OXYGEN:

FRIEND OR FOE
LIHUA ZHANG, M.D.

Oxygen is a drug
xygen plays a vital role in the breathing processes and in
the metabolism of the living organisms.

xygen is one of the most widely used therapeutic agents.

t is a drug in the true sense of the word, with specific

biochemical and physiologic actions, a distinct range of
effective doses, and well-defined adverse effects at high
doses.

Benefit a high-oxygen strategy

could have
xygen-derived free radicals!

igh O2 increase tissue O2 tension

ecrease in surgical site infection?

Biologically advantageous uses of

Oxygen-derived free radicals
killing of bacterial;
killing of malarial parasites;
destruction of circulating tumor cells, particularly in the
pulmonary circulation where the oxygen tension is highest.

Supplemental Perioperative Oxygen

To Reduce The Incidence Of SurgicalBa
wound Destruction
Infection
ckground
by oxidation, or oxidative killing, is the

most important defense against surgical pathogens and depends

on the partial pressure of O2 in contaminated tissue. An easy
method of improving O2 tension in adequately perfused tissue is
to increase the concentration of FiO2.
M
ethods randomly, 500 pts, colorectal resection, FiO2 30% or
80% during the operation and for two hours afterward. GA, abx,
wound with culture-positive pus.
Re
sults Among 250 pts with FiO2 80%, 13 (5.2%) had surgicalwound infections, as compared with 28 of 250 pts 30% FiO2
(11.2% P=0.01). The absolute difference between groups was
6%, with a relative risk reduction of 54%.
N Engl J Med 2000; 342:161-7

Supplemental Perioperative O2
and the Risk of Surgical Wound Back
ground
Supplemental perioperative oxygen has been variously
Infection
reported to halve or double the risk of surgical wound infection. To
A Randomized Controlled

test the hypothesis that supplemental oxygen reduces infection risk

Trial
in
patients following colorectal surgery.
Meth
ods randomly, 300 pts, colorectal resection, FiO2 30% or 80%
during the operation and for six hours afterward. GA, abx, wound
with culture-positive pus.
Resu
lts Among 148 pts with FiO2 80%, 22 (14.9%) had surgical-wound
infections, as compared with 35 of 143 pts with FiO2 30% (24.4%
P=0.04). The absolute risk reduction was 9%, with a relative risk
reduction of 39%.
JAMA 2005; 294:2035-2042

anadian Association of General Surgeons and

American College of Surgeons Evidence Based
Reviews in Surgery. 21. recommended that
In general, widespread adoption of clinical practice change
requires a preponderance of evidence.

H
owever, there is little cost and no risk to the administration
of perioperative supplemental oxygen. Given that the
intervention makes sense from a biological and scientific
perspective, being easy to perform and relatively noninvasive,
practical, and with an excellent risk:benefit profile,
incorporating it into current quality improvement activities
aimed at reducing surgical site infection should be relatively
straightforward.
Can J Surg 2007; 50: 214-216

High-Concentration Supplemental
Perioperative O2 to Reduce the Objec
tive 1. anaerobic bacteria
infections, C-section
oxidative killing; 2. colorectal
surgery
Incidence
of
Post
SSI
with supplemental O2 decreased SSI by 50%.
A Randomized Controlled Trial

Meth
od 143 women undergoing C-section under regional anesthesia to
receive 30% or 80% FiO2 via non re-breathing mask during the operation
and for 2 hours after.
Resul
ts Post c-section infection occurred in 17/69 (25%) with 80% O2 compared
with 10/74 (14%) of women with 30% FiO2 (relative risk 1.8, P=.13). The
stopping P value for futility was P > 0.11, suggesting these differences
were unlikely to reach statistical significance with continued recruitment.
Obstet Gynecol 2008; 112: 54552

Effect of High Perioperative FiO2 on

SSI and Pulmonary Complications
After Abdominal Surgery

O
bjective
To assess
whether use of 80%
O2 reduces
the frequency of
The
PROXI
Randomized
Clinical
Trial
SSI without increasing the frequency of pulmonary complications in
pts undergoing abdominal surgery.
M
ethod a pt- and observer-blinded randomized clinical trial, 1400 pts
undergoing acute or elective laparotomy. Pts receive FiO2 80% or
30% during and for 2 hours after surgery.
R
esults SSI, atelectasis, pneumonia, respiratory failure, and mortality
within 30 days 80% O2 compared with 30% O2 did not result in a
difference in risk of SSI and of pulmonary complications after
abdominal surgery.
JAMA, 2009; 302: 1543-1550

Disadvantage of hyperoxia
egative effect on pulmonary function: atelectasis, shunt
ay promote development of acute lung injury and increase
mortality
fter re-expansion of previously atelectatic lung,
upregulation of pro-inflammatory cytokines
issue damage arising from oxygen-derived free radicals
ause arterial vasoconstriction

O2 and Anesthesia
Pr
eoperative:
Pre
oxygenation, denitrogenization, optimal O2 concentration for induction
Int
raoperative:
FiO
2 used in ventilation, optimal O2 concentration for extubation
Po
stoperative:
Su
pplemental O2 through nasal cannula, face mask; shunt and PA
equation

What is the function of Nitrogen to

human?
itrogen is a non-reactive gas. It helps to reduce the effect
of O2 by controlling the rate of combustion, oxidation
(rusting of iron and corrosion of metals).

here is so much nitrogen in our atmosphere that it adds

extra mass to the air.

uring inspiration, air is inhaled, oxygen is absorbed, and

nitrogen keeps our lung alveoli open.

I
f nitrogen is replaced by another gas, that is
if it is actively washed out of the lung by
either breathing high concentrations of
oxygen, or combining oxygen with more
soluble nitrous oxide in anesthesia, the
process of absorption atelectasis is
accelerated. It is important to realize that
alveoli in dependent regions, with low V/Q
ratios, are particularly vulnerable to
collapse.

Optimal Oxygen Concentration

during Induction of General
Anesthesia
ackground: The use of 100% oxygen during induction

of anesthesia may produce atelectasis.

ethods: 36 healthy, nonsmoking women, randomized,

FiO2 100, 80, or 60% for 5 min during the induction of

GA. Ventilation was then withheld until the oxygen
saturation, assessed by pulse oximetry, decreased to
90%. Atelectasis formation was studied with CT.
Anesthesiology 2003; 98:28 33

esults: Atelectasis 5.63.4% of the total lung area,

0.60.7%, and 0.20.2% in the groups breathing 100, 80,
and 60% O2, (P < 0.01). The corresponding times to reach
SpO2 90% were 41184, 30359, and 21369 s, (P <
0.01).

onclusion: During routine induction of general

anesthesia, 80% oxygen for oxygenation caused
minimal atelectasis, but the time margin before
unacceptable desaturation occurred was
significantly shortened compared with 100%
oxygen.

Examples of CT scans of a patient with healthy lungs, before and after induction of
anaesthesia.

Magnusson L , Spahn D R Br. J. Anaesth. 2003;91:61-72

2003 by Oxford University Press

Twodimensional representation of a volume image from an anaesthetized subject.

Magnusson L , Spahn D R Br. J. Anaesth. 2003;91:61-72

2003 by Oxford University Press

Measurement of atelectatic surface by CT of the lung at the level of the interventricular

septum and corresponding histograms.

Magnusson L , Spahn D R Br. J. Anaesth. 2003;91:61-72

2003 by Oxford University Press

Samples of CT scans of a morbidly obese and a nonobese patient before anaesthesia, after
extubation and 24 h later.

Magnusson L , Spahn D R Br. J. Anaesth. 2003;91:61-72

2003 by Oxford University Press

The Effect of Increased FIO2

Before Tracheal Extubation on Gen
eral anesthesiaAtelectasis
promotes pulmonary atelectasis, which can be
Postop
eliminated by a vital capacity (VC) maneuver (inflation of the lungs
to 40 cm H2O for 15 s).
High
-inspired O2 favors recurrence of atelectasis. Therefore, 100% O2 before
tracheal extubation may contribute to atelectasis.
Res

ults VC maneuver+FiO2=0.4 group, postoperative atelectasis was

smaller (2.6% 1.1% of total lung surface, P<0.05) than in the FiO2=1.0
group (8.3%6.2%) and in the VC maneuver+Fio2=1.0 group (6.8%
3.4%).
Anesth Analg 2002, 95:177781

Supplemental Oxygen Impairs

H
Detection
by
ypoventilation canof
be Hypoventilation
detected reliably by pulse oximetry
only when patients breathe room air. In patients with
Pulse
Oximetry
spontaneous ventilation, supplemental oxygen often masked
the ability to detect abnormalities in respiratory function in
the PACU. Without the need for capnography and arterial
blood gas analysis, pulse oximetry is a useful tool to assess
ventilatory abnormalities, but only in the absence of
supplemental inspired oxygen.

Chest 2004; 126;1552-1558

Alveolar gas equation and clinical

use
PAO2=
(PB - PH2O) x FiO2 PaCO2/RQ
= (760
- 47) x 0.21 40/0.8 = 149.7 50 = 99.7
= (760
- 47) x 0.21 50/0.8 = 149.7 62.5 = 87.2
= (760
- 47) x 0.3 - 50/0.8 = 213.9 62.5 = 151.4
= (760
- 47) x 0.3 - 70/0.8 = 213.9 87.5 = 126.4

Isoshunt curves showing the effect of varying amounts of shunt on PaO2.

Note: there is little benefit in increasing inspired oxygen concentration in
patients with very large shunts.

Major causes of hypoxemia

1. Alveolar Hypoventilation.
2. Ventilation perfusion (V/Q) mismatch: common
causes of V/Q mismatch are atelectasis, patient
positioning, bronchial intubation, one-lung
ventilation, bronchospasm, pneumonia, mucus
plugging, acute respiratory distress syndrome
(ARDS) and airway obstruction.
3. Shunt (normal shunt about 2%): hypoxemia
caused by shunt can not be overcome by increasing
the inspired oxygen concentration.
4. Diffusion abnormalities.
5. Low barometric pressure
6. Low inspired oxygen concentration (decreased
FiO2).

Specific treatment for arterial

hypoxemia
Hypoventilation
Increase alveolar ventilation
Low ventilation/perfusion ratio CPAP
Intrapulmonary shunt
CPAP
Diffusion defect
Steroids (?)
Low barometric pressure
Return to sea level
pressure
Low inspired oxygen
Oxygen!
concentration (<21%)

Although oxygen supplementation will increase oxygen

tension in every instance, oxygen is the specific
treatment for reversal of the pathologic condition
causing arterial hypoxemia in only 1 instance: low
inspired oxygen concentration (<21%).

recommendation for perioperative management

Summary and grading of

Preoxygenation

atelectasis

Use of high FiO2, (0.8)

Grade B

Reduces

CPAP 6cmH20Reduces atelectasis

Grade B

Improves artenal oxygenation Grade B

Prolongs nonhypoxic apnea time

Grade B

25 ' Head-up tilt

Grade B

Reduces atelectasis

Improves artenal oxygenation Grade B

Prolongs nonhypoxic apnea time

Grade B

Intraoperative management
exchanges

alveolar inflammation
dysfunction

Use of PCV

Grade B

Reduces peak airway pressure Grade A

Reduce VT to 5-8 ml kg- 1
Reduces

Grade B

Reduces postoperative pulmonary

Grade C

alveolar inflammation in association with low

morbidly obese

Grade B

Reduces

Improves arterial oxygenation during

Prevents atelectasis relapse after a vital

Grade B

infection in major abdominal surgery

Use 5-1 0 cmH2O PEEP

tidal volume ventilation Grade B

Improves arterial oxygenation in

one-lung ventilation Grade B

capacity maneuvre

Does not improve gas

Grade A

Set Fi0 2 to 0.8

Reduces wound

Does not reduce PONV

Grade B
Protects cardiovascular system NO
Eur J Anaesthesiol 2009; 26: 1-8

s early as 1775, Joseph Priestley suggested that

oxygen might not be an entirely unmixed blessing:

.though pure dephlogisticated air might be very

useful as a medicine, it might not be so proper for us in
the usual healthy state of the body: for, as a candle
burns so much faster in dephlogisticated than in
common air, so we might, as may be said, live out too
fast, and the animal powers be too soon exhausted in
this pure kind of air.

References
othen HU. Oxygen: avoid too much of a good thing! .
European Journal of Anaesthesiology 2010, 27:493494 ;
owns JB. Has Oxygen Administration Delayed Appropriate
Respiratory Care? Fallacies Regarding Oxygen Therapy.
RESPIRATORY CARE 2003, 48: 611-620;
owns JB. Is Supplemental Oxygen Necessary? Journal of
Cardiothoracic and Vascular Anesthesia, 2006, 20: 133-135;
unn JF. Oxygen-friend and foe Journal of the Royal Society of
Medicine, 1985, 78: 618 622.

Thank you.

Questions?