TERAPI OKSIGEN

Dept. Anestesiologi & Terapi IntensifFK USU/RSUP H.Adam Malik-MedanModul 5

Discovery of Oxygen : 1772Carl Wilhelm ScheeleGerman - Swedish-pharmaceutical chemist Scheeles house and pharmacy in KopnigOxygen, nitrogen, chlorine, many chemicals. Tasted chemicals. ? Cause of death at age 43

Discovery of Oxygen : 1774Joseph Priestly: 1774Pneumatic troughMinister and Teacher Supporter of American and French Revolutions Isolated 8 gases including oxygen ; Emigrated to the US

Discovery of Oxygen : 1775Antoine- Laurent LavoisierLawyer, Scientist Paris Arsenal French Revolution Guillotined 1794Oxygen: acid producer, identified as an element

Leland Clark, PhD. CCHMC1949: 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

B - breathing (nafas)BernafasTidak ber-nafasBeri bantuan nafassecara aktif+ OKSIGENMouth to mouthMouth to maskAmbu bagJackson ReesT- piece

normaltidakhipoventilasi hiperventilasiPertahankan jalan nafas tetap bebas OKSIGEN maskerSIAPPertahankanjalan nafas tetap bebask/p OKSIGENmaskerA-B-CLife Support

*Manfaat oksigen pada pasien dengan gangguan airwayMeningkatkan kadar oksigen di alveoliMeningkatkan jumlah oksigen di FRCMengurangi derajat hipoksemia darah

Dengan nafas yang terbatas, lebih banyak oksigen dapat masuk ke alveoli

OKSIGEN DIPERLUKAN PADA PROSES METABOLISMEUNTUK PEMBENTUKAN ENERGI BIOLOGIS ( ATP )

METABOLISME SECARA ANAEROBIK AKAN MENGAKIBATKAN GANGGUAN PEMBENTUKAN ATPDAN PEMBENTUKAN ASAM LAKTAT/ ASIDOSIS

TERAPI OKSIGEN DIINDIKASIKAN BILA TERJADI GANGGUAN OKSIGENASI JARINGAN DAN UNTUK MENCEGAH PENYULIT YANG TERJADI KARENA HIPOKSEMIA

Proses Produksi EnergiGlukosa + O2 H2O + CO2 + 38 ATP

Glukosa tanpa O2 Lactic Acid + 2 ATP(Anerobik)

Tahapan Respirasi

1. VENTILASI

2. PERFUSI PARU - PARU

3. PERTUKARAN GAS DI PARU-PARU

4. TRANSPORT OKSIGEN

5. EKSTRAKSI ( OXYGEN UPTAKE )

DERAJAT HIPOKSEMIA DITENTUKAN DENGAN

1. A-a DO2 ( Alveolar - arterial O2 Difference )

= PAO2 - PaO2PAO2 = ( PB - PH2O ) X FiO2 - PaCO2 / R 2. PaO2 / FiO2Transport Oksigen

DO2 = CO ( Hb X SaO2 X 1,34 + 0,003 X PaO2)

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

1. Ketersediaan Oksigen JaringanAvailable O2 = CO x Ca O2Bila Ca O2 turun --> kompensasi dengan menaikkan CO

2. Cardiac Output (CO)Volume aliran darah yang membawa oksigen ke jaringanCO = Heart Rate x Stroke Volume

3. Oksigen dalam darah Ca O2 = (Hb x Sa O2 x 1,34) + (Pa O2 x 0,003)Transport oksigen dalam sirkulasi darah

Oxygen is a DRUG Must be considered as a drugTOO MUCH of a drug can cause overdosing problems

TOO LITTLE isnt enough to treat the symptoms

Goals of Oxygen TherapyCorrect hypoxemiaDecrease symptoms associated with hypoxemiaDecrease 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 OximetryNon-invasive monitoring technique that estimates the oxygen saturation of Hgb (SaO2)May be used continuously or intermittentlyMust correlate values with physical assessment findingsNormal SaO2 values 95 to 100%

Table Approximate PaO2 versus O2 Hemoglobine Saturation Levels

PaO2 LevelsO2 Hemoglobin Saturation Levels

90 mm Hg100 %60 mm Hg90 %30 mm Hg60 %27 mm Hg50 %

Oxygen saturation or O2 sat

2.bin

3.bin

Factors Affecting SaO2 MeasurementsLow perfusion statesMotion artifactNail polish when using a finger probeIntravascular dyesVasoconstrictor medicationsAbnormal HemoglobinToo much light exposure

Medical Research Council (MRC) Trial 198187 patients

Severe COPD

O2 15 hours/day

6.bin

Nocturnal Oxygen Therapy Trial (NOTT) 1980203 patients

Severe COPD

7.bin

Criteria for Ordering O2 TherapyPaO2 at or below 55 mm HgSaturation O2 < 88% restingPO2

PEDOMAN UMUM TERAPI OKSIGEN Bila :

PaO2 < 60 mmHg SaO2 < 90 %

Indications for oxygen therapyRespiratory compromiseCyanosisTachypnoeaHypoxaemiaPartially obstructed airway

Cardiac compromiseChest painShockTachycardiaArrhythmiasNeurological deficitsCVASpinal injuriesComa

Indications for oxygen therapy

Long Term SignClubbing

Aims of oxygen therapyto increase PaO2 to acceptable level with concentration of oxygento decrease respiratory rate and work of breathingHypoxaemia with high PaCO2 24% initiallycareful monitoring with regular ABGs

Types of oxygen deliveryNasal cannulaeMedium concentration maskFixed concentration maskNon - rebreathe bagHumidified circuitsHigh flow systems

NASAL PRONG 24 - 40 %

SIMPEL MASK 40 - 50 %

VENTURI - MASK24 - 50 %

PARTIAL REBREATHING60 - 80 %

NON REBREATHING - 90 %

CPAP - 100 %

VENTILATOR - 100 %

Alat FiO2

Nasal CannulaeFlow rate up to 4l/minUnable to determine exact concentrationComfortable allows patient to eat, drink talkCan still be used if patient is

mouth breathingCan use continuously with

meals and activity

Nasal prong Keuntungan : mudah penggunaan ringanekonomisdisposablenyaman,pasien bisa mobilisasi Kerugian : mudah lepas maksimum FiO2 40 %iritasi telinga Tehnik lain dengan kateter :1. Nasal kateter2. Transtracheal kateter.

Medium concentration maskHudson/ MC maskFlow rate must be at least 5 l/minExact concentration of oxygen depends on patients respiratory patternPoor humidificationUseful 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

Simple mask

( 35 - 60 % dengan flow 6 - 10 L )

2. Partial rebreathing ( 35 - 60 % dengan flow 6 - 10 L )

3. Non rebreathing ( 90 % , bila tidak ada kebocoran )

Partial Rebreather MaskConsists of mask with exhalation ports and reservoir bagReservoir bag must remain inflatedO2 flow rate - 8 to 10LClient can inhale gas from mask, bag, exhalation portsPoorly fitting; must remove to eat

Non-rebreather MaskConsists of mask, reservoir bag, 2 one-way valves at exhalation ports and bagClient can only inhale from reservoir bagBag must remain inflated at all timesO2 flow rate- 10 to 15LPoorly fitting; must remove to eat

Fixed concentrationVenturi masksDeliver a fixed concentration of oxygenMust be set at minimum flow rate as shown on barrelFiO2 0.24 0.6Able to increase flow rate

without altering concentrationBernouilli principle

Venturi MaskMost reliable and accurate method for delivering a precise O2 concentrationConsists of a mask with a jetExcess gas leaves by exhalation portsO2 flow rate- 4 to 15LCan cause skin breakdown; must remove to eat

14 l/min air entrained14 l/min air entrained2 l/min oxygen jet

2 l/min oxygen jet30 l/minThe Bernoulli Effect

Non Rebreathe bagsReservoir bagsDeliver FiO2 0.6 0.8Flow rate must be set to 15 L/minFill reservoir 2 thirds before applyingUseful in acute situationShould not be worn >24hrs

Alat Terapi Oksigen

I . FIXED SYSTEM ( FiO2 TIDAK DIPENGARUHI FAKTOR PASIEN )1. SISTIM VENTURI - HIGH FLOW2. 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 / PRONG2. SIMPLE MASK3. MASKER DAN REBREATHING BAGIII. BAYI - ANAK :1. HEAD BOX2. INKUBATOR3. COT / TENT.

Alat-alat Terapi oksigen

Nasal prongSimple maskRebreathing maskT - piece

Salter Oxy-FrameNasal CannulaFace Masks

13.bin

OxymizerPendant

14.bin

15.bin

Tracheostomy Collar/ MaskO2 flow rate 8 to 10LProvides accurate FiO2Provides good humidity; comfortable

T-pieceUsed on end of ET

tube when weaning from ventilatorProvides accurate

FiO2Provides good humidity

Transtracheal Oxygen (TTO)

Konsentrasi Oksigen yang dihasilkan tergantung pada :

1. Alat2. Cara pemberian3. Pasien kooperatif atau tidak4. 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 distressNon-respiratory distressMinute vol(RR x TV)

O2 flow rate

Oxygen concentration20 l/min(40bpm x 500ml)

2 l/min

2 l/min of 100% oxygen +18 l/min air drawn into mask (21%)= 20 l/min minute volumeFiO2 = (1.0 x 2) + (0.21 x 18) / 30 = 0.29 (29%)5 l/min(10bpm x 500ml)

2 l/min

2 l/min of 100% oxygen +3 l/min air drawn into mask (21%)= 5 l/minFiO2 = (1.0 x 2) + (0.21 x 3) / 5 = 0.53 (53%)

Tanda mengarah ke GAGAL NAPAS

1. PERNAPASAN ABDOMINAL DOMINAN

2. GERAK OTOT NAPAS TAMBAHAN - STERNOCLEIDOMASTOID - INTERCOSTAL

3. RETRAKSI SUPRASTERNAL,INTERCOSTAL

GAGAL NAFASNafas dibantu alat - ventilator

HumidificationPrevents cilia destruction

Prevents damage to mucus glands

Aids sputum clearance

Indications for humidificationOxygen therapy at higher flow rates

Patients with copious secretionsSystemic hydrationIV fluidsSaline nebulisers

Complications with humidified oxygen

Bronchoconstriction

Decreased lung function if over-humidified

Increased risk of infection

regulatorFlowmeter + humidifier

*Pengatur tekanan tinggi dan penunjuk tekanan tabungFlowmeter pengaturaliran oksigenHumidifier, pelembabSebaiknya dikosongkan saja(mudah jadi sarang kuman)Pada waktu transportdiperlukan oksigen tinggi,air harus dibuang krn menghambataliran oksigen

Precautions of Supplemental Oxygen1. Oxygen toxicity2. Depression of ventilation3. Retinopathy of Prematurity4. Absorption atelectasis5. Bacterial infection with humidifiers

Oxygen ToxicityPatients 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 VentilationCOPD patients with CO2 retention have blunted stimuli to breathingHypoxic drive theoryThey have a different stimulus to breathe then normalGOLDEN RULE:

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

Retinopathy of PrematurityIs an abnormal eye condition in some premature infants who receive high FIO2Retinal arteries hemorrhage and scaring cause retinal detachment and blindness.

Absorption AtelectasisThe 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 ControlTherapist must use an aseptic technique when handling supplemental oxygen and humidity equipmentNever drain water from the tubing back into the heated humidifierAlways date the opened containerOnly use sterile liquids in reservoirs

Oxygen: a fire hazardNEVER smoke while using supplemental oxygenSevere facial burns can and do happen

SIDE EFFECTS OF OXYGENNasal dryingNasal bleedingIncrease in blood carbon dioxide (CO2)Atelectasis (collapse)Airway inflammationLung edema/ inflammationDamage to retina: infants, high O2

Misconceptions about OxygenOxygen is addicting postpone use as much as possibleHigh Oxygen concentration is bad for youI only need Oxygen when I am short of breathOxygen can burn spontaneouslyOxygen is used in terminal diseaseHumidity is needed for everyone on oxygen

Clinical GuidelinesConsider Oxygen as a drugUse the lowest FIO2 .Use it for the shortest possible timeKeep oxygen below 50% ifIf you have to - accept lower saturations than normal in some situationsCheck equipment regularly for contaminants

SummaryOxygen is required for cell metabolismOxygen requirements are higher in critically ill patientsBe aware of different delivery systemsAlways consider humidificationSafety aspects

Terima kasih atas perhatian andaSemoga Tuhan selalu memberkahi kita semuaAmin

*Group I criteria include any of the following: Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)

An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake) An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.