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Oxygen therapy

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Oxygen therapy

  1. 1. Oxygen source Inspired Oxygen (Fio2) Alveolar Oxygen (PAO2) Arterial Oxygen (PaO2) Caplillary Oxygen (PcO2) Tissue Oxygen Mitochondrial Oxygen Venous Oxygen (PvO2)
  2. 2. Atmospheric Oxygen (21%) Oxygen Cylinders Liquid Oxygen Oxygen Concentrator
  3. 3.  PIO2= (P B - P H2O)FiO2  At sea level: PIO2= (760-47)X 0.21 = 149.7 mmHg
  4. 4. PAO2= PIO2- (PACO2/R) R: Exchange Ratio= 0.8 PACO2=PaCO2 ( CO2 is freely diffusible) PAO2= 150- (40/0.8) = 100 mmHg
  5. 5. Diffusion Capacity •Property of the alveolar-capillary membrane •Ease with which oxygen moves from inhaled air to the red blood cells in the pulmonary capillaries
  6. 6.  The arterial PaO2 is less than PAO2 due to presence of:  Intrapulmonary Shunts Deep true bronchial veins Thebesian veins  Normal venous admixture <5%  Blood through low V/Q units  Total shunt because of the above factors is 2% of CO.
  7. 7.  Low FiO2 Low PIO2 Low PAO2 Low PaO2  High altitude  Exposure to fires which consume O2  Exhaled gas used for CPR.
  8. 8.  Results in: Hypoxemia CO2 retention  Causes: Airway Obtruction Low Minute ventilation : Low RR or Low TV PaO2 + PaCO2 = 140 mmHg.
  9. 9.  Focal Hypoventilation  Shunt Effect  Wasted Perfusion HYPOXEMIA Hypoxemia without hypercarbia (Type 1 RF)  Dead Space Effect  Wasted Ventilation INCREASED WORK OF BREATHING Minute Ventilation- PaCO2 Disparity ( Type II RF ) V/Q <1 Low V/Q Units V/Q >1 High V/Q Units V/Q=1.0 V/Q=0 V/Q= infinity
  10. 10. Type I or Hypoxemic (PaO2 <60 at sea level): Failure of oxygen exchange  Increased shunt fraction (Q S /QT )  Due to alveolar flooding  Hypoxemia refractory to supplemental oxygen. Type II or Hypercapnic (PaCO2 >45): Failure to exchange or remove CO2  Decreased alveolar minute ventilation (V A )  Often accompanied by hypoxemia that corrects with supplemental oxygen Type III Respiratory Failure: Perioperative RF Type IV Respiratory Failure: Shock
  11. 11. Alveolar arterial oxygen difference P(A-a)O2  Normal is 5-15 mm Hg because oxygenated blood is mixed with deoxygenated blood.  Affected by: Age : Increases with age FiO2: Increases with increasing FiO2.  Indicator of pulmonary parenchymal dysfunction.
  12. 12.  Normal P/F > 400; Maximum P/F = 700  Relation between PaO2 and FiO2 is non linear and influenced by: - Denitrogenation Absorption Atelectesis -PEEP  Advantage: Simple - bypasses need to calculate PAO2  Disadvantage: Cannot distinguish between Type 1 and Type II RF  S/F = 64+ 0.84 X (P/F)
  13. 13.  Thickened interface between air and blood: Collagen deposition Cellular infiltration  Reduced surface area for diffusion: Low V/Q due to partially collapsed alveoli  Decreased Delivery with Normal Oxygen Extraction: Reduced Hb Reduced SaO2 Reduced Blood Volume Reduced CO  Normal delivery with increased O2 consumption or extraction
  14. 14. : 0.003 X PaO2 ( Normal is 0.3-0.5ml ) (19.5 ml)  % of heme binding sites saturated with oxygen is the Hb oxygen saturation %.  CaO2 = (1.34 X Hb X SaO2) + 0.003 X PaO2  Eg at 100% SaO2, Hb 15g%, PaO2 120 mm Hg  CaO2= (1.34 X 15 X 100/100)+(0.003 X 120) =20.46ml
  15. 15.  Depends on oxygen content and cardiac output = CO X CaO2 = 5000 X 20/100 = 1000ml/min : Oxygen consumption by tissue per min. 250ml/min at rest : Oxygen Extraction Ratio VO2/DO2 = 0.25 (Normal range is 0.22-0.32) Indicates balance b/w delivery and uptake Low Values: Flow Maldistribution Metabolic Poison High Values: Compensatory increase in extraction for reduced delivery.
  16. 16. Inspired Air: 150 Alveolar : 100 Arterial :95 Capillary: 50 Tissue: 20 Mitochondria: 1-20 Mitochondrial function is jeopardized at PO2<30mmHg or SPO2 of 30%
  17. 17.  Documented hypoxemia: Pa02 <60 mm Hg or Sa02 <90%  An acute care situation in which hypoxemia is suspected & substantiation of hypoxemia is required within an appropriate period of time following initiation of therapy.  Severe trauma  Acute myocardial infarction  Short-term therapy (e.g., postanesthesia recovery)
  18. 18. Low Flow Devices  Nasal cannula  Nasal catheter  Transtracheal catheter Reservoir  Simple mask  Partial rebreathing mask  Nonbreathing mask High Flow Devices  Air-entrainment mask  Air-entrainment nebulizer  T-piece with a venturi device  Breathing circuits with reservoir bags Enclosure  Oxyhood  Tent  Isolette
  19. 19. Patient's inspiratory flow > flow delivered by the device Air dilution Variable flow
  20. 20.  Flow: 1-6 L/min (adults), <2 L/min (infants)  FiO2: 24%-44%  Advantages: Use on adults, children, infants; Easy to use; well tolerated Disposable; low cost.  Disadvantages: Unstable, easily dislodged High flow uncomfortable Can cause dryness, bleeding; polyps; deviated septum Mouth breathing may reduce FIO2.  Use: Patient in stable condition who needs low FIO2 Home care patient who needs long term therapy.
  21. 21.  Flow: 1-6 L/min  FiO2 Range: 22%-45%  Advantages: Use on adults, children, infants Good stability Disposable; low cost.  Disadvantages: Difficult to insert May provoke gagging, air swallowing, aspiration Polyps, deviated septum may block insertion; Needs regular changing  Use: Procedures in which cannula is difficult to use (bronchoscopy) Long-term care of infants.
  22. 22.  Oxygen enters directly into the lungs by a small flexible catheter which passes from the lower neck to trachea.  Flow: 1/4-4 L/min  FiO2: 22%-35%  Advantages: Lower 0 2 use and cost; Eliminates nasal and skin irritation Improved compliance Increased mobility  Disadvantages: High cost Surgical complications Infection Mucus plugging Lost tract  Use: Home care or ambulatory patients who need increased mobility or do not accept nasal oxygen
  23. 23. Reserve volume (flow x time) ≥ patient's tidal volume Fixed flow devices if RV > Inspiratory flow
  24. 24.  Flow: 1/4-4 L/min  FiO2: 22%-35%  Advantages: Lower 02 use and cost Less discomfort because of lower flow  Disadvantages: Unattractive, cumbersome Poor compliance Must be regularly replaced Breathing pattern affects performance  Use: Home care or ambulatory patients who need increased mobility
  25. 25.  Flow: 5-10 L/min  FiO2: 35%-50%, Variable.  Advantages: Use on adults, children, infants Quick, easy to apply Disposable, inexpensive.  Disadvantages: Uncomfortable Must be removed for eating Skin irritation Pressure sores Blocks vomitus in unconscious patients.  Uses: Emergencies, short term therapy requiring moderate FIO2, mouth breathing patients requiring moderate FIO2.
  26. 26. Partial Rebreathing System Non Rebreathing System
  27. 27.  Flow: 6-10 L/min (prevent bag collapse on inspiration)  FiO2: Maximum of 40-70%  Advantages: Use on adults, children, infants Quick, easy to apply; Disposable, inexpensive.  Disadvantages: Uncomfortable Must be removed for eating Prevents radiant heat loss Blocks vomitus in unconscious patients.  Use: Emergencies Short term therapy requiring moderate FIO2 Mouth breathing patients requiring moderate FIO2
  28. 28.  6-10 L/min (prevent bag collapse on inspiration)  FiO2: 60-80%  Advantages: Same as simple mask; High FIO2  Disadvantages: Same as simple mask Potential suffocation hazard  Use: Emergencies Short term therapy requiring high FIO2
  29. 29. The High-flow system always exceeds the patient's flow Provide fixed FIO2.
  30. 30.  Flow: Varies  FiO2: 24%-60%  Advantages: Easy to apply; disposable, inexpensive; stable, precise Fio2  Disadvantages: Limited to adult use,  Use: Patients in unstable condition who need precise Fio2.
  31. 31.  Flow: 10-15 L/min input, Should provide output flow of atleast 60 lit/min  FiO2: 28%-100%  Advantages: Provide temperature control and humidification  Disadvantage: FiO2<0.28 and >0.40 not ensured FiO2 varies with back pressure High infection risk
  32. 32.  T-piece: Attaches to ETT or tracheostomy tubes Can be variable performance or fixed performance.  Breathing Circuits: Consist of inspiratory and expiratory limb with reservoir bag. Two limbs are connected through a Y-connector to either a tight fitting mask or an endotracheal tube.
  33. 33. Cover the face and the body
  34. 34.  Flow: >7 L/min  FiO2: 21 %-100%  Advantages: Full range of FIO2  Disadvantage: Difficult to clean & disinfect .  Use: Infants who need supplemental oxygen
  35. 35.  Flow: 12-15 L/min  FiO2: 40%-50%  Advantages: Provides concurrent aerosol therapy  Disadvantages: Expensive, cumbersome; Unstable FIO2 (leaks); Requires cooling; Difficult to clean, disinfect; Limits patient mobility Fire hazard  Use: Toddlers or small children who need low to moderate FIO2 and aerosol
  36. 36.  Hyperbaric oxygen therapy is the therapeutic use of oxygen at pressures greater than 1 atm.  Indications:
  37. 37.  Inhibition of Hypoxic pulmonary vasoconstriction  Increased SVR with reduced coronary, cerebral and renal blood flows.  Reduced cardiac output & haemodynamic instability.  Increased production of reactive oxygen species.  Paradoxical decrease in O2 consumption due to maldistribution of blood flow due to peripheral shunts which open up to protect the vital organs from non-physiological effects of hyperoxia.
  38. 38.  CO2 Narcosis: In COPD patients, high FiO2 removes the hypoxic drive & causes hypoventilation and narcosis.  Denitrogenation Adsorption Atelectasis  O2 Toxicity:  Respiratory: ARDS Like syndrome  Neurological: Seizures (Hyperbaric)  Children: Bronchopulmonary dysplasia Retrolental fibroplasia
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