oxygen therapy
TRANSCRIPT
Oxygen Therapy
Dr.Indubala Maurya MD,DNB,MNAMS
Assistant Professor Dept of Aanesthesia & Critical
Care,MGMCRI
• Definition • Physiology
– O2 content – Hypoxia
• Orthobaric Oxygen Therapy – Indication – Device for oxygen therapy
• Hyperbaric oxygen therapy• Side effects of Oxygen Therapy
Why oxygen Why oxygen is required for is required for
survival?survival?
Aerobic metabolism Aerobic metabolism oxidative phosphorylationoxidative phosphorylation
Glucose → CO2 + H2O + 38 ATP Glucose → CO2 + H2O + 38 ATP
Anaerobic metabolismAnaerobic metabolismGlucose → Lactic acid + 2 ATPGlucose → Lactic acid + 2 ATP
↓↓
H+ + lactate –H+ + lactate –
Anoxia No oxygen availability in
tissues
Hypoxia Lack of oxygen availability in
tissues
Hypoxemia Lack of oxygen in the blood
Basics
What is O2 Therapy ?
Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxia.
Types of Oxygen TherapyTypes of Oxygen Therapy• Giving Oxygen more
than 21% at ambient atm pressure
• Giving Oxygen more than 21% at high atm pressure ( >1 atm)
Orthobaric Hyperbaric
Three clinical goals of O2 therapy
1. Treat hypoxia
2. Decrease work of breathing
3. Decrease myocardial Work
• FIO2 ( Fraction of O2 in inspired gas)– 0.21 (21%)
• PaO2(Partial pressure of Oxygen in arterial blood– 98-100 mmHg ( 5 -6 times of FIO2)
• SaO2(saturation of Hb in arterial Blood) – 100%
• PvO2 (Partial pressure of Oxygen in Venous blood )– 40 mmHg
• SvO2 (saturation of Hb in Venous Blood) – 75%
Oxygen Transport
O2 Content in Blood
Hemoglobin-Bound O2• Oxygen-binding capacity of hemoglobin : 1.34 mL O2 /gm of Hb)• SO2 : O2 saturation of Hb
Dissolved O2• Solubility of oxygen in plasma
– solubility coefficient 0.003 mL/100 mL/mm Hg• Partial pressure of oxygen (PO2) in blood.
Hb X 1.34 X SaO2
0.003 X PaO2 mmHg
Arterial O2 Content (CaO2)
egNormal person Hb: 14gSaO2: 98-100%PaO2: 100 mmHgArt. blood Art. blood = 14g x 1.39 x 100% + 0.3 = 14g x 1.39 x 100% + 0.3 = 20 ml / 100ml of blood= 20 ml / 100ml of blood
0.003 X PaO2 mmHgHb X 1.34 X SaO2
Venous O2 Content (CvO2)
Normal PersonHb: 14gSvO2: 75 %PvO2: 40 mmhg
Ven. blood Ven. blood 14g x 1.39 x 75% + 0.1 = 14g x 1.39 x 75% + 0.1 = 15ml /100ml of blood15ml /100ml of blood
Tissue extraction = 5ml/ 100 ml of bloodTissue extraction = 5ml/ 100 ml of blood
Hb X 1.34 X SvO2 0.003 X PvO2 mmHg
Dissolved ODissolved O22 in in plasmaplasma
0.003ml / mm PO2 / 100ml of blood
Breathing Air (PaO2 100mm Hg)
0.3ml / 100ml of blood
O2 therapyOrthobaricBreathing 100% O2 (PaO2 600mm Hg)
1.8ml / 100ml of blood HyperbaricBreathing 100% O2 at 3 Atm. Pressure5.4ml / 100ml of blood
What are the Types of What are the Types of
HypoxiaHypoxia??
Types of hypoxiaTypes of hypoxia• Hypoxic hypoxia – PaO2↓
• Anaemic hypoxia – O2 content ↓, PaO2 normal
• Stagnant hypoxia
• Histotoxic hypoxia
Hypoxic hypoxiaHypoxic hypoxia• Causes
– O2 poor air, hypoxic gas mixture– High altitude – Hypoventilation– Shunts – Septal defects – Diffusion defects - pneumonia, lobar
collapse
Anaemic hypoxia• Oxygen carrying capacity of blood is
decreased. – Anemia :↓ haemoglobin– Altered haemoglobin
• CO poisoning • meth / sulph-haemoglobin
Normal Person (breathing 100% O2)
(14gm x 1.34ml ) + 1.8ml = 20.5ml (1.8 is 9% 20.5)Anaemic patient (breathing 100% O2)
(4gm x 1.34ml )+ 1.8ml = 7.2 ml (1.8 is 25% of 7.2)
Stagnant hypoxia• Inadequate tissue perfusion• Generalized:
- Hypovolemia- Mitral stenosis- Constrictive pericerditis- Myocardial ischaemia
• Localized hypo perfusion: - Arterial obstruction, thrombus,
oedema
Histotoxic hypoxia
• Cells can not utilize the oxygen .• Electron transfer system of cytochrome
oxidase is paralysed.• e.g.
– cyanide poisoning
Benefit of OBenefit of O22 therapy in therapy in HypoxiaHypoxia
Hypoxic hypoxia + + +Anaemic hypoxia +Stagnant hypoxia +Histotoxic hypoxia -
Clinical presentation of Hypoxia
Effects of hypoxia• Acute hypoxia :
- Restlessness- Disorientation, confusion- In-coordination, Impaired judgment
- Hyperventilation air hunger-Circulatory changes
(tachycardiabrady )
• Chronic hypoxia :- fatigue, drowsiness, ↓ work capacity- inattentiveness ,apathy, delayed reaction time
Assessment of need• Presence of clinical indicators • Measurement of inadequate oxygen saturations
– by invasive or noninvasive methods,• Arterial blood gas• Pulse oximetry
Errors in pulse oximetry• Artificial fingernails• Dark pigmentation • Electrical interference • Intravenous dyes • Movement• Nail Polish • Pulsatile venous system• Radiated light
How to assess oxygenation ?
• Arterial blood gases• PaO2 = 100 mmhg• Pulse oximetry• SpO2=98-100%
Oxygen therapy is must whenever Oxygen therapy is must whenever PaO2 < 60 mmHg or SpO2 < 90 %PaO2 < 60 mmHg or SpO2 < 90 %
FACTORS THAT DETERMINE WHICH SYSTEM TO USE
1. Patient comfort / acceptance 2. The level of FiO2 that is needed
3. The requirement that the FiO2 be controlled within a certain range4. The level of humidification and /or nebulization5. Minimal resistance to breathing6. Efficient & economical use of oxygen
Orthobaric Oxygen therapy
Oxygen therapy devicesVariable performance devices
• No capacity – nasal catheters, cannulae• Small capacity – masks• Large capacity – mask with bag
Fixed performance devices• HAFOE systems (High air flow oxygen enrichment
device » Venti Mask
• Anaesthesia circuits• Ventilators
Variable performance device
e.g.• Nasal cannula• Simple face mask• Partial rebreathing mask• Non - rebreathing mask
FiO2 depends on
•O2 flow
•Patient factors
•Device factors
Nasal CatheterNasal Catheter
O2 Flowrate (L/min)
123456
Fi O2
0.240.280.320.360.400.44
Nasal CatheterNasal CatheterMerits• Easy to fix• Keeps hands free• Not much interference with further airway
care• Useful in both spont. breathing and
apnoeicDemerits• Mucosal irritation (uncomfortable)• Gastric dilatation (especially with high flows)
Nasal cannula• Simple plastic tubing + prongs
Simple face maskSimple face mask
Simple Face Mask – ?
Simple face maskSimple face mask
NO YES
Simple Face Mask
Simple face mask
Placing of mask over the patient’s face increases the size of the oxygen reservoir beyond the limits of the anatomic reservoir ;therefore a higher FiO2 can be delivered.
.
Simple face maskSimple face mask
O2 Flowrate (L/min)
5-66-77-8
Fi O2
0.400.500.60
• Advantages: – Simple– lightweight, FiO2 upto 0.60
• Disadvantages: – need to remove when speak, eat, drink, vomiting,
expectoration of secretions– drying / irritation of eyes– uncomfortable when facial burns / trauma – Application problem when RT in situ
Partial Rebreathing mask Partial Rebreathing mask (polymask)(polymask)
Partial Rebreathing maskPartial Rebreathing mask(polymask)(polymask)
O2 Flowrate (L/min)
678
Fi O2
0.600.700.80
Advantages: • FiO2 delivered >0.60 is delivered in mod. to
severe hypoxia, • Exhaled oxygen from anatomic dead space is
conserved.
Disadvantages: • insufficient flow rate may lead to rebreathing of
CO2,• Claustrophobia• drying and irritation of eyes
Non Rebreathing maskNon Rebreathing mask
10 – 15 Ltr/min flow rate – 50-100 O2 conc.
Merits• Higher Oxygen Conc.
Demerits• Air dilution (if not fitting properly) • Rebreathing (if O2 flow is inadequate)
• Interfere with further airway care• Uncomfortable (sweating, spitting)
Fixed performance device: Ventimask
Simple face maskSimple face mask
NO YES
Simple Face Mask
VENTURI VALVE
Color FiO2 O2 Flow
Blue 24% 2 L/minWhite 28% 4 L/min
Orange 31% 6 L/minYellow 35% 8 L/min
Red 40% 10 L/minGreen 60% 15 L/min
Venturi valve
Venturi principle
Hyperbaric Oxygen therapy
Hyperbaric oxygen (HBO) exposure (breathing oxygen at increased ambient pressure, typically 2-3 atmospheres absolute [ATA]) causes an increase in PaO2.
Indication For HBOT • Poisoning :• Carbon monoxide • Infections :
– Clostridial myonecrosis• Acute ischemia
– Crush injury• Chronic ischemia
– Radiation necrosis • Ischemic ulcers
– diabetic ulcers
If conc. of OIf conc. of O22 which a patient is getting which a patient is getting is not known is not known
then the situation is similar to then the situation is similar toa drug being administereda drug being administered without knowing the dose without knowing the dose
which can do harm if given morewhich can do harm if given more or provide insufficient effect if given less or provide insufficient effect if given less
O2 ToxicityO2 Toxicity
Side Effects • Rentrolental fibroplasia in neonates• Resp system:
– Loss of surfactant – Atelactasis – Hypoventilation in COPD pt
• CNS: – Convulsion (HBOT)
100% - not more than 12hrs100% - not more than 12hrs 80% - not more than 24hrs 80% - not more than 24hrs 60% - not more than 36hrs 60% - not more than 36hrs