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Oxygen Therapy Faisal Malmstrom, Critical Care Department SKMC.

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Presentation on theme: "Oxygen Therapy Faisal Malmstrom, Critical Care Department SKMC."— Presentation transcript:

1 Oxygen Therapy Faisal Malmstrom, Critical Care Department SKMC

2 Carl Wilhelm Scheele Priestly and Lavoisier

3 ABC  Air goes in and out, blood goes round and round. Any variation on this is a bad thing. Any variation on this is a bad thing. Airway obstruction needs to be addressed immediately Airway obstruction needs to be addressed immediately

4 Respiratory failure  Type 1 (hypoxemic) Saturation < 90%. PaO 2 <60 mm Hg Saturation < 90%. PaO 2 <60 mm Hg  Type 2 (hypercapnic) PCO 2 >50 mmHg, pH 50 mmHg, pH<7.35

5 Definitions  Hypoxemia  Hypoxia

6 Hypoxemia  Low alveolar oxygen tension (ambient, hypoventilation) (ambient, hypoventilation)  Ventilation-perfusion mismatch  Right to left shunt (venous admixture) intracardiac intracardiac extracardiac extracardiac  Impaired oxygen diffusion (uncommon)

7 Alveolar gases

8 V/Q mismatch  Ventilated but not perfused: increased dead space ventilation, VT=VD+VA VD= VD equipment + VD anatomic + VD physiologic VD= VD equipment + VD anatomic + VD physiologic  Perfused but not ventilated: shunt >20% Shunt fraction, minimal improvement with increased FiO2 >20% Shunt fraction, minimal improvement with increased FiO2

9 Hypoxia  Hypoxemic Hypoxia  Anaemic Hypoxia  Stagnant Hypoxia ( distributive or low CO)  Histotoxic Hypoxia VDO2= CO x Hb x SAT/100 x 1.34ml/gHb+ (PaO2 x 0.003mlO2/100ml/mmHg)

10 Symptoms of Hypoxemia and Hypoxia  Dyspnea, tachypnea. Hyperventilation  +/- Cyanosis ( Hb, perfusion) >15g/l  Impaired mental performance----coma  Seizures, permanent brain injury  Tachycardia/Hypertension – Hypotension/Bradycardia( 30 mmHg)  Lactic acidosis

11 Indications for Oxygen therapy  Cardiac and respiratory arrest  Hypoxemia ( pO2 < 58.5 mmHg, Sat<90%)  Hypotension ( Systolic BP < 100 mmHg)  Low Cardiac Output and Metabolic Acidosis ( bicarbonate <18 mmol/l)  Respiratory distress ( RR>24/minute) American College of Chest Physicians and NHLBI

12 Treatment I  Empiric oxygen treatment Cardiac/ respiratory arrest Cardiac/ respiratory arrest Hypotension Hypotension Respiratory Distress Respiratory Distress Trauma Trauma GCS decrease from any cause GCS decrease from any cause Postoperative Postoperative

13 Treatment II  Verify hypoxemia Pulse oximetry Pulse oximetry ABG’s ABG’s  Start Oxygen treatment.  Treatment goal ( sat level)  Administration mode, flow, when to stop

14 Copyright ©2006 BMJ Publishing Group Ltd. Currie, G. P et al. BMJ 2006;333:34-36 The oxyhaemoglobin dissociation curve showing the relation between partial pressure of oxygen and haemoglobin saturation

15 Copyright ©2000 BMJ Publishing Group Ltd. Dodd, M E et al. BMJ 2000;321: Charting Oxygen treatment

16 Bad medicine To withhold Oxygen out of fear of hypercarbic ventilatory failure is poor practice To withhold Oxygen out of fear of hypercarbic ventilatory failure is poor practice Identify patients at risk (COPD) Identify patients at risk (COPD) Use Venturi masks FiO2. Use Venturi masks FiO2. ABG’s/ O2-sat to direct therapy ABG’s/ O2-sat to direct therapy Support ventilation (BiPAP, intubation) Support ventilation (BiPAP, intubation)

17 Oxygen Hazards  Fire ( airway fires)  Tissue toxicity, pulmonary and retina  Decreased hypoxemic drive and increased VD in COPD.  Seizures (hyperbaric)  Mucosal damage due to lack of humidity

18 Oxygen administration  Low flow systems  High Flow systems (HFOE)

19 Nasal Prongs

20 Copyright ©1998 BMJ Publishing Group Ltd. Bateman, N T et al. BMJ 1998;317:

21 Face Mask (“Hudson”)

22 Non-rebreather

23 Venturi Mask

24 Venturi valve

25 Copyright ©1998 BMJ Publishing Group Ltd. Bateman, N T et al. BMJ 1998;317:

26 Copyright ©2006 BMJ Publishing Group Ltd. Currie, G. P et al. BMJ 2006;333:34-36 Long term oxygen therapy prolongs survival in hypoxaemic patients with COPD when used for ≥15 hours/day. (Results from the nocturnal oxygen therapy trial (NOTT) and the MRC trial)

27 Take home message  Acute empiric oxygen treatment is ok but hypoxemia should be verified with pulse oximetry and /or ABG’s when situation more stable.  Oxygen is a drug and should be ordered as such: mode of administration, flow rate, FiO2 (venturi), treatment goal, monitoring, when to stop.  Never withhold oxygen out of fear of possible hypercarbia  Avoid overzealous treatment- Adequate saturation for the patient. COPD 88-90%


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