PULMONARY

SURFACTANTS AND
OXYGEN THERAPY
Pulmonary surfactants

• Lung/pulmonary surfactants are naturally

occurring compounds or lipoproteins containing
lipids and apoproteins that reduce the surface
tension within the alveoli, allowing expansion of
the alveoli for gas exchange.
• Lung surfactants are indicated for the following:
i. Rescue treatment of infants who have RDS.
ii. Prophylactic treatment of infants at high risk
for development of RDS who have evidence of
respiratory immaturity(premature and LBW
<1.35Og)
iii. This drug is being tried in the treatment of
adult RDS and with adults after near drowning.

• Examples include beractant, poractant, calfactant-

natural
• lucinactant (Surfaxin)- synthetic
Corticosteroids and surfactant for prevention of neonatal RDS

• The steroids stimulate (via the fibroblast-pneumonocyte

factor) production of surfactant phospholipids by
alveolar type II cells, enhance the expression of
surfactant-associated proteins, reduce microvascular
permeability, and accelerate overall structural
maturation of the lungs.
• Antenatal corticosteroids decrease the incidence of
respiratory distress syndrome and other neonatal
morbidities in preterm infants and are considered
standard of care for women at risk of preterm delivery
• Dexamethasone 12mg od IM 2-3 days is commonly used.
• Betamethasone can also be used.
Oxygen therapy
• Oxygen therapy has been in use for centuries.
• Oxygen)(O2) is gas used as a drug/medication and a such
should be prescribed and administered in the right
manner with regards to presenting indications for it's use
which is always in the case of hypoxaemia.
• It has side effects and specific risks, but, with objective
monitoring and administration it is a potent therapy for
the patient with respiratory condition.
• Oxygen is an expensive medication; thus, it's indication
must be met before use.
• Oxygen therapy is delivery of oxygen at a higher
concentration than room air (at a higher FiO2) and is
used to treat hypoxia, which is a condition of very low
concentration of oxygen in the tissue.
• Hypoxia is caused by hypoxemia, which is a condition of
low oxygen in the blood.
• This makes sense because if there isn't enough oxygen in
the blood, the blood can't deliver enough oxygen to the
body tissues as it circulates.
• Oxygenation is usually measured using the following:
1. The most common measurement is the pulse oximeter,
which measures estimated oxygen saturation or SpO2 using
a sensor applied to the skin. These sensors can be
intermittent or continuous, and this test is non-invasive.
2. The most accurate measurement is ABG or arterial
blood gas, which is tested by drawing blood from a
patient's artery and testing it using laboratory equipment
to determine the level of oxygen in arterial blood. This is
painful and intermittent.
• Regardless of how the level of O2 in someone's blood is
determined, a low level of O2 is the main reason for
delivery of oxygen therapy to a patient.
A pulse oximeter to estimate oxygen saturation
Symptoms of hypoxia include the following:
i. Shortness of breath
ii. Anxiety or agitation, which may progress to drowsiness
if not treated
iii. Fast heart rate and increased blood pressure, which
may progress to low heart rate and low blood pressure
if not treated
iv. Paleness, which may progress to cyanosis (or a blue
tinge to tissue) if not treated
v. Headaches, which may progress to confusion, blurred
vision, loss of muscle coordination and eventually coma
if not treated
Potential causes of hypoxia include the following:
i. Neurological causes, including any brainstem damage or
neurologic disease that affects the body's ability to appropriately
regulate breathing
ii. Cardiovascular issues, including anemia, heart problems like
heart attack, congestive heart failure, heart rhythm problems,
etc., which can affect the ability of the body to circulate
oxygenated blood
iii. Toxins, including cyanide poisoning, carbon monoxide poisoning,
medications (including narcotics) that depress respiratory drive
iv. Lung diseases, including asthma, COPD, bronchitis, pneumonia,
trauma etc.
• The long-term solution is to figure out why the patient is
experiencing hypoxemia and/or hypoxia and reverse the cause.
• In the meantime, however, oxygen can be administered in higher
concentrations to support the patient.
Other indications include:
Pre-oxygenation in induction and difficult intubation.
Pre and post suctioning
Postoperative oxygenation especially in abdominal and
chest surgeries
Hyperbaric oxygen therapy indicated in decompression
sickness, gas embolism, gas gangrene and carbon monoxide
poisoning. It involves entering a special chamber to
breathe in pure oxygen in air pressure levels 1.5 to 3 times
higher than average. The goal is to fill the blood with
enough oxygen to repair tissues and restore normal body
function.
Anaemic Hypoxia: it’s benefits is limited due circulatory
deficit
In aerosol drug delivery.
Risks Of Oxygen Therapy
• Oxygen therapy is generally safe, but it can cause side effects.
• They include
a dry or bloody nose, tiredness, and morning headaches.
Oxygen poses a fire risk, so you should never smoke or use
flammable materials when using oxygen.
• If you use oxygen tanks, make sure your tank is secured and stays
upright.
• If it falls and cracks or the top breaks off, the tank can fly like a
missile.
 Depression of ventilation:
• It is seen in COPD patients with chronic carbondioxide
(CO2)retention who have hypoxic respiratory drive to breath.
Increased arterial tension to normal can lose the hypercapnoeic
stimulus to maintain ventilation resulting in hypoventilation in
these patients
Absorption atelectasis:
• Given only pure oxygen results in the collapse of the dependent
part of the lungs as it quickly taken up from the alveoli.
• It is also a risk in general anaesthesia induction
Retinopathy of prematurity (ROP):
• It usually occur in low birth weight, very premature infant. That
is why in preterm infants, 50-80 mmHg PaO2 is recommended
in infants receiving oxygen
Bacterial contamination associated with certain nebulization and
humidification systems is a possible hazard
Pulmonary toxicity:
• Patients exposed to high oxygen levels for a prolonged period
of time have lung damage.
Delivery Devices for Oxygen Therapy
• The oxygen delivery devices are grouped into two:
• A. Low flow oxygen delivery system
• B. High flow oxygen delivery system

A. Low flow oxygen delivery systems

• are those that the exact fraction of oxygen in the
inspired air (FiO2) will be based on the patient's
anatomic reservoir and minute ventilation. (the amount
of air that enters the lungs per minute).
• They include:
1. Nasal Cannula:
• It can carry upto 1 – 6Litres of O2 Per Minute
• It is the recommended device for oxygen delivery in
children less than 5years of age
• Used for patients with minor hypoxia or increased work
of breathing and patients who won't tolerate a mask.
• It is ideal for long term oxygen therapy. It does not
increase dead space and there is no rebreathing
2. Simple Mask:
• It can carry upto 5 – 10Litres of O2 per Minute
• Flowrates should be set at 5 L/min or more to avoid
rebreathing expired CO2 retained in the mask
• High-flow oxygen required to prevent rebreathing of CO2,
which occurs when a patient breaths in CO2 that they just
exhaled.
• The patient still breathes a large percentage of room air (up to
75%) through holes in the side of the mask.
• It slightly increases dead space and there is little
rebreathing.
• It is usually uncomfortable for patients, obstruct eating
and drinking and also, muffles speech.
• Face mask
3. Non-rebreather:
• The non-rebreathing mask is similar to the partial
rebreathing mask except it has a series of one-way valves.
• One valve is placed between the bag and the mask to prevent
exhaled air from returning to the bag.
• The flow should be between 6- 15 L/min.
• Do not administer fewer than 6L/min due to the risk of
rebreathing CO2.
• A valve closes during expiration to keep expired air from
entering the reservoir bag.
• Additional valves on the side of the mask open during
exhalation but close during inhalation to prevent breathing of
room air.
• Do not allow the reservoir bag to deflate due to the risk of
rebreathing CO2.
• A non-rebreather consists of a face mask connected to a
reservoir bag that’s filled with a high concentration of
oxygen.
• The reservoir bag is connected to an oxygen tank.
• The mask covers both your nose and mouth. One-way
valves prevent exhaled air from reentering the oxygen
reservoir.
• A non-rebreather mask is used in emergency situations to
prevent hypoxemia.
B. High flow oxygen delivery systems
• deliver a prescribed gas mixture (either high or low) at flow rates that
exceed patient demand.
1. Venturi mask
• used to deliver precise concentrations of oxygen in critically ill patients
with copd due to low carbon dioxide build up
• If air-entrainment/venturi masks is available it can be used to accurately
deliver preset oxygen concentration to the trachea up to 40% but the
inspiratory flowrates is usually inadequate for adults in respiratory distress

OTHERS
• Aerosol masks, tracheostomy collars, T-tube adapters, and face
tents can be used with high-flow supplemental oxygen systems but not all
aerosol generators can deliver high oxygen concentration at the needed
flows rate.