OXYGEN THERAPY

dr. RSW
INTRODUCTION
• Oxygen is an essential subtrate for life
• Normal cellular function is dependent on an adequate influx of
oxygen to the tissues
• The goal of cardio-respiratory function is to provide adequate
oxygenation of the tissue
• Failure of the lungs to oxygenate the blood or failure of circulation
system to maintain adequate output can cause tissue hypoxia and
death
OXYGEN DELIVERY and UTILIZATION
• Transport O2  integrated function of the pulmonary, cardiovascular
and hematology systems
• In normal conditions  PO2 from ambient atmosphere to tissue 
impact on tissue oxygenation
• Tissue hypoxia occurs when oxygen delivery is inadequate to meet
tissue metabolic demands
MECHANISMS of HYPOXIA
• Aerobic metabolism required a balance between O2 delivery (DO2)
and O2 utilization (VO2)
• If DO2 ↓ or VO2↑  tissue must shift from aerobic to an-aerobic
metabolism
• When an imbalance ↑  lactic acid ↑ progessive acidodosis 
disrupted cellular metabolism  cell death
THE MAJOR CAUSED of TISSUE
HYPOXIA
1. Arterial hypoxemia
2. Impaired O2 delivery
a. Circulatory: hypovolemia, heart failure
b. Distributive: sepsis, arterial insuficiency
c. Defective blood O2 transport: inherited abnormal Hb, acquired abnormal Hb
(CO poisoning), anemia
3. Excessive or improved tissue utilization
COMPARISON of THE FORMS OF
HYPOXIA
HYPOXEMIC ANEMIC CIRCULATORY HISTOTOXIC
PaO2 Decreased Normal Normal Normal
CaO2 Decreased Decreased Normal Normal
DO2 Decreased Decreased Decreased Normal
HYPOXEMIA
• A reduction in the partial pressure of O2 in arterial blood
• Adult, children, infant (> 28 days): PaO2 <60 mmHg or SaO2 < 90%
• Neonatus : PaO2 < 50 mmHg or SaO2 < 88%
HYPOXEMIA
• 4 clinical aspects:
1. Clinical setting (including diagnosis or differential diagnosis
2. Arteraial blood gas result
3. Chest X-ray findings
4. Responses in PaO2 to the administration of O2
HYPOXEMIA
• 5 physiologic mechanisms for hypoxemia:
1. Low inspired oxygen pressure
2. Alveolar hypoventilation
3. Ventilation/perfusion mismatch (low V/Q ratio)
4. Right to left shunt
5. Disffusion abnormality
MECHANISM of HYPOXEMIA
CAUSES
A ↓ O2 intake
B V/Q mismatching
C Alveolar hyperventilation
D R to L shunting
E Diffusion defect
CONDITIONS EFFECT OF O2 THERAPY
High altituide Rapid ↑ in PaO2
Obstructive airway diseases, Moderate rapid ↑ in PaO2
pulmonary oedema
COPD Initial response ↑ in PaO2
ARDS, Pneumonia, Pulonary Variable ↑ in PaO2 depend on size
Embolism, ASD of shunt
Pulmonary Fibrosis Moderate rapid ↑ in PaO2
HYPOXEMIA
• The most : alveolar hypoventilation, V/Q mismatch and R to L shunt
• Alveolar hypoventilation: if purely, it is enough with maintaining
minute ventilation
• V/Q mismatch : correction with supplemental O2 therapy
• R to L shunt: need other modalities beside O2 therapy
PHYSIOLOGIC RESPONSES TO
HYPOXEMIA
• Hypoxemia induces several hysiologic responses designed to maintain adequate
oxygen delivery to the tissues
• At a partial pressure of arterial oxygen (PaO2) below 55 mmHg, ventilatory drive
increases  leading to a higher PaO2 and a lower partial pressure of
carbondioxide (PaCO2)
• The vascular beds supplying hypoxic tissue dilate, inducing a compensatoy
tachycardia that increases cardiac output and improves oxygen delivery
• The pulmonary vasculature constricts in response to alveolar hypoxia, thereby
improving the match between ventilation and perfusion in the affected lung
• Subsequantly, the secretion of erytropoetin by kidney causes erytropoesis, thus
increasing the oxygen carrying capacity of the blood and oxygen delivery
ASSESING HYPOXEMIA
• Symptoms
• Arterial blood gas analysis
• Pulse oximetry (PaO2)
• Transcutaneous (PtO2)
ASSESING HYPOXEMIA: symptoms
• Dyspnea
• Rapid and shallow of breath
• Respiratory rate 35x/min
• Nose tip respiration
• Retraction of intercostal space
• Cyanosis (advance stage) : fatigue, disorientation, tachycardia,
bradycardia, arrythmia, hypertension, hypotension, etc.
ASSESING HYPOXEMIA: Blood Gas
Analysis
• Gold standard
• PaO2 and SaO2
• SaO2  amount of O2 that bound to Hb
• Saturation level is depend on oxy-hemoglobin dissociation
ASSESING HYPOXEMIA: Blood Gas
Analysis
PaO2 (mmHg) SaO2 (%)
97 97 Normal
≥ 80 ≥ 95 Normal range
< 80 < 95 Hypoxemia
60-79 90-94 Mild Hypoxemia
40-59 75-89 Moderate Hypoxemia
<40 <75 Severe Hypoxemia
ASSESING HYPOXEMIA: Pulse-oxymetri
• Good accurate if SaO2 > 80%

ASSESING HYPOXEMIA: Transcutaneus

partial pressure of oxygen (PtcO2)
HYPOXEMIA DETECTION
• AaDO2  Alveolar-arterial Oxygen gradient
• < 20 mmHg : normal
• 20-40 mmHg : V/Q mismatch
• 40-60 mmHg : R to L shunt
• > 60 mmHg : Impairment of diffusion
DIAGNOSTIC APPROACH to THE
PATIENTS with HYPOXEMIA
• Establish a WD or DD based on CH and PE
• Examine ABG for
a. Wheter hypoxemia is present
b. Degree of hypoxemia
c. Alveolar hypoventilation
• Examine chest X—ray:
a. Clear lung field or mild abnormality: hypoventilation or low V/Q
b. Significant air space filling: intra-pulmonary shunt
• Determine the likely mechanism and initate O2 therapy:
a. Small O2 supplementation for hypoventilation and/or low V/Q
b. Large O2 supplementation for shunt
• Assess the response of patient
OXYGEN THERAPY
• Concept of oxygen as therapeutic agent was introduced in the 1920s
by Alvin Barach
• Oxygen therapy for acute and chronic respiratory failure
INDICATIONS for OXYGEN THERAPY
• Treatment of documented hypoxemia
• Situations in which hypoxemia is suspected
• Decreasing the work of breathing
• Decreasing myocardial work
• Severe trauma
WHAT is OXYGEN?
• Oxygen:
a. A colorless gas
b. Odorless gas
c. Sustain aerobic life
d. Support combustion
OXYGEN THERAPY
• Purpose: to increase the content of oxygen in the arterial blood
delivered to the tissues to facilitate aerobic metabolism
• Given with caution (Small et all 1992) 
a. wrong patient,
b. incorrect dosage,
c. improper application of delivery service,
d. omission of indication
THE GOAL of OXYGEN THERAPY
 to maintain PaO2 > 60 mmHg
 to maintain SaO2 > 90%
• Prevent cell and tissue hypoxia
• Decreased work of breathing
• Decreased work of cardiac tissue
OXYGEN THERAPY
• Factors in O2 prescription:
a. Goal of therapy
b. Percentage or flow of O2 (LPM)
c. Duration of therapy
INDICATIONS OF OXYGEN THERAPY
• Hypoxemia
• Suspected hypoxemia shock, CO toxicity
• Decreasing of work of breathing  post anethesia recovery
• Decreasing of myocardial work  myocardial infarction
• Severe trauma
METHODE of OXYGEN
ADMINISTRATION
• Oxygen giving in simple way
• FiO2 as low as possible to maintain PaO2 > 60 mmHg and SaO2 > 90%

OXYGEN ADMINISTRATION DEPEND

ON
• Need of FiO2
• Patients convenience
• Level of humidity
• Need of nebulizer therapy
TYPE of OXYGEN THERAPY
• Supplemental : < 30 days
• Short Term Oxygen Therapy : 30-90days
• Long Term Oxygen Therapy : > 9 days
LONG-TERM O2 DELIVERY SYSTEMS
• Gas supplies:
• O2 concentrators and liquid O2
• Delivery devices:
• low-flow devices (nasal cannulae, trantracheal
catheters)
EXPECTED FRACTION of INSPIRED
OXYGEN
100% OXYGEN FLOW RATE FiO2 (%)
1 L/min 24
2 L/min 28
3 L/min 32
4 L/min 36
5 L/min 40
6 L/min 44
DETERMINE OF OXYGEN DOSE
1. Count PAO2 Prior Example:
• (713 x FiO2) - (PaCo2 BGA x 1,25) FiO2: 0,21
2. Hitung PAO2 New PaCO2 BGA: 60
• (PAO2 prior x target PaO2) / PaO2 Target PaO2: 95
BGA PaO2 BGA: 40
3. FiO2 newto be administered to
patient: PAO2 prior= 149,73-75= 74,73
• [PAO2 New+ (1,25 x PaCO2 PAO2 new= 7099/40=177,48
BGA)]/713
FiO2 new = (177,48+75)/713
= 0,415 (35,4%)
RANGE of FiO2 from
PERFORMANCE OXYGEN
DELIVERY DEVICES
THE KEY OF OXYGEN
ADMINISTRATION
• For whom
• How to administer
• How to follow up/monitoring

Oxygen administration = drug  can give advantage  indication, dose

and compication
THE KEY OF OXYGEN ADMINISTRATION:
for whom
Is there Chronic Hypercapnea?

Yes No

Target SpO2= 88-92% Target SpO2= 94-98%

THE KEY OF OXYGEN ADMINISTRATION: How
to administer ? (Techniques of O2 administration)
1. The choice of delivery system is based on:
• The degree of hypoxemia
• Requirement for precision of delivery
• Patient comfort
• Cost
2. The methods of oxygen delivery:
• Oxygen cylinders
• Oxygen concentrator
• Oxygen liquid
O2 DELIVERY SYSTEM in ACUTE
SETTING
• Low-flow O2 devices
a. Nasal cannule, transtracheal catheter
b. Simple O2 mask
c. Mask with reservoir bags:
1. Non-rebreathing mask
2. Partial rebreathing mask
• High-flow O2 devices
a. Jet-mixing ventury mask
b. Reservoir nebulizer blenders
NASAL CANNULE
• Flow rate 1-6 l/min with FiO2 24-
44%
• Advantages:
o Low price
o Simple and comfort
o can eat and drink
o E.g. COPD
• Disadvantage:
o Flow pressure injury
o Dry and irritated nasal mucose
 OXYGEN MASKS
• Fraction use higher than cannule
• Device from light-plastic and
covers nose-mouth
• Divided into:
o Simple mask
o RM
o NRM
o Ventury mask
o High-flow
OXYGEN MASKS: simple mask
• Advantages:
o simple, light
o Can be moisturized
o FiO2 until 60%
• Disadvantages:
o Not comfort
o Dry and irritate of eye
o Difficult to eat and discard sputum
 without valve
OXYGEN MASKS: RM
• Advantages:
o FiO2 until 60%
o Expiratory oxygen from dead-space
maintaned
• Disadvantages:
o Low-flow: rebreathing CO2 without valve

o Claustrophobia
o Difficult to eat and discard sputum
o Dry and irritated of eye
o Not comfort for severe shortness of
breath
OXYGEN MASKS: NRM
valve 2 mask

• Advantage:
o FiO2 > 80%
• Disadvantages:
o Not fomfort valve 1
o Claustropobia
o Dificult to eat and discard
Oxygen hose
sputum
o Dry and irritated of eye
o Sticky mask valve
OXYGEN MASKS: ventury

• Oxygen concentration  in a
mask with air in it  oxygen is
given with an exact number
• Tools used nonaerosol  percent
fixed (24%, 28%, 31%, 36%, 40%,
50%)
 OXYGEN MASKS: HFNC
• Can provide oxygen from 2 L
/ min to 60 L / min
• Expensive
• Humidity can be regulated
so as to prevent the dryness
of the airways and improve
the mucosiliary clearance
• Reduces the frequency of
breathing compared to
other devices, in heart
failure and palliative
patients.
THE KEY OF OXYGEN
ADMINISTRATION: How to monitor
• Patient monitoring
• Blood O2 levels
a. Arterial blood gases
b. Non-invasive: oxymetri, transcutaneous
• Equipment
COMPRESSED GAS
• Low cost in general
• Wide-spread availability
• But
• Multiple tank requirement
• Frequent deliveries required
• Heavy and unsightly tanks
• Difficult ambulation
• Can provide high liter flow,
10-12 liters per minute
• Small cylinders E are
portable but not very
convenient
• E cylinders provide only a
few hours at 2-3 liters per
minute
OXYGEN DELIVERY SYSTEMS
MEDICAL GAS CYLINDER LETTER CODES and
APPROXIMATE COMPRESSED OXYGEN
VOLUME
MEDICAL GAS CYLINDER
LETTER CODES and
APPROXIMATE
COMPRESSED OXYGEN
VOLUME
LIQUID-PORTABLE DEVICE
• Long weight
• Long-range portable cannister
• Practical ambulatory system

But
• More expensive than concentrator

Alone
• Not available in smaller places
LIQUID OXYGEN SYSTEMS
• Provides 1-6 liters per minute
flow
• High oxygen support in
smallest package (very
portable)
OXYGEN CONCENTRATOR
• Low cost
• Convenient
• Attractive equipment
• Wide-spread avaibility

But
• Electricity required
• Not portable
• May need back-up tank
OXYGEN CONCENTRATOR
• Provide 1-5 liters per minute of flow
• Provide 93-96% oxygen
• Adequate for home use
• Now Portable avaibility
EFFECT of LTOT in COPD PATIENTS
WITH HYPOXEMIA
1. Increasing survival rate:
• Oxygen therapy 15 hours per day is better compare to no oxygen
• Continuous oxygen therapy (> 19 hours per day) more effective compare too 12 hours per day
2. Improves pulmonary hemodynamic
• Partial relieve of pulmonary hypertension
• Relieve from cor pulmonale
3. Avoid the need of hospital stay
4. Improving exercise capacity
5. Reduces dyspnea
6. Improves neuro-psychologic function
7. Improves quality of life
LENGTH of OXYGEN ADMINISTRATION
• Patients breathing oxygen will have better chance of survival, the
longer the oxygen partial pressure and therefore oxygen saturation
remain in the normal range (PaO2 > 65 mmHg)
• They should breath O2 for 24 hours a day if possible
• Application of at least 14 hours is desirable
• Patients who reportedly use LTOT for less than 12 hours a day have
not shown improved survival rates
PRESCRIBING OXYGEN
• LTOT should only be prescribed by doctors who have sufficient
experience and the necessary equipment for diagnostic and
therapeutic oxygen applications
• e.g. blood gas analysis device, pulse oximeter, ambulatory nocturnal
sleep monitoring
DOSAGE of OXYGEN
• Effectiveness of oxygen is assessed by giving the patient
supplementary oxygen at 1,2 or 3 l/min through a nasal cannule for
20 min each.
• Blood gases are drawn from the hyperemic earlobe
• Pulse oximeter is sufficient for follow-up control studies
• Follow-up in a sleep lab can be necessary to diagnose hypoventilation
with or without apnea, which may necessitate NIV in addition to
oxygen administration
BTS guideline for emergency
oxygen use in adult patients Critically ill or peri- Yes Commence treatment
arrest condition with: RM/NRM/BVM

No

At risk of hypercapnic
respiratory failure

Yes No
SpO2 target: 88-92% SpO2 target 94-98%

Start 28% or 24% O2

SpO2 <94% on air or O2
then ABG
 pH < 7.35 & pH ≥ 7.35 & Yes. Commence O2 & No
pCO2 > 45 pCO2 > 45 ABG

Monitor SpO2. O2
pCO2 ≤45 pCO2 ≥ 45 not required unless
below SpO2 target

Treat with lowest

Consider NIV or IV FiO2 with Venturi Consider IV
Mask to achieve
SpO2 target 88-92%

Treat SpO2 target

Repeat ABG every
Treat with lowest 94-98%. Repeat Treat urgently SpO2 Treat to achieve
30-60 mnt. If resp
FiO2 with Venturi ABG in 30-60 mnt SpO2 target
acid. NIV/ICU target 94-98% or
Mask to achieve at risk of 88-92% if COPD
Reduce FiO2 if PO2 ≥
SpO2 target 88-92% hypercapnic resp.
60
fail.
POINTS of VIEW
• Oxygen therapy has well-established indications in acute conditions and
there has been increase in the use of LTOT
• Hypoxemia, acute or chronic are the main indication for using O2 as therapy
• The goal of oxygen therapy is to maintain PaO2 > 60 mmHg or SaO2 > 90%
• The device for oxygen source, the technique for delivery and the dose
should be prepared individually
• Knowledge of various technique of oxygen administration, establishment of
clear therapeutic end-points, monitoring of efficacy of treatment and
awareness of potential toxicity of oxygen are required
CONCLUDING REMARK
• Oxygen therapy should be given if there is indications
• Dosage and length of oxygen therapy should be administered as
prescribed dose
• Considering the need of LTOT with careful judgment