EMERGENCY MEDICINE

Oxygen Therapy
CP Singh*, Nachhattar Singh**, Jagraj Singh***, Gurmeet Kaur Brar****, Gagandeep Singh****

Abstract
The primary goal of oxygen therapy is to correct alveolar and/or tissue hypoxia. Therefore, any disorder causing
hypoxia is a potential indication for oxygen administration. But the tissue oxygen delivery depends upon an adequate
function of cardiovascular (cardiac output and flow), haematological (Hb and its affinity for oxygen) and the respiratory
(arterial oxygen pressure) systems. Therefore, tissue hypoxia is not relieved by oxygen therapy alone – functioning of
all the three organ systems also needs to be improved.
Oxygen therapy should be administered according to guidelines. Proper monitoring of oxygen therapy is recommended
to ensure adequate oxygenation and to save precious oxygen from wastage. The use of pulse oximeter is a simple,
quick, non-invasive, and reliable method to assess it.

Introduction system like chest wall and respiratory muscles,

airways and lungs, CNS (including medullary
Many biochemical reactions in the body depend
respiratory centres), spinal cord, CVS, and
on oxygen utilisation. Supply of oxygen to the
endocrine system. A disorder in any portion of
tissues depends on many factors like ventilation,
these systems can lead to respiratory failure2.
diffusion across alveolar-capillary membrane,
haemoglobin, cardiac output, and tissue Respiratory failure
perfusion 1. Oxygen therapy is required for
respiratory failure in many conditions like severe During respiratory failure, there is an inability to
asthma, chronic bronchitis, pneumonia, and keep the arterial blood gases at normal level, while
myocardial infarction, etc. Through this article, breathing air at rest at sea level, and the partial
we have made an attempt to review the pressure of oxygen is usually below 60 mmHg
physiological basis of hypoxia, basis of oxygen with or without partial pressure of carbon dioxide
therapy, its indications, administration devices, above 49 mmHg in arterial blood.
and its hazards.
Types
Respiratory system Respiratory failure may be acute or chronic.
The respiratory system is concerned with the Acute respiratory failure develops suddenly or
delivery of an adequate amount of oxygen to slowly if lungs are already diseased; while
and elimination of a corresponding amount of chronic respiratory failure develops slowly due
carbon dioxide from the cells of the body and to underlying lung disease. Respiratory failure
maintenance of normal acid-base balance in may occur even if lungs are normal as in
the body. Proper supply of oxygen and diseases of nervous system, chest wall, or upper
elimination of carbon dioxide from various airways. Inadequate gas exchange is associated
tissues of the body depends on the optimal with hypoxaemia with or without hypercarbia
functioning of various parts of the respiratory (Type-1 respiratory failure or lung failure), while
inadequate ventilation leads to hypoxaemia with
* Senior Lecturer; hypercarbia (Type-2 or ventilatory failure). Type-
** Prof. and Head; 1 respiratory failure occurs when there is disease
*** Registrar;
of peripheral gas exchanging parts of body and
**** PG Student;
Department of Medicine, type-2 in COPD, bronchial asthma,
GGS Medical College and Hospital neuromuscular disease, and chest wall
Faridkot-151203 (Punjab). disorders3.
Different causes of acute respiratory failure are3 oxygen therapy and they need mechanical
ventilation (Positive end expiratory pressure - PEEP).
A. Defective ventilation
In type-2 respiratory failure with previous normal

Respiratory centre depression
lungs, there is inadequate alveolar ventilation and
Drugs such as narcotics, anaesthetics, and
in these patients ventilatory assistance is needed.
sedatives In patients with previous lung disease as in acute
Cerebral infarction
exacerbation of COPD, controlled oxygen therapy
Cerebral trauma
is needed. Mechanical ventilation should be

Neuromuscular disorders avoided in patients with COPD as the weaning
Myasthenia gravis from the ventilator is very difficult.
Guillain-Barre syndrome
Brain or spinal injuries Hypoxia and hypoxaemia
Polio, porphyria, botulism.
Hypoxia is lack of oxygen at the tissue level while

Airways obstruction
hypoxaemia implies a low arterial oxygen tension
Chronic obstructive pulmonary disease
below the normal expected value (85-100 mmHg).
Acute severe asthma

Restrictive defects Hypoxaemia due to pulmonary disorders :
Interstitial lung disease
Presentation of acute respiratory failure is sudden
Kyphoscoliosis, ankylosing spondylitis
in a previously healthy person while it is gradual
Bilateral diaphragmatic palsy
in a patient with pre-existing chronic respiratory
Severe obesity
disease. There are signs and symptoms of
B. Impaired diffusion and gas exchange hypoxaemia alongwith those of the underlying
Pulmonary oedema and/or complicating disease. The general features
Acute respiratory distress syndrome attributed to hypoxaemia are restlessness,
Pulmonary thromboembolism palpitation, sweating, altered conciousness,
Pulmonary fibrosis headache, confusion, and cyanosis. Blood
pressure may initially rise but it falls as the severity
C. Ventilation-perfusion abnormalities
of hypoxaemia worsens. Hypercapnia
Chronic obstructive pulmonary disease accompanies hypoxaemia whenever there is
Pulmonary fibrosis hypoventilation, such as conditions listed at A in
Acute respiratory distress syndrome Table.
Pulmonary thromboembolism
During acute respiratory failure we require higher
Management concentration of oxygen initially to correct
hypoxaemia so as to prevent organ damage. Not
The aims of therapy in respiratory failure are to only the correction of PaO2 but also oxygen delivery
achieve and maintain adequate gas exchange and to the tissue and its proper utilisation are equally
reversal of the precipitating process that led to important. Diagnosis is made from the total clinical
the failure. In type-1 respiratory failure, high presentation of the disease and the relevant
concentration of oxygen is given to correct investigations. Acute respiratory failure is
hypoxaemia. At the outset it should be determined established by blood gas and pH determinations.
whether the hypoxaemia can be relieved by oxygen
therapy alone or it needs oxygen and ventilatory
ARDS
intervention. The decision is made on the presence
or absence of hypercapnia and of lung disease. In such cases to correct hypoxaemia, ventilator
Patients with ARDS do not improve with simple controlled administration of oxygen often with PEEP

Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001 179
(positive end expiratory pressure) is required. The and hypoxaemia which depends on the amount
desirable PaO2 of about 60 mmHg with lowest of pulmonary circulation occluded.
possible FiO2 is achieved with PEEP of about 10-
Pulmonary infarction is prevented by alveolar
15 cmH2O. After the initial 24 hours, FiO2 should
oxygen and systemic bronchial vascular
not exceed 60% (to reduce the risk of O2 toxicity).
anastomosis which can be enriched with oxygen
Acute severe bronchial asthma therapy.

Patients with acute severe asthma or status Spontaneous pneumothorax and

asthmaticus have severe air ways obstruction and pneumomediastinum
inflammation. They are generally hypoxaemic.
Hypoxaemia may be precipitated by these in a
Hypoxaemia is corrected by giving oxygen via
patient having pre-existing lung disease. 100%
nasal cannula or face mask at a flow rate of 4-6
oxygen may be given for a short period as it causes
L/min to achieve FiO2 of 35-40%. Flow rate may
denitrofication of pleural and mediastinal air which
be adjusted to maintain PaO2 of about 80 mmHg
is then ultimately absorbed in the circulation. Such
or more. The risk of hypercarbia and CO2 narcosis
a modality should not be tried beyond 12-16 hours
is more in COPD rather than acute severe asthma
to avoid oxygen toxicity.
and in such cases assisted ventilation is required.
Administration of sedatives and tranquilizers must Indications for oxygen therapy
be avoided. Sedatives may precipitate the CO2
retention not only in patients with COPD but also Oxygen can be given in high or low concentration
in asthma. in all the conditions associated with hypoxaemia.
In conditions like COPD in which there is a risk
Severe pneumonia for hypercarbia, low concentration should be used.
In severe acute viral or bacterial pneumonias, there In acute lung conditions (without underlying
may be hypoxaemia and respiratory failure. chronic lung disease) like pulmonary embolism,
Oxygen is given at a flow rate of 4-6 L/min to pneumonia, tension pneumothorax, acute severe
achieve PaO2 above 60 mmHg. Bronchial hygiene asthma, pulmonary oedema, or myocardial
and treatment with antibiotics and other drugs is infarction, a higher concentration of oxygen can
meanwhile continued. be given. Similarly in fibrosing alveolitis, there is
no retention of CO2, so high concentration can
Interstitial lung disease be given as in these conditions there is no danger
Patients may have respiratory failure due to of induction of hypoventilation. Maintaining PaO2
fulminant onset or because of intercurrent above 60 mmHg gives O2 saturation of 90%.
infection. The lungs are stiff and compliance is During acute exacerbation of COPD,
low. As these patients need oxygen for prolonged chemoreceptor drive for ventilation is eliminated
periods, one should wean oxygen to FiO2 of about which leads to reduced alveolar ventilation.
40% as early as possible. Some patients may Hypoxaemia should be reduced immediately by
become dyspnoeic even after mild exertion and giving oxygen generally in a concentration of 24%
such cases benefit from oxygen administration to improve oxygenation without losing the
before and after physical activity. respiratory stimulant effect.

Pulmonary thromboembolism Goals of oxygen therapy

Hypoxaemia in the presence of pulmonary The goal is to relieve hypoxaemia by increasing
thromboembolism is common but not essential. alveolar tension, to reduce the work of breathing,
Oxygen is required when there is breathlessness and to decrease the work of myocardium. Oxygen

180 Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001
should be used like a drug in various conditions can be calculated by the formula 20+4xO2 flow
and its dose should be individualised. Arterial (L/min)7.
blood gases should be measured repeatedly in
patients with acute respiratory failure on oxygen Monitoring oxygen therapy
therapy. The goal is to maintain PaO2 above 60 Oxygen therapy should be given continuously and
mmHg. Oxygen should be given in low dose should not be stopped abruptly until the patient
continuously since small increase in FiO2 causes has recovered, since sudden discontinuation can
increase in PaO2 as most patients of COPD lie on wash-out small body stores of oxygen resulting in
the steep part of oxy-haemoglobin curve5. fall of alveolar oxygen tension. The dose of oxygen
should be calculated carefully. Partial pressure of
Oxygen delivery systems oxygen can be measured in the arterial blood.
Oxygen can be administered conveniently by oro- Complete saturation of haemoglobin in arterial
nasal devices like nasal catheters, cannulae, and blood should not be attempted. Arterial PO2 of
different types of masks. These are simple, less 60 mmHg can provide 90% saturation of arterial
expensive, and comfortable. blood, but if acidosis is present, PaO2 more than
80 mmHg is required. In a patient with respiratory
Nasal catheter failure, anaemia should be corrected for proper
oxygen transport to the tissue. A small increment
The light rubber nasal catheter is inserted after
in arterial oxygen tension results in a significant
lubricating its tip with liquid paraffin until the tip
rise in the saturation of haemoglobin. Under
is visible behind the uvula in the oropharynx.
normal situations, no additional benefit is secured
Nasal cannulae by raising PaO2 level to greater than 60 to 80
mmHg. An increase of 1% oxygen concentration
In hospitalised patients, these cannulae with two elevates oxygen tension by 7 mmHg. It is necessary
soft pronged plastic tubes are inserted about 1 to maintain normal haemoglobin level in the
cm in each naris. These are comfortable and well presence of respiratory disease as proper oxygen
tolerated. These are used in patients without transport to the tissues is to be maintained.
hypercapnia who require supplementary oxygen
upto 40%. These can be easily used for domiciliary Measurement of arterial blood gases repeatedly
oxygen therapy. Oxygen has to be humidified while is difficult so a simple and non-invasive technique
using these6. like pulse oximeter may be used to assess oxygen
therapy.
Venturi mask
When to stop oxygen therapy
It fits lightly over the nose and mouth. Oxygen
flowing at a high velocity in the form of a jet Weaning should be considered when the patient
through a narrow orifice to the base of the mask becomes comfortable, his underlying disease is
creates negative pressure, entraining atmospheric stabilised, his BP, pulse rate, respiratory rate, skin
air through the perforations in the face piece. They colour, and oxymetry are within normal range.
are available in different forms and can deliver Weaning can be gradually attempted by
low fixed concentrations of oxygen at 24%, 28%, discontinuing oxygen or lowering its concentration
35%, and 40%. These are somewhat for a fixed period for e.g., 30 min. and re-
uncomfortable and have to be removed while evaluating the clinical parameters and SpO2
eating or drinking. By using oxygen at flow rate of periodically. Patients with chronic respiratory
1,2,3 L/min, we can achieve roughly 24%, 28%, disease may require oxygen at lower
and 35% with mask, catheter, or cannulae. FiO2 concentrations for prolonged periods. Prospects

Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001 181
of long term domiciliary oxygen need to be Selection of patients
discussed with the patient after the acute need is
Following guidelines are used to select patients
over8.
for instituting the treatment.
Dangers of oxygen therapy 1. A definite documented diagnosis responsible
for chronic hypoxaemia.
There are three types of risks associated with
2. An optimal medical treatment should be in
oxygen use.
effect.
1. Physical risks 3. Patient in a stable condition.
Oxygen being combustible, fire hazard and tank 4. Oxygen administration should have been
explosion is always there. This is more with high shown to improve hypoxaemia and provide
concentration of oxygen, use of pressure clinical benefit in such patients.
chambers, and in smokers. Catheters and masks The following specific indices are used while
can cause injury to the nose and mouth. Dry and prescribing long term oxygen therapy :
non-humidified gas can cause dryness and
1) At rest in non-recumbent position, PaO2 ≤ 55
crusting.
mmHg.
2. Functional risks 2) Patient with PaO2 more than 55 mmHg if:
Patients who have lost sensitivity to CO2 and are a) While on optimal medical treatment, shows
upon the hypoxic drive are in danger of ventilatory features of hypoxic organ dysfunction like
depression as seen in patients of COPD. secondary pulmonary hypertension, cor-
Hypoventilation can lead to hypercapnia and CO2 pulmonale, polycythaemia, or CNS
narcosis although the risk is small with low flow dysfunction.
oxygen therapy. Arterial pH may be a better guide b) Patient shows fall in PaO 2 below 55
than PaCO2 for monitoring oxygen therapy. As mmHg during sleep with disturbed sleep
long as pH does not suggest acidosis, long term pattern, cardiac arrhythmias, or
oxygen therapy can benefit the patients with CO2 pulmonary hypertension. These patients
retention. are benefitted by nocturnal oxygen
therapy.
3. Cytotoxic damage c) There is fall in PaO2 during exercise and
COPD patients on long term oxygen therapy, on oxygen therapy improves exercise
autopsy, show proliferative and fibrotic changes tolerance.
in their lungs. In acute conditions, most of the
structural damage occurs from high FiO2 as the Benefits
oxygen can lead to the release of various reactive Long term oxygen therapy benefits patients with
species which attack the DNA, lipids, and SH- COPD and other chronic pulmonary diseases with
containing proteins. hypoxaemia as it increases their survival and
quality of life. Patients of interstitial lung disease
Long term oxygen therapy become comfortable and there occurs
Long term domiciliary oxygen therapy was used improvement in pulmonary hypertension and right
initially for patients with COPD and chronic heart failure.
respiratory insufficiency but now its use has also
been extended to patients with breathing disorders Oxygen dosage
during sleep or exercise9. COPD patients are given oxygen at the rate of 1-

182 Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001
2 L/min. Some of the patients with other chronic oxygen delivery, to reduce cost of oxygen
respiratory diseases may require higher flow rates. delivery, and to improve cosmetic appearance.
PaO2 should be maintained at 60 mmHg or so.
During sleep or exercise or other activities, flow Perspectives of domiciliary oxygen use
rate may be increased by 1-2 L/min. in India
As the facilities and expertise for domiciliary
Home oxygen
oxygen therapy are available mainly in cities, use
The aim of oxygen therapy at home is to make is restricted mainly to cities. Although this sector is
the patient active and encourage exercise and not organised, more and more people are using
other activities outside the home. Patients of COPD this facility and with increased compliance. At
with hypoxaemia at rest, having arterial PaO2 present, there is no organised supply of oxygen
below 55 mmHg or patients with cor pulmonale and the cost is high. Supply is difficult in rural
or secondary polycythaemia having PaO2 between areas. Also, the patients have to be selected
55-59 mmHg in a stable clinical state need home carefully taking into account their education,
oxygen. income, and social status.
Two types of oxygen systems are available for use Various studies in India show that although the
at home : treatment is still irregular and inadequate, patients
a) Stationary (Compressed high pressure gas show definite improvement in well-being and
cylinders or O2 concentrators) : prologation of life span. Limited sources of supply,
high costs, difficulty in procurement of oxygen,
These are useful for bedridden patients. They
lack of medical expertise, no clear-cut policy on
are of low cost. They separate oxygen from
reimbursement to employees, all come in the way
nitrogen by adsorption principle of a molecular
of its frequent use. Let us hope these difficulties
sieve. They are not portable and create a lot
are resolved in due course of time.
of noise. They need backup of tank system if
there is electricity failure. Conclusion
b) Portable system (Transfilling gaseous or With these basic guidelines for oxygen
liquid system): administration, one can easily deliver a fairly
They are useful for ambulatory patients consistent concentration. The hazards of oxygen
including those who have to remain away from toxicity must be kept in mind but hypoxia must
house for work. They are light weight and can not be left untreated in view of toxicity since
provide oxygen at the rate of 2 L/min for about hypoxia is common and the damage it causes is
6-9 hours. Oxygen is filled from a stationary rapid and severe in comparison to oxygen toxicity
source. They are costly. Oxyspec (single prong which is uncommon and even pulmonary injury
nasal cannula), oxymizer and oxymizer caused by it is relatively slow in development.
pendant conserver connula (their reservoir
system stores oxygen during exhalation), References
electronic demand oxygen delivery system 1. Shankar PS. Oxygen therapy. Quart Med Res 1980; 30:
(Pulser supplying short bolus of enriched 1-20.
oxygen early in inspiration on triggering of 2. Shankar PS. Chest Medicine, 3rd ed. New Delhi, IBH
inspiratory sensor by negative nasal pressure), and Oxford 1990; 375-403.
and small polythene transtracheal catheter (for 3. Jindal SK, Gupta D. Oxygen therapy. JIMSA 1999; 12:
41-5.
transtracheal oxygen administration) are
4. Rogers RM. Acute respiratory failure. Med Times 1978;
thought to be useful to improve efficiency of 106: 28-30.

Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001 183
5. Cherniach RM. Management of acute respiratory failure Rehabilitative Respiratory Care. Lea & Febiger,
in chronic obstructive pulmonary disease. Sem Resp Med Philadelphia 1982; 3: 74-87.
1986; 8: 158-64. 9. Fillmer JD, Snider GL. American College of Chest
6. Gibson RI, Comer PB, Backham RW et al. Actual tracheal Physicians (ACCP). National Heart, Lung and Blood
oxygen concentration with commonly used oxygen Institute (NHLBI) Conference on Oxygen Therapy. Arch
equipment. Anaesthesiology 1976; 44: 71-3. Intern Med 1984; 144: 1645-55.
7. Campbell EJM. The Burns Amberson Lecture. The 10. Petty TL. Home oxygen therapy. Mayo Clin Proc 1987;
management of acute respiratory failure in chronic 62: 841-7.
bronchitis and emphysema. Amer Rev Resp Dis 1967; 11. Singh V, Kothari K, Khandelwal R. Adequacy Assessment
96: 626-39. of oxygen therapy. JAPI 2000; 48: 701-3.
8. Petty TL. Clinical applications of oxygen in Intensive and

With Best Compliments from

ALEMBIC
Presents Comprehensive Diabetic Range

GLZ 80/40 GLZ Plus

(Gliclazide Tab) (Gliclazide + Metformin)
80mg 500mg

ALA-100 Forminal 500/850

(Alpha Lipoic Acid) (Metformin)

&
Sionara 100/200 (Celecoxib 100/200mg Cap)
GOLD STANDARD IN ARTHRITIS MANAGEMENT

184 Journal, Indian Academy of Clinical Medicine
Vol. 2, No. 3
July-September 2001