Modul 5

TERAPI OKSIGEN
Dept. Anestesiologi & Terapi Intensif
FK USU/RSUP H.Adam Malik-Medan

Discovery of Oxygen : 1772

Carl Wilhelm Scheele

German - Swedishpharmaceutical chemist

Scheeles house and

pharmacy in
Kopnig

Oxygen, nitrogen, chlorine, many chemicals.

Tasted chemicals. ? Cause of death at age 43

Discovery of Oxygen :
1774

Joseph Priestly: 1774

Pneumatic trough

Minister and Teacher Supporter of American and French

Revolutions
Isolated 8 gases including oxygen ; Emigrated to the US

Discovery of Oxygen :
1775

Antoine- Laurent Lavoisier

Oxygen: acid producer,
identified as an element
Lawyer, Scientist Paris Arsenal French Revolution Guillotined
1794

Leland Clark, PhD. CCHMC

1949: Bubble oxygenator at Fels
Research Institute, Yellow Springs, OH
1951: First heart lung machine with
MDs Samuel Kaplan and James
Helmsworth
Developed numerous electrodes
including the oxygen electrode to
measure oxygen in blood

A-B-C
Life
Support

B - breathing (nafas)

Bernafas

Tidak ber-nafas

tidak

normal

hipoventilasi

Pertahankan
jalan nafas
tetap bebas
k/p OKSIGEN
masker

hiperventilasi

Pertahankan jalan nafas

tetap bebas
OKSIGEN masker

SIAP

Beri
bantuan nafas
secara aktif
+ OKSIGEN

Mouth to mouth
Mouth to mask
Ambu bag
Jackson Rees
T- piece

Manfaat oksigen pada

pasien dengan gangguan
airway
Meningkatkan kadar oksigen di alveoli
Meningkatkan jumlah oksigen di FRC
Mengurangi derajat hipoksemia darah

Dengan nafas yang terbatas, lebih

banyak oksigen dapat masuk ke alveoli
9

OKSIGEN DIPERLUKAN PADA PROSES METABOLISME

UNTUK PEMBENTUKAN ENERGI BIOLOGIS ( ATP )
METABOLISME SECARA ANAEROBIK AKAN
MENGAKIBATKAN GANGGUAN PEMBENTUKAN ATP
DAN PEMBENTUKAN ASAM LAKTAT/ ASIDOSIS
TERAPI OKSIGEN DIINDIKASIKAN BILA TERJADI
GANGGUAN OKSIGENASI JARINGAN DAN UNTUK
MENCEGAH PENYULIT YANG TERJADI KARENA
HIPOKSEMIA

Proses Produksi
Energi
Glukosa + O2 H2O + CO2 + 38 ATP
Glukosa tanpa O2 Lactic Acid + 2
(Anerobik)

Tahapan
Respirasi
1. VENTILASI
2. PERFUSI PARU - PARU
3. PERTUKARAN GAS DI PARU-PARU
4. TRANSPORT OKSIGEN
5. EKSTRAKSI ( OXYGEN UPTAKE )

Transport Oksigen
DO2 = CO ( Hb X SaO2 X 1,34 + 0,003 X PaO2)
DERAJAT HIPOKSEMIA DITENTUKAN DENGAN
1. A-a DO2 ( Alveolar - arterial O2 Difference )
= PAO2 - PaO2
PAO2 = ( PB - PH2O ) X FiO2 - PaCO2 / R
2. PaO2 / FiO2

Kecukupan transport oksigen

(Available O2 )
Rumus Nunn-Freeman
Av. O2 = CO {(Hb x SaO2 x 1.34) + (pO2 x 0.003)}
Disederhanakan :
Av. O2 = CO x Hb x 1.34
Jika CO dapat naik sampai 2 x
Hb boleh tinggal nya
Available O2 tidak berkurang !
Contoh :
Av.O2 = 50 x 15 x 1.34 = 1005
Av.O2 = 100 x 7.5 x 1.34 = 1005

Oxygen is a DRUG
Must be considered as a drug
TOO MUCH of a drug can cause
overdosing problems
TOO LITTLE isnt enough to treat
the symptoms

Goals of Oxygen
Therapy

Correct hypoxemia
Decrease symptoms associated
with hypoxemia
Decrease workload on
cardiopulmonary system

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

HIPOKSIA- HIPOKSEMIA
TERAPI OKSIGEN

Assessing
Oxygen Levels

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

Table Approximate PaO2 versus

O2 Hemoglobine Saturation
Levels
PaO2 Levels

O2 Hemoglobin
Saturation Levels

90 mm Hg

100 %

60 mm Hg

90 %

30 mm Hg

60 %

27 mm Hg

50 %

Oxygen saturation or O2 sat

Factors Affecting SaO2

Measurements
Low perfusion states
Motion artifact
Nail polish when using a finger
probe
Intravascular dyes
Vasoconstrictor medications
Abnormal Hemoglobin
Too much light exposure

Medical Research Council (MRC) Trial

1981

87 patients
Severe
COPD
O2 15
hours/day

Nocturnal Oxygen Therapy Trial

(NOTT) 1980

203 patients

Severe COPD

Criteria for Ordering O2

Therapy
PaO2 at or below 55 mm Hg
Saturation O2 < 88% resting
PO2 <55 mm Hg or < 88% for 5 min (sleep)
A drop in PO2 10 mm Hg or 5% in O2 sat.
during sleep
Symptoms or signs of heart failure
(corpulmonale), pulmonary hypertension,
erythrocytosis, P pulmonale on EKG
PO2 <55 mm Hg or < 88% during exercise

PEDOMAN UMUM
TERAPI OKSIGEN
Bila :

PaO2 < 60 mmHg

SaO2 < 90 %

Indications for oxygen

therapy
Respiratory
compromise

Cyanosis
Tachypnoea
Hypoxaemia
Partially obstructed airway

Indications for oxygen

therapy
Cardiac
compromise
Chest pain
Shock
Tachycardia
Arrhythmias

Neurological
deficits
CVA
Spinal injuries

Long Term Sign

Clubbing

Aims of oxygen
therapy
to increase PaO to acceptable
2

level with concentration of oxygen

to decrease respiratory rate and
work of breathing
Hypoxaemia with high PaCO2
24% initially
careful monitoring with regular
ABGs

Types of oxygen
delivery

Nasal cannulae
Medium concentration mask
Fixed concentration mask
Non - rebreathe bag
Humidified circuits
High flow systems

Alat
FiO2
NASAL PRONG

24 - 40 %

SIMPEL MASK

40 - 50 %

VENTURI - MASK

24 - 50 %

PARTIAL REBREATHING

60 - 80 %

NON REBREATHING

- 90 %

CPAP

- 100 %

VENTILATOR

- 100 %

Nasal Cannulae
Flow rate up to 4l/min
Unable to determine exact
concentration
Comfortable allows patient to eat,
drink talk
Can still be used if patient is
mouth breathing
Can use continuously with
meals and activity

Nasal prong
Keuntungan :
mudah penggunaan
ringan
ekonomis
disposable
nyaman,pasien bisa mobilisasi
Kerugian :
mudah lepas
maksimum FiO2 40 %
iritasi telinga
Tehnik lain dengan kateter :
1. Nasal kateter
2. Transtracheal kateter.

Medium concentration
mask
Hudson/ MC mask
Flow rate must be at least 5 l/min
Exact concentration of oxygen
depends on patients respiratory
pattern
Poor humidification
Useful post-operatively

Masker oksigen
Konsentrasi O2 bervariasi antara 24 - 100 %
Kerugian :
1. Tidak nyaman,
2. Iritasi kulit akibat pemakaian masker ketat
3. Kontrol FiO2 sukar,( kecuali dengan sistim venturi )
4. Kalau pasien makan harus dilepas
Komplikasi yang dapat terjadi :
1. Bila pasien muntah dapat terjadi aspirasi
2. Dapat mengakibatkan retensi CO2 dan
hipoventilasi
kalau flow terlalu rendah atau lubang ekshalasi
tersumbat.

Masker
Oksigen
1.Simple mask
( 35 - 60 % dengan flow 6 - 10 L )
2. Partial rebreathing
( 35 - 60 % dengan flow 6 - 10
L)
3. Non rebreathing

Partial Rebreather
Mask
Consists of mask with
exhalation ports and
reservoir bag
Reservoir bag must remain
inflated
O2 flow rate - 8 to 10L
Client can inhale gas from
mask, bag, exhalation ports
Poorly fitting; must remove
to eat

Non-rebreather Mask
Consists of mask,
reservoir bag, 2 oneway valves at
exhalation ports and
bag
Client can only inhale
from reservoir bag
Bag must remain
inflated at all times
O2 flow rate- 10 to 15L
Poorly fitting; must
remove to eat

Fixed concentration
Venturi masks
Deliver a fixed concentration of oxygen
Must be set at minimum flow rate as
shown on barrel
FiO2 0.24 0.6
Able to increase flow rate
without altering concentration
Bernouilli principle

Venturi Mask
Most reliable and accurate
method for delivering a
precise O2 concentration
Consists of a mask with a
jet
Excess gas leaves by
exhalation ports
O2 flow rate- 4 to 15L
Can cause skin breakdown;
must remove to eat

The
Bernoulli
Effect

30
l/min

2 l/min
oxygen jet

14 l/min
14 l/min air
air
entrained
entrained 2 l/min
oxygen

Non Rebreathe bags

Reservoir bags
Deliver FiO2 0.6 0.8
Flow rate must be set to 15
L/min
Fill reservoir 2 thirds before
applying
Useful in acute situation
Should not be worn >24hrs

Alat Terapi Oksigen

I . FIXED SYSTEM ( FiO2 TIDAK DIPENGARUHI FAKTOR
PASIEN )
1. SISTIM VENTURI - HIGH FLOW
2. LOW FLOW BREATHING CIRCUITS ( CPAP,
BAG-MASK,JAKSON-REES ,MESIN ANESTESI )
II. VARIABLE SYSTEM ( FiO2 TERGANTUNG PADA FLOW
OKSIGEN,ALAT YANG DIGUNAKAN DAN PASIEN )
1. NASAL KATETER / PRONG
2. SIMPLE MASK
3. MASKER DAN REBREATHING BAG
III. BAYI - ANAK :
1. HEAD BOX
2. INKUBATOR
3. COT / TENT.

Alat-alat
Terapi oksigen

Nasal prong

Simple mask

T - piece

Rebreathing mask

Nasal Cannula

Salter Oxy-Frame

Face Masks

Oxymizer

Pendant

Tracheostomy Collar/
Mask
O2 flow rate 8 to 10L
Provides accurate
FiO2
Provides good
humidity;
comfortable

T-piece
Used on end of ET
tube when weaning
from ventilator
Provides accurate
FiO2
Provides good
humidity

Transtracheal Oxygen (TTO)

Konsentrasi Oksigen
yang dihasilkan tergantung pada
1.
2.
3.
4.

Alat
Cara pemberian
Pasien kooperatif atau tidak
Pola napas pasien.

Pasien dengan tidal volume rendah,

takhipneu dan pola napas tidak normal ,
maka konsentrasi O2 yang masuk ke pasien
akan berubah

Oxygen flow rate and

concentration
Respiratory
distress

Non-respiratory
distress

Minute vol
(RR x TV)

20 l/min
(40bpm x 500ml)

5 l/min
(10bpm x 500ml)

O2 flow rate

2 l/min

2 l/min

Oxygen
concentration

2 l/min of 100% oxygen +

18 l/min air drawn into mask (21%)
= 20 l/min minute volume
FiO2 = (1.0 x 2) + (0.21 x 18) / 30

2 l/min of 100% oxygen +

3 l/min air drawn into mask (21%)
= 5 l/min
FiO2 = (1.0 x 2) + (0.21 x 3) / 5

= 0.29 (29%)

= 0.53 (53%)

Tanda mengarah ke GAGAL NAPAS

1. PERNAPASAN ABDOMINAL DOMINAN
2. GERAK OTOT NAPAS TAMBAHAN
- STERNOCLEIDOMASTOID
- INTERCOSTAL
3. RETRAKSI SUPRASTERNAL,INTERCOSTAL

GAGAL NAFAS
Nafas dibantu alat - ventilator

Humidification
Prevents cilia destruction
Prevents damage to mucus
glands
Aids sputum clearance

Indications for
humidification
Oxygen therapy at higher flow rates
Patients with copious secretions
Systemic hydration
IV fluids
Saline nebulisers

Complications with
humidified oxygen
Bronchoconstriction
Decreased lung function if
over-humidified
Increased risk of infection

regulator

Flowmeter + humidifier

Flowmeter pengatur
aliran oksigen

Pengatur tekanan tinggi dan

penunjuk tekanan tabung

Humidifier, pelembab
Sebaiknya dikosongkan saja
(mudah jadi sarang kuman)

Pada waktu transport

diperlukan oksigen tinggi,air harus
dibuang krn menghambat
aliran oksigen

66

Precautions of
Supplemental Oxygen
1. Oxygen toxicity
2. Depression of ventilation
3. Retinopathy of Prematurity
4. Absorption atelectasis
5. Bacterial infection with
humidifiers

Oxygen Toxicity
Patients exposed to high oxygen
levels for a prolonged period of time
have lung damage.
First damage is capillary
epithelium, leading to edema,
thickened membranes and finally
to pulmonary fibrosis and
hypertension.

A Vicious Cycle

Depression of
COPDVentilation
patients with CO retention
have blunted stimuli to breathing
2

Hypoxic drive theory

They have a different stimulus to
breathe then normal

GOLDEN RULE:
You should never stop giving oxygen to a
patient in need.

Retinopathy of
Prematurity
Is an abnormal eye condition in
some premature infants who
receive high FIO2
Retinal arteries hemorrhage and
scaring cause retinal detachment
and blindness.

Absorption
Atelectasis
The alveoli in the lungs collapse and
cause shunting in the capillary lung
fields.
Loss of nitrogen in the blood
causes less total venous pressure.
This leads to the collapse of of the
alveolus.

Pressure gradients that cause

absorption atelectasis

Infection Control
Therapist must use an aseptic
technique when handling
supplemental oxygen and humidity
equipment
Never drain water from the tubing
back into the heated humidifier
Always date the opened container
Only use sterile liquids in reservoirs

Oxygen: a fire
hazard
NEVER smoke while using
supplemental oxygen
Severe facial burns can and
do happen

SIDE EFFECTS OF OXYGEN

Nasal drying
Nasal bleeding
Increase in blood carbon dioxide (CO2)
Atelectasis (collapse)
Airway inflammation
Lung edema/ inflammation
Damage to retina: infants, high O2

Misconceptions about
Oxygen
Oxygen is addicting postpone use as
much as possible
High Oxygen concentration is bad for you
I only need Oxygen when I am short of
breath
Oxygen can burn spontaneously
Oxygen is used in terminal disease
Humidity is needed for everyone on oxygen

Clinical Guidelines
Consider Oxygen as a drug
Use the lowest FIO2 .
Use it for the shortest possible time
Keep oxygen below 50% if
If you have to - accept lower
saturations than normal in some
situations
Check equipment regularly for
contaminants

Summary
Oxygen is required for cell
metabolism
Oxygen requirements are higher in
critically ill patients
Be aware of different delivery
systems
Always consider humidification
Safety aspects

Terima kasih atas perhatian anda

Semoga Tuhan selalu memberkahi kita semua
Amin