OXYGEN THERAPY
Presenter: Dr Alok G Belgaumkar
Moderator: Dr Gandeeva Ramesh
Carbon structures
life.
Oxygen ignites it.
Objectives:
Everyone should know
When to give oxygen therapy
Which delivery system to be opted
Curing the signs and symptoms
What it does to the body
Causing the side effects
When to stop the therapy
Contents:
Introduction
Indication
Pathophysiology of hypoxia
Factors determining system to be used
Oxygen delivery methods
Oxygen toxicity
Oxygen therapy in Covid 19 patients
Introduction:
Oxygen was discovered in the late
18th century.
Joseph Priestley, a
minister in England, made his
discovery after attempting to
melt mercury oxide using a
magnifying glass and the sun’s
rays
Introduction:
History of oxygen therapy:
Thomas Beddoes, considered the father of respiratory therapy,
worked with the inventor James Watt to generate oxygen and other gases,
and opened a Pneumatic Institute in Bristol, England, in 1798, using
oxygen and nitrous oxide to treat asthma, congestive heart failure, and
other ailments
The first cylinders for storing oxygen were developed in 1868, which
allowed its use in general anesthesia
By 1885, George Holtzapple used oxygen to manage a young patient with
pneumonia, and established its role in acute care
The Story of Oxygen | Respiratory Care [Internet]. [cited 2020 May 26]. Available
from: [Link]
Body oxygen content:
Primary goal of supplemental oxygen therapy is to ensure appropriate oxygen
delivery to vital end organ tissues.
Tissue hypoxia is governed by the balance between oxygen delivery and
oxygen utilization.
Oxygen delivery is determined by the cardiac output and the oxygen content
of arterial blood, as described by the formula:
DO2 (oxygen delivery) = CO (cardiac output) × CaO2(oxygen content of arterial
blood)
Where CaO2 is calculated by the formula:
CaO2 (mL O2/dL) = (1.34 × hemoglobin concentration × SaO2)+ (0.0031 ×
PaO2)
Hence the causes of poor oxygen delivery can be narrowed to three
categories:
1. Low cardiac output states (i.e., various forms of shock)
2.
3. low hemoglobin concentration states (i.e., anemia)
4.
5. low SaO2 states (i.e., arterial hypoxemia or
hemoglobinopathies).
Oxygen cascade:
Indications of oxygen therapy:
American college of Chest Physicians and National Lung and Blood Institute
recommendations for oxygen therapy are
Cardiac and Respiratory arrest
Hypoxamia (PaO2 < 60 mmHg, SaO2 <90%)
Hypotension (systolic BP < 100 mmHg)
Low cardiac output and metabolic acidosis
Respiratory distress (respiratory rate > 24/min)
Pathophysiology of Hypoxia
Signs and symptoms of hypoxia:
System Signs and Symptoms
Tachypnea, breathlessness, dyspnea,
Respiratory
cyanosis, pulmonary hypertension
Cardiovascular Increased cardiac output, palpitations, tachycardia,
bradycardia arrhythmias, hypotension, angina,
vasodilation, diaphoresis, shock
Headache, impaired judgment, inappropriate behavior,
Central nervous confusion, euphoria, delirium, restlessness, papilledema,
seizures, obtundation, coma
Neuromuscular Weakness, tremor, asterixis, hyperreflexia, incoordination
Sodium and water retention, lactic
Metabolic/renal
acidosis, acute tubular necrosis
FACTORS DETERMINING SYSTEM TO BE USED:
Oxygen delivery devices utilized in the acute setting may be divided into
The required flow depends on the patient’s degree of hypoxemia and
minute ventilation
1. low-flow
Patients with more moderate degrees of hypoxemia may only need low-
flow systems
2. high-flow delivery systems.
Patients who exhibit a high minute ventilation or are profoundly
hypoxemic require high-flow devices
Classification of oxygen therapy equipment:
Performance of the device- fixed , variable performance
Flow delivered by the device- low flow, high flow.
Patient dependency - dependent, patient independent.
Degree of dependency- low(nasal prongs), high (nippv, ippv)
Dorsch JA, Dorsch SE, Understanding Anaesthesia Equipments, 5 th edition
Low flow systems:
1. No capacity system a) Nasal cannula b) nasopharyngeal catheters
2.
3. Low capacity system (capacity <100 – 250 ml) : simple and nebulizer face
mask for adults
4.
5. High capacity system ( 250 - 500 ml) face mask with reservoir bag
6.
7. Very high capacity system (capacity >1500ml) incubators, oxygen hood, tents
Nasal cannula:
Low flow variable performance device with no capacity
They consist of two soft prongs that arise from oxygen supply tubing
Prongs are inserted into patients nares and secured to patients face with
adjustable strap
Oxygen is delivered at 0.5 to 5 litre/min
Approximately cannulas deliver 4% oxygen per litre of flow
Oxygen flow Percentage of oxygen
1 L/min : 24%
2 L/min : 28%
3 L/min : 32%
4 L/min : 36 %
5 L/min : 40%
Nasal cannula
Advantages:
Comfortable for patients
Ideal for claustrophobic patients
Ideal for oxygen dependent
patients requiring small
amounts of oxygen at home
Humidification is not required
upto 4 L/min
Disadvantages:
Unpredictable FiO2
Not appropriate for patients in
respiratory distress
Nasal cannula :
Equipment related potential
harm
Skin irritation
Improper sizing
Displacement and loss of oxygen
delivery
High flows leads to headache,
nose bleeds, irritation and
drying of nasal mucosa
Nasopharyngeal catheters:
Variable performance low
flow device with no
capacity
Soft tubes with several
distal holes
Available from 8-14 Fr size
Should be well lubricated
Depth of insertion should
be equal to the distance
from the ala nasi to tragus
The catheter is secured to
patient face and
connected to oxygen
tubing
Nasopharyngeal catheters (cont…):
Limitations:
Method is less commonly used in view of complexity
FiO2 is difficult to control and measure
Limited by excessive mucus drainage, mucosal oedema or pressure of
deviated nasal septum
Should be cleaned frequently to prevent occlusion
Catheter size < 8 Fr are less effective
Lower oxygen concentration is delivered if catheter is placed in nose
instead of nasopharynx
Small capacity systems:
Simple oxygen masks:
Low flow variable performance device with small capacity
Pediatric face mask has lower capacity ( 70 – 100ml) compared to adult face
mask ( 100 – 250ml)
Plastic reservoirs designed to fit over patient’s nose and mouth
Elastic strap is used to secure
Oxygen is delivered through a small bore tube connected to base of mask
Oxygen that gets collected in the apparatus dead space at end of expiration is
inhaled in the next breath
Exhaled gases are vented out through the holes on each side of mask, which
also serves as room air entrainment ports
Simple oxygen masks:
Simple oxygen mask can O2 flow rates
L/min
FiO2
deliver 35 – 60 % FiO2
5-6 0.4
6-7 0.5
7-8 0.6
Simple oxygen masks:
Advantages:
Quick and easy to setup and use
Disadvantages:
Unpredictable FiO2
Not more than 0.5 FiO2 can be delivered
Watch for :
Carbon-dioxide rebreathing with flowrates less than 2 L/min or if minute
ventilation is very high
Aerosol (nebulizer) face mask:
Variable oxygen, low flow device with medium capacity
Mask with large side holes is attached by large bore tubing to a nebulizer
which delivers water/drug in aerosol form
Advantages:
Humidified oxygen/gases can be given
Disadvantages:
Nebulizer is noisy
Unpredictable FiO2
Maximum FiO2 estimated at 0.5
Aerosol (nebulizer) face mask:
Watch for:
Attempts to minimize the noise
by decreasing oxygen flow on
flowmeter will interfere with
effective nebulization and thus
humidification
Tracheostomy mask:
Low flow variable
performance device with low
capacity
Advantages:
Designed for patients with
tracheostomy
Disadvantages:
Can require frequent cleaning or
replacement if patient is
coughing
High capacity system:
In all the previously discussed systems most of the oxygen stored in device,
during exhalation gets wasted as it is blown away by patient’s inspiratory flow
rates
Oxygen also gets wasted if oxygen flow rates are more than the patient’s
inspiratory flow rates
Hence large capacity devices have been designed to store this wasted oxygen
Reservoir face mask:
High oxygen, low flow, variable
performance devices
They provide higher FiO2 as
there is reservoir bag attached
to face mask, oxygen flows
directly to reservoir bag
Patient inhales preferentially
from reservoir bag, if the
reservoir empties during
inspiration then ambient air is
entrained
Reservoir face mask:
Partial rebreathing mask:
Simple mask with reservoir bag
Oxygen should always be supplied to maintain reservoir bag one third to
half full on inspiration
The reservoir receives fresh gas flow plus exhaled gas approximately equal
to volume of patient’s anatomical dead space
At flow of 6-7 L/min the system can provide 40-70% oxygen
Reservoir face mask:
Non-rebreathing masks:
Similar to partial rebreathing masks but donot permit mixing of exhaled gases
with fresh gas supply
A series of one way valves ensures a fresh oxygen supply with minimal dilution
from the entrainment of room air
This design provides a higher FiO2 than a simple and partial rebreathing masks
There should be minimum flow of 10 L/min
The delivered FiO2 of this system is 75-90% at flow of 12-15 L/min
Some masks might have a device which gives a visual indication of patient’s
breathing efforts (respiratory check masks)
Reservoir face mask:
Oxygen flow rate L/min No valves mask One way valve mask
3 0.5-0.65 0.45-0.6
6 0.6-0.75 0.6-0.75
9 0.65-0.8 0.65-0.8
12 0.7-0.85 0.7-0.85
15 0.75-0.9 0.75-0.9
Reservoir face mask:
Advantages:
Fast and easy to setup
Disadvantages:
FiO2 is variable if there is air entrainment due to poor mask fir
Watch for:
Reservoir bag should always remain inflated
Deflated bag indicates that the oxygen flow rates are low
Limitations:
May not be well tolerated by claustrophobic patients
May interfere with feeding
Reservoir face mask:
Potential harm due to
equipment:
Aspiration of vomitus may be
more likely in a patient with
obtunded airway reflex
Rebreathing of carbon dioxide
can occur if the total oxygen
flow is inadequate
Not appropriate for use in
neonates
High flow system
High flow systems are fixed performance oxygen delivery systems as they can
provide a specific FiO2 at flows that meet or exceeds the patients inspiratory
flow requirements
Venturi effect: it is based on the Bernoulli’s principle, as velocity of the fluid
increases, the pressure exerted by that fluid decreases, this can be applied to
both gases and fluids
The venturi effect explains how a second fluid can be entrained into the
stream of first, it can be done by either through a coaxial arrangement or
through a side arm into an area of low pressure
Venturi masks:
High flow fixed performance device
An air entrainment device contains
a jet orifice and air entrainment
ports and is designed to fit over
patients nose and mouth
Oxygen is supplied through bore
oxygen tubing under pressure
When in such condition oxygen is
forced through a small jet orifice
entering the mask, a negative
pressure is created which causes
room air to be entrained into the
mask through the apertures in to
the venturi barrel
Venturi masks:
This system is called high
airflow with oxygen
enrichment (HAFOE)
Variations in the size of the
entrainment ports determine
the FiO2 and variation in the
oxygen flowrate determines
the total flowrate
The barrels are color coded
and labelled with inspired
oxygen concentration and the
flow of oxygen required to
achieve it
Very high flow systems:
Oxygen hoods:
Transparent enclosure designed to
surround the head of neonate or
small infant
It has an opening for the neck and
comes in different size
Well tolerated and gives access to
chest, trunk and extremities
Limitations of size, can be used in
children less than one year
Hood delivers 80-90% oxygen at 10-
15 L/min
Very high flow systems:
Oxygen tent:
Transparent enclosures in larger sizes (so called tent house or huts) are
available for patients who are big for hoods
The subject lies in the tent, carbon-dioxide is removed by sodalime and
water-vapour by calcium chloride
The temperature in the tent is regulated by flowing and air over ice chunks
FiO2 of 0.6-0.7 can be achieved by flow rates of 10-12 L/min
The air changes 20 times/hour
High output nebulizer can circulate cooled mist in tent
Very high flow systems:
Limitations of oxygen tent:
Oxygen concentration may vary within the hood/tent, should be measured
as near to nose as possible
Decrease in oxygen concentration whenever enclosure is opened
Flows > 7L/min is required to washout carbon dioxide
Devices can be confining and isolating
FiO2 can vary from 0.21-1.0
Temperature of gases in the hood/tent should be maintained to provide
thermal environment
Closed incubators:
They are transparent enclosures
that provide a warm
environment for small infants
with temperature instability
Supplemental oxygen can be
added to incubators
FiO2 is maintained at 0.4
Humidified oxygen can be
provided
Nasal high flow (NHF) oxygen:
Apart from traditional oxygen therapy, noninvasive ventilation and invasive
mechanical ventilation; recently patient with respiratory failure has been
treated with a high flow nasal oxygenation
NHF allows the delivery of upto 60 L/min of heated and humidified gas via
a widebore nasal cannula
It has got a blender which allows the operator to choose the required FiO2
and thus prevents oxygen toxicity
Nasal high flow (NHF) oxygen:
OptiflowTM :
Unique wide bore nasal cannula is made of soft plastic thermoplastic
elastomer
The cannula prongs and base sit comfortably under nose
It has adjustable head strap which comfortably fits over patient’s ear
OptiflowTM was demonstrated to generate low level of positive pressure
when used at 35 L/min of gas flow
Thus may be helpful in avoiding reintubation in selected cases
In patients with nonhypercapnic acute hypoxaemic respiratory failure,
treatment with high flow oxygen has shown to reduce 90 day mortality
Bag and mask ventilation:
Self inflating
bags(AMBU Bags)
consists of football
sized bladder,
oxygen inlet,
reservoir, one-way
valves, PEEP valve
Breathing circuits
Non self inflating reservoirs with gas inlet and valve.
Flow to the reservoir should be kept high to prevent deflation.
Provides constant FiO2 of >90%
Mask are designed to provide a comfortable leak free seal for
manual ventilation.
Limitation - In spontaneously breathing person flow has to be
adjusted with the valve.
Risk of aspiration
Helium oxygen therapy:
Helium is premixed with o2
(80+20% / 70+30%)
Indication - relief in patients
with acute distress from
upper airway obstructions -
subglottic edema, tracheal
tumors, foreign bodies
In anaesthetic practice,
pressures needed to
ventilate with small-
diameter tracheal tubes can
be substantially reduced
when the 79%+21%
mixture is used
Hyperbaric oxygen therapy:
Uses a pressurized chamber to expose the patient to oxygen tensions
exceeding ambient barometric pressure (760 mmHg at sea level)
One person hyperbaric chamber uses 100% oxygen to pressurize the chamber
Larger chambers allow for simultaneous treatment of multiple patients and
for presence of medical personnel in the chamber with patients
Multiplace chambers use air to pressurize the chamber whereas patients
receive 100% oxygen by mask, hood, tracheal tube
Hyperbaric oxygen therapy:
Indications:
Decompression sickness (bends)
Certain forms of gas embolism
Gas gangrene
Carbon monoxide poisoning
Treatment of certain wounds
OXYGEN THERAPY IN
COVID 19
MINISTRY OF HEALTH AND FAMILY WELFARE
Give supplemental oxygen therapy immediately to patients with SARI and
respiratory distress, hypoxemia, or shock: initiate oxygen therapy at 5 L/min
and titrate flow rates to reach target spo2≥90% in non-pregnant adults and
spo2 ≥92-95 % in pregnant patients
Children with emergency signs (obstructed or absent breathing, severe
respiratory distress, central cyanosis, shock, coma or convulsions) should
receive oxygen therapy during resuscitation to target spo2≥94%; otherwise,
the target SpO2 is ≥90%.
MINISTRY OF HEALTH AND FAMILY WELFARE
All areas where patients with SARI are cared for should be equipped with
pulse oximeters, functioning oxygen systems and disposable, single-use,
oxygen-delivering interfaces (nasal cannula, simple face mask, and mask with
reservoir bag)
Use contact precautions when handling contaminated oxygen interfaces of
patients with COVID –19
On use of High Flow Nasal Oxygen in COVID 19:
Guideline Recommendations:
While HFNO does carry a small risk of aerosol generation, it is
considered a recommended therapy for hypoxia associated
with COVID-19, as long as staff are wearing optimal airborne
PPE
The risk of airborne transmission to staff is low when optimal
PPE and other infection control precautions are being used
Negative pressure rooms are preferable for patients receiving
HFNO
Respiratory Management of COVID 19 - Physiopedia [Internet]. [cited 2020 May 24].
Available from: [Link]
Hyperbaric oxygen treatment of novel
coronavirus (COVID-19) respiratory failure
Paul G Harch Department of Medicine, Section of Emergency and
Hyperbaric Medicine, Louisiana State University Health Sciences Center, New
Orleans, LA, USA
In conclusion, preliminary evidence from China strongly suggests that based
on the immutable science of HBOT and recent clinical application to
deteriorating severely hypoxemic COVID-19 pneumonia patients HBOT has
significant potential to impact the COVID-19 pandemic
Harch PG. Hyperbaric oxygen treatment of novel coronavirus (COVID-19) respiratory
failure. Med Gas Res [Epub ahead of print] [cited 2020 May 26
Covid 19 treatment guidelines:
Oxygenation and Ventilation:
from the Surviving Sepsis Campaign (SSC) Guidelines for adult sepsis,
pediatric sepsis, and COVID-19
For adults with COVID-19 who are receiving supplemental oxygen, the Panel
recommends close monitoring for worsening respiratory status and that
intubation, if it becomes necessary, be performed by an experienced
practitioner in a controlled setting (AII)
For adults with COVID-19 and acute hypoxemic respiratory failure despite
conventional oxygen therapy, the Panel recommends high-flow nasal cannula
(HFNC) oxygen over noninvasive positive pressure ventilation (NIPPV) (BI)
In the absence of an indication for endotracheal intubation, the Panel
recommends a closely monitored trial of NIPPV for adults with COVID-19 and
acute hypoxemic respiratory failure for whom HFNC is not available (BIII)
Oxygen toxicity:
Oxygen toxicity:
Hypoventilation:
Seen in patients with COPD who have chronic CO2 retention
These patients develop an altered respiratory drive that becomes partly
dependent on the maintenance of relative hypoxemia
Elevation of arterial oxygen tension to “normal” can therefore cause
severe hypoventilation
Oxygen therapy can be indirectly hazardous for patient being monitored
with pulse oximetry while receiving opioids for pain
Hypoventilation as a consequence of opioid may fail to cause worrisome
change in oxygen saturation, despite respiratory rates as infrequent as 2
per minute
Hence prevention of hypoventilation by continuous monitoring in COPD
patients and opioid recipient patients is necessary
Absorption Atelectasis:
High concentration of of oxygen
can cause pulmonary atelectasis
in areas of low V/Q ratios
As nitrogen is “washed out” of
lungs, the lowered gas tension
in pulmonary capillary blood
results in increased uptake of
alveolar gas and absorption
atelectasis
Prevention/treatment:
absorption atelectasis does not
appear to occur in patients
ventilated with 80% oxygen or
less
Pulmonary toxicity:
Prolonged high concentration of oxygen may damage the lungs
Toxicity is dependent both on the partial pressure of oxygen in the inspired
gas and the duration of exposure
Molecular oxygen is unusual in that each atom has unpaired electrons
This gives the molecule the paramagnetic property that allows precise
measurements of oxygen concentration
Oxygen toxicity is thought to be due to intracellular highly reactive O2
metabolites (free radicals) such as superoxide and activated hydroxyl ions,
singlet O2 and hydrogen peroxide
They readily react with cellular DNA, sulfhydryl proteins and lipids
Pulmonary toxicity:
In experimental animals oxygen mediated injury of alveolar capillary
membrane produces that is pathologically and clinically indistinguishable
from ARDS, that occurs in patients who have inhaled gas with a FiO2 >60%
for longer than 48 hours
Pulmonary O2 toxicity in newborn infants is manifested as
bronchopulmonary dysplasia
Treatment of pulmonary toxicity:
Oxidative injury is kept in check by vast array of endogenous antioxidants
Superoxide dismutase is an enzyme that facilitates the conversion of
superoxide radical to hydrogen peroxide
Glutathione is a sulfur containing tripeptide that is considered major
intracellular antioxidant in the human body
Treatment of pulmonary toxicity:
N-acetylcysteine is a glutathione analogue that can cross cell membranes and
serve as glutathione surrogate
Selenium is an essential trace element that serves as a cofactor for peroxidase
enzyme in humans
Vitamin-E(alpha-tocopherol) is lipid-soluble vitamin that is found in the
interior of cell membranes, it serves as chain breaking antioxidant to halt the
progression of lipid peroxidation
Vitamin-C is water soluble antioxidant
Retinopathy of prematurity(ROP):
Formerly termed as retrolental fibroplasia, is a neovascular retinal
disorder that develops in 84% of premature survivors born at less than 28
weeks gestation
ROP may include disorganized vascular proliferation and fibrosis and may
lead to retinal detachment and blindness
Hyperoxia and hypoxia are risk factors but not primary cause of ROP
Other risk factors include low birth weight and complexity of
comorbidities
Hyperbaric oxygen toxicity:
The high inspired oxygen tension associated with hyperbaric oxygen
therapy greatly accelerate oxygen toxicity
Prolonged exposure to oxygen partial pressure in excess of 0.5
atmospheres can cause pulmonary oxygen toxicity
Symptoms and signs:
Retrosternal burning
Cough
Chest tightness and
Progressive impairment of pulmonary function
Hyperbaric oxygen toxicity:
Patients exposed to O2 at 2 atmospheres or more are also at risk for CNS
toxicity expressed as
Behavior changes
Nausea
Vertigo
Muscular twitching
Convulsions
Fire hazards:
Oxygen vigorously supports combustion
Potential to promote fires and explosions
Tissue oxygen
Despite our dependence on oxygen for metabolic energy production, aerobic
metabolism is carried out in an oxygen restricted environment
According to estimates, there is only 13 mL of oxygen in all the tissues of the
human body
Humans are described as obligate aerobic organism, more accurately
described as microaerophilic organisms
The oxygen restricted environment in the tissues can be viewed as safeguard
against damaging effects of oxygen metabolites
Summary of equipment:
SURPRISE
A 21 year old male with Covid-19 positive patient admitted in covid-19 ward
came with complaints of breathlessness and on examination patient was
conscious oriented and vitals were stable, on auscultation
CVS S1 S2 heard, no murmurs
RS: B/L VBS with B/L basal crept BP: 110/60 mmHg
CNS: GCS: E4V5M6, HR: 108/min
ABG analysis shows pH: 7.35 SpO2: 85%
RR: 25/min
pO2: 60mmHg
pCO2: 33mmHg
SO2: 80%
Thank you
WHO let the dogs out?
References:
Butterworth FJ, Mackey CD, Wasnick DJ; Morgan & Mikhail Clinical
Anaesthesiology 6th Edition McGraw-hill Education 2018 P:1283-1288
Kulkarni PA, Divatia VJ, Patil PV: Objective Anaesthesia Review A
Comprehensive Textbook for the Examinees 4th Edition; JAYPEE The Health
Sciences Publisher; New Delhi; 2017 P504-5017
Dorsch JA, Dorsch SE, Understanding Anaesthesia Equipments, 5th edition
References:
Davey AJ, Diba A; Ward’s Anaesthetic equipment, 5th edition
Ely J, Clapham M. Delivering Oxygen to Patients. BJA. CEPD reviews.
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Parke R, Mcguinness S, Eccleston M. Nasal high flow therapy delivers low level
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