PowerPoint Presentation

Reza PramayudhaOxygen TherapyOxygen delivery to the periphery determined by two major factors:Oxygen content of arterial blood andBlood flow Oxygen deliveryOxygen delivery is calculated as the product of cardiac output and arterial oxygen content. Total oxygen delivery is calculated as: Oxygen delivery

Aerobic metabolism requires a balance between oxygen delivery (Do2) and oxygen utilization (Vo2)A biphasic relationship between Do2 and Vo2 has been observed during normal aerobic metabolismOxygen transport and oxygen utilization are independent variablesMechanisms of HypoxiaPada saat istirahat rata-rata laki-laki dewasa membutuhkan kira-kira 225- 250 ml oksigen per menit, dan meningkat sampai 10 kali saat beraktivitas. Jika aliran oksigen ke jaringan berkurang, atau jika penggunaan berlebihan di jaringan maka metabolisme akan berubah dari aerobik ke metabolisme anaerobik untuk menyediakan energi yang cukup untuk metabolisme. Apabila ada ketidakseimbangan, akan mengakibatkan produksi asam laktat berlebihan, menimbulkan asidosis dengan cepat, metabolisme selular terganggu dan mengakibatkan kematian sel.4Major causes mechanistically divided into three broad categories:Arterial hypoxemia, Reduced oxygen delivery, and Excessive or dysfunctional tissue utilization.tissue hypoxiaBerdasarkan mekanismenya, penyebab hipoksia jaringan dibagi dalam 3 kategori, yaitu: 1). Hipoksemia arteri, 2). Berkurangnya aliran oksigen karena adanya kegagalan transport tanpa adanya hipoksemia arteri, dan3). Penggunaan oksigen yang berlebihan di jaringan.5

Causes of ARTerial HypoxemiaThe most common pathophysiological causes of hypoxemia in lung disease:ventilation-perfusion mismatchtrue shuntdiffusion barrierPathophysiologyCirculatory hypoxia results when fully oxygenated blood is delivered to tissues in insufficient quantity or at an inadequate level to support tissue metabolic needsCirculatory causesClinical manifestations of hypoxia are highly variable and nonspecific and depend on both duration of the hypoxia (acute or chronic) and the individuals fitness.Clinical ManifestationsManifestasi klinik hipoksia tidak spesifik, sangat bervariasi, tergantung pada lamanya hipoksia (akut atau kronik), kondisi kesehatan individu dan biasanya timbul pada keadaan hipoksia yang sudah berat. 9

Symptoms and signs associated with acute hypoxiaManifestasi klinik dapat berupa perubahan status mental/bersikap labil, pusing, dispneu, takipneu, respiratory distress, dan aritmia. Sianosis sering dianggap sebagai tanda hipoksia, namun hal ini hanya dapat dibenarkan apabila tidak terdapat anemia.

10Short-Term Oxygen TherapyLong-Term Oxygen TherapyINDICATIONS FOR OXYGEN THERAPY11Short-Term Oxygen Therapy

Terapi oksigen jangka pendek merupakan terapi yang dibutuhkan pada pasien-pasien dengan keadaan hipoksemia akut, di antaranya pneumonia, PPOK dengan eksaserbasi akut, asma bronkial, gangguan kardiovaskular, emboli paru. Pada keadaan tersebut, oksigen harus segera diberikan dengan adekuatPada kondisi ini, oksigen harus diberikan dengan Fi02 60-100% dalam waktu petldek sampai kondisi membaik dan terapi yang spesifik diberikan.12

Long-Term Oxygen Therapy (LTOT)- Pada pasien dengan PPOK dan kor pulmonal, terapi oksigen jangka panjang (long-term oxygen therapy/ LTOT) dapat meningkatkan jangka hidup sekitar enam sampai tujuh tahun. Angka kematian menurun pada pasien dengan hipoksemia kronis apabila oksigen diberikan lebih dari 12 jam sehari- Berdasarkan beberapa penelitian didapatkan bahwa terapi oksigen jangka panjang dapat memperbaiki harapan hidup. Karena adanya perbaikan dengan terapi oksigen jangka panjang, maka saat ini direkomendasikan untuk pasien hipoksemia (Pa02 < 55 mmHg atau saturasi oksigen < 88%) oksigen diberikan secara terus menerus 24 jam dalam sehari. Pasien dengan Pa02 56 -59 mmHg atau saturasi oksigen 89%, kor pulmonal atau polisitemia jugamemerlukan terapi oksigen jangka panjang.- Pasien yang menerima terapi oksigen jangka panjang harus dievaluasi ulang dalam 2 bulan untuk menilai apakah hipoksemia menetap atau ada perbaikan dan apakah masih dibutuhkan terapi oksigen?13Choice of delivery system is based upon a variety of criteria:The degree of hypoxemiaRequirement for precision of deliveryPatient comfortCostTechnique of Oxygen AdministrationClassification of Oxygen Delivery Systems

Provide a fraction of the patients minute ventilatory requirement as pure oxygen, the remainder of the ventilatory requirement is fullled by addition of another gas, usually entrained room airFlows supplied through these devices are low (less than 6 L/min)Cannot deliver constant inspired oxygen concentrations variations in the amount of entrained room airLow-flow Oxygen DeviceNasal cannulesimple, inexpensive,easy to usewell-toleratedFio2 may vary greatlyOxygen masksachievable fraction of inspired oxygen above 0.44Simple face masks require a ow of inspired oxygen of 5 to 6 L/min to avoid accumulation of CO2 within the mask.

Low-flow Oxygen Devices

Fraction of Inspired OxygenLow-flow Oxygen DevicesNasal CannulaSimpleCan use continuously with meals and activityFlow rates in excess of 4L cause drying and irritationDepth and rate of breathing affect amount of O2 reaching lungsadults 6 LPMinfants/toddlers 2 LPM children 3 LPMFIO2 is not affected by mouth breathing

19Kateter nasal dan kanul nasal merupakan alat dengan sistem arus rendah yang digunakan secara luas. Kanul nasal arus rendah mengalirkan oksigen ke nasofaring dengan aliran 1-6 L/m, dengan Fi02 antara 0,24 - 0,44 (24% - 44%). Aliran yang lebih tinggi tidak meningkatkan Fi02 secara bermakna di atas 44% dan dapat mengakibatkan mukosa membran menjadi kering.Simple MaskLow to medium concentration of O2Client exhales through ports on sides of maskShould not be used for controlled O2 levelsO2 flow rate 5 to 8LCan cause skin breakdown; must remove to eat.

20Partial Rebreather MaskConsists of mask with exhalation ports and reservoir bagReservoir bag must remain inflatedO2 flow rate - 6 to 10L FIO2=60%-80%Client can inhale gas from mask, bag, exhalation portsPoorly fitting; must remove to eat

21Non-Rebreathing 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 15L Fio2= 95-100%Poorly fitting; must remove to eat

22

Partial vs Non-rebreathing Masksclinical indications for use of a high-flow oxygen delivery system:treatment of hypoxic patients who depend on their hypoxic drive to breathe but who require controlled increments in Fio2young, vigorous patients with hypoxemia who have an abnormal ventilatory pattern and whose ventilatory requirements may exceed the delivery capabilities of low-ow systems.High-flow Oxygen Devices

Fraction of Inspired OxygenHigh-flow Oxygen DevicesVenturi 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 15L & Narrowed orificeFio2, 24%-60%Can cause skin breakdown; must remove to eat

26Tracheostomy Collar/MaskO2 flow rate 8 to 10LProvides accurate FIO2Provides good humidity; comfortable

27T-pieceUsed on end of ET tube when weaning from ventilatorProvides accurate FIO2Provides good humidity

2829Goal of therapy is an SPO2 of >90% or for documented COPD patients(Spo2 8892%)-(Pao2=55-60)As SPO2 normalizes the patients vital signs should improveHeart rate should return to normal for patientRespiratory rate should decrease to normal for patientBlood pressure should normalize for patientGoal of Oxygen Therapy29Pulmonary oxygen toxicity develops insidiously after a variable lag period, during which the biochemical and cellular changes occurDevelopment of chest pain, tachypnea, or cough in a patient breathing elevated concentrations of oxygen alert to the possibility of oxygen toxicityOxygen ToxicityThank YouMichael F. Beers. Oxygen therapy and pulmonary oxygen toxicity.In: Fishman AP, ed. 4th. Ed. Fishman' s pulmonary diseases anddisorders. 2008;2627-42.Reference: