03 penerapan terapi oksigen pada kegawat daruratan dengan aplikasinya
DESCRIPTION
nursing emergency to give any rescue about disfunction respiratory systemTRANSCRIPT
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Goals and Indications
• Goals : is to provide tissue oxygenation at the lowest inspired FiO2
• Indications :1. Documented Hypoxemia
• Infants & Children : PaO2 < 60 mmHg or SaO2 < 90% (breathing room air)
• Neonates : PaO2 < 50 mmHg or SaO2 < 88%
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• Indications2. In Acute care situation in which hypoxemia is
suspected :• Shock
• Severe trauma
• Short term therapy (during certain medical procedures)
Goals and Indications
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Contraindications
• No specific contraindications
• Nasal cannulas : Nasal Obstruction
• Nasopharyngeal catheters : Basal skull fracture, Maxillofacial trauma & Nasal obstruction
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Relation between PO2 and exposure time for O2 toxicity
Time (hours)
Insp
ired
PO
2 (a
tm)
8
7
76
6
5
5
4
4
3
3
2
2
1
1 Several days
CNS limits
Pulmonary limits
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Increased FiO2
O2 Toxicity
Low PaO2
Increased Shunting
The vicious circle that can occur in managing hypoxemia with High FiO2
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Hazards, Precautions & Complications
• Physiologic:• Preterm infants (ROP)
• Paraquat, bleomycin : pulmonary fibrosis
• High FiO2 : Absorption atelectasis, BPD, free radicals
• Equipment related• Hypoxemia, Hyperoxemia
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• O2 transported from lungs to tissues.
• O2 moves down a partial pressure gradient at each interface:• From alveolar gases into blood.
• From arterial blood into tissues.
• Into cells and into mitochondria.
• CO2 transported from tissues to lungs.
• CO2 moves down a partial pressure gradient at the same interfaces.
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PAO2
Oxygenation
• The key factors which affect adequate oxygenation:
• FiO2 (affect Alveolar O2 tension)
• Alveolar gas exchange
• The mixed venous oxygen content
• The distribution of ventilation to perfusion
FiO2
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Alveolar Oxygen Tension
FiO2 PAO2
• PAO2 = (PB - PH2O)FiO2 - PaCO2/RQ• PAO2 = Alveolar O2 tension
• PB = Barometric pressure (760 mmHg at sea level)
• FiO2 = fraction of inspired oxygen
• PaCO2 = arterial CO2 pressure
• RQ = respiratory quotient = 0.8• PH2O = Water vapor tension (47 mmHg)
PAO2
FiO2
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Alveolar Oxygen Tension
• PAO2 = (PB - PH2O)FiO2 - PaCO2/RQ
• PAO2 = (PB - PH2O)FiO2 - PaCO2/0.8
10 years old boy in Surabaya breathing room air
• PAO2 = (PB - PH2O)FiO2 - PaCO2/0.8
• PAO2 = (760- 47)0.21 - 40/1.25 = 100 mmHg
PAO2
FiO2
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Oxygen in Blood
• O2 is held in 2 compartments in blood– Physically dissolved in plasma– Chemically bound on hemoglobin
• Solubility of O2 in plasma = 0.003ml/dl blood/mmHg
• The effective carrying capacity of Hb = 1.34 ml O2/g Hb
20 40 60 80 100 120 140 180 2000
PO2
5
10
15
20
25
Hb = 15 g/dL
Hb = 8 g/dL
Dissolved O2
O2
Con
tent
(m
L/1
00m
L)
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0.40.2 0.6 0.8 1.0
300
200
100
700
600
500
400
FiO2
Alv
eola
r P
O2
VA/Q = 1
VA/Q << 1
VA/Q > 1
. .
. .. .
West JB Respir Physiol 1969;7:8818
0.2 0.4 0.6 0.8 1.0
100
200
300
400
FiO2
Art
eria
l PO
20
10%
25%
50%
Arterial PO2 is plotted as a function of FiO2 for a variety of RL shunts(Benator SR, etal: Br J Anaesthesiol 1973;45:722)
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The Goal of Oxygen therapy
• To achieve adequate tissue oxygenation with the lowest fractional concentration of inspired oxygen (FiO2)
20
100
80
60
40
20
20
15
10
5
0
120 140100806040200
PaO2 mmHg
CaO
2 m
l/d
l
Hb
15
gm
/dl
SaO
2 %
A
B
21
0 1 2 3 4 5 6 7 8
Duration of exposure, days
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.21
Fi02
Risk of clinical oxygen toxicity
Clinically safe
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Oxygen Administration
• Equipment : Smaller versions of the adult devices
• Low flow (Variable performance oxygen delivery systems)
• High flow (Fixed performance oxygen delivery systems)
• Reservoir • Enclosure
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Oxygen therapy devices
Low flow Reservoir High flow Enclosure
Nasal cannula
Nasal catheter
Simple mask
Partial rebreathing mask
Non rebreathing mask
Air entraintment mask
(Venturi mask)
Oxyhood
Incubator
O2 Tent
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25
A
BC
Flo
w
Insp.
Exp.
A = Low flow deviceB = High flow deviceC = Reservoir device
= Patient’s flow
= Device’s flow
Nasal cannula• Advantages
• Easy to use• Disposable• Useful for
moderate O2 need
• Disadvantages• Irritating nose and
throat (> 6 L/min)• Low FiO2• Variability in
actual FiO226
A
Nasal cannula
• FiO2 determined by– Capacity of available O2 reservoir– O2 flow– Patient’s breathing pattern
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Nasal cannula
• Anatomic reservoir capacity– 2/3 ml/kgBW
• O2 flow– xL/min = x1000ml/60 sec = 16.7 ml/sec
• Breathing pattern– Cycle time– I : E ratio– The filling time anatomic reservoir
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2L/min O2 nasal cannula provided to a 5 kg infant
breathing 40 times/min (assuming I:E ratio of 1:2)
Tidal volume : 6 ml/Kg
Anatomic reservoir : 2/3 ml/Kg
O2 flow : 1L/min = 16.7ml/sec
Inspir. O2 Volume : Inspiratory time x flow
Room air (flow)
volume :
Tidal volume - (inspir O2 volume +
anatomic reservoir volume)
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2L/min O2 nasal cannula provided to a 5 kg infant
breathing 40 times/min (assuming I:E ratio of 1:2)
Tidal volume : 30 ml
Anatomic reservoir : 3.3 ml
Inspir. O2 Volume : 16.7 ml
Room air (flow) volume : 10 ml = 10 ml x 0.21 = 2.1 ml O2
Total O2 volume : 3.3 + 16.7 + 2.1 = 22.1 ml
FiO2 provided : Total O2 volume/Tidal volume = 22.1
ml/ 30 ml = 0.7430
2L/min O2 nasal cannula provided to a 5 kg infant, goes
sleep, breathing 30 times/min (assuming I:E ratio of 1:2)
Tidal volume : 6 ml/Kg
Anatomic reservoir : 2/3 ml/Kg
O2 flow : 1L/min = 16.7ml/sec
Inspir. O2 Volume : Inspiratory time x flow
Room air (flow)
volume :
Tidal volume - (inspir O2 volume +
anatomic reservoir volume)
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2L/min O2 nasal cannula provided to a 5 kg infant, goes
sleep, breathing 30 times/min (assuming I:E ratio of 1:2)
Tidal volume : 30 ml
Anatomic reservoir : 3.3 ml
Inspir. O2 Volume : 22.38 ml
Room air (flow) volume : 4.32 ml = 10 ml x 0.21 = 0.91 ml O2
Total O2 volume : 3.3 + 22.38 + 0.91 = 26.58 ml
FiO2 provided : Total O2 volume/Tidal volume = 26.58
ml/ 30 ml = 0.9032
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QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Recommended Flow meterFor newborn
High Flow Systems
• Air entraintment System
• Venturi Systems
• Enclosure Systems
• Fixed FiO2 (WYSWYG)
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Equation for Computing O2 percentage, Ratio, and Flow
% O2 = (Air flow x 21) + (O2 flow x 100)Total flow
Liters airLiters O2
= (100 - %O2)(%O2 - 21)
1. To compute O2% of a mixture of Air and O2
2. To compute air-to-O2 ratio needed to obtain O2%
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3. To compute the total output flow from an air entrainment device (given the oxygen input)
• Compute the air-to-O2 ratio• Add the air-to-O2 ratio parts• Multiple the sum of the ratio parts by the O2 input flow
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4. To compute the flow of oxygen and air needed to obtain a given O2% at a given total flow
• Compute the oxygen flow:
• Compute the air flow:
O2 flow = Total flow x (O2% - 21)79
Air flow = Total flow - O2 flow
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QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
FiO2
(%%)
O2 Flow
(L/min)
Total Flow
(L/min)
Red 24 3 105
Yellow 28 6 68
Blue 31 8 63
Orange 35 10 56
Green 40 12 33
Venturi Flow (Salter Lab Ideal)
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QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Color FiO2
(%)
O2 Flow
(L/min)
Total Flow
(L/min)
Blue 24 3 78
White 28 6 66
Orange 31 8 72
Yellow 35 12 72
Red 40 15 60
Pink 50 15 40
Venturi Flow (Hudson RCI)
Ventury Systems• Total flow 3 - 4 times minute ventilation• A 50 Kg asthmatic patients breathing 40
times per minute ( I:E = 1:3)• Minute volume = 50 x 6 x 40 = 9 Liters• Needs total flow = 9 x 4 = 36 L/minute• Please be informed about the total flow.
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Oxygen Hood
• Advantages– Permit access to the chest, trunk
and extremities for continue care
– Well tolerated by infants
– Can deliver up to 100% oxygen
(flow 10 - 15 L/min)
• Disadvantages
– Very noisy for the patients
– Generally not large enough to be used over the age of 1 year
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Low-flow High-flow Enclosure systems
FiO2 Variable Fixed Variable (depend on devices)
Newborn Nasal Cannula,Simple oxygen mask
An air entrainment mask (venturi systems)
Oxygen hoods,Closed incubators
Infant &
Children
Nasal cannula,Nasopharyngeal
catheters,Simple oxygen mask,
Reservoir masks
An air entrainment mask (venturi systems)
Oxygen hoods,Oxygen tents
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