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Oxygen Therapy & O 2 Delivery Systems. Dr. J. S Dali MAMC. www.anaesthesia.co.in [email protected] Oxygen Therapy. ?. Oxygen Therapy. Partial Pr of O 2 in insp. gas (P i o 2 ). Oxygen Therapy. Partial Pr of O 2 in insp. gas (P i o 2 ). Conc. of O 2 (Fi o 2 )

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oxygen therapy1

Oxygen Therapy

Partial Pr of O2 in insp. gas

(Pi o2)

oxygen therapy2

Oxygen Therapy

Partial Pr of O2 in insp. gas

(Pi o2)

Conc. of O2 (Fi o2)

(Orthobaric)

Total Pressure

(Hyperbaric)

father of modern o 2 therapy1

Father of modern O2 Therapy

O2 lack not only stops the machine,

but totally ruins the supposed machinery

J.S Haldane-1917

aim of o 2 therapy1

Aim of O2 Therapy

To restore tissue O2 towards normal

o 2 cascade
O2 Cascade

Air

mitochondria

o 2 cascade1
O2 Cascade

159mm Hg

(20.95 % of 760)

Atm. Air

(dry)

?

Lower Resp. Tract

(moist 37oc)

149mm Hg

(20.95 % of 713)

o 2 cascade2
O2 Cascade

159mm Hg

(20.95 % of 760)

Atm. Air

(dry)

Humidification

6 Vol % (47mm Hg)

Lower Resp. Tract

(moist 37oc)

149mm Hg

20.95 % of 713 (760-47)

o 2 cascade3
O2 Cascade

Lower Resp. Tract

(moist 37oc)

149mm Hg

(20.95 % of 713)

?

?

101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

PA O2 = FI O2 (Pb – 47) – PaCo2 x F

= PI O2 –PaCo2

= PI O2 – PaCo2 if breathing 100% O2

R.Q

o 2 cascade4
O2 Cascade

Lower Resp. Tract

(moist 37oc)

149mm Hg

(20.95 % of 713)

O2 consumption

Alv. ventilation

101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

PA O2 = FI O2 (Pb – 47) – PaCo2 x F

= PI O2 –PaCo2

= PI O2 – PaCo2 if breathing 100% O2

R.Q

o 2 cascade5
O2 Cascade

101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

?

Arterial blood

97mm Hg

Pa O2 = 100 – 0.3 x age (years) mm Hg

A – a = 4 – 25 mmHg

o 2 cascade6
O2 Cascade

101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

Venous admixture

Arterial blood

97mm Hg

Pa O2 = 100 – 0.3 x age (years) mm Hg

A – a = 4 – 25 mmHg

venous admixture physiological shunt

O2 Cascade

Venous admixture(physiological shunt)

Low VA/Q

Normal True shunt

(normal anatomical shunt)

venous admixture physiological shunt1

O2 Cascade

Venous admixture(physiological shunt)

Low VA/Q

Normal True shunt

(normal anatomical shunt)

Pulmonary

(Bronchial veins)

Extra Pulm.

(Thebesian veins)

venous admixture physiological shunt2

O2 Cascade

Venous admixture(physiological shunt)

Low VA/Q

Normal True shunt

(normal anatomical shunt)

Pulmonary

(Bronchial veins)

Extra Pulm.

(Thebesian veins)

Normal = upto 5 % of cardiac output

o 2 cascade7
O2 Cascade

PA O2 = 101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

?

Venous admixture

?

Arterial blood

Pa O2 = 97mm Hg

Pa O2 = 100 – 0.3 x age (years) mm Hg

A – a = 4 – 25 mmHg

o 2 cascade8
O2 Cascade

PA O2 = 101mm Hg

(14 % of 713) or (15 % of 673)

673 = 760 – 47 – 40

Alveolar air

PI O2

Venous admixture

PV O2

Arterial blood

Pa O2 = 97mm Hg

Pa O2 = 100 – 0.3 x age (years) mm Hg

A – a = 4 – 25 mmHg

o 2 cascade9
O2 Cascade

Pa O2 = 97mm Hg

(Sat. > 95 %)

Arterial blood

Utilization by tissue

Cell Mitochondria PO2 7 – 37 mmHg

Mixed Venous blood

PV O2 = 40mm Hg

Sat. 75%

– The critical level for aerobic metab. to continue

o 2 cascade10
O2 Cascade

Pa O2 = 97mm Hg

(Sat. > 95 %)

Arterial blood

Utilization by tissue

Cell Mitochondria PO2 7 – 37 mmHg

Mixed Venous blood

PV O2 = 40mm Hg

Sat. 75%

Pasteur point – The critical level for aerobic metab. to continue (1 – 2 mmHg PO2 in mitochondria)

which patient is better placed
Which patient is better placed – ?

AB

Hb 14gm (normal) 7gm (Anaemic)

C.O. 5 L (normal) 4 L (Low)

PaO2 23 mm 60 mm

O2 Flux 375ml 350ml

which patient is better placed1
Which patient is better placed – ?

AB

Hb 14gm (normal) 7gm (Anaemic)

C.O. 5 L (normal) 4 L (Low)

SPO2 40 % 90 %

PaO2 23 mm 60 mm

O2 Flux 375ml 350ml

Min. gradient for O2 transfer from cap. to cell (app. 20 mm Hg)

= sat. 20 – 30% = 200 – 300ml O2 flux

Critical Level for O2 delivery / critical O2 flux

o 2 cascade11
O2 Cascade

Pa O2 = 97mm Hg

(Sat. > 95 %)

Arterial blood

Utilization by tissue

Cell Mitochondria PO2 7 – 37 mmHg

Mixed Venous blood

PV O2 = 40mm Hg

Sat. 75%

Pasteur point – The critical level for aerobic metab. to continue (PO2 1-2 mmHgin mitochondria, 22mmHg in capillary)

o 2 cascade12
O2 Cascade

Pa O2 = 97mm Hg

(Sat. > 95 %)

Arterial blood

?

Utilization by tissue

?

Cell Mitochondria PO2 7 – 37 mmHg

Mixed Venous blood

PV O2 = 40mm Hg

Sat. 75%

Pasteur point – The critical level for aerobic metab. to continue (PO2 1-2 mmHgin mitochondria, 22mmHg in capillary)

o 2 cascade13
O2 Cascade

Pa O2 = 97mm Hg

(Sat. > 95 %)

Arterial blood

Perfusion

Utilization by tissue

O2 content (Hb Conc.)

Cell Mitochondria PO2 7 – 37 mmHg

Mixed Venous blood

PV O2 = 40mm Hg

Sat. 75%

Pasteur point – The critical level for aerobic metab. to continue (PO2 1-2 mmHgin mitochondria, 22mmHg in capillary)

slide28

O2 contentPer 100 ml Art. blood 14g x 1.39 x 100% = 20 ml Ven. blood 14g x 1.39 x 75% = 15ml Tissue extraction 25% = 5ml

slide29

O2 contentPer 100 ml Art. blood 14g x 1.39 x 100% = 20 ml Ven. blood 14g x 1.39 x 75% = 15ml Tissue extraction 25% = 5ml 1% = 0.2ml Art. blood 7g x 1.39 x 100% = 10 ml Ven. blood 7g x 1.39 x 50% = 5ml Tissue extraction 50% = 5ml 1% = 0.1ml

slide30

PO2O2 contentPer 100 ml97mm Art. blood 14g x 1.39 x 100% = 20 ml 40mm Ven. blood 14g x 1.39 x 75% = 15ml Tissue extraction 25% = 5ml 1% = 0.2ml 97mm Art. blood 7g x 1.39 x 100% = 10 ml ? Ven. blood 7g x 1.39 x 50% = 5ml Tissue extraction 50% = 5ml 1% = 0.1ml

slide31

PO2O2 contentPer 100 ml97mm Art. blood 14g x 1.39 x 100% = 20 ml 40mm Ven. blood 14g x 1.39 x 75% = 15ml Tissue extraction 25% = 5ml 1% = 0.2ml 97mm Art. blood 7g x 1.39 x 100% = 10 ml 27mm Ven. blood 7g x 1.39 x 50% = 5ml Tissue extraction 50% = 5ml 1% = 0.1ml

oxygen therapy3

Oxygen Therapy

Indications

oxygen therapy indications
Oxygen Therapy Indications

FIO2

Barometric Pressure

PIO2

oxygen therapy indications1
Oxygen Therapy Indications

FIO2

-FIO2 during anaes.

- Rebreathing

Barometric Pressure

- High altitude

PIO2

oxygen therapy indications2
Oxygen Therapy Indications

FIO2

-FIO2 during anaes.

- Rebreathing

Barometric Pressure

- High altitude

PIO2

  • O2 Consumption

Alveolar Ventilation

PAO2

oxygen therapy indications3
Oxygen Therapy Indications

FIO2

-FIO2 during anaes.

- Rebreathing

Barometric Pressure

- High altitude

PIO2

  • O2 Consumption
  • convulsions
  • thyrotoxicosis
  • -shivering
  • -pyrexia
  • Alveolar Ventilation
  • resp. depression
  • Resp. muscle paresis
  • resp.effort (trauma)
  • airway obstruction

PAO2

oxygen therapy indications4
Oxygen Therapy Indications

FIO2

-FIO2 during anaes.

- Rebreathing

Barometric Pressure

- High altitude

PIO2

  • O2 Consumption
  • convulsions
  • thyrotoxicosis
  • -shivering
  • -pyrexia
  • (7 % / o C)
  • Alveolar Ventilation
  • resp. depression
  • Resp. muscle paresis
  • resp.effort (trauma)
  • airway obstruction

PAO2

oxygen therapy indications5
Oxygen Therapy Indications

Low VA/Q

Normal Anat. shunt

PaO2

oxygen therapy indications6
Oxygen Therapy Indications
  • Low VA/Q
  • Abn. Pulmonary shunt
  • - pneumonia
  • lobar atelectasis
  • ARDS
  • Normal Anat. shunt
  • Abn.extra Pulm. Shunt
    • cong. heart disease
    • (R L )

PaO2

oxygen therapy indications7
Oxygen Therapy Indications
  • Low VA/Q
  • Abn. Pulmonary shunt
  • - pneumonia
  • lobar atelectasis
  • ARDS
  • Normal Anat. shunt
  • Abn.extra Pulm. Shunt
    • cong. heart disease
    • (R L )

PaO2

Hypoxic hypoxia

slide42

Simple Rule

Hypoxia due to hypoventilation

Slight increase in O2 conc.

(Thus the importance of ventimask)

Higher O2 conc.

slide43

Simple Rule

Hypoxia due to hypoventilation

Slight increase in O2 conc.

(Thus the importance of ventimask)

Higher O2 conc.

  • hypercapnoea
  • absence of cynosis
oxygen therapy indications8
Oxygen Therapy Indications
  • Low VA/Q
  • Abn. Pulmonary shunt
  • - pneumonia
  • lobar atelectasis
  • ARDS
  • Normal Anat. shunt
  • Abn.extra Pulm. Shunt
    • cong. heart disease
    • (R L )

PaO2

Perfusion

Hb concentration

Cell

PO2

oxygen therapy indications9
Oxygen Therapy Indications
  • Low VA/Q
  • Abn. Pulmonary shunt
  • - pneumonia
  • lobar atelectasis
  • ARDS
  • Normal Anat. shunt
  • Abn.extra Pulm. Shunt
    • cong. heart disease
    • (R L )

PaO2

Perfusion

local - PVD, thrombosis gen – shock, Hypovol., card. Failure cardiac arrest

  • Hb concentration
  • Anaemia
  • CO poisoning

Cell

PO2

which patient is better placed2
Which patient is better placed – ?

AB

Anaemic patient Patient with Hb 14gm%

Hb = 7gm % Normal Hb 7gm%

Hb Co 7gm%

which patient is better placed3
Which patient is better placed – ?

AB

Anaemic patient Patient with Hb 14gm%

Hb = 7gm % Normal Hb 7gm%

Hb Co 7gm%

2,3 DPG

Shift to R Shift to L

unloading of O2 unloading of O2

(blood tissue) (blood tissue)

PVO2 – ? PVO2 – ?

which patient is better placed4
Which patient is better placed – ?

AB

Anaemic patient Patient with Hb 14gm%

Hb = 7gm % Normal Hb 7gm%

Hb Co 7gm%

2,3 DPG

Shift to R Shift to L

unloading of O2 unloading of O2

(blood tissue) (blood tissue)

PVO2 – 27 mm Hg PVO2 – ?

which patient is better placed5
Which patient is better placed – ?

AB

Anaemic patient Patient with Hb 14gm%

Hb = 7gm % Normal Hb 7gm%

Hb Co 7gm%

2,3 DPG

Shift to R Shift to L

unloading of O2 unloading of O2

(blood tissue) (blood tissue)

PVO2 – 27 mm Hg PVO2 – 14mmHg

which patient is better placed6
Which patient is better placed – ?

AB

Anaemic patient Patient with Hb 14gm%

Hb = 7gm % Normal Hb 7gm%

Hb Co 7gm%

2,3 DPG

Shift to R Shift to L

unloading of O2 unloading of O2

(blood tissue) (blood tissue)

PVO2 – 27 mm Hg PVO2 – 14mmHg

Cardiac Output

dissolved o 2 in plasma
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

dissolved o 2 in plasma1
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

Breathing 100% O2

dissolved o 2 in plasma2
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

Breathing 100% O2 (PaO2 600mm Hg)

1.8ml / 100ml of blood

dissolved o 2 in plasma3
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

Breathing 100% O2 (PaO2 600mm Hg)

1.8ml / 100ml of blood

Breathing 100% O2 at 3 Atm. Pressure

dissolved o 2 in plasma4
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

Breathing 100% O2 (PaO2 600mm Hg)

1.8ml / 100ml of blood

Breathing 100% O2 at 3 Atm. Pressure

5.4ml / 100ml of blood

dissolved o 2 in plasma5
Dissolved O2 in plasma

0.003ml / 100ml of blood / mm PO2

Breathing Air (PaO2 100mm Hg)

0.3ml / 100ml of blood

Breathing 100% O2 (PaO2 600mm Hg)

1.8ml / 100ml of blood

Breathing 100% O2 at 3 Atm. Pressure

5.4ml / 100ml of blood

Basis of Hyperbaric O2 therapy

benefit of o 2 therapy in hypoxia
Benefit of O2 therapy in Hypoxia

Hypoxic hypoxia (gas phase) + + +

Anaemic hypoxia (fluid phase – const.) +

Stagnant hypoxia (fluid phase – flow) +

Histotoxic hypoxia (tissue phase) -

benefit of o 2 therapy in hypoxia1
Benefit of O2 therapy in Hypoxia

Hypoxic hypoxia (gas phase) + + +

Anaemic hypoxia (fluid phase – const.) +

Stagnant hypoxia (fluid phase – flow) +

Histotoxic hypoxia (tissue phase) -

Normal Person (breathing 100% O2)

14gm x 1.34ml = 18.7ml + 1.8ml = 20.5ml (1.8 is 9% 20.5)

benefit of o 2 therapy in hypoxia2
Benefit of O2 therapy in Hypoxia

Hypoxic hypoxia (gas phase) + + +

Anaemic hypoxia (fluid phase – const.) +

Stagnant hypoxia (fluid phase – flow) +

Histotoxic hypoxia (tissue phase) -

Normal Person (breathing 100% O2)

14gm x 1.34ml = 18.7ml + 1.8ml = 20.5ml (1.8 is 9% 20.5)

Anaemic patient (breathing 100% O2)

4gm x 1.34ml = 5.4ml + 1.8ml = 7.2 ml (1.8 is 25% of 7.2)

oxygen therapy indications10
Oxygen Therapy Indications

Physical effects of O2

oxygen therapy indications11
Oxygen Therapy Indications

Physical effects of O2

“Air in the body – where it should not be”

oxygen therapy indications12
Oxygen Therapy Indications

Physical effects of O2

“Air in the body – where it should not be”

Surgical emphysema

Pneumothorax

Air embolism

Bowel decompression

slide67
Tissue requirement per 100ml = 5ml

Dissolved Fraction = 1.8 ml

Balance = 3.2 ml

0.2ml x 16% = 3.2ml

84% saturation = PO2 50mm Hg

oxygen therapy indications13
Oxygen Therapy Indications

Pre oxygenation / ?

oxygen therapy indications14
Oxygen Therapy Indications

Pre oxygenation / denitrogenation

To the O2 reserve in the body – ?

o 2 delivery systems1
O2 Delivery systems

Ambient pressure

  • Variable performance devices
  • Fixed performance devices
o 2 delivery systems2
O2 Delivery systems

Ambient pressure

  • Variable performance devices
  • Fixed performance devices

Positive pressure ventilation

  • Non invasive (BIPAP, CPAP)
  • Invasive
o 2 delivery systems3
O2 Delivery systems

Ambient pressure

  • Variable performance devices
  • Fixed performance devices

Positive pressure ventilation

  • Non invasive (BIPAP, CPAP)
  • Invasive

ECMO

o 2 delivery systems4
O2 Delivery systems

Ambient pressure

  • Variable performance devices (Pt. dependent) low flow
    • No capacity system – no rebreathing

nasal catheter / cannulae

    • Capacity system – chance of rebreathing
      • Small – (mass shell only)
      • Large – (with reservoir bag)
  • Fixed performance devices (Pt. independent) high flow
    • HAFOE (ventimask)
    • Anaesthesia circuits
slide76
High flow system

The gas flow is sufficient to meet all inspiratory requirement

Low flow system

The gas flow is insufficient to meet all inspiratory requirement.

Part of tidal volume is provided by room air.

variables
Variables

O2 flow rate

Patient factors

Device factors

variables1
Variables

O2 flow rate

Patient factors

  • Inspiratory flow rate
  • Expiratory time (active exp. flow + exp. pause)

Device factors

variables2
Variables

O2 flow rate

Patient factors

  • Inspiratory flow rate
  • Expiratory time (active exp. flow + exp. pause)

Device factors

  • Physical volume (capacity)
  • Vent resistance (tight fit)
nasal catheter
O2 Flowrate (L/min)

1

2

3

4

5

6

Fi O2

0.24

0.28

0.32

0.36

0.40

0.44

Nasal Catheter
slide92

Normal Anatomic Reservoir

(50ml)

6 Ltr/min

= 100ml/sec

= 50ml/1/2 Sec

nasal catheter1
Nasal Catheter

Merits

  • Easy to fix
  • Keeps hands free
  • Not much interference with further airway care
  • Useful in both spont. breathing and apnoeic
nasal catheter2
Nasal Catheter

Merits

  • Easy to fix
  • Keeps hands free
  • Not much interference with further airway care
  • Useful in both spont. breathing and apnoeic
  • Small but definite rise in FiO2 (dose not critical)

Demerits

  • Mucosal irritation (uncomfortable)
  • Gastric dilatation (especially with high flows)
slide101
For higher O2 Concentration

gadgets with storage capacity (reservoir)

problem of re-breathing

minimized / avoided by higher flows

simple face mask2
O2 Flowrate (L/min)

5-6

6-7

7-8

Fi O2

0.40

0.50

0.60

Simple face mask
poly mask

Poly mask

What type of circuit it is – ?

poly mask1

Poly mask

What type of circuit it is – ?

Modified T – Piece

non rebreathing mask
Non Rebreathing mask

Non Rebreathing Mask

face masks
Face Masks

Merits

  • Higher Oxygen Conc.

Demerits

  • Rebreathing (if O2 flow is inadequate)
  • Interfere with further airway care
  • Proper fitting is required
  • Uncomfortable (sweating, spitting)
bag valve mask assembly ambu resuscitator
Bag – Valve – Mask assembly(Ambu Resuscitator)

Bag – Valve – Mask assembly(Ambu Resuscitator)

bag valve mask assembly ambu resuscitator1
Bag – Valve – Mask assembly(Ambu Resuscitator)
  • Delivers O2 during BOTH spont. & artf. Vent
  • O2 concentration
    • 30 – 50% (without reservoir)
    • 80 – 100% (with reservoir)
  • To deliver 100% O2
bag valve mask assembly ambu resuscitator2
Bag – Valve – Mask assembly(Ambu Resuscitator)
  • Delivers O2 during BOTH spont. & artf. Vent
  • O2 concentration
    • 30 – 50% (without reservoir)
    • 80 – 100% (with reservoir)
  • To deliver 100% O2
    • Reservoir – as large as bag vol
    • O2 flow rate > minute volume (10 l/m)
  • Drawback – keeps rescuer’s hands engaged
pocket mask
Pocket Mask
  • Delivers O2 in BOTH spont. & aponeic
  • Allows use of both hands – for maintaining airway
  • Upto 4 ltr reserve vol. (rescuer’s vital capacity)

O2 Flowrate (L/min)

5

10

15

Fi O2

0.40

0.50

0.80 (Spont.)

0.54 (M - mask)

incubator
Incubator
  • Small infants – not on ventilator
  • Works on venturi principle
  • Complete air change – 10 times / hour
  • Control of humidity & temperature
  • O2 conc. falls rapidly when access ports are open
o 2 tents
O2 tents
  • For children – not tolerating mask / catheter
  • Large capacity system
  • Upto 50% O2 concentration
  • Large tent cap. and leak port – limited CO2 build up.
  • Disadvantage
    • Limited access
    • Risk of fire
    • Conflict in O2 therapy / nursing care
slide122

Can You name the device ?

Written over it – 28 % @ 4 L P M – ?

If flow is doubled (8 LPM) – what will the %age of O2 delivered by the device ?

If flow is halved (@ 2 LPM) – what will be the %age of O2 received by the patient ?

What is the likely entertainment ratio of this device ?

1 2 4 8 16

What precaution to be taken for humidification of gases while using this device ?

slide124

Works on principle of constant pressure jet – mixture.

  • O2 jet entrains air as per entrain. ratio.
  • Total flow > PIFR (30 – 35 L/min)
  • Eliminates the problem of dead space & leak free connection.
slide127

Works on principle of constant pressure jet – mixture.

  • O2 jet entrains air as per entrain. ratio.
  • Total flow > PIFR (30 – 35 L/min)
  • Eliminates the problem of dead space & leak free connection.
  • Upper limit is 60 %.
  • Humidification of O2 supply is not sensible.
slide129

If conc. of O2 which a patient is getting is not known then the situation is similar toa drug being administered without knowing the dosewhich can do harm if given more or provide insufficient effect if given less

ad