OXYGEN THERAPY

Dr.Ahmad Abdul-Sattar,MD Islamic Hospital

Introduction

The application of O2 to ill patients was 1st attempted more than century & a half ago,and till 1945 there was serious debate in the medical literatures as to whether O2 should play a therapeutic role in medicine.

As a gas O2 constitutes 21% of the R.A. As a treatment, this percent can be incr. according to the patient condition or requirements, but this is not 100% with out any possible side effects .

CO2 Oxygen 21%

Nitrogen& rare gases 78%

ROOM AIR

O2 is a weak oxidizing agent, but some of its metabolites are potent oxidants. Despite the therapeutic purpose of O2 use,O2 administration seems to be more of a knee-jerk response to the presence of a life-threatening condition. In a recent survey >50 % of hospitalized patients were receiving O2 R/ without written order.

O2 as R/ is common in medical practice. Nearly all ICU patients need O2 R/. Does O2 protect cells from injury in critically ill patient ?

Goals of O2 therapy

1- Treat & prevent hypoxemia. 2- Support patient with tissue hypoxia. 2- Decrease the work of breathing. 3- Decrease myocardial work. 4- Cluster headache treatment. 5- Hyperbaric O2 therapy.

Arterial hypoxemia VS/ tissue hypoxia

*Arterial hypoxemia = low O2 sat.<90% ,or low paO2< 70mmHg. *tissue hypoxia = low O2 delivery to the tissues, with production of lactic acidosis . DO2= 13.4 x (C.O./BSA) x Hb x SaO2

patient
Clinical studies reveal poor 1 correlation between arterial 2 paO2 & tissue hypoxia.

Arterial paO2

Blood lactate (N.< 4 mmol/L)

22
30 32 33 34 37 39

0.9
0.25 0.86 1.57 2.03 2.08 1.12

3 4 5 6 7

Severe hypoxemia without evidence of tissue hypoxia

1-Treat & prevent hypoxemia

Hypoxemia may be dramatically improved by increasing the inspired O2 fraction. e.g.: 1-providing supportive care for anesthetized patient. 2- CNS trauma,coma..etc

3-hypoxemia due to: - thoracic wall trauma,N.M.diseases, 4- pleural space disease,as pneumothrax,hemothorax,pleural effusion, diaphragmatic hernia 5-airway obstruction:F.Body,laryngeal paralysis,edema,neoplasm.

5-Pulmonary diseases: ***pul.edema, fibrosis,asthma, atelectasis, pneumonia, PE 6-Other causes as hypoxia due to high altitudes, CO poisoning, met-Hbia, administration of (NO)

2-Support patient with tissue hypoxia

DO2 = 13.4 x CI(C.O./BSA) x Hb x SaO2 Examples: -patient with severe anemia & acute hemorrhage,sickle cell crisis. -patient in shock state: septic shock, cardiac shock, anaphylactic shock, etc

Supportive O2 therapy in such a case may not be so beneficial alone, but needs correction of the underlying circulatory problem via i.v.vol.expansion,positive inotropes or pressor agents,blood transfusion,or treat problems with cellular O2 uptake.

3-Decrease work of breathing

Enriched inspired O2 may allow more alveolar O2 levels,the result is a decreased need for total ventilation,which means decreased work of breathing at no expense to the oxygenation status.

4-Decrease myocardial work

5-Hyperbaric O2 therapy

The patients are placed in an oxygenation chamber, the chamber is filled with 100% O2 at pressures greater than 1 atm at sea level (760mm Hg). Commonly, O2 is given at 2-2.4 atm.(1520-1800 mmHg) for 40-60 min.SID-BID.

Hperbaric O2 therapy

Aids in healing chronic complicated wounds, acute traumatic soft tissue injuries and serious wound infections. It may be helpful in treating certain toxicoses(cyanide or CO poisoning)

Oxygen delivery systems

Invasive & non-invasive. Invasive via ETT or tracheostomy. Noninvasive: 1-nasal cannula or nasal prongs. 2-low flow O2 mask(simple face mask).

3-masks with reservoir bags. a.partial rebreathing mask. b.non-rebreathing mask. 4-high flow O2 mask(venturi mask). 5-commercial O2 cages. 6-CPAP & BIPAP masks.

Nasal cannula

Delivers a constant flow of O2 to the nasopharynx and oropharynx. Typically each 1 liter/min. flow incr. FIO2 4%, max. FIO2 ~50%

NASAL CANNULA--O2 THERAPY

O2 Flow
1 L/min.
2 L/min.

FIO2
24%
28%

3 L/min.
4 L/min.

32%
36%

5 L/min.
6 L/min.

40%
44%

Advantages: -easy to use. -well tolerated. -does not interfere with talking & eating. -it does not cause claustrophobia.

Nasal cannula
Disadvantages: -inability to achieve high FIO2 in patients with high ventilatory demand. -tissue desiccation. - pain from higher flows. -reported spontaneous gastric rupture!!

Low flow O2 mask

(simple face mask)

No valves or reservoirs. Deliver O2 at flow rates between(5-10 liters/min.). The minimum flow rate 5 L/min. is needed to clear exhaled gas from the mask. Max.FIO2 ~60%. Nothing gained at higher flow rates. Lower rates(2-4L/min.)similar to nasal cannula.

Low-flow O2 masks
O2 Flow
5-6 L/min. 6-7 L/min. 7-8 L/min.

FIO2
40% 50% 60%

Low flow O2 mask

Advantages : it will add slightly higher FIO2 than nasal cannula. Disadvantages: -interfere with feeding & speech. -cant be tolerated by some patients.

Masks with reservoir bags

1-partial rebreathing mask. 2-non-rebreathing mask.

Partial rebreathing system: -higher FIO2 up to70-80% -no exhalation valve to prevent CO2 into reservoir. -transport uses.

Partial rebreathing mask

O2 FLOW
6 L/min.

FIO2
60%

7 L/min.
8 L/min.

70%
80%

9 L/min.
10 L/min.

80% +
80% +

Partial rebreathing mask

Advantages: -uses less oxygen than other masks. -higher possible FIO2. *Disadvantages: -interferes with feeding & speech. -aerosolized bronchodilator therapy is not possible.

Non-rebreathing mask

Higher possible FIO2 up to 90+. Vents all expired tidal volume. Valve at the reservoir to prevent expired gas going into the reservoir. Reservoir should be inflated during entire cycle.

NON-REBREATHING MASK
O2 FLOW O2 FLOW FIO2 FIO2

10 L/min.

80% +

15 L/min.

90%+

Non-rebreathing mask

Advantages: -Highest possible FIO2. -fixed performance. Disadvantages: -similar to partial rebreathing mask.

High-flow O2 mask (venturi)

O2 with high flow,no valves ,no reservoir. Works depending on Bernoulli principle & jet-mixing. FIO2 :24,28,32,40,50%. Not more than 50% FIO2.

Venturi mask

Advantage: -it can provide constant FIO2. -suitable for those patient with type 2 respiratory failure. Disadvantage: -inability to deliver high concentration of inhaled O2.

Cpap / Bipap mask

Full face mask. nasal mask. Other devices.

Toxicity of inhaled O2

* 95 % of the O2 molecules will be reduced to H2O and 5% will be partially reduced( free radicals).free radicals( FRs) leak into the cytosol & from the cell.FRs cause much of the cellular damage seen in O2 toxicity. **FRs scavengers prevent the body from their toxic effect:( vit.E, vit.C, vit.B6,B2, vit.A, selenium & plasma protein.)

When O2 concentrations are increased,the defense system may be overwhelmed by increased no. of O2 derived free radicals, this leads to increased cellular damage. FRs attack lipids, proteins & nucleic acids of the cells.

Safe vs. toxic FIO2

The consensus is that inhalation of a gas mixture with an FIO2 above 0.60 for a period longer than 48 h is a toxic exposure to inhaled O2.

Pulmonary O2 toxicity

The lung is the primary organ affected by O2 toxicity. It acts as barrier The severity of O2 toxicity depends on FIO2 & duration of exposure,also there is individual variation.

Pulmonary O2 toxicity

Phases POT: 1-initiation : *incr.production of FRs. *depleted antioxidant. *no evidence of lung injury. *length of this phase is variable.

POT
2-Inflammation : *destruction of pul.endothelial cells. * incr. inflammatory mediators. *development of pul.edema. 3-Destruction: *more destruction. *associated with incr. mortality.

POT

4-proliferation: *capillary endothelial cell hypertrophy. *incr. monocytes. *incr. type 2 pneumocytes. incr.surfactant production.

POT

5-fibrosis: *collagen deposition i.e. incr.interstitial lung fibrosis *permanent lung damage.

Neurologic O2 toxicity

Seizures are the most common manifestation N.O.T.(especially with hyperbaric therapy.) The causes -decr.GABA level(-amino butyric acid.). -decr. Activity of multiple enzyme systems (due to incr. production of FRs )

Preventive measures of O2 toxicity

Limit O2 inhalation. Limit the FIO2. Support antioxidant protection *evaluate selenium& vit.E periodically.