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OXYGEN THERAPY
O2 toxicity primarily affects the lungs and the central nervous system
(CNS).
Two primary factors determine the harmful effects of O2: PO2 and
exposure time
The higher the PO2 and the longer the exposure, the greater the
likelihood of damage. Effects on the CNS, including tremors,
twitching, and convulsions, tend to occur only when a patient is
breathing O2 at pressures greater than 1 atm (hyperbaric pressure).
Pulmonary effects can also occur with enriched O2 environments at
normal atmospheric pressures.
PROLONGED O2 EXPOSURE
-Damage capillary endothelium
-Interstitial edema follows
-thickens the alveolar-capillary
membrane
-If the process continues, type I
alveolar cells are destroyed,
and type II cells proliferate
Results of most studies indicate that adults can breathe up to 50% for
extended periods without major lung damage.
Rather than applying strict cutoffs, one can weigh both FiO2 and
exposure time in assessing the risks of high PO2
The goal always should be to use the lowest possible FiO2
compatible with adequate tissue oxygenation
Limit patient exposure to 100% O2 to less than 24 hours whenever
possible. High FiO2 is acceptable if the concentration can be
decreased to 70% within 2 days and 50% or less in 5 days
Depression of Ventilation
The primary reason some patients with COPD hypoventilate when given
O2 is most likely suppression of the hypoxic drive.
In these patients, the normal response to high partial pressure of carbon
dioxide (PCO2) is blunted, the primary stimulus to breathe being lack of
O2 as sensed by the peripheral chemoreceptors.
The increase in the blood O2 level in these patients suppresses peripheral
chemoreceptors, depresses ventilatory drive, and elevates the PCO2.
High blood O2 levels may disrupt the normal ventilation/perfusion
balance and cause an increase in dead space-to-tidal volume ratio
(VD/VT) and in PaCO2
Retinopathy of Prematurity
Whether a device delivers a fixed or variable FiO2 depends on how much of the
patient’s inspired gas it supplies.
If the system provides all of the patient’s inspired gas, FiO2 remains stable, even
under changing demands.
If the device provides only some of the inspired gas, the patient must draw the
remainder from the surrounding air. In this case, the more the patient breathes, the
more air dilutes the delivered O2, and FiO2 is lower.
If the patient breathes less with this type of device, less air dilutes the O2, and FiO2
increases.
A system that supplies only a portion of the inspired gas always provides a variable
FiO2.FiO2 supplied with such systems can vary widely from minute to minute and
even from breath to breath.
Low-Flow Systems
Nasal Cannula
a disposable plastic device consisting of
two tips or prongs approximately 1 cm
long that are connected to several feet of
small-bore O2 supply tubing
The user inserts the prongs directly into the
vestibule of the nose while attaching the
supply tubing either directly to a flowmeter
or to a bubble humidifier.
In most cases, a humidifier is used only
when the input flow is greater than 4 L/min.
Nasal Cannula
Common Problems
inaccurate flow
system leaks
obstructions
device displacement
skin irritation
Reservoir Systems
ADVANTAGES DISADVANTAGES
All high-flow systems mix air and O2 to achieve a given FiO2. These gases are mixed with air-
entrainment devices or blending systems.
Computations involving mixtures of air and O2 are based on a modified form of the dilution
equation for solutions:
O2 concentration in these two volumes
Because they dilute source O2 with air, entrainment devices always provide
less than 100% O2.
The more air they entrain, the higher is the total output flow, but the
delivered FiO2 is lower.
High flow is possible only when low O2 concentration is delivered. For these
reasons, airentrainment devices function as true high-flow systems only at
low FiO2.
If the flow output from an air-entrainment device decreases to less than a
patient’s inspiratory flow, air dilution occurs, and FiO2 becomes variable.
Air-Entrainment Systems
desired O2
percentage
With most nebulizer systems, the extremely small size of the jet needed
for aerosol production limits the maximum O2 input flow to 12 to 15 L/min
at 50 psig.
For example, the total output flow of an air-entrainment nebulizer set to
deliver 40% O2 ranges from 48 to 60 L/min.
Although this amount may be adequate for most patients, it is
insufficient for patients with very high inspiratory flow or minute volume
The actual FiO2 received by patients may be affected by the choice of
airway appliance. The FiO2 delivered by face tent is consistently less
than the set nebulizer concentration, especially at higher level
Air-Entrainment Nebulizer
There are two ways to assess whether the flow of an airentrainment nebulizer meets
the patient’s needs.
The first method is simple visual inspection. With this approach (generally used only with
a T tube), the RT sets up the device to deliver the highest possible flow at the
prescribed FiO2. After connecting the system to the patient, the RT observes the mist
output at the expiratory side of the T tube. As long as mist can be seen escaping
throughout inspiration, flow is adequate to meet the patient’s needs, and the
delivered FiO2 is ensured.
The second way to assess the adequacy of nebulizer flow is to compare it with the
patient’s peak inspiratory flow. A patient’s peak inspiratory flow during tidal breathing
is approximately three times minute volume. As long as the nebulizer flow exceeds this
value, the delivered FiO2 is ensured. If the patient’s peak flow exceeds that provided
by the nebulizer, the device functions as a low-flow system with variable FiO2
Providing Moderate to High FiO2
at High Flow
The solution is to boost the total output flow. With AEMs, total output flow
can be boosted with a simple increase in input flow. For a 35% AEM (5 : 1
ratio) with an input flow of 8 L/min, the total output flow is 48 L/min. This
flow is insufficient to ensure 35% O2 delivery to all patients.
Simply increasing the input flow to 12 L/min boosts the output flow of the
AEM by 50%, to 72 L/min. The new high flow ensures delivery of the set O2
concentration to essentially all patients
This solution is impossible with most air-entrainment nebulizers. Because
the small jets in many of these devices limit O2 flow to 12 to 15 L/min, the
input flow cannot be increased beyond these levels.
Providing Moderate to High FiO2 at
High Flow
alternatives for boosting the FiO2
capabilities in these situations