FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH 1
 Learning objectives
 Indications of oxygen therapy,
 Delivering oxygen with delivery devices
 Monitoring oxygen therapy using pulse
oximeters and clinical parameters,
 Using humidifiers and nebulizers when needed
 Oxygen therapy on specific conditions
 Describe adverse effects of oxygen therapy

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By the end of this module, participants will be able to:
Describe the indications of oxygen therapy,
Deliver oxygen using delivery devices
Monitor oxygen therapy using pulse oximeters and
clinical parameter
Use humidifiers and nebulizers when needed
Identify Oxygen therapy on specific conditions
Describe adverse effects of oxygen therapy

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 Cardio respiratory arrest
 Respiratory distress (RR>24/min) in adult
 Hypoxia with pulse oximeter measurement
(saturation of oxygen <93%) except for COPD
 Hypotension (systolic BP <90 mm Hg)
 Low cardiac output and metabolic acidosis
(bicarbonate<18 mmol/l)

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 Increase FiO2- initiate supplemental administration
of oxygen with nasal prong, and face mask
 Increase MV- assist breathing with BVM, non-
invasive CPAP, invasive mechanical ventilation
 Increase Cardiac Output- treat causes of
hypotension and shock

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 Increase oxygen carrying capacity – blood
transfusion when there is symptomatic anemia
 Optimize V/Q relationship – treat pulmonary
edema, and when necessary with PEEP/CPAP
 Decrease oxygen consumption from- pain,

shivering or fever – optimal use of analgesics

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 Survey shows 85% of patients on oxygen were poorly
supervised and oxygen is prescribed inappropriately.
 Oxygen is a drug and has to be prescribed and the prescription
has to indicate
1. Flow rate,
2. Delivery system,
3. Monitoring, what and how frequent to monitor
4. When to report
5. When to change the device
6. When and how to stop oxygen administration

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 Nasal cannula
 Face mask – simple, partial rebreathing,
non-rebreathing,
 Ambubag or Bag Valve Mask (BVM) – assisted
breathing
 None invasive CPAP/BiPAP

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 Used for correction of mild hypoxia
with no marked tachypnea
 Is suitable and better tolerated by
patients
 When the nasal prong is attached
to a cylinder there must be a
pressure regulating gage, flow
meter with a bottle and water for
humidification

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 Oxygen via nasal prongs (1-5litre/minute)
◦ To shorten the hypoxia time and patients sufferings oxygen
has to be started from the highest, in this case 5L/m,
◦ monitor the response to this flow rate, & if the saturation is
above 93% you can titrate down ward gradually.
◦ With 1-5litters/min, inspired oxygen concentration rises to
25-40% (Each litter increases oxygen concentration by 4%)

 If saturation is not improving change to facemask

with high flow rate.

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 Facemasks could be
◦ with reservoir or without, none rebreathing or simple

 A flow rate of 6-15 liters/minute provides a

rise in inspired oxygen concentration
◦ up to 60-70 percent, when the mask is simple
◦ or above 80% when face mask is with reservoir and
none rebreathing

 The flow rate shouldn’t be < 6 liters/minute

to avoid rebreathing, i.e. breathing of their
own exhaled gas which is rich in CO2

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 In severe hypoxia start from10-15L/m, and titrate
down ward based on response.
 If no response consider
◦ CPAP (non invasive)if the patient has adequate breathing
effort and conscious and cooperative
◦ or invasive (intubation and ventilation with mechanical
ventilator) respiratory support

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 Has an attached reservoir bag,
◦ which contain 1 liter of oxygen as reserve,
and

◦ connected to oxygen tank with high flow.

 Exhaled air is directed through a one-way

valve around the connection of the mask to
prevents the inhalation of room air & re-
inhalation of exhaled air
 Allows for administration of higher oxygen
concentration(60-80%)

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 It requires that the patient can breathe unassisted
 It allows for the delivery of higher concentrations of
oxygen than nasal cannulas and simple mask
 Before a NRB is placed on the patient, the reservoir
bag is inflated with oxygen to greater than two-
thirds of its volume, at a rate of 15 liters per minute
 Make sure the bag is always inflated, so that the
patient have a constant source of oxygen to breathe

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Bag Valve Mask has 3 parts
1. Bag with oxygen connector
2. Unidirectional valve between
the face mask and the bag
3. Face mask

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 BVM is used for temporary assist breathing and
oxygenation during respiratory arrest, bradypnea or
low breathing rate<10b/m
 Severe respiratory failure till appropriate definitive
airway management and ventilation is ready.
 This device is life saving and the techniques on how
to use them has to be practiced by all professionals.

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 NIV is defined as a ventilation modality that
supports breathing without the need for
intubation or surgical airway
 Two methods
◦ CPAP -continuous positive airway pressure
◦ BiPAP- Bi Phasic Airway Pressure
 Used both at emergency and ICU

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 Obstructive sleep apnea syndrome
 Exacerbation of COPD, Asthma
 Severe Pneumonia
 Acute CHF with pulmonary edema with sign and
symptoms of congestion
 Neuromuscular disorders
 Acute lung injury
 Weaning from ventilator

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 Respiratory arrest or unstable cardiorespiratory status
 Uncooperative patients
 Inability to protect airway (impaired swallowing and
cough reflexes)
 Trauma or burn involving the face
 Facial, esophageal, or gastric surgery
 Apnea (poor respiratory drive)
 Reduced consciousness

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 Extreme anxiety 
 Morbid obesity
 Copious secretions
 Need for continuous or nearly continuous
ventilatory assistance
 Diseases with air trapping, such as asthma

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 The patient must be
breathe spontaneously
 CPAP is mainly used for
hypoxemic respiratory
failure, such as in acute
pulmonary edema (Is a
choice)

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 CPAP reduces left ventricular trans mural pressure,
therefore increasing cardiac output. Hence, it is an
effective for treatment of acute pulmonary edema
 CPAP increases the functional residual capacity
(FRC) and opens collapsed alveoli, which, in turn,
enhances gas exchange and oxygenation

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 Caution is advised in patients
◦ With borderline low blood pressure
◦ They may become hemodynamically unstable, as one
of the disadvantages of CPAP is reduced venous
return.

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 It provides 2 levels of positive pressure:
◦ inspiratory positive airway pressure (IPAP)
◦ and expiratory positive airway pressure (EPAP).

 helpful in cases with respiratory fatigue or failure.

◦ BiPAP helps in improving patient comfort.

 During exhalation, pressure is variably positive.

 Airflow in the circuit is sensed by a transducer and
is augmented to a pre-set level of ventilation.

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 BiPAP is a particularly effective when patients are not
improving on CPAP alone.
 Adds inspiratory assistance that reduce the work of
breathing in cases at risk of hypercapnea (e.g, COPD)
 A common practice is to use
◦ initial IPAP settings of 10-12 cm H 2 O pressure
◦ and EPAP settings of 5-7 cm H 2 O,
◦ and then adjust IPAP to 15-20 cm H 2 O, depending on the
response over the next hour or so.

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 In conditions such as lung collapse or pulmonary
edema, the initial EPAP may have to be high.
 However, an EPAP that is too high can lead to reduce
preload. Hence, a balance in adjusting the
ventilatory settings is desirable.
 The fraction of inspired oxygen (FiO 2) is another
useful variable in titrating the response to
oxygenation.

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 Invasive management of respiratory failure is
considered when all other none invasive methods
were not effective or the condition of the patient
doesn’t give time for trial of the above.
 It is accomplished with endotracheal intubation

and Mechanical ventilation.

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 Humidification is needed when oxygen is given via
a facemask and
 For all patients with an endotracheal tube or a
tracheostomy
 Not required when oxygen is used at a low flow
rate (< 4 L/min) through nasal prongs

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 Cold, dry air increases heat and fluid loss
 Medical gases such as 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.

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 Medical conditions
 Trauma and surgery
 Obstetric care
 Recovery from surgery & anesthesia

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 Acute Respiratory Failure (ARF) or severe
respiratory distress
◦ Tachypnea, (fast breathing)
◦ Cyanosis
◦ Use of accessory muscles, restlessness,
◦ Palpitation, sweating,
◦ Altered consciousness, headache, confusion

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 Acute respiratory distress syndrome (ARDS),
 Severe asthma,
 Severe pneumonia,
 Severe sepsis,
 Tension pneumothorax,
 Pulmonary thromboembolism,
 Severe COPD.

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 Higher concentrations of oxygen are required initially
◦ Achieved by higher flow rates via facemasks.
◦ Reduce hypoxemia as fast as possible to avoid organ damage.

 In case hypoxemia is not correctable, assisted ventilation

may be required.
 correction of blood PaO2 is not the only objective of

therapy.
◦ Therefore, all the factors responsible for tissue oxygen delivery
should be taken in to consideration.

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 The primary insult in trauma is due to direct impact
of the event (like lung contusion, brain hemorrhage,
rupture of spleen or liver, or muscle crush injury)
 Secondary injury is from hypoxia and hypovolemia
 Secondary injury can be prevented by treating
hypoxemia, hypotension, hypoglycemia, etc
◦ Oxygen therapy in major trauma should normally be started
at a high flow, using a facemask with an oxygen reservoir.

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Maternal causes of Hypoxia
◦ Maternal haemorrhage, maternal sepsis
◦ Reduced consciousness level with pre-eclampsia or
eclampsia, Amniotic fluid embolism
◦ Shock , CHF, Cardiac diseases, pulmonary TB, Pneumonia

Fetal causes
◦ Fetal distress
◦ Cord prolapse

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 Give high flow of oxygen 6-10l/min with face mask
and proper monitoring of the response is important
to achieve 94-98% saturation
◦ Pre-oxygenate with 100% of oxygen for 4 minutes before
induction of anesthesia
◦ At least 30% oxygen mixture of gas should be used during
maintenance of anesthesia for elective caesarean section
 During spinal anesthesia for caesarean section ,
◦ Elective C/S-the mother’s SpO2 should be monitored with a
pulse oximeter, and oxygen administered if the level falls
below 95%.
◦ Emergency C/S for fetal distress, then administer oxygen to
the mother, even if the mother is not hypoxemic

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 During recovery the patient is at risk of hypoxia
◦ due to airway obstruction- laryngospasm and poor
consciousness state), retained secretions, atelectasis, or increased
oxygen consumption due to shivering.

 Oxygen provision is essential

◦ can be provided via facemask at 6 liters and above/min
◦ Nasal prongs are also best tolerated, 2–3 litres/minutes
◦ Administration of oxygen in the perioperative period (up
to 2 hours postop) reduces incidence of wound infection

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 Post-op airway obstruction can be masked by high-
concentration of oxygen, so after anesthesia patients
should be observed for signs of obstructed
breathing, and for their consciousness level .
 Assessment for airway obstruction and suctioning of
the airway and monitoring with pulse oximetry
should be routine until consciousness returns.

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 Respiration quality:
◦ Observe for fast breathing to gradually decrease
◦ use of accessory muscle also decreases
 Vital Sign/V/S –
◦ heart rate and blood pressure are affected by hypoxia
◦ monitor RR, Pulse, blood pressure closely
 Mental status
 Pain: Treat it to decrease oxygen demand.
 Oxygenation- with pulse oximetry and document
◦ Should ensure persistently above 93% saturation
 Measure and document End Tidal CO2 with capnometer when
available.
◦ The normal amount is 40-50mmHg.

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 Oxygen toxicity can be considered when a patient
takes oxygen concentrations >60% for >24 -48hrs.
 Oxygen toxicity manifest as
◦ new onset of convulsions due to cerebral vasoconstriction,
◦ damage to pulmonary epithelium due to oxygen radicals
and worsening of the respiratory failure

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 CO2 Narcosis -in patients with COPD or respiratory
insufficiency, which results in developing hypercapnia
 Respiratory centre relies on hypoxemia to maintain
adequate ventilation. When given oxygen it reduce
their respiratory drive, causing respiratory depression
and a rise CO2 levels in the blood
 Sub sternal pain: occurs when breathing elevated
pressures of oxygen for extended periods

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 Common causes of hypoxemia in adults should be
identified for oxygen therapy
 Indication of oxygen should be guided by pulse oximetry
when available.
 Oxygen should be provided in appropriate techniques
 Pulse oximetry should guide the monitoring of oxygen
therapy and when to stop.
 Adverse effects of oxygen should be minimized through
proper techniques of administration

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THANK YOU!!!

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