Effect of Oxygen Therapy Using non - rebreathing Mask

Against CO2 Partial Pressure Blood in Patients with

Moderate Head Injuries
Hendrizal1, Syaiful Saanin1, Hafni Bachtiar2
Abstract
The partial pressure of CO2 is very influential on cerebral blood flow (CBF) and intra kanial
pressure. The background of this research is that the pressure of the gas mixture in the theory of
John Dalton stated that if one of the gas pressure in the gas mixture increases, the partial pressure
of other gases will decline. This study aimed to determine whether the increase in oxygen
concentration in the non-rebreathing mask (NRM) will decrease the partial pressure of CO2, so
that it can be used to decrease PaCO2 while PaO2 still higher to protect brain from higher of ICT
(intra-cranial pressure) state in patients with head injuries. Method: This research is a Clinical
Trial with one shoot pretest and posttest design in patients with moderate head injury with GCS
9-13 conducted conservative treatment at the hospital Dr. M. Djamil Padang. In patients assessed
blood CO2 partial pressure before and after 6 hours of oxygen therapy using the NRM. Total
sample of 16 patients who met the incluton criteria. Result: The result showed significant
differences in blood CO2 partial pressure before and after oxygen therapy using the NRM (P
<0.05). There was a decrease of bloodCO2partial pressureafter oxygen therapy using NRM from
32.06 6.35 to 39.00 3.74. Discussion: Oxygen therapy using NRM can decrease blood CO2
partial pressure that can be used to reduce the intra-cranial pressure in patients with moderate
head injury.
Keywords: Oxygen Therapy, Non-Rebreathing Mask, Blood CO2 Partial Pressure
INTRODUCTION
Incidence of head injury from year to year is increasing along with the increasing mobility of
people . In the United States , approximately 500,000 cases per year of patients who entered the
hospital is about 17,500 patients with head injuries and died diantarnya pertahun.1 In Indonesia,
there is no complete file , from medical record file in RSUPN Dr. Cipto Mangunkusumo 1998
registered patients with head injuries as many as 1091 people with severe head injuries 137
people . The RSA " Jaury " Ujung Pandang in 1997 , recorded from 6128 patients were treated ,
322 of them are people with head injuries.1,2
Ranked highest head injury patients treated in Part Neurosurgery RS M. Djamil Padang . Data
Section of Neurosurgery at 2000 recorded 534 patients with head injury who were treated with
mortality rates reaching over 10 % and in 2011 as many as 502 people . The high morbidity and
mortality due to head injury is a challenge for specialists Neurosurgery to lower it. The
Untuktujuan need a good comprehensive treatment that includes diagnosis , therapy and
prognosis.2,3
Good management of head injury should start from the scene , during transport , in the
emergency department , to do definitive therapy . A true and proper management will affect
patient outcome . The main purpose management of head injuries is to optimize the recovery of

the primary head injury and preventing secondary head injury caused by ischemia. Protection of
the brain is a series of actions taken to discourage or reduce damage to brain cells caused by
ischemia.1-3,5,6
The introduction of acid-base is critical to the management of neurosurgical patients, particularly
patients undergoing neurosurgical intensive care. For example, patients with moderate head
injury, the patient's brain tissue acidosis can occur that can cause cerebral edema due to
obstruction of tranpor Na + and H + and Cl and HCO3. Factors affecting acid-base regulation is
the brain tissue levels of CO2, buffer system, as well as the addition of acid metabolites by body
metabolism.7-12
From the published literature, it was found that the incidence of changes in PaO2 and PaCO2 in
severe head injury are highly variable, value ranges between 30 to 84%, mortality caused by
changes in the gas pressure is ranging between 16-30%, and 10-20% including through the
mechanism of vasodilation and increased blood flow rate to brain.2 PaCO2 changes in patients
with severe injuries kranioserebral vary. But all the literature agrees that arterial PaCO2 should
be maintained in the normal threshold. If PaCO2 increases, there will be vasodilatation of blood
vessels of the brain that lead to an increase in the rate of blood flow to the brain, and eventually
there will be increase in intracranial pressure. Increased intracranial pressure with implications is
a factor that must be prevented because there will worsen outcome existing output . Meanwhile ,
if the arterial PaCO2 levels drop too low , through the mechanisms of vasoconstriction will cause
spasms in the blood vessels of the brain as well as threatening to iskemik.8 Weiner suggested that
a decrease of 1 mmHg PaCO2 will decrease the rate of blood flow to the brain by 2% . Some
researchers put a limit numbers normal PaCO2 levels between 35-45 mmHg ( some authors refer
to the figure of 30 mmHg as a minimum threshold for the rate of blood flow to the brain which
adekuad ) by PaCO2 exceeds 45 mmHg was able to increase intracranial pressure , increase
blood flow to brain whereas when PaCO2 decreased to 26 mmHg and continued to decline to
below 25 mmHg , the CBF ( cerebralblood flow) will drop below the figure of less than 17 mm
Hg / 100 g / min ( Currie gives a figure of a decrease in CBF below 20 cc / 100 gr / min ) .1,8-11
From the literature , obtained information that changes in arterial PaO 2 , does not have as a
result of changes in PaCO2 , but they also agreed to maintain PaO 2 remained within normal
limits even tend to be high . If PaO2 are within levels that are too low , it will cause hypoxia
which can cause the blood vessels of the brain vasodilitasi will be followed by an increase in the
rate of blood flow to the brain , and lead to an increase in pressure intracranial . When PaO 2
levels are too high , there will be vasoconstriction of blood vessels . Winer says that changes in
PaO 2 levels as much as 15 % percent , will only change slightly blood flow to otak.1,9-11
In patients with head injuries is important to maintain PaO 2 levels in the normal range . In some
literature mentioned that we should maintain PaO 2 of at least 100 mmHg , there are even
authors who give a higher value , which ranged between 140-160 mmHg . Nasal oxygen
administration could use canul , oxygen or hyperbaric oxygen mask chamber.9,11
One way of governance to control increased intracranial pressure is to do an act of reduction in
PaCO2, in the acute phase of trauma. Decrease done to reach the levels of PaCO2 20-30 mmHg,
which is known as hyperventilation action. This will decrease PaCO2 causes vasoconstriction of

blood vessels of the brain and this condition will directly lead to a decrease in the rate of blood
flow to the brain; with the result (indirectly) will reduce the pressure intrakranial.10,12
The background of this study is that the pressure of the gas mixture Dalton theory says that if one
of the gas pressure in the gas mixture increases the partial pressure of other gases will decrease,
so the authors would like to know whether the increase in oxygen concentration in the nonrebreathing mask will reduce the partial pressure of CO2, so it can be used to reduce PaCO2
while PaO2yang to sustain high to lower ICT (Intra Cranial Pressure) in patients with head
injury.
In patients with head injuries need to maintain a stable PaO 2 with oxygen therapy and to prevent
an increase in PaCO2 , such as by using the NRM ( non- rebreathing mask ) . Is oxygen therapy
with NRM effect on PaCO2 changes .
METHODS
This study is a research study design Clinical Trial with one shoot pretest and posttest .
Dilakakukan research in RS Dr. M. Djamil Padang , at IGD danruang HCU (High Care Unit )
surgery . The study population was all injured patients clod amurni GCS 9-13 who came for
treatment to a hospital emergency room Dr. M. Djamil Padang .
Samples were head injury patients Pure GCS 9-13 . Sampling using a non - probability sampling
with consecutive sampling technique for the study population could not be calculated (infinite ) .
In the experimental study sample size was 16 patients .
RESULTS
Trial Clinical studies have been conducted on 16 patients with moderate head injuries that go to
the hospital emergency department Dr. M. Djamil Padang on November 15, 2012 until January
2, 2013 that meet the inclusion and exclusion criteria . Based on respondent characteristics
average age of patients was 18 years with a standard deviation of 14.81 .

Table 1. The frequency distribution of blood pH before oxygen therapy with NRM
pH
f
%
Tinggi (> 7,45)
0
0

Normal (7,35-7,45)
Rendah (<7,35)
Total

16
0
16

100
0
100

Table 1 shows all the blood pH before oxygen therapy using the NRM within normal limits .
Table 2. The frequency distribution of blood pH after oxygen therapy with NRM
pH
f
%
Tinggi (> 7,45)
2
12,5
Normal (7,35-7,45)
12
75
Rendah (<7,35)
2
12,5
Total
16
100
From Table 2 above it can be seen that the pH of the blood after the use of oxygen therapy with
NRM largely normal with a percentage of 75 % .
Table 3. The frequency distribution of blood pCO2 before Oxygen therapy with NRM

pCO2 Darah (mmHg)

Tinggi (> 45 )
Normal (35-45)
Rendah (< 35 )
Total

f
0
16
0
16

%
0
100
0
100

In Table 3. looked pCO2 blood prior to use oxygen therapy using NRM all within normal limits (
100 % ) .
Table 4. The frequency distribution of blood pCO2 after Oxygen therapy with NRM
pCO2 Darah (mmHg)
Tinggi (> 45 )
Normal (35-45)
Rendah (< 35 )
Total

f
1
2
13
16

%
6,25
12,5
81,25
100

Of Table 4. It is seen that after the use of oxygen therapy using the NRM majority of pCO2 to be
low with the percentage of 81.25 % .
Table 5. Changes in pCO2 before and after Oxygen therapy using NRM
Rata-rata
Standard deviasi
pCO2sebelum
39,00
3,74
pCO2setelah
32,06
6,35

That based on Table 5. impairment of blood pCO2 after oxygen therapy using the NRM of 32.06
39.00 6.35 into 3.74 .
Statistical Analysis with Paired t test found a significant relationship pCO2 blood before and
after oxygen therapy using the NRM with significant values ( p < 0.05 ) .

DISCUSSION
From the results of a study of 16 samples of patients with head injury was from December 2012
to January 2013 who entered the hospital emergency department . Dr. M. Djamil Padang
obtained average value pCO2 before and after oxygen therapy using non - rebreathing mask
respectively 32.06 6.35 and 39.00 3.74 . The pH value of the blood after administration of
this therapy are at 75 % of normal values .
From the results of paired t test obtained significant relationship pCO2 before and after oxygen
therapy using NRM and a decline in the average value of pCO2 after oxygen therapy. From these
results it is concluded test research hypothesis acceptable. The results are consistent with the
theory of a gas pressure of the mixture according to the "John Dalton", that a high fraction of
inspired O2 will increase the partial pressure of the gas that can reduce CO2 partial pressure in
the NRM. According to "Guyton A". partial pressure of oxygen in the alveoli is 104 mmHg
(13.6%) of the total pressure of the gas mixture, whereas carbon dioxide 27 mmHg. NRM using
oxygen therapy can increase the fraction of inspired oxygen of more than 90% so that the effect
of the use of this NRM will also reduce the partial pressure of the gas in the alveoli. The high
pO2 in the alveoli also effect Halden where high oxygen partial pressure will increase the release
of CO2 bond with hemoglobin in the blood. Further result is a gas diffusion velocity of blood
into the alveoli increase due to differences in carbon dioxide partial pressure is greater.
From the description of blood pH can be seen that 75 % are in the normal range after oxygen
therapy with NRM , in accordance with the " Guyton A " that pCO2 decrease will lower the pH
of the blood , but the body has a buffer system which will adjust the pH within normal limits
CONCLUSION
1. The pH value of blood after the oxygen therapy using non - rebreathing mask mostly within
normal limits .
2. The blood pCO2 after oxygen therapy using non - rebreathing mask large sebagan below
normal .
3. There was blood pCO2 penurunaan on oxygen therapy using a non - rebreathing mask .
suggestion
Non - rebreathing mask can be used to lower blood pCO2 between 25 to 35 mmHg in patients
with head injury was the increased pressure due to intra kanial secondary brain injury with strict
monitoring of blood gas analysis in the acute phase . Need to monitor blood gas analysis in
patients with head injury who use oxygen therapy using non - rebreathing mask .
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