OXYGEN THERAPY

dr. I MADE ARTAWAN, M.Biomed., Sp.An

FK UNDANA 2018
 INTRODUCTION
• There is 3 essential component for life :
• OXYGEN
• WATER
• NUTRITION

• OXYGEN  THE MOST ESSENTIAL

• NO OXYGEN IN A BRIEF TIME ➡ DEATH

 INTRODUCTION
• Atmosphere provide large amount of Oxygen

• Respiration system ➡️ Provide Oxygen to the body

• Cardiovascular system ➡️ Deliver oxygen to the tissue and

cell

• Metabolism result (CO2), enter the circulation system dan

washout by the respiration system
 INTRODUCTION
• Humans are described as obligate aerobic organisms ➡️
organisms that require oxygen to survive, more accurately
described as microaerophilic organisms ➡️ organisms that
require only low concentrations of oxygen to survive.

• There is only about 13 mL of O2 in all the tissues of the

human body.

• Oxygen does not readily dissolve in water ➡️ need

hemoglobin to transport oxygen, and this limits the volume
of dissolved oxygen in the tissues of the body.
INTRODUCTION
 INTRODUCTION
• Dissolved O2 (mL/L) = 0.03 × PO2

• The concentration of dissolved O2 will be 0.03 × 5= 0.15 mL/L

inside cells and 0.03 × 15 = 0.45 mL/L in the interstitial fluid.
An average sized adult has an intracellular volume of about
23 liters and an interstitial fluid volume of about 16 liters, so
the total volume of dissolved O2 will be 0.15 × 23= 3.5 mL in
cells and 0.45 × 16= 9.6 mL in the interstitial fluid.

• The oxygen-restricted environment in tissues can be viewed

as a safeguard against the damaging effects of oxygen
metabolites.
 O2 PROVIDER

• ATMOSPHERE (mmHg) • INSPIRATION (mmHg)

• N2 = 597.0(78.62%)
• O2 = 159.0(20.84%)
• CO2= 0.3(0.04%)
• H2O= 3.7(0.50%)
_________________
• TOTAL= 760.0(100%)
• N2 = 563.4(74.09%)
• O2 = 149.3(19.67%)
• CO2= 0.3(0.04%)
• H2O= 47.0(6.20%)
_________________
• TOTAL= 760.0(100%)
 O2 PROVIDER

• ALVEOLI (mmHg) BLOOD GAS

• N2 = 569.0(74.9%)
• O2 = 104.0(13.6%) (mmHg)
• CO2= 40.0(5.3%)
• H2O= 47.0(6.2%) - PvO2= 40
_________________ - PvCO2= 50
• TOTAL= 760.0(100%) 
- PaO2 = 100
- PaCO2= 40
 VENTILATION
• ALVEOLI (mmHg) • EXPIRATION (mmHg)
• N2 = 569.0(74.9%) • N2 = 566.0(74.5%)
• O2 = 104.0(13.6%) • O2 = 120.0(15.7%)
• CO2= 40.0(5.3%) • CO2= 27.0(3.6%)
• H2O= 47.0(6.2%) • H2O= 47.0(6.20%)
_________________
• TOTAL= 760.0(100%) • TOTAL= 760.0(100%)
O2 DELIVER
 O2 DELIVERY

(O2Del) = CaO2 x CO
CaO2 = Arterial O2 content
CO = Cardiac Output
NORMAL = 800 - 1000 ml/minutes
 ARTERIAL OXYGEN CONTENT (CAO2)

CaO2 = l,34 x Hb x SaO2 + 0,003 x PaO2

1,34 = (ml) O2 bind by l gr Hb

Hb = hemoglobin
SaO2 = Oksi-Hb arterial saturation
(Hb bind to O2)
0,003 = O2 solubility in plasma
PaO2 = Partial Pressure O2 arterial
ASSUME : PaO2 = 100 mmHg, SatO2 = 100%,
Hb = 14 g/dl, ➡️ CaO2 = 181 ml/L
 VENOUS OXYGEN CONTENT (CVO2)

CvO2 = l,34 x Hb x SvO2 + 0,003 x PvO2

1,34 = (ml) O2 bind l gr Hb
Hb = hemoglobin
SvO2 = venous Oksi-Hb saturation
(Hb Bind to O2)
0,003 = O2 solubility in plasma
PvO2 = partial pressure parsial O2 venous
ASSUME : PvO2 = 40 mmHg, SatO2 = 75%,
Hb = 14 g/dl ➡️ CvO2 = 136 ml/L
 OXYGEN USE

INSPIRATION = 150 mmHg

ALVEOLAR = 104 mmHg
ARTERIAL = 100 mmHg
CAPILLAR = 51 mmHg
TISSUE = 20 mmHg
MITOCHONDRIA = 1-10 mmHg
O2 CASCADE
O2 RELEASE TO THE TISSUE

• DEPEND ON :
• SatO2-Hb
• OXYHEMOGLOBINE
DISSOSIASION CURVE
POSITION
• TO THE LEFT = STRONG
OXYHB BIND
• TO THE RIGHT = WEAK
OXYHB BIND ➡️ EASY TO
RELEASE
 CURVE SHIFT

• TO THE LEFT: • TO THE RIGHT :

• TEMP  • TEMP 
• pH  • pH 
• PCO2  • BOHR EFFECT
• 2-3 DPG  • 2-3 DPG 
• ATP  • ATP 
• Hb ABNORMAL • MCHC 
• KARBOKSI-HB • ABNORMAL HB
• MET-HB • CORTISOL
• ALDOSTERON
 OXYGEN CONSUMPTION/RESERVOIR

VO2 = CI (CaO2 - CvO2)

CI = “cardic index” (CO/BSA)
CaO2 = Arterial O2 content
CvO2 = Venous O2 content
O2 consumption on resting = 200 - 250 ml/minutes
O2 reservoir = 550 - 800 ml/minutes
 DEFINITION

OXYGEN THERAPY : TREATMENT USE OXYGEN TO

PREVENT OR TO TREAT HYPOXEMIA-HYPOXIA-
ANOXIA-DISOXIA BY :
• INCREASE OXYGEN SUPPLY
• INCREASE OXYGEN DELIVERY
• INCREASE RELEASE/UPTAKE BY THE TISSUE
 HISTORY OF OXYGEN THERAPY

• FIRST TIME USE AS MEDICINE BY :

THOMAS BEDDOES (1794)

• FIRST TIME USE IN ANESTHESIA BY :

EW ANDREWS MD (1868)

• POPULAR FOR PNEUMONIA THERAPY BY :

GE HOLTZAPPLE (1850)
 PHYSICAL CHARACTERISTIC OF O2

• CHEMISTRY SYMBOL ➡️ O2
• MOLECULE WIEGHT ➡️ 32.00
• SPECIFIC GRAVITY ➡️ 1.1052
• COLORLESS, ODORLESS, TASTELESS
• IN CILINDRE ➡️ LIQUID/GAS
• PRESSURE IN CILINDRE ➡️ 1800-2400 psig
• NOT EASY BURNED BUT HELPING FIRE PROCESS
 INDICATIONS
• Documented hypoxemia as evidenced by
• PaO2 < 60 mmHg or SaO2 < 90% on room air
• PaO2 or SaO2 below desirable range for a specific clinical
situation
• Acute care situations in which hypoxemia is suspected
• Severe trauma
• Acute myocardial infarction
• Short term therapy (Post anaesthesia recovery)

Respir Care 2002;47:707-720

 BASIC CONCEPTS OF OXYGEN THERAPY

• INCREASE SUPPLY
• INCREASE FiO2
• INCREASE ALVEOLAR VENTILATION
• INCREASE DELIVERY
• INCREASE O2 CONTENT
• MAINTAIN OR INCREASE CARDIOAC OUTPUT
• INCREASE O2 RELEASE TO THE TISSUE
• DECREASE O2 CONSUMPTION
• OXYGEN THERAPY MUST BE CONTINUE
 ASSESSMENT

• The need for oxygen therapy should be assessed by

1. Monitoring of BGA - PaO2, SpO2
2. Clinical assessment findings.
PAO2 AS AN INDICATOR FOR OXYGEN THERAPY
• PaO2 : 80 – 100 mm Hg : Normal
60 – 80 mm Hg : cold, clammy
extremities
< 60 mm Hg : cyanosis
< 40 mm Hg : mental deficiency
memory loss
< 30 mm Hg : bradycardia
cardiac arrest

PaO2 < 60 mm Hg is a strong indicator for

oxygen therapy
 CLINICAL ASSESSMENT OF HYPOXIA
MILD TO MODERATE
• CNS : • Respiratory :
- restlessness - dyspnea
- disorientation - tachypnea
- lassitude - shallow & laboured breathing
- headache
• Skin :
• Cardiac :
- tachycardia - paleness
- mild hypertension - cold
- peripheral vasoconstriction - clammy
 CLINICAL ASSESSMENT OF HYPOXIA
SEVERE
• CNS : • Respiratory :
- somnolence - increasing dyspnoea
- confusion - tachypnea
- impaired judgement - possibly bradypnoea
- loss of coordination
- obtunded mental status
• Skin :
• Cardiac : - cyanosis
- bradycardia
- arrhythmia
- hypotension
 TYPE OF OXYGEN THERAPY
• NORMOBARIC :
• USE O2 PRESSURE 1 ATM
• COMMON USE IN CLINICAL PRACTICE

• HYPERBARIC
• USE O2 HIGH PRESSURE (>1 ATM) IN A SPESIFIC
CHAMBER
• THERAPY FOR SPESIFIC CASE
 METHOD/DEVICE FOR OXYGEN THERAPY

DEVICE CRITERIA :

1. FiO2 EASY TO ADJUST

2. NOT MAKE CO2 ACUMULATION
3. MINIMAL AIRWAY RESISTANCE
4. EFFICIENT
5. COMFORT TO USE
 SYSTEM FOR OXYGEN THERAPY
• “NON REBREATHING” SYSTEM

• USE ONE WAY VALVE FOR

• INSPIRATION-EXPIRATION
• ROOM AIR DILUTION
• GAS FLOW = PATIENT MINUTE VOLUME
• 2 WAY :
• HIGH FLOW = MINUTE VOLUME
• LOW FLOW ➡️ NEED ROOM AIR DILUTION
“NON REBREATHING” SYSTEM
 SYSTEM FOR OXYGEN THERAPY

• “REBREATHING” SYSTEM

• ONE WAY VALVE

• TWO PIPE FOR INPIRATION AND EXPIRATION
• CO2 ABSORBER
• COMMON USE IN ANESTHESIA MACHINE
• LOW FLOW
“REBREATHING” SYSTEM
 SYSTEM FOR OXYGEN THERAPY
• HIGH FLOW SYSTEM :
• USE VENTURI MASK FiO2
24 - 60%
• AVAILABLE
24 – 60%
 BENEFIT AND WEAKNESS

• BENEFIT • WEAKNESS

• STABLE FiO2 • EXPENSIVE

• CONTROLLED • MUST CHANGE DEVICE IF
TEMPERATURE NEED TO CHANGE FiO2
• GUARANTEE OF HUMIDITY • UNCOMFORT
 SYSTEM FOR OXYGEN THERAPY

• LOW FLOW SYSTEM

• APART OF TIDAL VOLUME TAKEN FROM ROOM AIR

• PRODUCE FiO2 21% - 90% DEPEND ON DEVICE
• FiO2 AFFECTED BY :
• RESERVOIR CAPACITY
• OXYGEN FLOW PER LITRE
• COMMON USE IN CLINICAL PRACTICE
 SYSTEM FOR OXYGEN THERAPY

• CRITERIA O2 THERAPY WITH LOW FLOW SYSTEM :

• PATIENT IN STABLE CONDITION
• NORMAL TIDAL VOLUME
• NORMAL RESPIRATION RATE
• REGULAR TYPE OF BREATHING

• IF NOT MET WITH ONE CRITERIA ABOVE ➡️ USE HIGH

FLOW SYSTEM
SYSTEM FOR OXYGEN THERAPY
SYSTEM FOR OXYGEN THERAPY
 CLINICAL GUIDANCE FOR OXYGEN THERAPY

• PATIENT ASSESMENT AND HYPOXIA DIAGNOSE

• CHOOSE METHOD
• SPECIFY FiO2 : HIGH >60%
MODERATE 35 - 60%
LOW <35%
• CLINICAL MONITORING OF AWARENESS AND
CARDIOVASCULAR SYSTEM
• MONITORING BGA
• CHANGE METHOD IF NEEDED
 HYPOXEMIA TREATMENT
• MILD HYPOXEMIA : (PaO2 <80 mmHg)
• NASAL CATHETER 2-4 LPM OR
• SIMPLE MASK 4 LPM
• MODERATE HYPOXEMIA (PaO2 < 60 mmHg)
• WITHOUT CO2 RETENTION : MASK = 4 - 12 LPM
• WITH CO2 RETENTION : VENTURI MASK START WITH FiO2
24% (MONITORING BGA)
• SEVERE HYPOXEMIA (PaO2<40mmHg)
• INDICATION FOR MECHANICAL VENTILATION
• WITH OR WITHOUT PEEP
 COMPLICATIONS OF OXYGEN THERAPY

1. Oxygen toxicity
2. Depression of ventilation
3. Retinopathy of Prematurity
4. Absorption atelectasis
5. Fire hazard
 O2 TOXICITY

• Primarily affects lung and CNS.

• 2 factors: PaO2 & exposure time

• CNS O2 toxicity (Paul Bert effect)

• occurs on breathing O2 at pressure > 1 atm
• tremors, twitching, convulsions
 O2 TOXICITY

• Eye toxicity ➡️ FIBROPLASI RETROLENTAL

• Respiration toxicity ➡️ Trecheobronchitis, Absorption

atelectasis

• Renal toxicity ➡️ Tubular damage

 HOW MUCH O2 IS SAFE?

100% - not more than 12hrs

80% - not more than 24hrs
60% - not more than 36hrs

Goal should be to use lowest possible FiO2

compatible with adequate tissue oxygenation
INDICATIONS FOR 70% - 100% OXYGEN THERAPY

1. Resuscitation

2. Periods of acute cardiopulmonary instability

3. Patient transport
 Oxygen is a drug.

When appropriately used, it is extremely

beneficial
When misused or abused, it is potentially
harmful