 and 12 L/minute.
• With this system, air is drawn during inspiration predominantly from the
fresh oxygen inflow and the reservoir. Entrainment of room air through the
exhalation ports and any gap between the face and mask is minimized.
• Gas in the reservoir is oxygen rich, despite the fact that it contains some
exhaled gas. This is because the early exhaled air that flows into the
reservoir (from respiratory dead space in the mouth and upper airways) is
oxygen rich and contains little CO2.
• In order to maintain a high percentage of oxygen in the reservoir and
minimize CO2 rebreathing, the oxygen flow rate must be adjusted to keep
the reservoir from collapsing.
(4) PARTIAL REBREATHING MASKS
• A partial rebreather mask is used primarily to conserve oxygen supply (for
instance, during transport) for patients who require higher oxygen
concentrations.
• Although the concentration of oxygen that is delivered is more reliable than
a simple mask, it is diluted by room air that can still be drawn into the
system through the exhalation ports and any gap between the face and
mask.
https://www.youtube.com/watch?v=33cd5i-j10g
One-way valve
(5) NON-REBREATHING MASKS
• As a single device, a nonrebreather mask reliably supplies the highest
concentration of oxygen that can be provided to a spontaneously breathing
patient in the short term (oxygen concentration up to 95%).
• Patients who are anticipated to require such high concentrations of oxygen
for longer periods of time should be transitioned to positive pressure
ventilation. Both noninvasive ventilation and endotracheal intubation
provide higher concentrations of oxygen secondary to decreased
entrainment of room air, as well as through increased mean airway
pressures to further improve oxygenation.
• A nonrebreathing mask is a mask and reservoir system modified with one-
way valves that limit the mixing of the oxygen supply with exhaled gases and
room air. A one-way valve is located between the reservoir and the mask. It
prevents flow of exhaled gas into the reservoir. Exhalation ports of the mask
also have one-way valves that permit the egress of expired gas during
exhalation and prevent room air from entering the mask during inspiration.
(5) NON-REBREATHING MASKS
• When valves are placed over both exhalation ports, oxygen flow rates of 10
to 15 L/minute are delivered, and a tight mask seal is achieved, a
nonrebreather mask provides FiO2 of up to 95%. However, as a safety
precaution, nonrebreather masks are manufactured with only one of the
two exhalation ports on the mask containing a one-way valve so that the
patient can still receive room air through the open port if the flow of oxygen
to the mask is inadvertently interrupted. Entrainment of room air through
this open exhalation port results in a lower FiO2. In addition, nonrebreathing
masks may not routinely achieve a tight seal against the face. Such a leak
with a nonrebreathing mask lowers oxygen delivery. Thus, in clinical
practice, nonrebreathing masks typically deliver oxygen concentrations
lower than 95%.
(6) VENTURI MASKS
• Ventimasks are colour coded and it states the flow of oxygen in litres per
minute required to deliver a specific inspired oxygen concentration.
• Holes on the Venturi device allow entrainment of room air by the Venturi
principle. These holes also flush expired gas.
• Advantages of using Ventimask include very precise measurement of
delivered oxygen and no rebreathing.
• However, the mask is hot and may irritate the skin. Oxygen concentration
may lower by kinking the tubing.
• Components of Ventimask:
- Body of the mask with holes
- Color-coded venturi device
- Corrugated tubing
- Adjustable head strap
(8) VENTILATION BAGS
• Ventilation bags are typically used to provide oxygen and assisted
ventilation, either with a mask or through an artificial airway (ie, an
endotracheal tube). Flow-inflating bags can be used to provide
supplemental oxygen to spontaneously breathing children.
(1) Self-inflating bags:
• A self-inflating (Ambu) bag reinflates with a recoil mechanism.
• It does not require a gas source to re-expand. However, during reinflation,
room air is entrained in the system, diluting the concentration of oxygen
that is delivered to the patient. Therefore, in order to consistently deliver
high concentrations of oxygen, a reservoir must be attached to the bag.
• The addition of a one-way valve over the exhalation port can also reduce
entrainment of room air during reinflation of a self-inflating bag attached to
an oxygen source.
Ambu bag:
https://youtu.be/ZPJQRogximU
https://youtu.be/m5X884XRajE
https://youtu.be/PJiRABugTfg
(8) VENTILATION BAGS
(2) Flow-inflating bags:
• Flow-inflating (anesthesia) bags require a gas source to remain inflated.
• When oxygen is used as the source, 100% oxygen can be delivered to the
patient.
• These systems are more complicated to use than a self-inflating bag. The
flow of oxygen and an outlet control valve must be adjusted to ensure safe
and effective ventilation. Consequently, flow-inflating bags should only be
used by clinicians with specific training and experience.
Positive pressure ventilation (PPV)
- by ambu pack
- by mechanical ventilation
- CPAP
SAFE OXYGEN THERAPY IN ACUTE
HYPERCAPNIC RESPIRATORY FAILURE
• Patients who present with acute hypercapnic acidosis frequently (but not
always) have co-existing hypoxemia that necessitates supplemental oxygen
therapy.
• The degree of hypoxemia is variable and depends upon the cause of
respiratory failure and presence of underlying chronic lung disease.
• The major concern with the delivery of oxygen to this population is the
development of worsening hypercapnia and consequently acidosis.
• In next slides, approach to oxygen administration is shown (adapted from
UpToDate).
THANK YOU