WORLD RESPIRATORY CARE WEEK-2007

OXYGEN THERAPY
C P Sreedhar Reddy Assistant Professor and In-Charge Respiratory Therapy MCOAHS, Manipal University, Manipal

Oxygen is a colorless, odorless, transparent and tasteless gas. It exists naturally

as free molecular oxygen and as a component of a host of chemical compounds. HISTORY OF OXYGEN DISCOVERY In 1774 AD, Joseph Priestley and the Swedish chemist Carl Wilhelm Scheele discovered oxygen independently of each other. Priestley called it pure or vital air or dephlogisticated air", i.e., air from which phlogiston (nitrogen) had been removed. He knew that this gas could support life in mice and could cause a candle to burn more vigorously. The French chemist Antoine Laurent Lavoisier coined the term oxygen. Oxygen constitutes almost 50% by weight of the earths crust and occurs in all living matter in combination with hydrogen as water. At standard temperature and dry (STPD) O2 has density of 1.429 g/l, slightly heaver than air (1.29 g/l). O2 is nonflammable, but it greatly accelerates combustion and increase burning speed with increasing O2 at a fixed total pressure or it increase in total pressure at a constant gas concentration. Both O2% and partial pressure influence the rate of burning. O2 is not very soluble in water, at room temperature and 1 atm pressure, only 3.3 ml of O2 dissolves in 100 ml of water, this small amount is sufficient for aquatic life. DEFINITION OF OXYGEN THERAPY Oxygen is considered as a drug in the medical field. Therapeutic administration of supplemental oxygen (>21%) to maintain adequate tissue oxygenation while minimizing cardiopulmonary work is called as oxygen therapy. In human arterial blood 1 gm of Hb carries 1.43 ml of O 2 and 15 grams of Hb carries 20.1 ml of O2 in 100 ml of arterial blood as a oxyhemoglobin form, and 0.3 ml of O 2 carries as dissolved form in 100 ml of plasma at 100 mm Hg of PaO 2. Total 100 ml of arterial blood carries 20.4 ml of O 2 (20.1 ml of O2 as oxy hemoglobin form and 0.3 ml of O2 as dissolved form in blood plasma. Oxygen Flux: defines the volume of O2 left from the left ventricle per minute.

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WORLD RESPIRATORY CARE WEEK-2007 The quantity of O2 transported by blood per minute which is calculated from the cardiac output and the quantity of O 2 carried by each ml of blood or O 2 content of blood. O2 Flux (ml O2/min) = Cardiac output (CO) (ml blood/ min) X Arterial O 2 content (CaO2) (ml of O2/ml of blood) Oxygen Flux = CO X CaO2 Oxygen Flux = Hb X 1.36 X saturation + 0.03 X partial pressure CaO2 (Arterial Oxygen Content): is the volume of O2 carried by 100 ml of blood (both as oxy hemoglobin form and dissolved form). It is 20.4 ml of O 2/100 ml of blood. If 100 ml of arterial blood carry 20.4 ml of O 2, the 5000 ml of blood carries 1020 ml of O2/minute. The normal Oxygen flux is approximately 1litre/minute. A conscious resting man utilizes 250 ml/min of O2 from the oxygen flux. Blood returning from tissues has 750 ml of O 2 which forms an oxygen reserve and it is used during stress and whenever lack of O 2 to the tissues. Whenever there is lack of oxygen to the tissues, human being utilizes this oxygen reserve, with which he can maintain tissue and cerebral oxygenation for approximately three minutes only.

OXYGEN SOURCES O2 Production O2 is produced by small quantities from chemical method (electrolysis of water and decomposition of sodium chlorate (NaClO 3). Large quantities of O2 production by fractional distillation and physical separation by using O 2 concentrators. There are three typical sources of oxygen used therapeutically: 1. Liquid oxygen is contained in thermally insulating tanks. The liquid has to boil changing into a gas for breathing. Large tanks are used by hospitals. Small tanks can be used domestically. Liquid oxygen tanks are refilled by liquid oxygen suppliers 2. Cylinders contain compressed gaseous oxygen. Small cylinders are used for first aid and for home oxygen patients when mobility is required. Cylinders are refilled by a gas supplier. 3. Oxygen Concentrators are electrically powered devices which remove nitrogen from air. They are most commonly used in a domestic situation, because they do not need refilling. However, a number of manufacturers have introduced portable oxygen concentrators. These have replaced the need to

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WORLD RESPIRATORY CARE WEEK-2007 use liquid or gas cylinders for mobility for many patients. These can typically use AC, DC, or battery power. First aid kits have been produced that create oxygen gas as the result of a chemical reaction between lightweight or widely available substances such as sodium per carbonate and water, although the rate and duration of oxygen supply is not high. Oxygen is most often delivered as continuous gaseous flow, measured in liters per minute (lpm).

CLASSIFICATION/TYPES OF OXYGEN THERAPY 1. Isobaric Oxygen Therapy (IBOT): Administration of >21% oxygen at 1 ATA. 2. Hyperbaric Oxygen Therapy (HBOT): Administration of oxygen at greater than 1 ATA (2-3 ATA).

INDICATION S OF OXYGEN THERAPY 1. In correction of acute hypoxemia: a. Severe dyspnea b. Carbon monoxide poisoning c. Shock d. Trauma e. Acute Myocardial Infraction f. Post anesthetic recovery g. Altered level of consciousness 2. Decrease the symptoms associated with chronic hypoxemia: In addition to actually relieving hypoxemia, oxygen therapy can help relieve the symptoms associated with certain lung disorders. Specially, patients with chronic obstructive lung disease (COPD) and some forms of interstitial lung disease report less dyspnea when receiving supplemental oxygen. Oxygen therapy also improves mental function among patients with chronic hypoxemia. 3. Decrease the workload hypoxemia imposes on the cardiopulmonary system:

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WORLD RESPIRATORY CARE WEEK-2007 The cardiopulmonary system compensates for hypoxemia by increasing ventilation and cardiac output. In case of acute hypoxemia, supplemental oxygen can decrease demands on both the heart and the lungs. Oxygen therapy increases blood oxygen content, the heart does not have to pump as much blood per minute to meet tissue demands. This reduced workload is particularly important when the heart is already stressed by disease or injury, as in myocardial infraction, sepsis, or trauma. Hypoxemia causes pulmonary vasoconstriction and pulmonary hypertension, it leads to increase workload on the right side of the heart. For patients with chronic hypoxemia, this increased workload over the long term can lead to right ventricular failure (cor pulmonale). Oxygen therapy can reverse pulmonary vasoconstriction and decrease right ventricular workload.

ASSESSING THE NEED FOR OXYGEN THERAPY There are three basic ways to determine whether a patient needs oxygen therapy. The first is use of laboratory measures to document hypoxemia by measuring PaO 2, SaO2 by arterial blood gas (ABG). Second, a patients need for oxygen therapy can be based on the specific clinical problem or condition like carbon monoxide poisoning, shock, cyanide poisoning, trauma, or acute myocardial infarction. Last, hypoxemia has many manifestations, such as tachypnea, cyanosis, and distressed overall appearance.

HAZARDS OF OXYGEN THERAPY Appropriate levels of oxygen are vital to support cell respiration. High blood and tissue levels of oxygen can be helpful or damaging, depending on circumstances. 1. Oxygen Toxicity 2. Depression of ventilation 3. Retinopathy of prematurity 4. Absorption Atelectasis

OXYGEN THERAPY DELIVERY SYSTEMS Administration Various devices are used for administration of oxygen.

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Depend on the general performance characteristics, individual capabilities and by design the oxygen therapy delivery devices traditionally are categorized in to four types: 1. 2. 3. 4. Low flow oxygen therapy devices Reservoir oxygen therapy devices High flow oxygen therapy devices Enclosure oxygen therapy devices

Among these four types of oxygen therapy devices, depend on the delivered FiO 2 and inspired gas (Peak inspiratory flow rate-PIFR) to the patient's, these devices are categorized in to two groups: 1. Variable performance oxygen therapy devices 2. Fixed performance oxygen therapy devices Variable Performance Oxygen therapy Devices (VPOD) These devices provides only some of the inspired gas (PIFR), the patient must draw the remainder from - the surrounding air. In this case, the more the patient breathes, the more air dilutes the delivered oxygen, and the lower is the FIO 2. If the patient breathes less with this type of device, less air dilutes the oxygen, and the FIO 2 increases. A system that supplies only a portion of the inspired gas always provides a variable FIO2. The FIO2 supplied with such systems can vary widely from minute to minute and even from breath to breath. (Examples: All low flow O 2 devices, Reservoir systems except closed nonbreathing circuit and all enclosure O 2 devices.) Fixed Performance Oxygen Therapy Devices (FPOD) These devices provide the entire patient's inspired gas (PIFR), the FIO 2 remains stable, even under changing demands. (Examples: High flow O 2 therapy devices and nonbreathing circuit of reservoir O 2 therapy devices. With the low-flow system the patient's inspiratory flow often exceeds that- delivered by the device; the result is air dilution. The greater the patient's inspiratory flow, the more air is breathed, and the lower is the FIO 2. The high-flow system always exceeds the patient's flow and thus provides a fixed FIO2. A fixed FIO2 can be achieved with a reservoir system, which stores a reserve volume (flow x time) that equals or exceeds the patient's tidal volume. For a reservoir system to provide a fixed FIO 2, the reservoir volume must always exceed the patient's tidal volume, and there cannot be any air leaks in the system.

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Although design plays an important role in the selection of these devices, clinical performance ultimately determines how the device is used. The user judges the performance of an oxygen delivery system by answering two key questions. First, how much oxygen can the system deliver (the FIO 2or FIO2range)? Second, does the delivered FIO2 remain fixed or vary under changing patient demands? Regarding the FIO2 range, oxygen systems can be broadly divided into those designed to deliver a low (<35%), moderate (35% to -60%), or high oxygen concentration (>60%). Some designs can deliver oxygen across the full range of concentrations (21% to 100%). Low-Flow O2Systems Typical low-flow systems provide supplemental oxygen directly to the airway at a flow of 8 L/min or less. Because the inspiratory flow of a healthy adult exceeds 8 L/min, the oxygen provided by a low-flow device is always diluted with air, the result is a low and variable FIO 2. Low-flow oxygen delivery systems include the nasal cannula, the nasal catheter, and the transtracheal catheter. Research studies on nasal low-flow systems show oxygen concentration ranging from as low as 22% at 1L/min to as high as 60% at 15 L/min. The range of 22% to 45% is based on 8 L/min as the upper limit of comfortable flow. These wide FIO 2 ranges occur because the oxygen concentration delivered by a low-flow system varies with the amount of air dilution. The amount of air dilution depends on several patient and equipment variables. The factors effects in varying FIO 2 levels with low flow oxygen therapy systems: Increases FiO2 levels Whenever high oxygen flow rates are used Whenever patients breath with closed mouth instead of opened mouth Whenever there is low PIFR is used Whenever low tidal volumes are used When there is a slow respiratory rates are used When ever there is hypo ventilation When ever patients use prolonged inspiratory time When ever high I: E ratios are used

Decreases FIO2 levels When ever low oxygen flow rates are used

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WORLD RESPIRATORY CARE WEEK-2007 Whenever patients breath with opened mouth instead of close mouth Whenever there is high PIFR is used Whenever high tidal volumes are used When ever patient is a tachypnic When ever there is hyper ventilation When ever patients breaths with shorter inspiratory time intervals When ever low I: E ratios are used

The devices covered under low flow systems are: Nasal cannula, nasal catheter and transtracheal catheter. Nasal Cannula (NC): Is a thin plastic disposable tube with two small nozzles (prongs) approximately 1 cm long, these protrude into the patients nostrils. The prongs are connected to several feet of small-bore oxygen supply tubing. It can only provide oxygen at low flow rates. It is often used in elderly patients, or patients who can benefit from oxygen therapy but do not require it to the degree of wearing an uncomfortable mask. It is especially useful in those patients where vasoconstriction could negatively impact their condition, such as those suffering from strokes, or "brain attacks." Use of the NC at relatively high rates can cause discomfort by drying the nasal passages. Recommended O2 flow ranges: 2 or less than 2 liters per minute (LPM) in infants and to 8 LPM in adults. Delivered FiO2 ranges: 22 45% Advantages: Use on adults, children, infants; easy to use, disposable, low cost and well tolerated. Disadvantages: Unstable, easily dislodged, high flow uncomfortable, can cause, dryness, bleeding, polyps, deviated septum and mouth breathing may reduce FIO2 Best Use: Patient in stable condition who needs low FIO 2, home care patient who needs long term therapy, low to moderate FIO2 while eating.

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Nasal Cannula

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WORLD RESPIRATORY CARE WEEK-2007 Nasal Catheter A nasal catheter is a soft plastic tube with several small holes at the tip. The clinician inserts the catheter by gently advancing it along the floor of either nasal passage and visualizing it just behind and above the uvula. If there is marked resistance to insertion, the other naris is used. Once in position, the catheter is taped to the bridge of the nose. If direct visualization is not possible, the catheter is blindly inserted to a depth equal to the distance from the nose to the tragus (lobe) of either ear. Placed too deep, the catheter can provoke gagging or swallowing of gas, which increases the likelihood of aspiration. Because it affects production of secretions, a nasal catheter should be removed and replaced with a new one (placed in the opposite naris) at least every 8 hours. Nasal cannulas have largely replaced catheters for simple oxygen administration. Recommended O2 flow ranges: to 8 LPM Delivered FIO2 ranges: 22 45% Advantages: use on adults, children, infants, good stability, disposable and low cost. Disadvantages: Difficult to insert, high flow increases back pressure, needs regular changing, polyps, deviated septum may block insertion, may provoke gagging, air swallowing and aspiration. Best Use: Procedures in which cannula is difficult to use (bronchoscope), long-term care of infants.

Nasal Catheter Clinical Procedures in Respiratory Care 9

WORLD RESPIRATORY CARE WEEK-2007 Transtracheal Catheter: This device is first described by Heimlich in 1982. A clinician inserts this thin polytetrafluoroethylene (Teflon) catheter with a guide wire directly into the trachea between the second and third tracheal rings a custom- sized chain necklace secures the catheter in position. Standard tubing connected directly to a flowmeter provides the oxygen source flow. Because flow is so low, no humidifier is needed. Because the transtracheal catheter resides directly in the trachea, oxygen builds up both there and in the upper airway during expiration. This process effectively expands the anatomic reservoir and increases the FIO 2 at any given flow. Compared with a nasal cannula, a transtracheal catheter needs 40% to 60% less oxygen flow to achieve a given arterial partial pressure of oxygen (PaO 2). Some patients need a flow of only 0.25 L/min to achieve adequate oxygenation. This can be of great economic benefit to those needing continuous long-term oxygen therapies. In addition, the low flow used with transtracheal delivery increases the duration of flow, or use time, for portable oxygen storage systems. This benefit can dramatically increase patient mobility. Transtracheal oxygen therapy can pose problems and risks. As a result, these devices have not received widespread acceptance. Careful patient selection, rigorous patient education, and ongoing self-care with professional follow-up evaluation can help minimize these risks. Recommended O2 flow ranges: to 4 LPM Delivered FIO2 ranges: 22 35% Advantages: Lower O2 use and cost, eliminates nasal and skin irritation, improved compliance, increased exercise tolerance, increased mobility, enhanced image. Disadvantages: High cost, surgical complications, infection, mucus plugging, lost tract. Best Use: Home care or arnbulatory patients who need increased mobility or do not accept nasal oxygen.

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Transtracheal O2 Catheter RULE OF THUMB: Estimating the FIO2 Provided by Low-flow Systems For patients with a normal rate and depth of breathing, each liter per minute of nasal oxygen increases the FIO2 approximately4%. For example, a patient using a nasal cannula at 4 L/min has an estimated FlO2 of approximately 37% (21+16). Troubleshooting with Low-Flow Systems Common problems with low-flow oxygen delivery systems include inaccurate flow, system leaks and obstructions, device displacement, and skin irritation. The problem of inaccurate flow is greatest when low flow flowmeter (< or =3 L/min) are used. Given the trend toward assessment of outcome of oxygen therapy (with either blood gases or pulse oximetry), ensuring the absolute accuracy of oxygen input flow usually is not essential. Nonetheless, like all respiratory care equipment, flow-meters should be subjected to regular preventive maintenance and testing for accuracy. Equipment failing preventive maintenance standards should be removed from service and repaired or replaced. RESERVOIR OXYGEN THERAPY DEVICES Reservoir systems have a mechanism for gathering and storing oxygen between patient breaths. Patients draw on this reserve supply when ever inspiratory flow exceeds oxygen flow into the device. Because air dilution is reduced, reservoir devices generally provide higher FIO 2 than do low flow systems ms reservoir devices can decrease oxygen use by providing FlO2 comparable with that of nonreservoir systems but at lower flow.

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WORLD RESPIRATORY CARE WEEK-2007 Reservoir systems in current use include reservoir cannulas, masks, and non rebreathing circuits in principle, enclosure systems, such as tents and hoods, operate as head- or -body- surrounding reservoirs. Reservoir Cannula Reservoir cannulas are designed to conserve oxygen. There are two types of reservoir cannulas: nasal reservoir and pendant reservoir. The nasal reservoir cannula operates by storing approximately 20mL of oxygen in a small membrane reservoir during exhalation. The patient draws on this stored oxygen during early inspiration. The amount of oxygen available increases with each breath and decreases the flow needed for a given FlO 2. Although the device is comfortable to wear, many patients object to its appearance and may not always comply with prescribed therapy. The pendant reservoir system helps overcome aesthetic concerns by hiding the reservoir under the patient's clothing on the anterior chest wall. Although the device is less visible, the extra weight of the pendant can cause ear and facial discomfort. At low flow, reservoir cannulas can reduce oxygen use as much as 50% to 75%. For example, a patient at rest who needs 2 L/min through a standard cannula to achieve arterial oxygen saturation (SaO2) greater than 90% may need only 0.5 L/min through a reservoir cannula to achieve the same blood oxygenation. During exercise, reservoir cannulas can reduce flow needs approximately 66%; the savings is approximately 50% at high flow. Although flow savings is fairly predictable, factors such as nasal anatomy and breathing pattern can affect the performance of the device. For these devices to function properly at low flow, patients must exhale through the nose (this reopens or resets the reservoir membrane). In addition, exhalation through pursed lips may impair performance, especially during exercise. For these reasons, prescribed flow settings should be individually determined by means of monitoring SaO 2 during both rest and exercise. The low flow at which the reservoir cannula operates makes humidification unnecessary. Excess moisture can hinder proper action of the reservoir membrane. Even regular use can cause membrane wear. For this reason, patients should replace the reservoir cannula approximately every 3 weeks. Replacement needs partially offset the oxygen cost savings afforded by these devices. Recommended O2 flow ranges: to 4 LPM Delivered FiO2 ranges: 22 35%

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WORLD RESPIRATORY CARE WEEK-2007 Advantages: Lower O2 use and cost, Lower O2 use and cost, increased mobility, less discomfort because of lower flow. Disadvantages: Unattractive, cumbersome, poor compliance, must replaced, breathing pattern affects performance. be regularly

Best Use: Home care or ambulatory patients who need increased mobility.

Reservoir Cannula

Pendant Reservoir Cannula Reservoir Masks Masks are the most commonly used reservoir systems. There are three types of reservoir masks: 1. Simple face mask 2. The partial rebreathing face mask 3. The nonrebreathing face mask Clinical Procedures in Respiratory Care 13

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Simple Face Mask The simple mask is a disposable plastic unit designed to cover both the mouth and the nose. The body of the mask itself gathers and stores oxygen between patient breaths. The patient exhales directly through open holes or ports in the mask body. Should oxygen input flow cease, the patient can draw in air through these holes and around the mask edge. The input flow range for an adult simple mask is 5 to 12 L/min. In general, if flow greater than 12 L/min is needed for satisfactory oxygenation, use of a device capable of a higher FIO2 should be considered. At a flow less than 5 L/min, the mask volume acts as dead space and causes carbon dioxide rebreathing. Because air dilution easily occurs during inspiration through its ports and around its body, the simple mask provides a variable FIO 2. How much the FIO2 varies depends on the oxygen input flow, the mask volume, the extent of air leakage, and the patient's breathing pattern. Recommended O2 flow ranges: 5 to 12 LPM Delivered FiO2 ranges: 35 - 50% Advantages: Use on adults, children, infants, quick, easy to apply, disposable, inexpensive. Disadvantages: Uncomfortable, must be removed for eating, prevents radiant heat loss, blocks vomitus, in unconscious patients. Best use: Emergencies, short-term therapy requiring moderate FIO2, mouth breathing patients requiring moderate FIO2

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Simple Oxygen Mask

The Partial Rebreathing Face Mask /Nonrebreathing Face Mask The partial rebreathing mask and the nonrebreathing mask have a similar design. Each has a 1Liter flexible reservoir bag attached to the oxygen inlet. Because the bag increases the reservoir volume, both masks provide higher FIO2capabilities than does a simple mask. The key difference between these designs is the use of valves. A partial rebreather has no valves. During inspiration, source oxygen flows into the mask and passes directly to the patient. During exhalation, source of oxygen enters the bag. However, because no valves separate the mask and the bag, some of the patients exhaled gas also enters the bag (approximately the first third). Because it comes from the anatomic dead space, the early portion of exhaled gas contains mostly oxygen and little carbon dioxide. As the bag fills with both the oxygen and dead space gas, the last 2/3 rd of exhalation (high in carbon dioxide) escapes out the exhalation ports of the mask. As long as the oxygen input flow keeps the bag from collapsing during inhalation, carbon dioxide breathing is negligible. Although it can provide higher FIO 2 than a simple mask, the standard disposable partial rebreather is subject to considerable air dilution. The result is delivery of a moderate but variable FiO2 depend on the same factors as with the simple face mask. A non rebreathing mask prevents rebreathing one way valves. An inspiratory valve sits atop the bag and expiratory valves covers the exhalation ports on the mask body. During inspiration, slight negative mask pressure closes the expiratory valve, preventing air dilution. At the same time, the inspiratory valve atop the bag opens, providing oxygen to the patient. During exhalation, valve action reverses the direction

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WORLD RESPIRATORY CARE WEEK-2007 of flow. Slight positive pressure closes the inspiratory valves, which prevents exhale gas from entering the bag. Concurrently, the one way expiratory valves open and the divert exhales gas out to the atmosphere. Because it is a close system, a leak free non rebreathing mask with competent valves and enough flow to prevent back collapse during inspiration can deliver 100% source gas. However modern disposable non rebreathers normally dont provide much more than approximately 70% oxygen. Large air leaks are the primary problem. Air leakage both around the mask body and through the open (nonvalved) exhalation port. This open exhalation port is a common safety feature design to allow air breathing if the oxygen source fails. Unfortunately, it also allows air dilution whenever inspiratory flow or volume is high. Although a disposable nonrebreather can deliver moderate to high oxygen concentration, the FiO 2 still varies with the amount of air leakage and the patients breathing pattern. Partial Rebreathing Face Mask Recommended O2 flow ranges: 6 to 10 LPM Delivered FIO2 ranges: 35 - 60% Advantages: Same as simple mask, moderate to high FIO 2 Disadvantages: same as simple mask, potential suffocation hazard Best use: Emergencies, short term therapy requiring moderate to high FIO2

Partial Rebreathing Face Mask Nonrebreathing Face Mask Recommended O2 flow ranges: 6 to 10 LPM Delivered FIO2 ranges: 55 - 70%

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Advantages: Same as simple mask, moderate to high FIO2 Disadvantage: Same as simple mask, potential suffocation hazard Best use: Emergencies, short term therapy requiring high FIO2

Nonrebreathing Face Mask Non rebreathing Reservoir Circuit (closed) A non rebreathing operates the same design principles as a non rebreathing mask but is more versatile. Unlike non rebreathing mask, these systems can provide a full range of FIO2 (21% to 100%) and deliver the prescribed concentration to both intubated and nonintubated patients. A typical non rebreathing circuit incorporates a blending system to premix air and oxygen. The gas mixture is warmed and humidified, ideally with a servo controlled heated humidifier. Gas then floes through large bore tubing in to an inspiratory volume reservoir, which includes a fail-safe inlet valve. The breathes through a closed airway appliance, in this case a mask with one way valves. A valved T-tube also can be used in the care of a patient with an endotracheal or tracheostomy tube.

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Non rebreathing Reservoir Circuit

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WORLD RESPIRATORY CARE WEEK-2007 Recommended O2 flow ranges: 3 X VE (Minute ventilation) Delivered FIO2 ranges: 21 - 100% Advantages: Full range of FIO2 Disadvantages: Potential suffocation hazard, requires 50 psi air/O 2, blender failure common Best use: Patients who need precise FIO2 at any level (21-100%) HIGH FLOW OXYGEN THERAPY SYSTEMS High-flow systems supply a given oxygen concentration at a flow equaling or exceeding the patient's peak inspiratory flow. An air-entrainment or a blending system is used. As long as the delivered flow exceeds the patient's flow, both systems can ensure a fixed FIO2. The rule of Thumb: To qualify as a high-flow device, a system should provide at least 60 Llmin total flow. This flow criterion is based on the fact that the average adult peak inspiratory flow during tidal ventilation is approximately three times the minute volume. Because 20 L/min is close to the upper limit of sustainable minute volume for persons who are ill, a flow of 3 x 20, or 60 L/min, should suffice in most situations. In a few rare circumstances, flow must reach or exceed 100 L/min. Principles of Gas Mixing All high-flow systems mix air and oxygen to achieve a given FIO 2. These gases are mixed with air-entrainment devices or blending systems. Computations involving mixtures of air and oxygen are based on a modified form of the dilution equation for solutions: VFCF = V1C1 + V2C2 In this equation, V1and V2 are the volumes of the two gases being mixed; C1and C2 the oxygen concentration in these two volumes; and VFand CF, the final volume and concentration of the resulting mixture. Air-Entrainment Mask Systems: Air-entrainment systems direct a high-pressure oxygen source through a small nozzle or jet surrounded by air-entrainment ports. The amount of air entrained at these ports varies directly with the size of the port and the velocity of oxygen at the jet. The larger the intake ports and the higher the gas velocity at the jet, the more air is entrained. Clinical Procedures in Respiratory Care 19

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Because they dilute source oxygen with air, entrainment devices always provide less than 100% oxygen. The more air they entrain, the higher is the total output flow, but the lower is the delivered FIO2. High flow is possible only when low oxygen concentration is delivered. For these reasons, air-entrainment devices function as true high-flow systems only at low FIO 2. If the flow output from an air-entrainment device decreases below a patient's inspiratory flow, air dilution occurs, and the FIO 2 becomes variable. The FIO2 provided by air-entrainment devices depends on two key variables: the airto-oxygen ratio and the amount of flow resistance downstream from the mixing site. Changing the input flow of an air-entrainment device alters the total output flow but has little effect on delivered FIO 2. In general, FIO2 remains within 1% to 2% of that specified by the manufacturer, regardless of input flow. The size of the jet and entrainment ports of a device determines the air-to-oxygen ratio and thus the delivered FIO 2. A more common clinical problem arises when the total output flow from an air-entrainment system must be determine. The total flow output of a system determines whether it truly performs as a high-flow device. MAGIC BOX: Many clinicians derive quick estimate by using a simple mathematical aid called the magic box .To use the magic box, simply draw a square and place 20 in the top left corner and 100 in the bottom left corner. Place the desired oxygen percentage in the center of the box (in this case 70%). Subtract diagonally from lower left to the upper right (disregard the sign). Subtract diagonally again from upper left to lower right disregard the sign). The resulting numerator (30) is the value for air, the denominator (50) being the value for oxygen. By convention, the air-to-oxygen ratio is expressed with the denominator (liters of oxygen) set to 1. Thus an air-entrainment device with a 7:1 ratio mixes 7 L of air with each liter of oxygen. To reduce any ratio to a ratio of x: 1, divide both the numerator and the denominator by the denominator. In the magic box Example: 30 = 30/50 = 0.61 50 50/50 1

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Magic Box The magic box can be used only for estimation of air to-oxygen ratio. For absolute accuracy, above Equation always should be used. The other major factor determining the oxygen concentration provided by an airentrainment device is downstream flow resistance. In the presence of flow resistance distal to the jet, the volume of air entrained always decreases. With less air being entrained, total flow output decreases, and the delivered oxygen concentration increases. Although the delivered oxygen concentration increases, the actual FIO 2 received by the patient may decrease, especially on devices set to deliver 30% to 50% oxygen. This phenomenon is caused mainly by the decrease in total output flow. As the total output flow decreases below that needed to meet the patient's inspiratory needs, room air must be inhaled. A similar event occurs if the air intake ports surrounding the jet are blocked. Under both conditions, these high-flow systems begin to behave as lowflow devices. The two most common oxygen delivery systems in which air entrainment is used are the air-entrainment mask (AEM) and the air-entrainment nebulizer. Air-Entrainment Mask The use of an oxygen mask for provision of controlled FIO 2 by means of air entrainment was first reported in 1941 by Barach and Eckman. The system provided relatively high FIO2 (greater than 40%) through the use of adjustable air-entrainment ports that controlled the amount of air mixed with oxygen. Some 20 years later, Campbell developed an entrainment mask that provided controlled, low FIO 2 and called the device a venti-mask. As the name venti-mask suggests, the operating principle behind these devices has often been attributed to the Venturi principle. This assumption is incorrect. Rather than having an actual Venturi tube that entrains air, these devices have a simple restricted Clinical Procedures in Respiratory Care 21

WORLD RESPIRATORY CARE WEEK-2007 orifice or jet through which oxygen flows at high velocity. Air is entrained by shear forces at the boundary of jet flow, not by low lateral pressures. The smaller the orifice, the greater is the velocity of oxygen and the more air is entrained. Typical AEM, designed to deliver a range of low to moderate FIO 2 (0.24-0.40). The mask consists of jet orifice or nozzle around which is an air-entrainment port (upper drawing). The body of the mask has several large ports, which allow escape of both excess flow from the device and exhaled gas from the patient. In this design, the FIO 2 is regulated by selection and changing of the jet adapter. The smallest jet provides the highest oxygen velocity and thus the most air entrainment and the lowest FIO 2 (0.24). The largest jet provides the lowest oxygen velocity and thus the least air entrainment and the highest FIO2 (0.40). Other AEM designs may vary both jet and entrainment port size to provide an even broader range of FIO 2. The aerosol entrainment collar fits over the air entrainment ports. For controlled FIO2 at flow high enough to prevent air dilution, the total output flow of an AEM must exceed the patient's peak inspiratory flow. With an entrainment ratio exceeding 5:1, an AEM set to deliver less than 35% oxygen has little trouble meeting or exceeding the 60 L/min high-flow criterion. At settings above 35%, however, total AEM flow decreases significantly, and the FIO 2 becomes variable. For example, when set to deliver 50% oxygen, some AEMs provide a FIO 2 as low as 0.39. Recommended O2 flow ranges: Varies, should provide output flow >60 L/min Delivered FIO2 ranges: 24 - 50% Advantages: Easy to apply, disposable, inexpensive, stable, precise FIO 2 Disadvantages: Limited to adult use, uncomfortable, noisy, must be removed for eating, FIO2>0.40 not ensured, FlO2varies with back pressure. Best use: Patients in unstable, condition who need precise low FIO2

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Air-Entrainment Mask

COLOR CODING SYSTEM OF VENTURI KITS FOR DESIRED O2 FLOWS AND FIO2 Color of Venturi kit Blue White Orange Yellow Red Green Required O2 flow 2 LPM 4 LPM 6 LPM 8 LPM 12 LPM 15 LPM Delivered fixed FIO2% 24% 28% 31% 35% 40% 60%

A Venturi kit

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Jet Orifice

O2 inlet from the source

Fixed FIO2 to the Patient

Air Entrainment Ports

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Air-Entrainment Nebulizer Pneumatically powered air entrainment nebulizers have most of the features of AEMs but have added capabilities, including additional humidification and temperature control. Humidification is achieved through production of aerosol at the nebulizer jet. Temperature control is provided by an optional heating element. In combination, these added features allow delivery of particulate water (in excess of needs for body temperature and pressure, saturated) to the airways. Because of added humidification and heat control. air-entrainment nebulizers have been the traditional device of choice for delivering oxygen to patients with artificial tracheal airways. The oxygen typically is delivered with a T tube or a tracheostomy mask. An alternative is to use an aerosol mask or a face tent to deliver an oxygen mixture with aerosol to patients with intact upper airways. Whereas AEMs can vary both jet and entrainment port size to obtain a given FIO 2, gas-powered nebulizers have a fixed orifice. Thus air-to-oxygen ratios can be altered only by varying entrainment port size. Most nondisposable nebulizers have fixed entrainment settings, such as 100%, 70%, and 40%. Disposable nebulizers usually have a continuous range of settings from 28% to 100%. As do AEMs, air-entrainment nebulizers perform as fixed-performance devices only when output flow meets or exceeds the patient's inspiratory demand. Unlike AEMs, however, air-entrainment nebulizers do not allow easy increases in nebulizer output flow by means of an increase in oxygen input. With most nebulizer systems, the extremely small size of the jet needed for aerosol production limits the maximum oxygen input flow to 12 to 15 L/min at 50 psig. For example, the total output flow of an air-entrainment nebulizer set to deliver 40% oxygen ranges from 48 to 60 L/min. Although this amount may be adequate for most patients, it is not sufficient for those with very high inspiratory flow or minute volume. The actual FIO2 received by patients may be affected by the choice of airway appliance. For example, the FIO 2 delivered by face tent is consistently less than the set nebulizer concentration, especially at higher levels. Air-entrainment nebulizers should be treated as fixed performance devices only when set to deliver low oxygen concentration (35% or less). When a nebulizer is used to deliver a higher concentration of oxygen, the clinician must determine whether the flow is sufficient to meet patient needs. There are two ways to assess whether the flow of an air-entrainment nebulizer meets the patient's needs. The first method is simple visual inspection. With this approach (generally used only with a T tube), the clinicians sets up the device to deliver the highest possible flow at the prescribed FIO 2. After connecting the system to the patient, the clinicians observe the mist output at the expiratory side of the

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WORLD RESPIRATORY CARE WEEK-2007 T tube. As long as mist can be seen escaping throughout inspiration, flow is adequate to meet the patient's needs, and the delivered FIO 2 is ensured. The second way to assess the adequacy of nebulizer flow is to compare it with the patient's peak inspiratory flow. A patient's peak inspiratory flow during tidal breathing is approximately three times minute volume. As long as the nebulizer flow exceeds this value, the delivered FIO 2 is ensured. If the patient's peak flow exceeds that provided by the nebulizer, the device functions as a low-flow system with variable FIO2. Recommended O2 flow ranges: 10-15 L/min input, should provide output flow of at least 60 L/min Delivered FIO2 ranges: 28 - 100% Advantages: Provides temperature control and extra humidification Disadvantages: FlO2 <0.28 or >0.40 not ensured, FIO2 varies with back pressure, high infection risk Best use: Patients with artificial airways who need low to moderate FIO2 Troubleshooting with Air-Entrainment Systems The major problem with air-entrainment systems is ensuring that the set FIO 2 actually is delivered to the patient. Problems usually do not occur when the devices are used to deliver low FIO2 (<0.35). However, the design of these devices makes it difficult to provide even moderate FIO 2 at the high flow needed to ensure a set oxygen concentration. The performance of all air-entrainment devices is affected by downstream resistance. The result can be inaccurate FIO 2 that makes delivery of a low oxygen concentration difficult with air-entrainment nebulizers. Providing Moderate to High FIO2 at High Flow. Air-entrainment masks and air-entrainment nebulizers differ in ratio settings and input/output flow capabilities. Most AEMs can be set to deliver no more than 50% oxygen. When set according to the manufacturer's specifications to provide more than 35% oxygen, AEMs simply do not generate enough flow to ensure the set FIO 2. The solution is to boost the total output flow. With AEMs, total output flow can be boosted with a simple increase in input flow. For example, for a 35% AEM (5:1 ratio) with an input flow of 8 L/min, the total output flow is 48 L/min. This flow is not sufficient to ensure 35% oxygen delivery to all patients. Simply increasing the input flow to 12 L/min boosts the output flow of the AEM 50%, to 72 L/min. The new high flow ensures delivery of

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WORLD RESPIRATORY CARE WEEK-2007 the set oxygen concentration to essentially all patients. This solution is not possible with most air-entrainment nebulizers. Because the small jets in these devices limit oxygen flow to 12 to 15 L/min, the input flow cannot be increased above these levels. The simplest approach to achieving higher FIO 2 with these devices is to add a 50- to 150-mL aerosol tubing reservoir to the expiratory side of the T tube. Given its simplicity, adding an open volume reservoir to the expiratory side of T tubes is standard procedure in most clinical settings. Unfortunately, this approach can be used only in the treatment of intubated patients. Even then, the small reservoir size limits the ability of this system to ensure stable FIO 2, especially greater than 40%, and larger reservoirs can cause rebreathing. Rather than a simple open reservoir, a closed-reservoir or nonrebreathing system can be used. These systems combine an inspiratory volume reservoir (usually a compliant 3- to 5-L anesthesia bag) with a one-way expiratory valve. Whenever patient flow exceeds nebulizer flow, the expiratory valve closes, and the patient draws additional gas from the reservoir. Although they can ensure delivery of the set oxygen concentration, these systems pose considerable hazards. Should source flow stop for any reason, the patient can suffocate. For this reason, these systems must be equipped with an emergency inlet valve that allows room air breathing in the event of source gas failure. The third and most common approach to higher FIO 2 with air-entrainment nebulizer is to connect two or more devices together with a wye adapter. For example, whereas a single air-entrainment nebulizer set at 60% (1:1 ratio) with a maximum input flow of 15 L/min has a total output flow of only 30 L/m, connecting two of these devices together doubles the total output flow to 60 L/min (the minimum needed a high-flow device). This approach works well only, for delivery of a concentration of 60% or less to patients with a minute volumes less than 10 L/min. A fourth method for boosting the FIO 2 provided by air-entrainment nebulizers is to set the device to a lower concentration than that prescribed (to generate high flow) while bleeding supplemental oxygen into the delivery tubing. This increases both FIO 2 and total output flow. To achieve a specific FIO 2 in this type of system, the clinician must analyze the delivered concentration and carefully adjust the supplemental oxygen input flow until the concentration is the desired value. Commercial dual-flow systems entail a similar approach. One flow source powers the jet while another flow source provides supplemental oxygen. The Misty Ox (Medical Moulding Corp.) gas injection nebulizer is a good example. This system can provide an FIO2 of 0.70 to 0.75 at a flow of 60 Umin or more when oxygen powers the nebulizer at 40 Umin and air is injected. The Misty Ox also can provide an FIO 2 of 0.65 to 0.70 at higher flow (90 to 100 L/min) when air powers the nebulizer and oxygen is injected.

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If aerosol is not needed, a simple dual-flow device such as the Downs flow generator can be used. This device is attached to a 50-psig oxygen source and provides oxygen concentration of 30% to 100% at a flow up to 100 L/min. Problems with Downstream Flow Resistance Any increase in flow resistance downstream from (distal to) the point of air entrainment alters the performance of all air-entrainment systems. Increased downstream flow resistance increases back pressure. The increase in back pressure decreases both the volume of entrained air and the total flow output of these devices. With less air entrained, the delivered oxygen concentration increases; however, because total flow output also decreases, the effect on FIO 2 varies. High downstream flow resistance usually turns air-entrainment systems from high-flow (fixed) oxygen delivery systems into low-flow (variable) oxygen delivery systems incapable of delivering a precise and constant FIO2. This problem explains why it is extremely difficult to deliver less than 28% to 30% oxygen with an air-entrainment nebulizer.The 5 to 6 feet (1.5 to 1.8 m) of aerosol tubing normally used with these devices produces enough flow resistance to decrease air entrainment and prevent a lower FIO 2. A similar situation can occur when the entrainment ports of an air-entrainment device become obstructed (most common with AEMs). Delivered oxygen concentration increases, but total output flow decreases. The net effect usually is a variable FIO 2. Blending Systems When air-entrainment devices cannot provide high enough oxygen concentration or flow, use of a gas blending system should be considered. With a blending system, separate pressurized air and oxygen sources are input, and the gases are mixed either manually or with a precision valve (blender). This system allows precise control over both FIO2 and total flow output. Most blending systems can provide flow well in excess of 60 L/min, qualifying them as true fixed-performance delivery devices. For adults, gas is delivered from the blender either through an open system, such as an aerosol mask or T tube, or with a closed nonrebreathing system. Mixing Gases Manually When gases are mixed manually, separate air and oxygen flowmeters must be adjusted for the desired FIO2 at the needed flow. For adults, this approach requires calibrated high-flow flowmeters (at least 60 L/min).

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WORLD RESPIRATORY CARE WEEK-2007 Oxygen Blenders. Rather than manually mixing air and oxygen, the clinicians can use an oxygen blender. Air and oxygen enter the blender and pass through dual pressure regulators that exactly match the two pressures. Gas then flows to a precision proportioning valve. Because the two gas pressures at this point are equal, varying the size of the air and oxygen inlets provides precise control over the relative concentration. An alarm system gives an audible warning when either source gas fails or the pressure decreases below a specified value. The alarm system usually has a crossover or bypass feature whereby failure of one gas source causes the blender system to switch to the other. For example, should the air source fail when delivering 60% oxygen, the alarm sounds, and the blender switches over to delivery of 100% oxygen. Although they allow ideal control over both FIO 2 and flow, blenders are prone to inaccuracy and failure. To avoid these problems, the clinicians always should conduct an operational check of any blender before using it on a patient. The FIO 2should be checked and confirmed with a calibrated oxygen analyzer at least once per shift. As always, a device that does not perform according to expectations should be replaced I immediately. When a blender is used in the care of a neonate, an oxygen analyzer should be kept in-line at all times. In the use of a nonrebreathing or closed delivery system, (1) all breathing valves should be inspected and tested before application to a patient, and (2) a fail-safe inspiratory valve should be included in the delivery system. Recommended O2 flow ranges: should provide output flow of at least 60 L/min Delivered FIO2 ranges: 21 - 100% Advantages: full range of FIO2 Disadvantages: Requires 50 psi air + O2, blender failure or inaccuracy common Best use: Patients with high VE who need high FIO2

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WORLD RESPIRATORY CARE WEEK-2007 Oxygen Blender Enclosures The concept of enclosing a patient in a controlled-oxygen atmosphere is among the oldest approaches to oxygen therapy. Entire rooms once were used for this purpose. With today's simpler airway devices, enclosures are generally used only in the care of infants and children. The primary types of oxygen enclosures used for infants and children are tents, incubators, and hoods. Oxygen Tents Oxygen tents once were the most common method of oxygen therapy in the treatment of both adults and children. Today, use of oxygen tents in the care of adults is rare, but tents are still used for children. In general, tents are air-conditioned or cooled with ice to provide a comfortable temperature within a plastic sheet canopy. The main problem with tents is that frequent opening and closing of the canopy cause wide swings in oxygen concentration. Moreover, constant leakage makes a high FIO 2 impossible. For example, in large tents oxygen input flow of 12 to 15 L/min can provide only 40% to 50% oxygen levels. Comparable FIO 2 can be achieved in smaller pediatric or croup tents with flow between 8 and 10 L/min. Because of these limitations, tents are used primarily for pediatric aerosol therapy in the care of children with croup or cystic fibrosis. Recommended O2 flow ranges: 12-15 L/min Delivered FIO2 ranges: 40 -50% Advantages: Provides concurrent aerosol therapy Disadvantages: Expensive, cumbersome, unstable FIO2 (leaks), requires cooling, difficult to clean, disinfect, limits patient mobility, fire hazard Best use: Toddlers or small children who need low to moderate FIO2 and aerosol

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WORLD RESPIRATORY CARE WEEK-2007 Oxygen Hoods An oxygen hood is the best method for administration of controlled oxygen therapy to infants. An oxyhood covers only the head, leaving the infant's body free for nursing care. Oxygen is delivered to the hood through either a heated air-entrainment nebulizer or a blending system with a heated humidifier. A minimum flow of 7 L/min should be set to prevent accumulation of carbon dioxide. Depending on the size of the hood, flow of 10 to 15 L/min may be needed to maintain stable high oxygen concentration. Higher flow generally is not needed and may produce a harmful noise level and additional stress on neonatal patients. In the care of premature infants, it is especially important to ensure that the gas mixture is properly warmed and humidified and not directed toward the patient's face or head. Low temperatures or convection cooling produced by high flow over the head causes heat loss and cold stress. In premature infants, cold stress can increase oxygen consumption and even cause apnea. The temperature of gases provided to an infant in an Oxyhood should be precisely set to maintain a neutral thermal environment (NTE). The NTE temperature varies according to an infant's age and weight. For example, the NTE temperature for newborns weighing less than 1200 g is 35 C. For older infants weighing 2500 g or more, the NTE is lower, approximately 30 c. Recommended O2 flow ranges: >7 L/min Delivered FIO2 ranges: 21 -100% Advantages: Full range of FIO2 Disadvantages: Difficult to clean, disinfect Best use: Infants who need supplemental oxygen

Oxyhood

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WORLD RESPIRATORY CARE WEEK-2007 Incubators Incubators are polymethyl methacrylate (Plexiglas) enclosures that combine servocontrolled convection heating with supplemental oxygen. In older models, humidification was provided with a blow-over water reservoir located under the patient platform. Because of the high infection risk associated with this design, these systems are no longer in common use. When it is needed, supplemental humidity usually is provided with an external heated humidifier or nebulizer. Supplemental oxygen can be administered with a direct connection between the incubator and a flowmeter that has a heated humidifier. In some units, a filtered airentrainment device limits the delivered concentration to approximately 0.40. However, leaks and frequent opening of the incubator dilute the oxygen levels well below 40%. On the other hand, blockage of the inlet filter can cause less air entrainment and a higher oxygen concentration. Given the highly variable oxygen concentration provided by these devices, the best way to control oxygen delivery to infants in an incubator is with an Oxyhood. The Oxyhood is placed over the infant's head inside the incubator. The oxygen concentration and gas temperature within the Oxyhood, not in the incubator, must be assessed. It is ideal to monitor incubator or Oxyhood oxygen concentration continuously. Because hoods allow better FIO 2 control, and because servo-controlled radiant heating warmers are generally more convenient, Plexiglas incubators are not as popular as they used to be. However, these devices are still the best choice for providing infants in stable condition with a neutral thermal environment.

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Recommended O2 flow ranges: 8-15 L/min Delivered FIO2 ranges: 40 -50% Advantages: Provides temperature control Disadvantages: Expensive, cumbersome, unstable FIO2 (leaks), difficult to clean, disinfect, limits patient mobility, fire hazard. Best use: Infants who need supplemental oxygen and precise thermal regulation

COMPLICATIONS OF OXYGEN THERAPY Complications occur mainly when patient FIO 2 is 100% more than 24 hours. FIO 2 50% or < 50% more than two days. CNS toxicity (Paul Bert Effect): Using of O2 therapy greater than 1ATA causes tremmers, twitching and convolutions. Pulmonary Toxicity (Lawrens Smith Effect): Breathing FIO2 more than 50% for one to two days at 1 ATA causes retro sternal burning sensation. Broncho Pneumonia. Absorption Atelectasis due to decrease surfactant and loss of nitrogen in the alveoli. High PaO2 levels damages capillary endothelium, it leads to interstitial oedema it causes thickness of alveolar capillary membrane, it also destroys type I and type-II cells causes low ventilation perfusion ratios causes in increasing physiological dead space High O2 levels decreases vital capacity (VC) and total lung capacity (TLC) it leads to lung collapse. Oxygen toxicity causes over production of oxygen free radicals, these radicals causes cell damage.

Effects on Circulatory system: Oxygen toxicity causes peripheral vasoconstriction causes increasing blood pressure levels and it leads to decreasing heart rate.

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WORLD RESPIRATORY CARE WEEK-2007 Retinopathy of Prematurity (ROP): In neonates premature babies and low birth weight babies more than 60% oxygen for longer duration and PaO2 more than 80 mm Hg leads to ROP. Other toxic effects: High oxygen levels may cause Broncho Pulmonary Displasia (BPD), sudden closure of Patient Ductus Arteriosis (BPD) and CO2 narcosis in COPD patients.

References: 1. Egans Fundamentals of Respiratory Care (eighth edition), Robert L. Wilkins, James K. Stoller and Craig L. Scanlan, Mosby. 2. Entry Level Respiratory Therapist Exam guide (fourth edition), James R. Sills, Med, CPFT, RRT, Elsevier Mosby. 3. American Association for Respiratory Care: Clinical Practice Guideline: Oxygen Therapy in the home or extended care facility, respiratory care 37:980, 1992.

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