Oxygenation and Ventilation in ER

OXYGENATION &
VENTILATION
- Dr Varun Patel
Oxygenation Vs Ventilation
What is Oxygenation?
What is Ventilation?
When should you choose to Ventilate a

Patient?
Inadequate breathing efforts or No
breathing Efforts.
Criteria: Less than 6-8 breaths/min is
considered inadequate Respiratory Effort

Need for Ventilation.
Oxygenation
It increases the amount of Oxygen
delivered to the patient.
Oxygen passively diffuses from Alveoli to
Blood
It is an Open system (No Pressure, Many
Leaks)
-Disadvantages:
Cannot actively inflate lungs to remove
CO2
Key Concept for
Oxygenation:
What is FiO2?
What is FiO2 when we breath room Air?

Devices for Oxygenation:
NASAL PRONGS:
They are used to
deliver oxygen no more
than 6 L/min
Higher rates can cause
nasal mucosa to dry up
and lead to Epistaxis
Indicated for low to
moderate oxygen
requirements & for long
term Oxygen therapy
Simple Face
Mask:
Around 4-6 L/min
can be given
using face mask
FiO2 cannot be
ascertained
Venturi Mask:
Provides a
controlled FiO2
delivery
Indicated for
COPD patients
where controlled
flow of oxygen is
needed
Mask with reservoir
bag (High-Flow
mask)
Allows delivery of
higher FiO2 with
lower flow rate
Can deliver FiO2 of
upto 80%
Airway Devices:
Oropharyngeal
Airway:
Used in Unconscious
patients mainly.
Prevents tongue
back fall.
Prevents bite over
Advanced Airway
Provides access for
easy suctioning of
Oropharynx
Airway Devices:
Nasopharyngeal Airway:
Used in Conscious, semiconscious &
Unconscious patients.
Do not use in Head Injury (possible Basal
Skull #)
Case Scenarios:
A 40yr old Male comes to ER with
breathlessness and Fever since 4 days.
His examination findings reveal
Unilateral basal crepitations on Right
side. His P-104/min, BP-100/60mmHg,
SpO2-90% on Room Air.
What will be choice of Oxygenation
device?
How much do you set the flow rate on?
What is the choice of Airway device
here?
Hazards of Oxygenation:
Pulmonary Oxygen Toxicity: (Lorraine Smith Effect)
100% O2 for more than 12hrs
CNS Oxygen Toxicity: (Paul Bert Effect)
Symptoms of Toxicity:
Substernal pain, Irresistable Cough, Dyspnea,
Interstitial edema leading to Pulmonary Fibrosis,
convulsions, coma
Case Scenario:
A 65yr old known case of COPD comes to
ER with dry cough and intermittent
breathlessness. His P-122/min, BP-
146/80mmHg, SpO2- 90% on Room Air.
What will be the choice of Oxygenation
device?
What is the target level of SpO2 in this
case?
Take Home:
DO NOT OVER OXYGENATE
Maintain SpO2 level above 94, except for

Obstructive lung Diseases where 88-92
is enough.
Ventilation:
It is a method of delivering air to Alveoli
by replacing spontaneous breathing of a
patient.
Used in patients who are not breathing

spontaneously or breathing
inadequately.
Methods of Ventilation:
Mouth to Mouth Ventilation:
Mouth to Mask:
Bag Valve Mask:
Laryngeal Mask Airway:
Endotracheal tube:
Clinical Scenario:
A 70yr old female is brought to ER in an
Unconscious state with history of intake of
many pills of which relatives are unaware
of. Her vitals are P-60/min, BP-90/60mmHg,
SpO2-70% on Room Air, RR-4 breaths/min
in form of Kussmauls Breathing.
What is the device of choice for
Oxygenation and or Ventilation?
You try the device and you still cannot get
enough chest rise, what is your next plan
of Action?
Clinical Scenario:
In above example, you still cannot get
enough chest rise & her SpO2 levels
have dropped to 40% after all your
efforts. What is the next step in the
management?
Intubation:
Indications:
1. Apnoeic Patient in Respiratory Arrest
2. Partial obstruction or Complete

obstruction of Airway where basic
management is ineffective
3. Post-ROSC, if no respiratory effort
4. Patient presenting with clinics of high
probability of Respiratory Failure in near

future
Point to Note
Intubation is not indicated

during CPR
Rapid Sequence Intubation:
Indications:
1. Airway protection
2. Respiratory failure without Apnea
3. Status Epilepticus
4. Head Injury
5. Malignant Hyperthermia
Note: In all of these, patient is not in

Respiratory Arrest. We still have time.
Assessment:
Look:
Evaluate: (3-3-2)
Mallampati Score:
Obstruction:
Neck:
Pre-Oxygenation:
Replace Nitrogen with Oxygen in Alveoli.
Criteria: Oxygenate with 100% oxygen
for 3 mins
Avoid using BVM as far as possible. A
rebreather mask is ideal.
Position & Equipment:
Rapid Sequence intubation:
What equipment is necessary?
Induction Agents: (Midazolam is not Drug
of choice but can be used if others not
available)
Paralytic Agents:
What size tube to choose?
Anatomy of
Vocal Chords:
Cormack and Lehane classification:
Failed Intubation:
Algorithm:
Sellicks Maneuvre:
BURP Maneuvre:
Post Intubation Care:
Confirmation of Tube placement using
Auscultation points.
Confirmation of Tube using Waveform
Capnography tracing
Check for tube depth and position
Adjust Ventilator Settings as per
patients requirement.
Waveform Capnography:
ETCO2 Normal range: 35 to 37 mm Hg
Good CPR ETCO2 range: Maintain above
15mm Hg
Ventilator Settings:
Basics:
Modes of Ventilation:
Which mode to choose?
- The one with which you are comfortable.

Special Cases:
Special Cases:
Special Cases:
Special Cases:
Point to be noted:
You cannot be always right with your
ventilator settings in real life, even if you
are correct Theoretically.
Hence:

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OXYGENATION &

When should you choose to Ventilate a

considered inadequate Respiratory Effort

What is FiO2 when we breath room Air?

DO NOT OVER OXYGENATE

Maintain SpO2 level above 94, except for

Used in patients who are not breathing

2. Partial obstruction or Complete

4. Patient presenting with clinics of high

probability of Respiratory Failure in near

Intubation is not indicated

2. Respiratory failure without Apnea

Note: In all of these, patient is not in

- The one with which you are comfortable.

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