TERAPI OKSIGEN

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 Upper-Lower
Respiratory System
& Alveoli

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Center and
Control of
Respiration

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Pulmonary mechanoreceptors

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Oksigen juga OBAT!
 DO2 = CaO2 x CO

CaO2 = (SaO2 x Hb x 1.34) + (0.003 x PaO2)

g/dl ml ml mmHg
 DO2 Hb x SaO2 x CO

1. Anemic hypoxemia
2. Anoxic hypoxemia
3. Stagnant hypoxemia
Klasifikasi PaO2 (role of thumb)
Normal 80-100 mmHg
Hipoksemia ringan 60-80 mmHg
Hipoksemia moderat 40-60 mmHg
Hipoksemia berat <40 mmHg

GAGAL NAPAS
Gutierrez JA & Theodorou AA. Pediatric Critical Care Study Guide 2012 pp 27
Shift to left:
(1) Decreased hydrogen ions
(2) Decreased CO2
(3) Decreased temperature
(4) Decreased DPG

Gutierrez JA & Theodorou AA. Pediatric Critical Care Study Guide 2012 pp 28
VO2 = CO x (CaO2 CvO2)
Condition that increase VO2 % Increase
Minor surgery 7
Fever (each 1oC) 10
Bone fracture 10
Agitation 16
Increase work of breathing 40
Severe infection 60
Chest trauma 60
Multiple organ failure 20-80
Shivering 50-100
Burns 100
Sepsis 50-100
Head injury, sedated 89
Head injury, not sedated 138
Medication that increase VO2 % Increase
Norepinephrine (0.10-0.31 g/kg/min) 10-21
Dopamin (5 g/kg/min) 6
Dopamin (10 g/kg/min) 15
Dobutamine 19
Epinephrine (0.10 g/kg/min) 23-29

Gloria OD, Handbook of Hemodynamic Monitoring, 2nd edition, Saunders, 2004, pp 167
Procedures and Activities that increase VO2 % Increase
Dressing change 10
Nursing assessment 12
ECG 16
Physical exam 20
Visitors 22
Bath 23
Chest radiography 25
Endotracheal suctioning 27
Turn 31
Chest physiotherapy 35
Weight on sling scale 36
Getting out of bed 39
Nasal intubation 25-40
Factors that decrease VO2 % Decrease
Hypothermia (each 1oC) 10
Morphine sulphate iv push (0.5 mg/kg) 9-21
Morphine sulphate ic (0.2-0.5 mg/kg/hr) 21
Anesthesia 25
Anesthesia in burn patients 50
Assist/control ventilation 30
Propanolol in head injury 32
Neuromuscular blockade Abolishes the increase VO2 incurred
by shivering
Gloria OD, Handbook of Hemodynamic Monitoring, 2nd edition, Saunders, 2004, pp 167
O2 ER = SaO2 SvO2
a) VO2/DO2 relationship in normal b) Pathophysiological changes in VO2/DO2
condition relationship

a) Gutierrez JA & Theodorou AA, Pediatric Critical Care Study Guide 2012 pp 30
b) Caille V & Squara P, Crit Care 2006;10(Suppl 3):S4
VO2 = DO2 x O2ER
Gutierrez JA & Theodorou AA, Pediatric Critical Care Study Guide 2012 pp 32
 Hipoksia
distress

Reassess
O2 dosis
Cari penyebab

LOC
Resp. effort Monitoring
Chest exam
1. Patients demand

2. Flowmeter

3. O2 device

4. Monitoring
 Device Mask Reservoir Total storage
Nasal prongs No 50 ml (DS) 50 ml
Simple mask 100 200 ml 50 ml (DS) 150 250 ml
Mask reservoir 100 200 ml 650 1050 ml 750 1250 ml
Venturi mask 100 200 ml 50 ml (DS) 150 250 ml
DS = dead space = air in the hypopharynx.
Mask reservoir = partial rebreathing & non-rebreathing masks.
 Hypoxia

Hypoventilation Hyperventilation
High pCO2 Low pCO2

Positive ventilation Negative ventilation

 Type 1 Type 2
(Hypoxemic RF) (Hypercapnic RF)

PaO2 < 60 mmHg ABG PaO2 < 60 mmHg

Not
PaCO2 low or normal Oximeter PaCO2 > 45 mmHg

Question: COPD patient with PaCO2 of 60 mmHg, PaO2

of 61 mmHg and pH 7.37. Is there any RF? Which type?
<200 indicates a clinically significant gas
exchange derangement
Oxygen Flow Meter

3 3

2 2

1 1

The ball must sit either side of the line.

This diagram illustrates the correct
setting of the flow meter to deliver
a flow of 2 L per minute.
 Flow FiO2 reserv
1 L/min 24 % (0.24) Nasopharynx
2 L/min 28 % (0.28)
3 L/ min 32 % (0.32) Dead space
4 L/ min 36 % (0.36) 50 ml
5 L/ min 40 % (0.40)
6 L/ min 44 % (0.44)
Advantages Disadvantages
Tolerable Flow limitation?
(satisfaction+compliance)
Can use the mouth FiO2 limitation?
(eat, speak, treat)
Avoid high FiO2 in COPD Nasal drying and irritation
with high flow rate?
lA young female presented with dry cough, fever and SOB.
She was found hypoxic at the triage (Sat 87%). The nurse
put her in oxygen using nasal prong at flow of 4 L/min. She
improve a little pit to 91% saturation. What your next best
action to improve her oxygenation?
A. Shift her to simple mask at 5 L/min
B. Shift her to non-rebreathing mask at 5 L/min
C. Increase the nasal prong flow to 5 L/min
D. No need to make any change
 Characteristics Advantages Disadvantages
Flow not <5 L/ min Higher FiO2 compared Loose = air leak, mixed
CO2 retention to nasal prong room air (lower FiO2)
Loosely fitted to the Can use nebulizer Can not use the mouth
face to eat, drink, speak
Air leak-mixed room air
Max flow rate = 10 L/ Can use venture Limited FiO2 (Max
min 60%)
FiO2 = 40 60 % Patients demand not
Approx = 4%/L/min met in some cases
No reservoir bag
Storage ?
 As the patient had oxygen flow rate of 5 L/ min, her
saturation reached 93% for 15 min then she dropped again
to 89%. The nurse increased the flow to 6 L/min using
nasal prong but the saturation became 90% for 5 minutes.
You decided to shift to simple mask. What is the best flow
rate to start with? And why?
A. Simple mask at 5 L/min
B. Simple mask at 6 L/ min
C. Simple mask at 7 L/min
D. Simple mask at 10 L/min
 A known asthmatic young man resented with acute SOB
and he was found tachypneic (RR=35), tachycardic
(HR=120) and desaturated (SPO2=88%). You found diffuse
wheeze at auscultation with decreased air entry
bilaterally. You planned to give him oxygen plus nebulized
Ventolin initially, but he still continued desating while on
oxygen-powered nebulized therapy. Your best action of
management then is:
A. Shift to non rebreathing mask and continue nebulization.
B. Intubate the patient immediately for acute severe asthma.
C. Initiate non invasive mechanical ventilation and delay Ventolin
therapy.
D. Put him on nasal prong plus continue nebulized Ventolin with
simple mask at maximum flow rate.
The device Characteristics Advantages Disadvantages

Simple mask Mask no Nebulizer or Considerable air

5 10 L/min reservoir venture port mixing -
FiO2 ( 40 60%) Accepted FiO2 No use of mouth
Partial mask Simple mask + Higher FiO2 Less room air
5 to max to reservoir FiO2 (up to 80 %) mixing - no use of
Keep bag inflated nebulizer or
venturi
Non rebreathing Simple mask + Highest FiO2 No use of mouth,
5 to max to keep reservoir + one Negligible room venture or
bag inflated way valve air mixing nebulizer
FiO2 (up to 95%)
 A known COPD patient on home oxygen (2 L per nasal
prong) presented with acute exacerbation. At triage was
found tachypneic and desat (SPO2 75%). The nurse
started 4L O2 by nasal prong and you add non oxygen
power nebulized Ventolin. After 20 min, saturation
became 82%. You plan to continue nebulization plus
requesting ABG. What is the best O2 delivery device for
this patient at this level (ABG pending!)?
A. Simple mask at 5 L/min
B. Adjustable venturi mask
C. CPAP
D. Intubation and mechanical ventilation
Characteristics Advantages Disadvantages
High flow device Controlled FiO2 Limited low FiO2
Room air mixing Suitable for chronic Ignores patient O2
CO2 retention demand
Adjustable valve Can use nebulizer

Use simple mask or

CPAP
Indications Advantages Disadvantages
Hypoxia despite full O2 Decrease work of Unprotected airway
Hypoventilation breathing
CO2 retention Avoid intubation Gastric insufflation

Requirements Improve oxygenation Slow correction (time)

Conscious Improve ventilation Tight mask problems

cooperative vitally
stable airway Decrease venous
protected by their own return
reversible cause
Physiological

Objective

Subjective
Mask

Respiratory muscle unloading

Abdomen

Dyspnic are mouth breather.
More dead space.
Clustrophobia
Less dead space.
Claustrophobia.
Can use mouth.
Method of NIV CPAP BiPAP
Name Continuous Positive Airway Bilevel Positive Airway
Pressure Pressure

Descriptions Preset ePAP (PEEP) Preset iPAP/ ePAP

Pt initiate breathing Pt initiate breathing
ePAP ( 4 to 20 cmH2O) Can set backup RR
Open more alveoli iPAP (8 20 cmH2O)
(recruitment) ePAP (4 10 cm H2O)
Indications COPD APE(decrease Acute hypercapnia
venous return) sleep cardiogenic APE resp
apnea muscle fatigue/paralysis
 Indications Advantages Disadvantages
Severe hypoventilation Simple technique Uncontrolled hyperventilation
RR < 8/ min (learning) Gastric lung - ABG

Apnea Available Temporary

Cardiac arrest Positive pressure/ PEEP MOANS/ open airway
Assist ventilation/O2 Effectiveness?
Preoxygenation in RSI High FiO2 100% Utilize medical personnel
 While you are treating COPD patient with venturi mask
plus nebulized SABA, he is not improving and continued
desating after 1 hour of your management and his ABG
showed (pH 7.20, pCO2 65 mmHg, pO2 50 mmHg). His
vital signs: HR 125, RR 36, BP 85/54, GCS 14/15. what is
your best next action of management?
A. Shift to CPAP immediately.
B. Shift to BiPAP immediately.
C. Intubation and mechanical ventilation.
D. Give IV fluids and continue same plan.
 O2 is a drug, so it must be used judiciously.
Before move to mechanical ventilation, consider to make
the maximum use of simple devices available.
It is important to keep in mind each device capabilities and
limitations.
Monitoring during O2 therapy is vital.
NIV is an option but patient should meet the criteria for its
application.