Importance of Oxygen Therapy in Managing Respiratory Illnesses
OXYGEN
THERAPY
Developed with input from MOH, WHO,CDC,IDI
Module:
Learning
objectives
HE
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EMERGENCIES
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At
the end of this lecture, you
will
be able
to:
●
Describe importance of oxygen
therapy.
●
Recognize indications
for oxygen
therapy
in Managing
Acute Respiratory Infections
(including those due to COVID-19)
.
●
Describe
how
to
initiate oxygen
therapy.
●
Describe two different
methods
to
measure
blood
oxygen
levels.
●
Explain
how
to
titrate oxygen
therapy.
Importance
of
oxygen
therapy
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●
Hypoxaemia is a
life-threatening condition that
can
be
easily
treated
with
oxygen
therapy:
-
o
x
y
g
e
n
t
h
e
r
a
p
y
s
a
v
e
s
l
i
v
e
s
.
●
Oxygen therapy
is
an essential medicine that
should
be
available
in all
areas that may care for
SARI
patients.
●
Oxygen therapy
is
cost-effective.
●
Oxygen
therapy
is
safe
in newborns
(preterm and
term)
that are
hypoxic.
Importance of oxygen
thearpy
“
Effective oxygen delivery
systems
should be
a universal
standard of care
and should be
made
more
widely available.”
(WHO,
2016)
HE
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Oxygen: indications
1/2
●
In
the hospital setting, give oxygen
immediately
to patients
(adults and children)
with
SARI
who
have signs of severe
illness:
–
severe respiratory distress
–
sepsis
with
hypoperfusion
or
shock
–
alteration of
mental
status
–
or
hypoxaemia
•
SpO
2
< 90%
(if patient
is
haemodynamically
normal)
•
SpO
2
< 94%
(if patient with
any
emergency signs of
airway,
breathing or
circulation)
•
SpO
2
<
92–95%
(if
pregnant
woman).
D
o
N
O
T
d
e
l
a
y
o
x
y
g
e
n
a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
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Oxygen: indications
2/2
•
In
children, clinical signs that should trigger
oxygen therapy include (when pulse oximeter not
available):
–
central cyanosis
–
nasal
flaring
–
inability to
drink
or
feed (when due
to
respiratory
distress)
–
grunting
with
every
breath
–
depressed
mental
state
(i.e. drowsy,
lethargic)
–
and
in certain
conditions (severe
lower
chest indrawing, RR
≥
70
bpm,
head
nodding).
D
o
N
O
T
d
e
l
a
y
o
x
y
g
e
n
a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
If patient is critically ill,
give higher flow
rates
●
In
adults and older
children,
start
with
10–
15
l/min
via face mask
with
reservoir
bag.
●
Less
ill
patients
can
start
with
5
L/min by
nasal
cannula.
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In
children
< 5
years,
preference is nasal
cannula
HE
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Nasopharyngeal
catheter
●
For severe
hypoxaemia:
–
place
passed
uvula into the
pharynx
–
provides higher oxygen levels at
similar flow rates because
of
PEEP
–
needs to
be
humidified
–
neonates, dose
is 0.5
L/min
–
infants,
dose
is
1
L/min
–
use with
nasogastric
tube.
HE
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EMERGENCIES
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Oxygen therapy
in
children
●
Compliance may require assistance from nursing staff and
family members.
●
Humidification
is
not required when using standard flow rates,
as
natural nasal mechanisms heat and
humidify.
●
FiO
2
is
determined by flow rate, nasal diameter and body
weight:
–
in infants
up
to
10 kg: 0.5
L/min (35%);
1
L/min (45%);
2
L/min
(55%).
HE
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EMERGENCIES
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Monitor oxygen
levels
●
Clinical signs
are
not reliable indicators
of
hypoxaemia.
●
Pulse oximeters should be available
in
all settings caring
for patients with SARI and used
to
measure
the
SpO
2
-
pre-hospital, emergency
area, ward,
and
ICU.
●
Blood gas analyser should be
available in
the
ICU:
–
measures pH,
PO
2
,
and PCO
2
for
patients
on
mechanical
ventilation, with
severe hypoxaemia,
risk of
hypercapnea and shock states.
HE
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EMERGENCIES
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Oxygen titration
to
reach
target
•
Titrate oxygen
to
target:
–
SpO
2
≥
90%
in
adults and
children
–
SpO
2
≥
92–95%
in
pregnant
patients
–
SpO
2
≥
94%
if child or
adult
with
signs
of
multi-organ failure, including
shock,
alteration of
mental status, severe anaemia
until resuscitation
has
stabilized patients, then resume target
≥
90%.
•
Titrate oxygen up and down
to
achieve
target.
•
Wean oxygen when patient
is
stable.
HE
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EMERGENCIES
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Titrate oxygen:
use
appropriate dose and delivery
device
O
2
d
o
s
e
1
–
5
L
/
m
i
n
O
2
d
o
s
e
6
–
1
0
L
/
m
i
n
O
2
d
o
s
e
1
0
–
1
5
L
/
m
i
n
F
i
O
2
e
s
t
i
m
a
t
e
0
.
2
5
–
0
.
4
0
F
i
O
2
e
s
t
i
m
a
t
e
0
.
4
0
–
0
.
6
0
F
i
O
2
e
s
t
i
m
a
t
e
0
.
6
0
–
0
.
9
5
N
a
s
a
l
c
a
n
n
u
l
a
S
i
m
p
l
e
f
a
c
e
m
a
s
k
F
a
c
e
m
a
s
k
w
i
t
h
Medical Illustration, Leicester Royal
Infirmary,
Leicester,
UK
Make
sure
bag is
full
HEALTH
E
M
E
R
G
E
N
C
I
ES
r
e
s
e
r
v
o
i
r
b
a
g
p
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e
•
Ensure
single
patient use of nasal prongs,
simple
face masks and face masks
with
reservoir bag to
prevent nosocomial
infection.
•
H
u
m
i
d
i
f
i
c
a
t
i
o
n
i
s
n
o
t
n
e
c
e
s
s
a
r
y
w
h
e
n
d
e
l
i
v
e
r
i
n
g
l
o
w
f
l
o
w
r
a
t
e
s
.
T
h
e
o
r
o
p
h
a
r
y
n
x
a
n
d
n
a
s
o
p
h
a
r
y
n
x
p
r
o
v
i
d
e
s
u
f
f
i
c
i
e
n
t
h
u
m
i
d
i
t
y
.
-
In children, flow rates are considered high
when
> 2
L/kg/min.
•
Avoid
bubble bottles because of
risk
of
infection
.
HE
A
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T
H
EMERGENCIES
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e
IPC and oxygen
therapy
Recognize acute hypoxaemic
respiratory
failure
HE
A
L
T
H
EMERGENCIES
p
r
og
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mm
e
●
Patients not responding to increasing oxygen therapy
are developing acute hypoxaemic respiratory
failure:
–
signs
of
severe respiratory
distress
–
hypoxaemia (SpO
2
<
90%) despite escalating oxygen
therapy
–
SpO
2
/FiO
2
<
300 while
on
at least 10 L/min oxygen
therapy
–
Cardiogenic pulmonary
oedema not
primary
cause.
High-flow oxygen system
for
acute hypoxemic respiratory
failure
High-flow oxygen systems can be used for
adults and
children:
•
Selected
patient
must be awake, cooperative,
haemodynamically
stable
without urgent need
for
intubation.
•
May
generate
aerosols
so
should be used with
airborne
precautions.
HE
A
L
T
H
EMERGENCIES
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e
High-flow oxygen
system
●
Comfortable nasal cannula
interface.
●
Reliably titrates
FiO
2
up to
100%.
●
Humidification
prevents
dryness.
●
In adults,
delivers
flow
rates
as high as
60
L/min.
●
In infants and young children, maximum flow
rates
are
less,
based
on age and
weight:
–
i.e.
2
L/kg/min
up
to maximum of
60
L/min
HE
A
L
T
H
EMERGENCIES
p
r
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e
High-flow oxygen
therapy
•
Aims to
match
patient’s inspiratory
demand.
•
Reduces work
of
breathing.
•
Washes out nasopharyngeal dead
space.
•
Provides
low
level of
PEEP.
•
May
induce
less
injury to the lung in
ARDS.
•
Monitor
closely for need for
intubation.
HE
A
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T
H
EMERGENCIES
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▪
Appropriate use of oxygen
will
optimize quality
care and
minimizes
waste.
▪
When
using traditional nasal
cannula
and
face
mask, increasing flow rates does not reliably
deliver
higher oxygen concentrations
(FiO
2
),
because patients
also
breathes
in
room air,
which
dilutes oxygen making exact
FiO
2
variable.
HE
A
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T
H
EMERGENCIES
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Tips: about oxygen
use
Useful
website
HE
A
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T
H
EMERGENCIES
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•
http://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en/
Su
mm
a
ry
HE
A
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T
H
EMERGENCIES
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•
Give oxygen
immediately
to patients with
SARI
with severe respiratory
distress, sepsis with hypoperfusion/shock or hypoxaemia,
SpO
2
<90%.
•
In
critically
ill
adults and children start with highest
flow
rate available and
appropriate for
age.
•
Pulse oximeters should
be
available in all areas where emergency oxygen
is
delivered. Blood gas analyzer should
be
available in the
ICU
to also measure
ventilatory parameters (pH,
PaCo2)
•
Titrate oxygen to target
SpO
2
≥90% in adults and children,
> 92-95%
in
pregnant
females,
or ≥94%
during
resuscitation of patient with multi-organ
failure using the appropriate dose
(flow
rate) and delivery
device.
•
Newer high
flow
oxygen systems
can be
used in select cases of non-
hypercapneic, hypoxemic respiratory
failure.
Contributors
Dr T
Eoin West, University of Washington, Seattle,
USA
Dr
Janet
V
Diaz, WHO Consultant,
San Francisco,
USA
Dr Arjun
Karki, Patan Academy of
Health
Sciences, Kathmandu,
Nepal
Dr
Niranjan Bhat, Johns Hopkins University, Baltimore,
USA
Dr
Timothy Uyeki, Centers for Disease Control and Prevention, Atlanta,
USA
Dr
Simon Mardel, University Hospital of South Manchester NHS Foundation
Trust
Dr
Paula Lister, Great Ormond Street Hospital, London,
UK
Dr
Neill Adhikari,
Sunnybrook
Health
Sciences Centre, Toronto,
Canada
Dr Andy
Petros, Great Ormond Street Hospital, London,
UK
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Acknowledgements
Oxygen therapy is crucial in treating hypoxemia and saving lives, especially in patients with severe acute respiratory infections like COVID-19. This module covers the significance of oxygen therapy, indications for its use, methods to measure blood oxygen levels, and how to titrate oxygen therapy effectively. Effective oxygen delivery systems are emphasized to be a universal standard of care. Immediate administration of oxygen is emphasized for patients showing signs of severe illness, with specific SpO2 thresholds for different conditions. Higher flow rates are recommended for critically ill patients.
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Presentation Transcript
OXYGEN THERAPY Module: Developed with input from MOH, WHO,CDC,IDI
Learning objectives At the end of this lecture, you will be able to: Describe importance of oxygen therapy. Recognize indications for oxygen therapy in Managing Acute Respiratory Infections (including those due to COVID-19) . Describe how to initiate oxygen therapy. Describe two different methods to measure blood oxygen levels. Explain how to titrate oxygen therapy. HEALTH EMERGENCIES programme
Importance of oxygen therapy Hypoxaemia is a life-threatening condition that can be easily treated with oxygen therapy: - oxygen therapy saves lives. Oxygen therapy is an essential medicine that should be available in all areas that may care for SARI patients. Oxygen therapy is cost-effective. Oxygen therapy is safe in newborns (preterm and term) that are hypoxic. HEALTH EMERGENCIES programme
Importance of oxygen thearpy Effective oxygen delivery systems should be a universal standard of care and should be made more widely available. (WHO, 2016) HEALTH EMERGENCIES programme
Oxygen: indications 1/2 In the hospital setting, give oxygen immediately to patients (adults and children) with SARI who have signs of severe illness: severe respiratory distress sepsis with hypoperfusion or shock alteration of mental status or hypoxaemia SpO2 < 90% (if patient is haemodynamically normal) SpO2 < 94% (if patient with any emergency signs of airway, breathing or circulation) SpO2< 92 95% (if pregnant woman). Do NOT delay oxygen administration. HEALTH EMERGENCIES programme
Oxygen: indications 2/2 In children, clinical signs that should trigger oxygen therapy include (when pulse oximeter not available): central cyanosis nasal flaring inability to drink or feed (when due to respiratory distress) grunting with every breath depressed mental state (i.e. drowsy, lethargic) and in certain conditions (severe lower chest indrawing, RR 70 bpm, head nodding). Do NOT delay oxygen administration.
If patient is critically ill, give higher flow rates In adults and older children, start with 10 15 l/min via face mask with reservoir bag. Less ill patients can start with 5 L/min by nasal cannula. HEALTH EMERGENCIES programme
In children < 5 years, preference is nasal cannula Age of child Neonates Infants Pre-school aged School-aged Maximal oxygen flow rates 0.5 1.0 L/min by nasal cannula 1 2 L/min by nasal cannula 1 4 L/min by nasal cannula 1 6 L/min by nasal cannula If severe hypoxaemia persists despite maximal flow rates: start CPAP (if available) start secondary source of oxygen with face mask with reservoir bag insert nasopharyngeal catheter (passed uvula into the pharynx) and give oxygen at flow rates: neonates 0.5 L/min; infants 1 L/min. HEALTH EMERGENCIES programme
Nasopharyngeal catheter For severe hypoxaemia: place passed uvula into the pharynx provides higher oxygen levels at similar flow rates because of PEEP needs to be humidified neonates, dose is 0.5 L/min infants, dose is 1 L/min use with nasogastric tube. HEALTH EMERGENCIES programme
Oxygen therapy in children Compliance may require assistance from nursing staff and family members. Humidification is not required when using standard flow rates, as natural nasal mechanisms heat and humidify. FiO2 is determined by flow rate, nasal diameter and body weight: in infants up to 10 kg: 0.5 L/min (35%); 1 L/min (45%); 2 L/min (55%). HEALTH EMERGENCIES programme
Monitor oxygen levels Clinical signs are not reliable indicators of hypoxaemia. Pulse oximeters should be available in all settings caring for patients with SARI and used to measure the SpO2 - pre-hospital, emergency area, ward, and ICU. Blood gas analyser should be available in the ICU: measures pH, PO2, and PCO2 for patients on mechanical ventilation, with severe hypoxaemia, risk of hypercapnea and shock states. HEALTH EMERGENCIES programme
Oxygen titration to reach target Titrate oxygen to target: SpO2 90% in adults and children SpO2 92 95% in pregnantpatients SpO2 94% if child or adult with signs of multi-organ failure, including shock, alteration of mental status, severe anaemia until resuscitation has stabilized patients, then resume target 90%. Titrate oxygen up and down to achieve target. Wean oxygen when patient is stable. HEALTH EMERGENCIES programme
Titrate oxygen: use appropriate dose and delivery device Medical Illustration, Leicester Royal Infirmary, Leicester,UK Make sure bag is full O2 dose 1 5L/min O2 dose 6 10L/min O2 dose 10 15L/min FiO2 estimate 0.25 0.40 FiO2 estimate 0.60 0.95 FiO2 estimate0.40 0.60 Nasal cannula Simple face mask Face mask with reservoir bag HEALTH EMERGENCIES programme
IPC and oxygen therapy Ensure single patient use of nasal prongs, simple face masks and face masks with reservoir bag to prevent nosocomial infection. Humidification is not necessary when delivering low flow rates. The oropharynx and nasopharynx provide sufficient humidity. - In children, flow rates are considered high when > 2 L/kg/min. Avoid bubble bottles because of risk of infection. HEALTH EMERGENCIES programme
Recognize acute hypoxaemic respiratory failure Patients not responding to increasing oxygen therapy are developing acute hypoxaemic respiratory failure: signs of severe respiratory distress hypoxaemia (SpO2 < 90%) despite escalating oxygen therapy SpO2/FiO2 < 300 while on at least 10 L/min oxygen therapy Cardiogenic pulmonary oedema not primary cause. HEALTH EMERGENCIES programme
High-flow oxygen system for acute hypoxemic respiratory failure High-flow oxygen systems can be used for adults and children: Selected patient must be awake, cooperative, haemodynamically stable without urgent need for intubation. May generate aerosols so should be used with airborne precautions. HEALTH EMERGENCIES programme
High-flow oxygen system Comfortable nasal cannula interface. Reliably titrates FiO2 up to 100%. Humidification prevents dryness. In adults, delivers flow rates as high as 60 L/min. In infants and young children, maximum flow rates are less, based on age and weight: i.e. 2 L/kg/min up to maximum of 60 L/min HEALTH EMERGENCIES programme
High-flow oxygen therapy Aims to match patient s inspiratory demand. Reduces work of breathing. Washes out nasopharyngeal dead space. Provides low level of PEEP. May induce less injury to the lung in ARDS. Monitor closely for need for intubation. HEALTH EMERGENCIES programme
Tips: about oxygen use Appropriate use of oxygen will optimize quality care and minimizes waste. When using traditional nasal cannula and face mask, increasing flow rates does not reliably deliver higher oxygen concentrations (FiO2), because patients also breathes in room air, which dilutes oxygen making exact FiO2variable. HEALTH EMERGENCIES programme
Useful website http://www.who.int/patientsafety/safesurgery/pulse_oximetry/tr_material/en/ HEALTH EMERGENCIES programme
Summary Give oxygen immediately to patients with SARI with severe respiratory distress, sepsis with hypoperfusion/shock or hypoxaemia, SpO2<90%. In critically ill adults and children start with highest flow rate available and appropriate for age. Pulse oximeters should be available in all areas where emergency oxygen is delivered. Blood gas analyzer should be available in the ICU to also measure ventilatory parameters (pH, PaCo2) Titrate oxygen to target SpO2 90% in adults and children, > 92-95% in pregnant females, or 94% during resuscitation of patient with multi-organ failure using the appropriate dose (flow rate) and delivery device. Newer high flow oxygen systems can be used in select cases of non- hypercapneic, hypoxemic respiratory failure. HEALTH EMERGENCIES programme
Acknowledgements Contributors Dr T Eoin West, University of Washington, Seattle, USA Dr Janet V Diaz, WHO Consultant, San Francisco, USA Dr Arjun Karki, Patan Academy of Health Sciences, Kathmandu, Nepal Dr Niranjan Bhat, Johns Hopkins University, Baltimore, USA Dr Timothy Uyeki, Centers for Disease Control and Prevention, Atlanta, USA Dr Simon Mardel, University Hospital of South Manchester NHS Foundation Trust Dr Paula Lister, Great Ormond Street Hospital, London, UK Dr Neill Adhikari, Sunnybrook Health Sciences Centre, Toronto, Canada Dr Andy Petros, Great Ormond Street Hospital, London, UK HEALTH EMERGENCIES programme
