OXYGEN THERAPY

DR DEVENDRA BHATTARAI
PGY 1
INTERNAL MEDICINE

WHAT IS OXYGEN THERAPY?

Some diseases and conditions can prevent enough oxygenation of
blood, i.e. transfer of oxygen from the alveoli into the blood, which
occurs in lung.
Oxygen therapy is a treatment providing extra oxygen to buffer the
deficit.
Need for oxygen therapy is based on the results of tests, such as an
arterial blood gas test and a pulse oximetry test, measuring how
much oxygen is in blood.
A low oxygen level is an indication for oxygen therapy .

INDICATIONS
ACUTE DISEASES AND CONDITIONS
Serious condition that prevents from getting enough
oxygen.
Severe Pneumonia
Severe Asthma.
Respiratory distress syndrome (RDS) or
Bronchopulmonary dysplasis

CHRONIC DISEASES AND CONDITIONS

Long-term home oxygen therapy might be used to treat
some diseases and conditions, such as:

Chronic obstructive pulmonary disease

Late-stage heart failure.
Cystic fibrosis(cf)
Sleep-related breathing disorders such as sleep apnea

The most common indication for oxygen therapy in the acute

setting is arterial hypoxemia with a pao2 of less than 60 mm
hg.
Ventilation perfusion mismatch is the most common cause
of arterial hypoxemia.
Alveolar hypoventilation occurs when the volume of fresh
gas going to alveoli (alveolar ventilation) is reduced,
caused by diseases such as
a. CNS insults,
b. drug overdose,
c. thoracic cage abnormalities,
d. upper airway obstruction

 Shunts, either in the form of extreme ventilation perfusion

mismatch or anatomic right-to-left shunts, are often less
responsive to administration of supplemental oxygen.
A shunt occurs when blood reaches the arterial system
without passing through ventilated regions of the lung.
Role of diffusion impairment as a cause of hypoxemia is
controversial, although it is thought to play a role in exercise
oxygen desaturation seen in advanced interstitial lung
disease.

TECHNIQUES OF OXYGEN
ADMINISTRATION
Oxygen delivery devices are considered either low-flow or high-flow
appliances.
LOW-FLOW OXYGEN DEVICES

Simple, inexpensive, easy to use and well tolerated method to provide a

fraction of the patients minute ventilatory requirement as pure oxygen.
Oxygen supplied through these devices are low, usually less than 6l/min.
Cannot deliver constant inspired oxygen concentrations as fluctuations in
each tidal volume lead to variations in the amount of entrained room air

NASAL CANNULAE
Set to deliver oxygen at flows between 1-6L/min lead to an fio 2 between

0.24 and 0.44.

These higher flows may result in drying of mucous membranes.

OXYGEN MASKS
Masks which cover the nose and mouth are capable of delivering
oxygen concentrations up to 30-60%.
Depending on mask size, these devices provide a self-contained
reservoir of 100 to 200 ml of additional gas facilitating increase in
achievable fio2 above 0.44.
They require a flow of oxygen of 5-6l/min to avoid co 2 accumulation

within the mask.

CONSERVING RESERVOIR CANNULAE

Available in a mustache or pendant format

May allow considerable oxygen flow reductions accomplished by oxygen

being stored and inhaled through a reservoir chamber.

Estimates for oxygen savings ratio versus continuous flow standard

cannulae are 1.5:1 to 4:1 savings. These savings vary with liter flow with
the greatest savings at lower liter flows.

The limitations are the devices are larger and may be considered unsightly.

HIGH-FLOW OXYGEN DEVICES

Oxygen appliances that meet or exceed the patients inspiratory
demands are considered high-flow systems.

These devices are not generally used in the home care setting
because of the prohibitive higher liter flow required.

VENTURI MASK
The venturi mask meets or exceeds patient inspiratory demand
by using the Bernoulli principle.

Venturi masks are used when more precise amounts of fio 2 are

desired.

Provide a 24-50% fio2

PARTIAL AND NO-REBREATHING MASK

Can provide 65-95% fio2 depending on the liter flow and
configuration of exhalation valves.

In non-rebreathing circuits, the inspiratory gas is not made up of

any portion of the exhaled volume and the only inhaled co2 is
entrained from ambient room air.

Rebreathing is avoided through use of one way valves to

sequester expired from inspired gas.

HIGH-FLOW CANNULAE OR MASK

High flow systems offer liter flows in excess of 30l/min and offer a variety
of fi02 levels.

The purported benefit is that higher liter flows flush out dead space
thereby potentially decreasing carbon dioxide levels.

Mucosal drying with higher flow rates is a concern.

These systems like other high flow options are not yet available for home
use.

HOME OXYGEN CONCENTRATORS

Compressors that use a molecular sieve material to remove the
nitrogen from room air and provide oxygen concentrations of 8597% pure oxygen.

These concentrators can provide liter flows from 0.5l/min to

10l/min.

Portable oxygen concentrators are approved for airline travel.

NON-INVASIVE VENTILATION
NIV is indicated in:

COPD with a respiratory acidosis ph 7.257.35 (H+4556 nmol/l)

Hypercapnic respiratory failure secondary to chest wall

deformity (scoliosis, thoracoplasty) or neuro-muscular diseases

Cardiogenic pulmonary oedema unresponsive to CPAP

Weaning from tracheal intubation

Interfaces
Nasal mask,
Nasal pillows or prongs,
Oronasal mask, and
Mouthpiece.

NIV is not indicated in:

Impaired consciousness
Severe hypoxaemia
Patients with copious respiratory secretions

Benefits of NIV
Fewer patients referred to intensive care for intubation
Shorter stays on intensive care
Fewer deaths of patients with acute respiratory failure

INVASIVE VENTILATION

LONG TERM OXYGEN THERAPY

INDICATION
S

ADMINISTERING LONG-TERM OXYGEN THERAPY

The standard of care for administration of LTOT should be
continuous administration (24 h/day) with ambulatory capability.
Exceptions to continuous administration with ambulatory
capability include patients
1) incapable or unwilling to be mobile;
2) require oxygen only during sleep;
3) require oxygen only during exercise; or
4) refuse to use a portable device for ambulation.

AMBULATORY OXYGEN SYSTEMS

Weigh <10 lb
Provide oxygen at 2 L/min for 4-6 h and
Can be carried by the patient.
STATIONARY OXYGEN
Delivered via a concentrator, compressed gas or liquid.
LARGER PORTABLE OXYGEN SYSTEMS
Suitable for patients who only occasionally go beyond the
limits of the stationary delivery system (generally considered
to be 50 ft of tubing)
If the patient is not mobile beyond a 150 m radius, an oxygen
concentrator is suitable.

SETTINGS FOR REST, EXERTION AND SLEEP

REST
The resting oxygen flow rate can be adjusted, while monitoring oximetry to
Spo2 90%.
ABG to establish initial PaO2 with corroborating oximetry Sp,o2.
To insure equilibration, 20-30 min should be allowed after each change in
litre flow.

SLEEP
The flow can be increased 1 L/Min above the daytime resting prescription;
or
Nocturnal polysomnography or nocturnal pulse oximetry performed.

EXERTION
Maintain PaO2 >60 mmHg (8 kpa) or SaO2 >90%.
If the patient is using an oxygen-conserving system, titration should be
performed while the patient is using that system.

 THANK YOU

REFERENCES
ATS GUIDELINES
BTS GUIDELINES