Modul 5

TERAPI OKSIGEN

Dept. Anestesiologi & Terapi Intensif

FK USU/RSUP H.Adam Malik-Medan
Discovery of Oxygen : 1772

Carl Wilhelm Scheele Scheele’s house and pharmacy in

German - Swedish- Kopnig
pharmaceutical chemist

Oxygen, nitrogen, chlorine, many chemicals.

Tasted chemicals. ? Cause of death at age 43
 Discovery of Oxygen : 1774

Joseph Priestly: 1774 Pneumatic trough

Minister and Teacher → Supporter of American and French Revolutions

Isolated 8 gases including oxygen ; Emigrated to the US
 Discovery of Oxygen : 1775

Antoine- Laurent Lavoisier

Oxygen: acid producer, identified
as an element

Lawyer, Scientist → Paris Arsenal → French Revolution → Guillotined 1794

Leland Clark, PhD. CCHMC

• 1949: Bubble oxygenator at Fels

Research Institute, Yellow Springs,
OH

• 1951: First heart – lung machine with

MD’s Samuel Kaplan and James
Helmsworth

• Developed numerous electrodes

including the oxygen electrode to
measure oxygen in blood
A-B-C
Life
B - breathing (nafas)
Support

Bernafas Tidak ber-nafas

normal tidak
Beri
bantuan nafas
hipoventilasi
secara aktif
hiperventilasi
+ OKSIGEN

Pertahankan Pertahankan jalan nafas

jalan nafas tetap bebas Mouth to mouth
OKSIGEN masker Mouth to mask
tetap bebas Ambu bag
k/p OKSIGEN Jackson Rees
masker SIAP T- piece
 Manfaat oksigen pada pasien
dengan gangguan airway

• Meningkatkan kadar oksigen di alveoli

• Meningkatkan jumlah oksigen di FRC
• Mengurangi derajat hipoksemia darah

• Dengan nafas yang terbatas, lebih banyak

oksigen dapat masuk ke alveoli

9
OKSIGEN DIPERLUKAN PADA PROSES METABOLISME
UNTUK PEMBENTUKAN ENERGI BIOLOGIS ( ATP )

METABOLISME SECARA ANAEROBIK AKAN

MENGAKIBATKAN GANGGUAN PEMBENTUKAN ATP
DAN PEMBENTUKAN ASAM LAKTAT/ ASIDOSIS

TERAPI OKSIGEN DIINDIKASIKAN BILA TERJADI

GANGGUAN OKSIGENASI JARINGAN DAN UNTUK
MENCEGAH PENYULIT YANG TERJADI KARENA
HIPOKSEMIA
 Proses Produksi Energi

Glukosa + O2  H2O + CO2 + 38 ATP

Glukosa tanpa O2  Lactic Acid + 2 ATP

(Anerobik)
Tahapan Respirasi
1. VENTILASI

2. PERFUSI PARU - PARU

3. PERTUKARAN GAS DI PARU-PARU

4. TRANSPORT OKSIGEN

5. EKSTRAKSI ( OXYGEN UPTAKE )

Transport Oksigen
DO2 = CO ( Hb X SaO2 X 1,34 + 0,003 X PaO2)

DERAJAT HIPOKSEMIA DITENTUKAN DENGAN

1. A-a DO2 ( Alveolar - arterial O2 Difference )

= PAO2 - PaO2

PAO2 = ( PB - PH2O ) X FiO2 - PaCO2 / R

2. PaO2 / FiO2
 Kecukupan transport oksigen
(Available O2 )
• Rumus Nunn-Freeman
Av. O2 = CO {(Hb x SaO2 x 1.34) + (pO2 x 0.003)}
Disederhanakan :
Av. O2 = CO x Hb x 1.34

• Jika CO dapat naik sampai 2 x

Hb boleh tinggal ½ nya
Available O2 tidak berkurang !
• Contoh :
Av.O2 = 50 x 15 x 1.34 = 1005
Av.O2 = 100 x 7.5 x 1.34 = 1005
 Oxygen is a “DRUG”

Must be considered as a drug

– TOO MUCH of a drug can cause overdosing
problems

– TOO LITTLE isn’t enough to treat the

symptoms
Goals of Oxygen Therapy
Correct hypoxemia
Decrease symptoms associated
with hypoxemia
Decrease workload on
cardiopulmonary system
Hypoxemia – decrease in the
arterial oxygen content in
the blood

Hypoxia – decreased oxygen

supply to the tissues.
HIPOKSIA- HIPOKSEMIA

TERAPI OKSIGEN
 Assessing
Oxygen Levels
 Pulse Oximetry
Non-invasive monitoring technique
that estimates the oxygen saturation
of Hgb (SaO2)
May be used continuously or
intermittently
Must correlate values with physical
assessment findings
Normal SaO2 values – 95 to 100%
 Table Approximate PaO2 versus
O2 Hemoglobine Saturation Levels

O2 Hemoglobin Saturation
PaO2 Levels
Levels

90 mm Hg 100 %

60 mm Hg 90 %

30 mm Hg 60 %

27 mm Hg 50 %
Oxygen saturation or O2 sat
Factors Affecting SaO2
Measurements
Low perfusion states
Motion artifact
Nail polish when using a finger
probe
Intravascular dyes
Vasoconstrictor medications
Abnormal Hemoglobin
Too much light exposure
Medical Research Council (MRC) Trial 1981

87 patients

Severe COPD

O2 15 hours/day
Nocturnal Oxygen Therapy Trial (NOTT) 1980

203 patients

Severe COPD
Criteria for Ordering O2 Therapy
PaO2 at or below 55 mm Hg
Saturation O2 < 88% resting
PO2 <55 mm Hg or < 88% for 5 min (sleep)
A drop in PO2 10 mm Hg or 5% in O2 sat.
during sleep
Symptoms or signs of heart failure
(corpulmonale), pulmonary hypertension,
erythrocytosis, “P” pulmonale on EKG
PO2 <55 mm Hg or < 88% during exercise
PEDOMAN UMUM
TERAPI OKSIGEN
Bila :

PaO2 < 60 mmHg

SaO2 < 90 %
Indications for oxygen therapy

Respiratory compromise
Cyanosis
Tachypnoea
Hypoxaemia
Partially obstructed airway
Indications for oxygen therapy
Cardiac compromise
Chest pain
Shock
Tachycardia
Arrhythmias
Neurological deficits
CVA
Spinal injuries
Coma
 Long Term Sign

Clubbing
Aims of oxygen therapy
to increase PaO2 to acceptable level
with concentration of oxygen
to decrease respiratory rate and
work of breathing
Hypoxaemia with high PaCO2
24% initially
careful monitoring with regular
ABG’s
Types of oxygen delivery
Nasal cannulae
Medium concentration mask
Fixed concentration mask
Non - rebreathe bag
Humidified circuits
High flow systems
Alat FiO2
NASAL PRONG 24 - 40 %

SIMPEL MASK 40 - 50 %

VENTURI - MASK 24 - 50 %

PARTIAL REBREATHING 60 - 80 %

NON REBREATHING - 90 %

CPAP - 100 %

VENTILATOR - 100 %
 Nasal Cannulae

Flow rate up to 4l/min

Unable to determine exact concentration
Comfortable – allows patient to eat, drink
talk
Can still be used if patient is
mouth breathing
Can use continuously with
meals and activity
Nasal prong
Keuntungan :
mudah penggunaan
ringan
ekonomis
disposable
nyaman,pasien bisa mobilisasi
Kerugian :
mudah lepas
maksimum FiO2 40 %
iritasi telinga
Tehnik lain dengan kateter :
1. Nasal kateter
2. Transtracheal kateter.
Medium concentration mask
‘Hudson’/ MC mask
Flow rate must be at least 5 l/min
Exact concentration of oxygen
depends on patient’s respiratory
pattern
Poor humidification
Useful post-operatively
Masker oksigen
Konsentrasi O2 bervariasi antara 24 - 100 %

Kerugian :
1. Tidak nyaman,
2. Iritasi kulit akibat pemakaian masker ketat
3. Kontrol FiO2 sukar,( kecuali dengan sistim venturi )
4. Kalau pasien makan harus dilepas

Komplikasi yang dapat terjadi :

1. Bila pasien muntah dapat terjadi aspirasi
2. Dapat mengakibatkan retensi CO2 dan hipoventilasi
kalau flow terlalu rendah atau lubang ekshalasi
tersumbat.
 Masker Oksigen
1.Simple mask
( 35 - 60 % dengan flow 6 - 10 L )

2. Partial rebreathing
( 35 -  60 % dengan flow 6 - 10 L )

3. Non rebreathing
(  90 % , bila tidak ada kebocoran )
 Partial Rebreather Mask
Consists of mask with
exhalation ports and
reservoir bag
Reservoir bag must remain
inflated
O2 flow rate - 8 to 10L
Client can inhale gas from
mask, bag, exhalation ports
Poorly fitting; must remove to
eat
 Non-rebreather Mask
Consists of mask,
reservoir bag, 2 one-way
valves at exhalation
ports and bag
Client can only inhale
from reservoir bag
Bag must remain inflated
at all times
O2 flow rate- 10 to 15L
Poorly fitting; must
remove to eat
 Fixed concentration
‘Venturi’ masks
Deliver a fixed concentration of oxygen
Must be set at minimum flow rate as
shown on barrel
FiO2 0.24 – 0.6
Able to increase flow rate
without altering concentration
Bernouilli principle
 Venturi Mask
Most reliable and accurate
method for delivering a
precise O2 concentration
Consists of a mask with a jet
Excess gas leaves by
exhalation ports
O2 flow rate- 4 to 15L
Can cause skin breakdown;
must remove to eat
The Bernoulli
Effect 30 l/min

2 l/min oxygen jet

14 l/min air 14 l/min air

entrained entrained
2 l/min
oxygen jet
 Non Rebreathe bags
Reservoir bags’
Deliver FiO2 0.6 – 0.8
Flow rate must be set to 15 L/min
Fill reservoir 2 thirds before
applying
Useful in acute situation
Should not be worn >24hrs
Alat Terapi Oksigen
I . FIXED SYSTEM ( FiO2 TIDAK DIPENGARUHI FAKTOR
PASIEN )
1. SISTIM VENTURI - HIGH FLOW
2. LOW FLOW BREATHING CIRCUITS ( CPAP,
BAG-MASK,JAKSON-REES ,MESIN ANESTESI )

II. VARIABLE SYSTEM ( FiO2 TERGANTUNG PADA FLOW

OKSIGEN,ALAT YANG DIGUNAKAN DAN PASIEN )
1. NASAL KATETER / PRONG
2. SIMPLE MASK
3. MASKER DAN REBREATHING BAG
III. BAYI - ANAK :
1. HEAD BOX
2. INKUBATOR
3. COT / TENT.
 Alat-alat
Terapi oksigen
 Nasal prong

Simple mask

T - piece Rebreathing mask

 Nasal Cannula Face Masks

Salter Oxy-Frame
Oxymizer Pendant
Tracheostomy Collar/ Mask

O2 flow rate 8 to 10L

Provides accurate
FiO2
Provides good
humidity; comfortable
 T-piece

Used on end of ET
tube when weaning
from ventilator
Provides accurate
FiO2
Provides good humidity
Transtracheal Oxygen (TTO)
Konsentrasi Oksigen
yang dihasilkan tergantung pada :
1. Alat
2. Cara pemberian
3. Pasien kooperatif atau tidak
4. Pola napas pasien.

Pasien dengan tidal volume rendah,

takhipneu dan pola napas tidak normal ,
maka konsentrasi O2 yang masuk ke pasien
akan berubah
 Oxygen flow rate and concentration

Respiratory Non-respiratory
distress distress
Minute vol 20 l/min 5 l/min
(RR x TV) (40bpm x 500ml) (10bpm x 500ml)

O2 flow rate 2 l/min 2 l/min

Oxygen 2 l/min of 100% oxygen + 2 l/min of 100% oxygen +

concentration 18 l/min air drawn into mask (21%) 3 l/min air drawn into mask (21%)
= 20 l/min minute volume = 5 l/min
FiO2 = (1.0 x 2) + (0.21 x 18) / 30 FiO2 = (1.0 x 2) + (0.21 x 3) / 5
= 0.29 (29%) = 0.53 (53%)
Tanda mengarah ke GAGAL NAPAS

1. PERNAPASAN ABDOMINAL DOMINAN

2. GERAK OTOT NAPAS TAMBAHAN

- STERNOCLEIDOMASTOID
- INTERCOSTAL

3. RETRAKSI SUPRASTERNAL,INTERCOSTAL
GAGAL NAFAS
Nafas dibantu alat - ventilator
 Humidification

Prevents cilia destruction

Prevents damage to mucus

glands

Aids sputum clearance

Indications for humidification

Oxygen therapy at higher flow rates

Patients with copious secretions

Systemic hydration
IV fluids
Saline nebulisers
Complications with humidified
oxygen

Bronchoconstriction

Decreased lung function if over-

humidified

Increased risk of infection

 regulator

Flowmeter + humidifier
 Flowmeter pengatur
aliran oksigen

Pengatur tekanan tinggi dan

penunjuk tekanan tabung

Humidifier, pelembab
Sebaiknya dikosongkan saja
(mudah jadi sarang kuman)

Pada waktu transport

diperlukan oksigen tinggi,air harus
dibuang krn menghambat
aliran oksigen

66
 Precautions of Supplemental
Oxygen

1. Oxygen toxicity
2. Depression of ventilation
3. Retinopathy of Prematurity
4. Absorption atelectasis
5. Bacterial infection with humidifiers
 Oxygen Toxicity
Patients exposed to high oxygen levels
for a prolonged period of time have
lung damage.
First damage is capillary epithelium,
leading to edema, thickened
membranes and finally to pulmonary
fibrosis and hypertension.
A Vicious Cycle
 Depression of Ventilation
COPD patients with CO2 retention have
blunted stimuli to breathing
– Hypoxic drive theory
• They have a different stimulus to
breathe then normal
GOLDEN RULE:
You should never stop giving oxygen to a
patient in need.
Retinopathy of Prematurity
• Is an abnormal eye condition in some
premature infants who receive high
FIO2
– Retinal arteries hemorrhage and
scaring cause retinal detachment
and blindness.
 Absorption Atelectasis
• The alveoli in the lungs collapse and
cause shunting in the capillary lung
fields.
– Loss of nitrogen in the blood causes
less total venous pressure. This
leads to the collapse of of the
alveolus.
Pressure gradients that cause
absorption atelectasis
 Infection Control
Therapist must use an aseptic
technique when handling
supplemental oxygen and humidity
equipment
Never drain water from the tubing
back into the heated humidifier
Always date the opened container
Only use sterile liquids in reservoirs
 Oxygen: a fire hazard

NEVER smoke while using

supplemental oxygen
Severe facial burns can and do
happen
SIDE EFFECTS OF OXYGEN
Nasal drying
Nasal bleeding
Increase in blood carbon dioxide (CO2)
Atelectasis (collapse)
Airway inflammation
Lung edema/ inflammation
Damage to retina: infants, high O2
Misconceptions about Oxygen

Oxygen is “addicting” – postpone use as much

as possible
High Oxygen concentration is bad for you
I only need Oxygen when I am short of breath
Oxygen can burn spontaneously
Oxygen is used in terminal disease
Humidity is needed for everyone on oxygen
Clinical Guidelines
Consider Oxygen as a drug
Use the lowest FIO2 ….
Use it for the shortest possible time
Keep oxygen below 50% if…
If you have to - accept lower
saturations than normal in some
situations
Check equipment regularly for
contaminants
 Summary
Oxygen is required for cell metabolism
Oxygen requirements are higher in
critically ill patients
Be aware of different delivery systems
Always consider humidification
Safety aspects
 Terima kasih atas perhatian anda
Semoga Tuhan selalu memberkahi kita semua
Amin