Modalities of oxygen therapy in PICU

Dr Suresh Kumar. MBBS, MD, FIAP (PCC), DNB, PGDS, DM (fellow, PCC)
31-3-14
Overview
Need of oxygen therapy
Oxygen delivery system
Oxygen delivery devices
Individual oxygen delivery devices and techniques
Humidification
Complication of oxygen therapy
Practical considerations
 Joseph Priestley (1775)
Heated mercuric oxide and obtained air that caused candles to burn
more brightly
Dephlogisticated air (Oxygen)

From the greater strength and vivacity of the flame of a candle, in the
pure air, it may be conjectured, that it might be particularly salutary to
the lungs in certain morbid cases when the common air would not be
sufficient though the pure air (oxygen) might be very useful as a
medicine

Scott Haldane (18601936) was first to brought oxygen therapy to a

rational and scientific basis
Ubiquitous in modern medicine
 Oxygen administration and airway management are two of
the fundamental aspects of management in a patient with
acute respiratory failure
Proper application of oxygen therapy and airway
management are life saving
In the absence of O2 (hypoxia), cellular respiration ceases
and irreversible cellular injury and death occur within
minutes
Despite the importance of these therapies and their
frequent use in the acute care setting, their nuances are
often under-appreciated
Oxygen
Colourless, odourless

Medical grade O2 is manufactured by fractional

distillation of liquefied air

It is stored as a liquid to reduce the size of the

storage container
1 L of liquid O2 produces 860 L of gaseous O2
 Most important indication for O2 therapy is to treat hypoxemia
The alveolar gas equation illustrates how increasing the
inspired O2 fraction (FIO2) increases the alveolar PO2 (PAO2)
and subsequently the arterial PO2 (PaO2)
PAO2 = FIO2(PB-47)-1:25PaCO2

Increasing FIO2, lead to increase in PAO2

In cases of shunt (V/Q=0), supplemental O2 therapy has little
PAO = 0.21 X 713 - 40/0.8 = 100
effect on PaO2 2
PAO2 = 0.50isXlow
713V/Q- 40/0.8 = 306
If the cause of hypoxemia or diffusion defect,
supplementalPAO 2 = 0.80will
O2 therapy X 713 - 40/0.8
effectively = 520 the PaO2
increase
Oxygen therapy
Administration of oxygen at concentration higher than in environment
(>21%)
Purpose: Increase oxygen saturation in blood and tissues when it is low
due to disease or injury

For oxygen to increase PaO2, there has to be units of low ventilation with
normal or near normal perfusion
Any true extra or intrapulmonary R-L shunting will be largely unaffected
by increase in alveolar oxygen tension (PAO2)

Oxygen administration by simple tubes and masks to advanced support

systems like ECMO

Oxygen therapy in non-intubated children

 Goal of oxygen delivery
Maintain targeted SpO2 levels through the provision of
supplemental oxygen in a safe and effective way
Relieve hypoxemia and maintain adequate oxygenation
of tissues and vital organs
Give oxygen therapy in a way which prevents excessive
CO2 accumulation
Reduce the work of breathing
Efficient and economical use of oxygen
Ensure adequate clearance of secretions and limit the
adverse events of hypothermia and insensible water loss
Oxygen delivery system

Oxygen source

Pressure regulator and flow meter

Oxygen delivery device

Patient
Patient
Indications for oxygen delivery

Documented hypoxia/hypoxemia
Achieving targeted percentage of oxygen saturation
The treatment of an acute or emergency situation where hypoxemia or
hypoxia is suspected, and if the child is in respiratory distress manifested by:
Dyspnea, tachypnea, bradypnea, apnea
pallor, cyanosis
lethargy or restlessness
use of accessory muscles: nasal flaring, intercostal or sternal recession, tracheal tug
Circulatory compromise
Pulmonary hypertension
Short term therapy: post anesthetic or surgical procedure
Palliative care: for comfort
Oxygen sources
Medical oxygen can be provided from a

Wall source
Provide 50 psi (pounds per square inch ) of pressure

Cylinder
Operate at 1800-2400 psi
Too much
Cannot be directly delivered to patient or run the ventilator
Need down regulating valve
Flow meter to manipulate the flow rate
 Pressure regulator with flow meter
The pressure regulator controls the pressure coming out of the cylinder and is indicated
on the gauge in psi

The flow meter controls how rapidly the oxygen flows from the cylinder/wall source to
the victim

The flow rate can be set from 1-25 L/min

Oxygen delivery devices
Devices used to administer, regulate, and
supplement oxygen to a subject to increase the
arterial oxygenation

These system entrains oxygen and/or air to prepare

a fixed concentration required for administration

Tubing carries the oxygen from the regulator/flow

meter to the delivery device
 Oxygen delivery devices
Classified as:
Low-flow or variable-performance devices:
Provide oxygen at flow rates that are lower than patients inspiratory demands
When the total ventilation exceeds the capacity of the oxygen reservoir, room air is
entrained
FiO2 delivered depends on the ventilatory demands of the patient, the size of the
oxygen reservoir, and the rate at which the reservoir is filled
At a constant flow, the larger the tidal volume, the lower the FiO 2 and vice versa
FiO2 24-90%

High-flow or fixed-performance devices:

Provide a constant FiO2 by delivering the gas at flow rates that exceed the
patients peak inspiratory flow rate and by using devices that entrain a fixed
proportion of room air
Reliable
Oxygen delivery devices
Confusion: flow systems with oxygen concentrations

However, both are mutually exclusive in that a high-flow

system, viz. Venturi mask, can deliver FiO2 as low as 0.24,
whereas a low-flow system like a non rebreathing mask can
deliver FiO2 as high as 0.8

If the ventilatory demand of the patient is met completely by

the system: high-flow system

if the system fails to meet the ventilatory demand of the

patient: low-flow system
Oxygen delivery devices
A low-flow oxygen delivery system requires that the patient inspire
some room air to meet inspiratory demands
Popular: simplicity, patient comfort, and economics
FIO2 is determined by the size of the oxygen reservoir, the oxygen
flow rate, and the breathing pattern
For example, a nasal cannula at an oxygen flow rate >6 L/min
accomplishes minor increases in FIO2 because the nasopharyngeal
reservoir is filled with 100% oxygen at a 6 L/min flow rate
An oxygen reservoir must be increased (placing a mask over the
nose and mouth) to achieve an FIO2 greater than 40%
With abnormal ventilatory patterns, the larger the tidal volume, or
the faster the respiratory rate, the lower the FIO 2
Oxygen delivery devices
Low flow systems: High flow systems:
Nasal cannula Venturi system
Intranasal catheter Oxyhood
Simple mask Face tent
Partial rebreathing Oxygen tent
masks High flow nasal prongs
Non rebreathing mask

CPAP
Heliox
Hyperbaric oxygen
Oxygen delivery devices
The choice of delivery device:
Patients oxygen requirement

Efficacy of the device

Reliability

Ease of therapeutic application

Humidification needs

Age
Patient acceptance and tolerance
 Normal flow requirement

3-4 time the minute ventilation (MV = TV X RR)

eg 5 kgs child breathing at rates of 60/min

Flow rates needed: 3-4 X (60 X 6 X 5) = 5400-7200
ml/min
Nasal cannula/prongs

Two soft prongs in nostrils attached to the oxygen source

Held in place over the patients ears
Flow is directed to the nasopharynx: humidification and heat
exchange
To ensure the patient is able to entrain room air around the nasal
prongs and a complete seal is not created the prong size should
be approximately half the diameter of the nares
Available in different sizes
Infant
Pediatric
Adult
Select the appropriate size for the patient's age and size
 Nasal cannula/prongs
Delivers 24-44% FiO2 at flow rate of 1-6 L/min 1 = 24%
2 = 28%
The slower the inspiratory flow the higher the FiO 23 = 32%
4 = 36%
A maximum flow of: 5 = 40%
2 LPM in infants/children under 2 years of age 6 = 44%
4 LPM for children over 2 years of age

With the above flow rates humidification is not

usually required
If flow >6 L/min, variable FiO2, need humidification
Nasal cannula/prongs
Indications
Low to moderate oxygen requirement
No or mild respiratory distress
Long term oxygen therapy
Contraindications
Poor efforts, apnea, severe hypoxia
Mouth breathing
Advantages
Less expensive (Rs 70/-)
Comfortable, well tolerated
Able to talk and eat
Disadvantages
Doesnot deliver high FiO2
Irritation and nasal obstruction
Less FiO2 in nasal obstruction
FiO2 varies with breathing efforts
Nasal cannula/prongs
Practical considerations:
Position the nasal prongs along the patient's cheek and secure
the nasal prongs on the patient's face with adhesive tape
Position the tubing over the ears and secure behind the
patient's head
Ensure straps and tubing are away from the patient's neck to
prevent risk of airway obstruction
Check nasal prong and tubing for patency, kinks or twists at
any point in the tubing and clear or change prongs if necessary
Check nares for patency - clear with suction as required
Change the adhesive tape frequently as required
Check frequently that both prongs are in nostrils
 Intranasal catheters
Flexible catheter with holes at distal 2 cms
FiO2 35-40%
Measured from nose to ear, lubricated
and inserted to just above the uvula
Deep insertion can cause air
swallowing and gastric distension
Must be repositioned every 8 hours to
prevent breakdown
No advantages over nasal cannula
 Simple masks
Made up of clear flexible plastic
that can be moulded to fit
patients face
Volume: 100-300 mL.
FiO2 40-60% at 6-10 L/min
Fits persons face without much
discomfort
Perforations, act as exhalation
ports
Vents in the mask allow for the
dilution of oxygen
 Simple masks
Indications:
Medium flow oxygen desired, mild to moderate respiratory distress
When increased oxygen delivery for short period (<12 hrs)
Contraindications:
Poor respiratory efforts, apnea, severe hypoxia
Advantage:
Less expensive (Rs 80/-)
Can be used in mouth breathers
Disadvantage
Uncomfortable
Require tight seal
Donot deliver high FiO2
FiO2 varies with breathing efforts
Interfere with eating, drinking, communication
Difficult to keep in position for long
Skin breakdown
Simple masks
Practical considerations:
Pediatric and adult sizes
Select a mask which best fits from the child's bridge of nose to the cleft of
jaw, and adjust the nose clip and head strap to secure in place
No pressure point or damage to eyes
Flow <4 L/min results in rebreathing and carbon dioxide retention
The FiO2 inspired will vary depending on the patient's inspiratory flow,
mask fit/size and patient's respiratory rate
Oxygen (via intact upper airway) via a simple face mask at flow rates of 4-
6 L/min does not require humidification
Humidification may be indicated/appropriate for patients with secretions
retention, or discomfort
Some conditions (eg. Asthma), the inhalation of dry gases can compound
bronchoconstriction
 Partial rebreathing face masks
Simple masks with additional reservoir
that allows the accumulation of the
oxygen enriched gas for rebreathing

Allows for the initial portion of the

expired gases containing little or no
CO2 (rich in oxygen) to be collected in a
reservoir while the remaining
expiratory gases are vented to the
atmosphere
Partial rebreathing face masks
Fio2 35-60 % flow rates of 6
6: 35%
to 15 L/min 8: 45-50%
Flow rate must be sufficient to keep 10: 60%
bag 1/3 to 1/2 inflated at all times 12: 60%
15: 60%
Minimum flow should be 6 L/min to
avoid patient breathing large part of
exhaled gases and rest of exhaled air
exit through vents
Partial rebreathing face masks
Indications:
Relatively high FiO2 requirement
Contraindications:
Poor respiratory efforts, apnea, severe hypoxia
Advantage:
Inspired gas not mixed with room air
Patient can breath room air through exhalation ports if oxygen
supply get interrupted
6: 35%
Disadvantage 8: 45-50%
More oxygen flow doesnot increase FiO2 10: 60%
Interfere with eating and drinking 12: 60%
15: 60%
Non-rebreathing face masks
Face mask + oxygen reservoir + a valve at exhalation port + a valve between
reservoir and mask
Patient inhales oxygen from the bag and exhaled air escapes through flutter
valves on the side of the mask
Oxygen flow into the mask is adjusted to prevent the collapse of the reservoir (12
L/min)
It prevent the room air from being entrained
10-15 L/min, FiO2 90-100%

6: 55-60%
8: 60-80%
10: 80-90%
12: 90%
15: 90-100%
Non-rebreathing face masks
Indications:
High FiO2 requirement >40%
Contraindications:
Poor respiratory efforts, apnea, severe hypoxia
Advantage:
Highest possible FiO2 without intubation
Suitable for spontaneously breathing patients with severe hypoxia
Disadvantage
Expensive (Rs 250/-)
Require tight seal, Uncomfortable
Interfere with eating and drinking
Not suitable for long term use
Malfunction can cause CO2 buildup, suffocation
 Non-rebreathing face masks

Practical considerations:
To ensure the highest concentration of oxygen is delivered to the
patient the reservoir bag needs to be inflated prior to placing on the
patients face
Ensure the flow rate from the wall to the mask is adequate to maintain
a fully inflated reservoir bag during the whole respiratory cycle
Do not use with humidification system as this can cause excessive 'rain
out' in the reservoir bag
Flow rate must be sufficient to keep bag 1/3 to 1/2 inflated at all times
Avoid kinking and twisting of reservoir
Check that vales and rubber flaps are working
Venturi masks or Air-entrainment masks

A Venturi mask mixes oxygen with room air,

creating high-flow enriched oxygen of a settable
concentration
It provides an accurate and constant FiO2 in range
of 24-50%
Venturi mask is often employed when the clinician
has a concern about CO2 retention
 Venturi masks or Air-entrainment masks

Dilutional masks
Work on Bernoulli principle
Oxygen is delivered through the jet nozzle, which increases its velocity
The high-velocity O2 entrains ambient air into the mask due to the viscous shearing
forces between the gas traveling through the nozzle and the stagnant ambient air
FiO2 depends on size of entrainment ports, nozzle, flow rate
The larger the port, the more room air is entrained and lower the FiO2
Reliably provide 25-60% FiO2 at 4-15 L/min
 3: 24%
3: 26%
6: 28%
6: 30%
9: 35%
12: 40%
15: 50%
Venturi masks or Air-entrainment masks

Indications:
Desire to deliver exact amount of FiO2
Contraindications
Poor respiratory efforts, apnea, severe hypoxia
Advantage:
Fine control of FiO2 at fixed flow
Fixed, reliable, and precise FiO2
Doesnot dry mucus membranes
High flow comes from the air, saving the oxygen cost
Can be used for low FiO2 also
Helps in deciding whether the oxygen requirement is increasing or decreasing
Disadvantage
Uncomfortable
Expensive (Rs 150/-)
Cannot deliver high FiO2
Interfere with eating and drinking
 Venturi masks or Air-entrainment masks
Practical considerations:
Oxygen must be humidified and warmed
Monitor FiO2 at flow rates ordered
Not effective for delivering FiO2 greater than 50%
To achieve the desired FiO2 use the diagram below
Appropriate air entrainment position for desired FiO2 the oxygen flow rate and total flow that will be delivered to
patient when these settings are utilized
To ensure that the patient's ventilatory requirements are met the total flow must exceed the patient's minute
ventilation
 Oxyhood

Small, clear plastic hood to cover infants head or head and upper torso
Patient more accessibility without disturbing O2 delivery
For newborns and young infants
Correct size: That has enough room for babys head to fit comfortably and allow free neck and head
movements without hurting baby
FiO2 80-90%, Flow 10-15 L/min
3-4 sizes are available; Too big: dilute the oxygen; Too small: discomfort and CO2 retention
Adequate flow of humidified oxygen ensures mixing of delivered gases and flushing out CO2
Oxygen gradient can vary as 20% from top to bottom. Continuous flow >6 L/min avoids this problem
Ensure the headbox has a gap all around the childs neck, this is important in preventing the
accumulation and re-breathing of CO2
Gas flow must be high enough to prevent re-breathing of CO2
Face tent/face shield
High flow soft plastic bucket
Well tolerated by children than face mask
10-15 L/min, 40% FiO2
Access for suctioning without need for interrupting
oxygen
Oxygen tent
Clear plastic sheet that cover childs upper body
FiO2 50%
Not reliable
Limit access to patient
Not useful in emergency situations
,
Continuous positive airway pressure

By applying underwater expiratory resistance

Indicated
When oxygen requirement >60% with a PaO2 of <60
mmHg
Clinical parameters and general conditions also act as
guiding criteria

CPAP reduce work of breathing, increases FRC and

helps maintain it, recruit alveoli, increase static
compliance, and improve ventilation perfusion ratio
 Continuous positive airway pressure

Methods:
Underwater (indigenous/bubble ,
commercial)
Ventilator
Used in
Early ARDS, acute bronchiolitis, pneumonia
It should be tried in spontaneously
breathing child who does not require
emergency intubation prior to conventional
ventilation
Can be used in early, incipient or frank
respiratory failure
Continuous positive airway pressure

Humidification add to the cost

Water vapors condense in tubing
Block
Trickle into airways: collapse, pneumonia
Single tube may not be compatible (commercially
available binasal prongs)
 High flow nasal prongs
Humidified high flow nasal prong (cannula) oxygen therapy is a
method for providing oxygen and continuous positive airway
pressure (CPAP) to children with respiratory distress
HFNP may reduce need for NCPAP/intubation, or provide support
post extubation
At high flow of 2 L/kg/min, using appropriate nasal prongs, a
positive distending pressure of 4-8 cmH2O is achieved
This improves FRC and reduces work of breathing
Because flows used are high, humidification is necessary to avoid
drying of respiratory secretions and for maintaining nasal cilia
function
MOA: application of mild positive airway pressure and lung
volume recruitment
High flow nasal prongs
Indications
Respiratory distress from bronchiolitis, pneumonia, congestive heart failure
Respiratory support post extubation
Weaning therapy from CPAP or BIPAP
Respiratory support to children with neuromuscular disease
HFNP can be used if there is hypoxemia and signs of moderate to severe respiratory
distress despite standard flow oxygen
Contraindications
Blocked nasal passages/coanal atresia
Trauma/surgery to nasopharanyx
Complications
Gastric distension
Pressure areas
Pneumothorax
 High flow nasal prongs
Equipment
Oxygen and air source
Blender
Flow meter
<7Kg : standard 0-15L/min flow meter
>7Kg: high flow oxygen flow meter, 50L/min flow
Humidifier (Fisher and Paykel MR850)
Circuit tubing to attach to humidifier
Children <12.5kg: small volume circuit tubing
Children 12.5kg: adult oxygen therapy circuit tubing
Nasal cannula to attach to humidifier circuit tubing
(size to fit nares comfortably)
Water bag for humidifier
Nasogastric tube
High flow nasal prongs
Set up of equipment
Appropriate size nasal cannula and circuit tubing
Connect nasal cannula to adaptor on circuit tubing,
and connect circuit tubing to humidifier
Attach air and oxygen hoses from blender to air
and oxygen supply
Connect oxygen tubing from blender to humidifier
Attach water bag to humidifier and turn on to 37C
High flow nasal prongs
Set up of equipment
Prongs should not totally occlude nares
Start the HFNP at the following settings:
Flow rate
10Kg 2 L/kg/min
>10Kg 2 L/kg/min for the first 10kg + 0.5L/kg/min for each kg above that (max
flow 50 L/min)
Start off at 6L/min and increase up to goal flow rate over a few minutes to allow
patient to adjust to high flow

FiO2
Always use a blender, never use flow meter off wall delivering FiO2 100%
Start at 50-60% for bronchiolitis and respiratory distress
 High flow nasal prongs
HFNP
Improves the respiratory scale score
Oxygen saturation
Patient's COMFORT scale
Reduce need for mechanical ventilation
Children with respiratory distress treated with high-flow nasal cannula. J Inten Care Med 2009
High-flow nasal cannula oxygen therapy for infants with bronchiolitis: Pilot study.
J Paediatr Child Health. 2014
High-flow nasal cannula (HFNC) support in interhospital transport of critically ill children
Intensive care med 2014
High-flow nasal prong oxygen therapy or nasopharyngeal continuous positive airway pressure
for children with moderate-to-severe respiratory distress? Pediatr Crit Care, 2013
High-flow nasal cannula therapy for respiratory support in children. Cochrane Database Syst
Rev.2014 Mar 7;3:CD009850
Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen
delivery. Intensive Care Medicine. 2011
Hyperbaric oxygen
The goal is to deliver extremely high partial pressure of oxygen, >760 mmHg
Indications:
Smoke inhalation
CO poisoning
CN poisoning
Thermal burns
Air embolism
Clostridium myenecrosis
Osteomyelitis (refractory)
Compromised skin grafts
Radiation injury
Acute traumatic ischemia/acute crush injury
Severe decompression sickness
Necrotizing fasciitis
Hyperbaric oxygen
Requires specialized equipment and personnel
with intensive care unit skills and knowledge of the
physiology and risks unique to hyperbaric oxygen
exposure (CNS and Pulmonary)
Cost, unavailability
Hyperbaric oxygen

The half-life of COHb is about five hours breathing

21% O2 at ambient pressure, a little more than one
hour breathing 100% O2 at ambient pressure, and
30 min breathing 100% O2 at 3 atm of pressure
Heliox
Heliox is a gas mixture of helium and oxygen: low density

Obstructive lung diseases (bronchiolitis, acute bronchial

asthma)
In spontaneously breathing patients with asthma, heliox decreases
PaCO2, increases peak flow, and decreases pulsus paradoxus
There may be benefit related to the combination of heliox with
aerosol bronchodilator delivery in patients with acute asthma

Heliox reduce resistance with upper airway obstruction (post

extubation stridor)
 Heliox
Care must be taken to administer heliox in a safe and effective
manner
To avoid administration of a hypoxic gas mixture, it is recommended
that 20% oxygen/80% helium is mixed with oxygen to provide the
desired helium concentration and FIO2
If an FIO2 requirement >40%, the limited concentration of helium is
unlikely to produce clinical benefit
When using an oxygen-calibrated flow meter for heliox therapy, it
must be remembered that the flow of heliox (80% helium and 20%
oxygen) will be 1.8 times greater than the indicated flow
 Heliox
For spontaneously breathing patients,
heliox is administered by face mask with a
reservoir bag

Y-piece attached to the mask allows

concurrent delivery of aerosolized
medications

Sufficient flow is required to minimize

contamination of the heliox with ambient
air: 12 to 15 L/min

Administration during mechanical ventilation can be problematic

Density, viscosity, and thermal conductivity of helium affect the delivered tidal
volume and the measurement of exhaled tidal volume
 Measurement of delivered oxygen
Oxygen analyser or FiO2 meter
Sensor digitally convert sensed
concentration into reading
Quality and accuracy of sensor is most
important
Expensive part
Calibration with every use
The oxyhood is ideal place, can be used
within masks held at moth or nose
 Monitoring
Oxygen should not be administered without an objective assessment of its
effect
Oxygen therapy should be used without wasting time and thought
Further therapy, amount, duration can then be formulated
FiO2 of 40-60% is adequate in most situations, 100% needed during
resuscitation
Increasing requirement of FiO2 to maintain same SpO2 is an omniuos sign
Children should be nursed in manner that makes them most comfortable
Mothers can be the best administrator of the oxygen
A frightened and agitated mother result into frightened and agitated child
Spend some time to explain the situation
Monitoring
Vital signs (hourly)
HR
RR (including level of distress)
BP
Temperature
SpO2
Breathing pattern
Level of consciousness and responsiveness
Color
ABG

SpO2 >92% and PaO2 > 60 mmHg are acceptable

Monitoring
Check and document oxygen equipment set up at
the commencement of each shift and with any
change in patient condition
Hourly checks should be made for the following:
oxygen flow rate
patency of tubing
humidifier settings (if being used)
Monitoring
Document
Day and time oxygen started
Method of delivery
Oxygen concentration and flow
Patient observation
Oronasal care and nursing plan

Oxygen is a drug and requires a medical order

Each episode of oxygen delivery should be ordered on
the medication chart
Humidification
Humidification: Addition of heat and moisture to a gas
Rationale:
Cold, dry air increases heat and fluid loss

Medical gases including air and oxygen have a drying effect on mucous

membranes resulting in airway damage

Secretions can become thick & difficult to clear or cause airway obstruction

In some conditions e.g. asthma, the hyperventilation of dry gases can compound

bronchoconstriction
Indications:
Patients with thick copious secretions

Non-invasive and invasive ventilation

Nasal prong flow rates of greater than 2 L/min (<2 years) or 4 L/min (>2 years)

Facial mask flow rates of greater than 5 L/min

All high flow systems require humidification

Patients with tracheostomy

 Humidification
Fisher & Paykel MR 850 Humidifier
Invasive Mode: Delivers saturated gas as
close to body temperature (37 degrees,
44mg/L) as possible. Suitable for patients
with:
Nasal Prongs
Invasive Ventilation
Tracheostomy attachment or mask

Non-Invasive Mode: Delivers gas at a

comfortable level of humidity (31-36
degrees, >10mg/L). Suitable for patients
receiving:
Face mask therapy
Non-invasive ventilation (CPAP/BIPAP)
 Humidification
Humidifier should always be placed at a level below the patient's
head
Water levels of all humidifiers should be maintained as marked to

ensure maximum humidity output

Condensation will occur in the tubing of heated humidifiers. This

water should be discarded in a trash contain and never returned

into the humidifier
Inspired gas temperature should be monitored continuously with

an inline thermometer when using heated humidifiers

The thermometer should be as close to the patient as possible

Warm, moist areas such as those within heated humidifiers are

breeding grounds for microorganisms (especially Pseumomonas)

The humidifier should be changed every 24 hours
Weaning
Depend on clinical and lab parameters
SpO2 is important
High flow and concentration should be gradually
lowered while monitoring
Low flow and concentration can be continued
without ill effects for long time
Adverse effects
Oxygen being combustible, fire hazard and tank explosion
Catheters and masks can cause injury to the nose and
mouth
Dry and non-humidified gas can cause dryness and crusting
Long term oxygen therapy: proliferative and fibrotic
changes lungs
In acute conditions, high FiO2 lead to the release of various
reactive species which attack the DNA, lipids, and SH
containing proteins
Infections
 Adverse effects
CO2 Narcosis :
In patients with chronic respiratory insufficiency----hypercapnea
Respiratory centre relies on hypoxemia to maintain adequate ventilation
Oxygen supplementation can reduce their respiratory drive, causing respiratory
depression and a further rise in PaCO 2 resulting in increased CO2 levels in the
blood
Monitoring of SpO2 or SaO2 informs of oxygenation only. Therefore, beware of
the use of high FiO2 in the presence of reduced minute ventilation
Pulmonary Atelectasis/absorption atelectasis
Pulmonary oxygen toxicity : High concentrations of oxygen (>60%) may
damage the alveolar membrane when inhaled for >48 hours resulting in
pathological lung changes
Retrolental fibroplasia: An alteration of the normal retinal vascular
development, mainly affecting premature neonates (<32 weeks gestation
or 1250g birthweight), visual impairment and blindness
Adverse effects
Signs and symptoms of oxygen toxicity
Nonproductive cough
Nausea, vomiting
Substernal chest pain
Fatigue
Nasal stuffiness
Headache
Sore throat
Hypoventilation
Nasal congestion
Dyspnea
Low concentration oxygen therapy
Reserved for children at risk of hypercapnic respiratory failure
Advanced cystic fibrosis and non cystic fibrosis brochiectasis
Severe kyphoscoliosis or severe ankylosing spondylitis
Severe lung scarring caused by TB
Musculoskeletal disorders with respiratory weakness
Overdose of opioids, benzodiazepines, or other drugs causing
respiratory depression.
Uncorrected cardiac defects.
Until blood gases can be measured, initial oxygen should be
given using a concentration of 28% or less, titrated towards a
SpO2 of 88-92%
Oxygen safety
Oxygen support combustion (rapid burning). Due to this the
following rules should be followed:
Do not smoke in the vicinity of oxygen equipment
Do not use aerosol sprays in the same room as the oxygen
equipment
Turn off oxygen immediately when not in use. Oxygen is heavier
than air and will pool in fabric making the material more
flammable. Therefore, never leave the nasal prongs or mask under
or on bed coverings or cushions whilst the oxygen is being supplied
Do not use any petroleum products or petroleum byproducts e.g.
petroleum jelly/Vaseline whilst using oxygen
Do not defibrillate someone when oxygen is free-flowing
Oxygen safety
Oxygen cylinders should be secured safely to avoid injury and damage to
regulator or valve
Do not store oxygen cylinders in hot place
Do not drag or roll cylinders
Do not carry a cylinder by the valve or regulator
Do not hold on to protective valve caps or guards when moving or lifting
cylinders
Do not deface, alter or remove any labeling or markings on the oxygen
cylinder
Do not attempt to mix gases in an oxygen cylinder or transfer oxygen from
one cylinder to another
Take home message
Oxygen therapy saves life
The selection of an appropriate oxygen delivery system
Clinical condition
Patient's size and needs
Therapeutic goals
Risks and hazards
Advantages far outweighs the risks
Hypoxia more dangerous than correctly delivered oxygen
Humidification
Monitoring and proper documentation
Donot forget to taper oxygen
Use but do not abuse oxygen
 References
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
Bateman, N.T. & Leach, R.M. (1998). ABC of Oxygen - Acute oxygen therapy. BMJ,
September 19; 317(7161): 798-801.
Ricard, J. & Boyer, A. "Humidification during oxygen therapy and non-invasive
ventilation: do we need some and how much"? Intensive Care Med (2009) 35: 963-965
Oxygen Therapy: Important Considerations. Indian J Chest Dis Allied Sci 2008; 50: 97-
107
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