1. بسم الله الرحمن الرحیم

2. Dr jarahzadeh MD.Intensivist
Oxygen Therapy
Dr jarahzadeh
MD.Intensivist

3. Oxygen Therapy
Administration of oxygen at an FIO2 > 21%

4. Introduction Oxygen is a drug Has a Drug Identification Number (DIN)
Colorless, odorless, tasteless gas
Makes up 21% of room air
Is NOT flammable but does support combustion. 4

5. Indications for Oxygen Therapy
Hypoxemia
Inadequate amount of oxygen in the blood
SPO2 < 90%
PaO2 < 60 mmHg
Excessive work of breathing
Excessive myocardial workload 5

6. Factors Influencing Oxygen Transport
Cardiac output
Arterial oxygen content
Concentration of Hgb
Metabolic requirements

7. Hypoxemia Hypoxia decrease in the arterial oxygen content in the blood
decreased oxygen supply to the tissues.

8. Causes of Hypoxemia Shunt Hypoventilation
As carbon dioxide increases oxygen falls
V/Q mismatching (ventilation/perfusion)
Pneumonia
Pulmonary edema
ARDS
Increased diffusion gradient
asbestosis
Early pulmonary edema 8

9. Clinical Manifestations of Hypoxia
Impaired judgment, agitation (restlessness), disorientation, confusion, lethargy, coma
Dyspnea
Tachypnea
Tachycardia, dysrhythmias
Elevated BP
Diaphoresis
Central cyanosis

10. Need For Oxygen Is Assessed By
Clinical evaluation
Pulse oximetry
ABG

11. Cautions For Oxygen Therapy
Oxygen toxicity – can occur with Fio2 > 60% longer than 36 hrs
Fio2>80%longer than 24 hrs Fio2>100%longer than 12hrs
Suppression of ventilation – will lead to increased CO2 and carbon dioxide narcosis
Danger of fire
Absorbtion Atelectasia
Premature retrolental fibroplasia

12. Methods of Dispensing Oxygen
Piped in
Cylinder
Oxygen concentrator

13. Classification of Oxygen Delivery Systems
Low flow systems
contribute partially to inspired gas client breathes
do not provide constant FIO2
Ex: nasal cannula, simple mask
High flow systems
deliver specific and constant percent of oxygen independent of client’s breathing
Ex: Venturi mask, non-rebreather mask, trach collar, T-piece

14. Nasal Cannula Used for low-medium concentrations of O2 Simple
Can use continuously with meals and activity
Flow rates in excess of 4L cause drying and irritation
Depth and rate of breathing affect amount of O2 reaching lungs
adults  6 LPM
infants/toddlers  2 LPM
children  3 LPM
FIO2 is not affected by mouth breathing
1lit o2=FIO2 4%
6 lito2=Fio2 24%
21%+24%=Fio2 45%

15. Simple Mask Low to medium concentration of O2
Client exhales through ports on sides of mask
Should not be used for controlled O2 levels
O2 flow rate- 6 to 8L
Can cause skin breakdown; must remove to eat.
1 lit o2=FIO2 6%
6 lito2=Fio2 36%
21% + 36%=Fio %

16. Partial Rebreather Mask
Consists of mask with exhalation ports and reservoir bag
Reservoir bag must remain inflated
O2 flow rate - 6 to 10L
FIO2=60%-80%
Client can inhale gas from mask, bag, exhalation ports
Poorly fitting; must remove to eat

17. Non-Rebreathing Mask
Consists of mask, reservoir bag, 2 one-way valves at exhalation ports and bag
Client can only inhale from reservoir bag
Bag must remain inflated at all times
O2 flow rate- 10 to 15L
Fio2= %
Poorly fitting; must remove to eat

18. Venturi Mask
Most reliable and accurate method for delivering a precise O2 concentration
Consists of a mask with a jet
Excess gas leaves by exhalation ports
O2 flow rate 4 to 15L & Narrowed orifice
Fio2, 24%-60%
Can cause skin breakdown; must remove to eat

19. Tracheostomy Collar/Mask
O2 flow rate 8 to 10L
Provides accurate FIO2
Provides good humidity; comfortable

20. T-piece Used on end of ET tube when weaning from ventilator
Provides accurate FIO2
Provides good humidity

21. Face Tent
Low flow
O2 wet
O2 flow, 4-8 lit
Fio2=40%

22. Oxygen Tent
Infant

23. Oxygen by transetracheal catheter
Fio %

24. Pulse Oximetry
Non-invasive monitoring technique that estimates the oxygen saturation of Hgb (SaO2)
May be used continuously or intermittently
Must correlate values with physical assessment findings
Normal SaO2 values – 95 to 100%

25. Pulse Oximetry

26. Pulse Oximetry

27. Factors Affecting SaO2 Measurements
Low perfusion states
Motion artifact
Nail polish(Blue) when using a finger probe
Intravascular dyes(methylen blue,indocyanine green,indigocarmine)
Vasoconstrictor medications
Abnormal Hgb(met-CoHb)
Too much light exposure

28. Nursing Interventions Related to Pulse Oximetry Monitoring
Determine if strength of signal is adequate
Notify physician if SaO2 < 92% or outside specific ordered limits
If continuously monitored, evaluate sensor site every 8 hrs and move PRN
Document SaO2, O2 requirements, client’s activity according to policy

29. Oxygen Therapy
Goal of therapy is an SPO2 of >90% or for documented COPD patients(Spo2 88–92%)-(Pao2=55-60)
As SPO2 normalizes the patients vital signs should improve”
Heart rate should return to normal for patient
Respiratory rate should decrease to normal for patient
Blood pressure should normalize for patient 29

30. Optimization My SpO2 is < 90%, what next?
Is the pulse oximeter working/accurate
Do I have a good signal?
Heart rate plus/minus ?
Is there adequate perfusion at the probe site?
Can the probe be repositioned?
Do other vital signs or clinical manifestations give evidence of hypoxemia? 30

31. Optimization cont. Check my source! Is the flow set high enough?
Ensure the O2 delivery device is attached to oxygen not medical air.
Follow tubing back to source and ensure patency
Are all connections tight?
Is the flow set high enough?
All nebs especially high flow large volume nebs need to be run at the highest rate.
Turn flow meter to maximum for large volume nebs. 31

32. Optimization cont. Reposition patient. Listen to chest.
Avoid laying patient flat on back.
Raise head of bed.
Encourage deep breathing/coughing
Listen to chest.
Wheezing?
Do they need a bronchodilator?
Crackles?
Encourage deep breathing/cough.
Are they fluid overloaded? 32

33. optimization cont. Can I improve the mechanics of breathing?
Patient position
Pursed lip breathing
Abdominal breathing.
Anxiety relief? 33

34. Optimization cont. Increase the flow:
With nasal prongs, increase the flow rate by 1 -2 lpm increments until target SpO2 is reached.
High flow nasal prongs can be maximally set at 15 lpm.
Call for physician assessment Medical if high oxygen flows are required. 34

35. Optimization cont.
What do I do if my patient is really hypoxemic (on low flow oxygen)?
Assess patient to determine cause of increasing oxygen requirements.
Best short term solution is non-rebreathe mask at 15 lpm. (reservoir stays inflated)
Goal saturation is still 88 – 92%.
Increase flow as required until re-assessed by physician 35

36. Optimization cont.
What do I do if my patient is really hypoxemic (on high flow oxygen)?
Assess patient to determine cause of increasing oxygen requirements.
Adjust FIO2 upwards in 10% increments titrating for target SPO2.
Call physician for further assessment 36

37. H1N1 points of emphasis
H1N1 decompensation requiring ICU admission usually begins with a systemic inflammatory response and pulmonary edema
CXR may not correlate with degree of oxygenation impairment
Gradually increasing oxygen requirement is a sentinel sign of impending respiratory failure 37

38. H1N1 points of emphasis
H1N1 Patients with escalating O2 needs warrant frequent monitoring for signs of impending respiratory failure
If a critical care triage system is operative, know the patient’s classification and prepare equipment accordingly – endotracheal intubation may not be an option 38

40. Questions?
Thank you for attention !