OXYGEN THERAPY

Dr Siddhartha Koirala
Dept of Anesthesiology & Critical Care Medicine.

Introduction
Anoxia or lack of oxygen not only stops the machine but also wrecks the machine. The total reserve of lung can sustain life for only 3 to 4 minutes after cessation of ventilation. So oxygen is one of the most essential drug widely available and frequently used.

 Therefore there are indications, contraindications and complications of its treatment. In practice oxygen is often prescribed without careful evaluation of its potential benefits, often in inappropriate doses and with inadequate supervision.

Definition
Oxygen therapy may be defined as an increase in partial pressure of oxygen in the inspired gas usually attained by an increase in the inspired concentration of oxygen.

Recognition of Inadequate Tissue Oxygenation

Clinical Assessment: Changes in mental status: agitation, irritability, drowsiness, headache Dyspnoea, Tachypnoea Cyanosis Tachycardia & cardiac arrhythmias Coma & Death

Laboratory Assessment Mixed venous oxygen saturation Arterial Blood Gas analysis

Indications for oxygen therapy

Respiratory failure High altitude and exercise Anaemia Anaesthesia: Intraoperative, postoperative period. Protection against respiratory arrest. Before Tracheal suctioning & Bronchoscopy

 Relief of pulmonary Hypertension Myocardial Infarction Pulmonary oedema ARDS Cyanide poisoning Carbon monoxide poisoning Hyperbaric oxygen therapy Cardiac and Respiratory arrest.

Oxygen Dosage
Cardiac and respiratory arrest: 100% Severe Hypoxemia: 70-90% Moderate Hypoxemia: 40-60% Low range hypoxemia: 20-30%

Oxygen cascade
The oxygen cascade describes the process of declining oxygen tension from atmosphere to mitochondria. At sea level, the atmospheric pressure is 760mmHg, and oxygen makes up 21% (20.094% to be exact) of inspired air: so oxygen exerts a partial pressure of 760 x 0.21 = 159mmHg.

 This is the starting point of the oxygen cascade, as one moves down through the body to the cell, oxygen is diluted down, extracted or otherwise lost, so that at cellular level the PO2 may only be 3 or 4mmHg.

Methods of Oxygen Therapy

Fixed Performance device or High Flow System

Variable performance or Low Flow System

High flow system

Inspired gas is supplied continuously at high flow.( 100% O2) The delivered FiO2 is not affected by variations in ventilatory level or breathing patterns. Indicated for patients who require a) Constant FiO2 b) Large inspiratory flow of gas(>40l/m)

Examples:
Anaesthesia bag( non rebreathing mask bag) Air-Entrainment Venturi masks.

Anesthesia bag or Bag Mask Valve System.

Anesthesia bag is non self inflating bag. This bag is like a football size bladder. Mechanism Requires compressed oxygen source to fill the bag. Advantages Preferred for Newborn Resuscitation Lung compliance can be felt on squeezing bag Can deliver free-flow 100% oxygen

 Disadvantages Requires a tight facial seal Higher risk of over-inflating lung. Technically more difficult to learn to use Technique Set oxygen supply flow meter to 510 L/min Adjust bag volume with flowcontrol valve

Self-inflating bag (Bagvalve mask or Ambu Bag)

Mechanism
Bag fills spontaneously after being squeezed

Advantages
Does not require an oxygen source Easier to learn to use

Disadvantages
Can not deliver 100% oxygen.

Air entrainment Venturi Mask

Goal: To create an open system with high flow around the nose and the mouth with a fixed FIO2. Oxygen is directed through a small bore tubing to a mixing jet. The final oxygen concentration depends up on the ratio of air drawnin through entrainment port.

 Indications to use 1.In patient whose hypoxemia can not be corrected with lower FiO2 devices such as nasal cannula. 2.COPD Patient who tend to hypoventilate with moderate FiO2. Venturi mask is the choice in such patients.

Low Flow System

Oxygen(100%) is supplied at a fixed flow that is only a portion of inspired gas. Therefore useful for patients with stable breathing patterns As ventilatory demand changes variable amount of room air will dilute the oxygen flow.

Examples:
Nasal cannulas Nasal mask Non reservoir oxygen mask Reservoir masks.

Nasal Cannula
It is a blind ended soft plastic tube. Different sizes available for adults, children and infants. Cannula are connected to flow meters with small bore tubing. Nasal cannula is used in patients who require oxygen therapy for prolonged period and is usually is well tolerated allows speaking, eating and drinking. Is non-claustrophobic.

 Oxygen flows continuously hence approx. 80 % of gas is wasted during expiration. The actual FiO2 delivered to patient with nasal cannulas is determined by oxygen flow ,Nasopharyngeal volume, and the patient inspiratory flow (Which depends on both vT and inspiratory time ).

 The oxygen from the nasal cannula can fill the nasopharynx during exhalation and with inspiration. The inspired oxygen % increases by approx.1-2 ( above 21%) per liter of oxygen flow with quite breathing in adult.

 Cannula can be expected to provide Fio2 up to 30-35 % with normal breathing and O2 flow of 3-4 L/min. However level of 40-50 % can be attained with O2 flow of >10 L/min. >5 L/min is poorly tolerated by the patient because of gas jetting into nasal cavity.

 In clinical practice the flow should be titrated according to vital signs, pulse oximetry and ABG measurement.

Nasal Mask
Nasal mask is a hybrid of the nasal cannula and the face mask. It can be applied to the face by head band strap. The lower edge of the masks flanges rest on the upper lip, surrounding the external nose. It provides supplemental oxygen equivalent to the nasal cannula under low flow conditions for adult patients.

 Patient comfort is more than nasal cannula. Oxygen is not jetted in to the nasal cavity as with the cannula. The nasal mask should be considered if it improves the patient comfort and compliance.

Non-reservoir oxygen mask

It is a simple face mask. Disposable light weight plastic device that covers both nose and mouth. Mask are fastened to the patient face by an adjustment of elastic head band.

 Due to not proper sealing of face with this mask when patient inhales he draws oxygen along with room air and so FiO2 varies depending on the size of leak, oxygen flow and breathing pattern. Body of the mask function as the reservoir for both the oxygen and the expired CO2.

 Minimum flow required to avoid rebreathing of CO2 is 5 L/min. During normal breathing for FiO2 of 0.3 to 0.6 the flow of O2 required is 5-10 L/min Drawbacks:-wearing for long period of time is uncomfortable, Speech is muffled, drinking/ eating is difficult.

Reservoir

mask

Some type of gas reservoir is added to the simple mask. These are disposable, lightweight, transparent plastic under the chin reservoir. Typical minimum flow of 10-15 L/min is required to raise the FIo2 up to 0.35-0.6.

Device

02 flow rates

FiO2 Range 1 21-24

Nasal Cannula

2 23-28 3 27-34

Simple Masks

5-6
7-8

30-45
40-60

Anesthesia bag Venturi mask

7-15

40-100

4-6 8-10 8-12

24 35 50

Hazards of O2 Therapy
Oxygen therapy can result in both respiratory and non-respiratory toxicity. Important Factors are;
Patient susceptibility The FiO2 Duration of oxygen therapy.

 Hypoventilation: - Seen in patients of chronic CO2 retention. Absorption atelectasis. - High concentration of O2 can cause pulmonary atelectasis in areas of low V/Q ratio. When the more insoluble nitrogen is replaced by oxygen, the alveolar volume decreases because of greater uptake of oxygen causing alveolar collapse.

 Pulmonary toxicity: Tracheo bronchitis, ARDS. - Oxygen toxicity is thought to be due to intracellular generation of highly reactive metabolite (free radicals ) such as superoxide, activated hydroxyl ions and hydrogen peroxide. - Oxygen-mediated injury of the alveolar capillary membrane produces a syndrome which mimics the ARDS.

 Neonatal retrolental fibroplasia - Oxygen therapy in Neonates with immature retina can lead to disorganized vascular proliferation and fibrosis, retinal detachment and eventually blindness. - Neonates of less than 44 weeks of gestational age are at risk of developing this complication.

 Fire hazards Oxygen vigorously supports combustion. It can cause fire and explosion. Seizures with hyperbaric oxygen.

 Principle of safe oxygen therapy is the use of low concentration of oxygen for short period of time. 50% oxygen can be used for unlimited period if necessary. When nothing is available in emergency atmospheric oxygen can be used for mouth to mouth ventilation and expired air still contains 16% oxygen