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WHAT AND HOW TO MONITOR
Rita RogayahDept. of Pulmonology and Respiratory Medicine
Faculty of Medicine, University of Indonesia
Introduction
O2 transportation from air to tissue required integration of 3 system :
Cardiovascular determine cardiac output and distribution of blood flow
Hematology determine the Hb concentration Respiratory determine the PaO2
If the process is inadequate hypoxia lack of oxygenation Hypoxia cant be measured directly
Hypoxemia lack of O2 in blood (PaO2 less than normal) measure by Pa O2 evaluation
O2 therapy supportive therapy in lung disease to prevent hypoxemia.
Goal of O2 therapy to provide the lowest dose of O2 increase PaO2 > 60 mmHg or O2Sat > 90% (therapeutic dose with minimal toxicity)
PaO2 and SaO2 in normal adult
PaO2(mmg) SaO2 (%)
Normal 97 97Normal range ≥80 >95Hypoxemia <80 <95
Mild 60-79 90-94Moderate 40-59 75-89Severe <40 <75
Hypoxemia lack of O2 in blood (PaO2 less than normal) measure by Pa O2 evaluation
O2 therapy supportive therapy in lung disease to prevent hypoxemia.
Goal of O2 therapy to provide the lowest dose of O2 increase PaO2 > 60 mmHg or O2Sat > 90% (therapeutic dose with minimal toxicity)
Monitoring of O2 supplementation :
1. Noninvasive : - Oxymetry- Capnometry and capnography- Transcutaneous- Physical examination
2. Invasive : blood gas analysis evaluation
Oximetry
Monitoring device that can be apply
continuously before being treated in the
hospital, emergency unit and outpatient
department
Oximetry
Applied two high waveform via pulsed vasculary tissue Arterial pulsasion pletismagnet wave
Amplitude ratio in screen SpO2
Probe is applied in :
- finger
- ear
- nasal
Clinical Indications
1. The need to monitor the adequacy of arterial oxyhaemoglobin saturation
2. The need to quantitate the response of arterial oxyhaemoglobin saturation to therapeutic intervention or a diagnostic procedure
Oximetry
Oximetry is applied : During surgical Post surgery Emergency medicine Sleep study Exercise testing Evaluation of LTOT
Oximetry
In poon periphery perfussion such as
hypotension, hypovolemic and hypotermic
and used of vasocontriction agent nasal
sensor
Motion artifact compare displayed with that obtained manually or by an electrocardiographic monitor
Lack of signal susceptible to the effect of motion artifact applied - warm towel
- central censor (nasal or ear)
Accuracy of reading oximetry depend on sources of light :- Sunlight- Fluorescent light- Infrared heat lamp - Phototherapy lampTo prevent sensor cover with qauze or towel
Others : nail polish colors dark skin pigmentation
Capnometry and capnography
Capnometry measurement and numeric display of CO2 concentration in alveolar ventilation evaluation and detection of CO2
concentration
Capnography graphic of O2 concentration, the waveform is called capnogram.
Capnogram is to measure PaCO2
Capnography
Graphyc evaluation :
1. To evaluate alveolar ventilation
2. Integration of airway and cardiopulmonary
function
Indication of capnomentry and capnography
Evaluation of the maximum exhaled CO2 concentration (end-tidal CO2) PaCO2 in spontaneously breathing
Evaluation of the maximum exhaled CO2 concentration (end-tidal CO2) PaCO2 in intubated patients being mechanically ventilated
Evaluate the severily of pulmonary disease Evaluate the response of intervention therapy Monitoring the integrity of the ventilator circuit and the
artificial airways
Indication of capnomentry …..
Monitoring the pulmonary blood flow Monitoring the concentration of CO2
when CO2 gas is being therapeutically administered
To ensure tracheal insulation instead of eosophageal
To evaluate the wave of capnography
Transcutaneous
Indicated for neonatal + children
Evaluate the sufficiency of artery oxygenation/ventilation
Evaluate diagnostic response & treatment intervention
Limitation Repeated calibration Changing of electrode position Required time for balancing after electrode
fitting The electrodes temperature effect to
measurement Suboptimal measurement hypoperfusion
area Haemodynamic disturbing underestimate of
PaO2, overestimate of PaCO2
Physical Examination Oxygen treatment : Improves cardiac function Decreases pulmonal hypertention Increases perfusion of vital organ
Hear rate & blood pressure stable Aritmia, cyanosis, tachypnea dismissed Neurologic disturbing dismissed
Artery blood gas analysis
Gold standard
Evaluate gas changing of O2 and CO2 and acid-base state
Blood gas analysis abnormal early sign of oxygenation disturbing or acid-base imbalance
Arterial blood gas value
Blood gas exchange normal value
Partial pressure carbondioxide (PaCO2) 35-45 mmHg
Partial pressure oxygen (PaO2) 80-100 mmHg
Oxygen saturation (SaO2) 95-97%
Concentration ion hydrogen (PH) 7,35-7,45
Ion bicarbonate (HCO3) 22-26 mEq/L
Radialis artery The best source Near the cutaneous surface Easy to be palpated Have the colateral system from ulnaris
artery
Blood gas analysis 15-20 minutes after
oxygen therapy or if there is clinical
worsening performed immediately (as
soon as possible)
Next evaluation
12 hours after giving FiO2 < 40% 8 hours after giving FiO2 > 40% 72 hours for acut myocard infark 2 hours for COPD patient 1 hour for neonatus
CONCLUSION
1. Monitoring of oxygen therapy - Noninvasive - Invasive
2. Monitoring noninvasive- Oximetry- Capnography - Physical examination
3. Monitoring invasiveBlood gas analysis gold standard