SEMINAR ON OXYGEN

INSUFFICIENCY

INTRODUCTIONOxygen is essential to life. All cells in the body require it, some being more sensitive than others. A person whose oxygen needs are meet adequately is not aware of the process of respiration.

MEANINGThe word oxygen comes from the Greek word meaning “acid former “because most mineral acids and carboxylic acids contains oxygen.

Oxygenation means the delivery of oxygen to the body’s tissues and cells. It’s necessary to maintain health and life.

The term oxygen was first coined by Antoine Lavoisier

ANTOINE LAVOISIER

THE ONE WHO COINED THE TERM OXYGEN

HISTORICAL ASPECTS OF OXYGEN

ANCIENT HINDU CONCEPT OF OXYGENThe presence of lungs had been recognized in ancient Hindu medicine. Both Charaka and Susrata the two famous physicians/ surgeons of the vedic period (500)BC,RECOGNIZED A ‘PRANA VAYU’, I.E LIFE AIR.

Charaka mentions the head , the chest, the ears, the tongue, the mouth and the nose as the seat of ‘prana vayu’.Susrata (1000)BC spoke of ‘ prana vayu’ as flowing in the mouth.

CHARAKA SUSRATA

ANCIENT GREEK CONCEPTIn the 4th century BC,ARISTOTLE

identified few essential elements – earth ,air, fire and water. The need for air remained well organized ,although its role was not identifiable.

MODERN HISTORY OF OXYGEN:Paracelsus, a Swiss scientist had suggested in

1541 that air contained a life sustaining substance.

Priestley called oxygen as the deep dephlogisticated air

Thomas beddoes used oxygen for the first time in early 1800 for treatment of medical disorders.

MODERN HISTORY OF OXYGENPARACELSUS PRIESTLY

ANATOMY OF RESPIRATION

ANATOMYTHE MAIN ORGANS INVOLVED IN THE PROCESS OF OXYGENATION ARE HEART & LUNGS. RESPIRATORY SYSTEM CAN BE DIVIDED INTO TWO PARTS

UPPER RESPIRATORY TRACT

LOWER RESPIRATORY TRACT

UPPER RESPIRATORY TRACTNOSESINUSESNASAL PASSAGESPHARYNXTONSILS AND ADENOIDSLARYNX TRACHEA

UPPER RESPIRATORY TRACT

NOSE

SINUSES

NASAL PASSAGES

PHARYNXTONSILS AND

ADENOIDS

LARYNX

TRACHEA

ADENOID TONSILS

Larynx: these voice organ that connects the pharynx and trachea .

the major function of the larynx is the vocalization.

protects the lower respiratory system from foreign substance and facilitates coughing

It consist of the following epiglottis, glottis, cricoids cartilage arytenoid cartilage and vocal cords.

Glottis: The opening between the vocal cords in the larynx.

Cricoid cartilage : The only complete cartilaginous ring in the larynx. (located below the larynx)

Arytenoid cartilage: These are used in the vocal cord movements with the thyroid cartilage.

Vocal cords: It produces sounds which are located in the lumen of the larynx

Trachea: These are called the wind pipe which is composed of the C shaped rings made of cartilages running down at regular intervals. it serves as a passage between larynx and bronchi.

CARTILAGES

LOWER RESPIRATORY TRACT

LOWER RESPIRATORY TRACTLUNGS: These are paired structures

enclosed inside the thoracic cage which is a air tight chamber with distensible walls.

When the capacity of the chest is increased air enters through the trachea (inspiration) because of the lower pressure within and it inflates the lung.

When the chest wall and the diaphragm return to their respiration (expiration) the lungs recoil and force air out.

PHYSIOLOGY OF RESPIRATION Air enters through nose, where it is warmed

humidified and filtered

Inspired air passes from the nose through pharynx

After this air moves to trachea passing through larynx

Trachea branches into two bronchi

Through bronchi air enters into the lungs and moves through primary bronchi and smaller

bronchi

Ending with the terminal bronchioles and then alveoli

Respiratory gas exchange

Respiratory gases are exchanged in the alveoli and the capillaries of the body tissues.

Oxygen is transferred from the lungs to the blood and carbondioxide is transferred from the blood to the alveoli.

At the tissue level, oxygen is transferred from the blood to tissues, and carbon dioxide is transferred from tissues to the blood to return to alveoli and be exhaled.

GAS EXCHANGE

DIFFUSIONMovement of gases from higher

concentration to the area of lower concentration.

Alveoli capillary layer enhances the diffusion to take place during the ventilation without any difficult.

OXYGEN TRANSPORT AND DELIVERYOxygen needs to be transported from the lungs to the tissues and carbon dioxide must be transported from the tissue to the lungs.

Normally most of the oxygen combines mostly with the hemoglobin in the red blood cells and its carried to tissues as oxyhemoglobin

PULMONARY PERFUSIONActual blood flow through the pulmonary

circulation.

PULMONARY CIRCULATION

VENTILATIONThe passage of oxygen from the atmosphere to the

Alveoli and the passage of carbon dioxide from the alveoli to the air require an uninterrupted air way.

Anything that interferes with the patency of any part of the respiration tract can interfere with the efficiency of respiration.

Normally the cough is the mechanism by which the respiratory tract is cleared off the foreign materials. Obstruction in the trachea, pharynx, larynx and bronchi can stimulate the cough reflex.

VENTILATION CONT…. Some patients have difficulty in clearing the mucous from the bronchial tree, perhaps because it is painful to cough because of lack of strength or because of unconsciousness

At any rate, fluids can accumulate and require nursing intervention for their removal.

Continual bed rest and maintaining a prone can contribute to this difficulty by limiting chest expansion and alveolar ventilation

CARDIVASCULAR PHYSIOLOGY CONTD….

STRUCTURE AND FUNCTION

The right ventricle pumps blood to the pulmonary circulation. The left ventricle pumps blood to the systemic circulation.

The circulatory system exchanges respiratory gases,nutrients,and waste products between the blood and the tissues.

MYOCARDIAL PUMPThe pumping action of the heart is essential to maintaining oxygen deliver The four chambers of heart fill during diastole and empty during systole.

The myocardial fibers have contractile properties that enable them to stretch during filling.

In a healthy heart this stretch is proportionally related to the strength of contraction.

In the diseased heart, starling's law does not apply because the stretch of the myocardium is beyond the heart’s physiological limits.

.

MYOCARDIAL BLOOD FLOW

To maintain adequate blood flow to the pulmonary and systemic circulation myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself.

Blood flow through the heart is unidirectional.

There are four heart valves that ensure this forward blood flow

VENTRICULAR DIASTOLEVENTRICULAR DIASTOLE

ATRIOVENTRICULAR VALVES (MITRAL AND TRICUSPID ) OPEN

BLOOD FLOW FROM HIGHER PRESSURE ATRIA INTO THE RELAXED VENTRICLES

IT REPRESENTS S1 OR THE FIRST HEART SOUND

AFTER VENTRICULAR FILLING THE SYSTOLIC PHASE BEGINS

SYSTOLIC PHASE

SEMILUNAR (AORTIC AND PULMONIC)VALVES OPEN

BLOOD FLOWS FROM VENTRICLE INTO THE AORTA & PULMONARY ARTERY

CLOSURE OF PULMONIC &AORTIC VALVES REPRESENTS S2 OR THE SECOND HEART SOUND

CORONARY ARTERY CIRCULATIONBlood in the atria and ventricles does not supply

oxygen and nutrients to the myocardium itself.

The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste.

the coronary arteries fill during ventricular diastole . the right and the left coronary arteries arise from the aorta just above and behind the aortic valve through openings called the coronary ostia.

CONDUCTION SYSTEMThe rhythmic relaxation and contraction

of the atria and ventricles depend on continuous, organized transmission of electrical impulses. these impulses are generated and transmitted by way of the cardiac conduction system.

The conduction system originates with the sinoatrial node(SA),the “pacemaker” of the heart

CONDUCTION SYSTEM CONTD…….

Impulses are initiated at the SA node at an intrinsic rate of 60 to 100 beats per minute. The resting adult rate is approximately 75 beats per minute.

An electrocardiogram (ECG) reflects the electrical activity of the conduction system.

PRINCIPLES RELEVANT TO OXYGEN 1. Oxygen is essential to life.2. A person can survive only a few minutes without

oxygen.3. An insufficient supply of oxygen impairs

functioning of al body systems.4. Irreparable brain damage may result from

prolonged periods of inadequate oxygen.5. Cells of the cerebral cortex begin to die as soon

as they are deprived of oxygen.6. Air at sea level containing approximately 20% of

oxygen and 0.04% carbon dioxide is sufficient to meet man’s oxygen needs.

7.Carbon di oxide concentrations between 3 and 10 % increase the rate and depth of respirations.

8.The body’s ability to meet its oxygen needs depends on the adequacy of functioning of the cardiovascular and the respiratory systems.

9.A patent airway is essential to normal respiratory functioning.

10.The respiratory tract is lined with mucus secreting epithelium.

11.Coughing, swallowing and sneezing are mechanisms by which the body attempts to rid itself of foreign materials in the respiratory tract.

12.Difficulty in breathing provokes anxiety.

CAUSES OF OXYGEN INSUFFICIENCY & FACTORS AFFECTING

AT BIRTHThe fluid filled lungs

drain first

PHYSIOLOGICAL FACTORSVARIOUS DISEASES AFFECT OXYGENATION INCLUDING RESPIRATORY DISEASE LIKE COPD,PNEUMONIA.CARDIOVASCULAR DISEASE LIKE CONGENITAL CARDIAC ANOMALIES

Click icon to add picture

•Change in ageing affects respiratory system.•Infection, physical or emotional stress

DECREASED OXYGEN CARRYING CAPACITY. Anemia and inhalation of toxic substances decreases the oxygen carrying capacity of blood.clients with anemia have complaints of fatigue,decreased activity tolerance and increased breathlessness and pallor and an increased heart rate.

BEHAVIOURAL FACTORSWhenever stress is there both psychological & physiological changes can affect the respiratory system.Person may experience light headedness,numbness,tingling of the fingers, toes, and around the mouth.

LIFESTYLE FACTORSPhysical activity

or exercise increase the rate and depth of respiration .

Smoking affects the oxygenation status.

ENVIRONMENTAL FACTORSaltitude heat, cold and air pollution affect oxygenation. The higher the altitude lowers is the pCo2 a patient breaths. Air pollution causes head ache, chocking and coughing even in healthy people.

MEDICATIONCertain medication including sedative , hypnotics(eg.diazepam) and narcotics including morphine can cause respiratory distresses

NURSING MANAGEMENT

ASSESSMENT

PHYSICAL EXAMINATION

Inspectionusing inspection techniques the nurse performs

the head to toe observation of the client for the skin and the mucus membrane , colour , general appearance, level of consciousness, breathing pattern and chest wall movement. Inspection includes observation of the

nails for clubbingthe chest wall movement for retraction paradoxical breathing , asynchronous breathing

and the clients breathing pattern clients effort during respiration, when especially

distress or flaring of noses, position distress

PALPATIONpalpation of the chest provides assessment data's

in several areas allows the nurse to feel for abnormal masses or

any lumps in the axilla and the breast tissue. Palpation of the extremities provides the data

about the peripheral circulation, the presence and the quality of the peripheral pulses, skin temp, capillary refill and colour.

Palpation should also include the feet and the legs to assess the presence or absence of peripheral edema palpation of the pulses in the neck and extremities is performed to assess the arterial blood flow

PERCUSSION

It allows the nurse to detect the presence of abnormal fluid or air in the lungs.

It is also used to determine the diaphragmatic excursion it may reveal hyper resonance , dull percussion tone or changes in the density of the lungs and the surrounding tissues

AUSCULTATIONIt enables the nurse to identify the normal and

abnormal fluid in heart and lung sounds. Auscultation of the cardio vascular system

should include the assessment of normal s1 and s2 sounds, the presence of abnormal s3 and s4 sounds (gallops), and murmurs or rubs.

Auscultation of lung sounds involves listening for the movement of air throughout all lung fields ; anterior , posterior and lateral.

Adventitious breath sound appears when there is a collapse of the lung segment, fluid in a lung segment or in case of narrowing or any obstruction of the airway.

Auscultation also evaluates the clients response intervention for improving their respiratory status.

Arterial blood gas analysis; ABG helps in the measurement of blood for

patients arterial oxygen Sputum studies; sputum is obtained for analysis to identify the

pathogenic organism and to determine malignancy or hypersensitivity which in turn is helpful to determine the causes for oxygen insufficiency.

The sputum may also be collected through endotracheal aspiration, bronchoscopal aspiration etc… the specimen are usually collected in the early morning en and carbon dioxide tensions

Chest X-rays and CT; To assess the fluids , tumor, foreign bodies and

other pathological conditions.BronchoscopicIt’s the direct inspection and examination of the

larynx , trachea and bronchi through a fibrotic flexible bronchoscope. The therapeutic bronchoscope are used to

Remove foreign from trachea bronchial treeRemove secretions obstructing the tracheal

esophageal treeTo destroy and excise tumor.

Thoracentesis a sample of the pleural fluid is obtained by the

thoracentesis for both diagnostic and therapeutic purposes.

By, thoracentesis pleural fluid is studied for Grams stain culture and sensitivity, acid fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein .

Pulmonary angiography pulmonary angiography is most commonly used to

investigate thrombotic disease of lungs, such as pulmonary emboli and abnormalities of vascular trees.

It involves a rapid injection of a radio opaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels through femoral vein, or branches of pulmonary artery and images are taken and analyzed

DIAGNOSTIC STUDIES PULMONARY FUNCTION TEST; these are used to assess the respiratory functions

and to determine the extent of dysfunction. These are used to find the; volume of the air in the lungsspeed and ease of air flow via airwaysstrength of the respiratory muscleThe PFT is performed by the technician using a

spirometer that has a volume collecting device attached to a recorder that demonstrates the volume and time simultaneously.

NURSING MANAGEMENT

HEALTH PROMOTION

MOBILIZATION OF THE PULMONARY SECRETIONS

NEBULIZATION

CHEST PHYSIOTHERAPY

HUMIDIFICATION

POSTURAL DRINAGE

Hyperventilation- it occurs when rapid and deep breathing results in excess of CO2 (hypocapnia). Causes of hyperventilation include anxiety , infection, shock, hypoxia, drugs (aspirin,amphetamines), diabetes mellitus, or acid base imbalance. A person who is hyperventilating may complain of feeling of lightheaded and tingly.

Hypoventilation- it occurs when the rate and depth of respiration are decreased and CO2 is retained or alveolar ventilation is compromised. Hypoventilation may be related to chronic obstructive pulmonary disease(COPD), general anesthesia, or other conditions that results in decreased respiration

POSTURAL DRINAGE

CLINICAL PRESCRIPTION OF OXYGEN Oxygen like a drug is used for most of the indications. It is generally used as an additional supplement to the other forms of drug therapy. In many other disease where oxygen deficiency is a major abnormality, oxygen constitutes the mainstay of therapy. Oxygen prescription or delivery was associated with significantly minor errors than those seen with the antibiotics. It is important to consider oxygen as a drug to get the maximum benefit. It is important to have oxygen therapy protocols and education programs especially for the nursing staff.

HAZARDS OF OXYGEN INHALATION

COMBUSTION

INFECTION

RETROLENTAL

FIBROPLASIS

ATELECTASIS

DRYING OF THE MUCUS

MEMBRANE

O2 TOXICIT

Y

O2 INDUCE

D APNEA

DAMAGE

ASPHYXIA

METHODS OF OXYGEN DELIVERYNasal cannula:It is the most common inexpensive method used to

administer oxygen to client.it delivers a relatively low concentration of oxygen (24% to 45%)at flow rate of 2-6 l/mt.

But this is not in use nowadays. In these days nasal prongs are used.

nasal cannula

Face mask:The simple face mask delivers oxygen concentrations

from 40% to 60%at flow rate of 5 to 8L/min respectively.

The face mask is sub divided into two types namely REBREATHER MASKNON REBREATHER MASK

Rebreather maskIn rebreather mask the oxygen the oxygen

reservoir bag that is attached allows the client to rebreath the exhaled air in conjunction with oxygen. Thus it increases FiO2(fractional oxygen of inspired air) by recycling expired oxygen.

Non rebreather maskIt delivers the highest oxygen concentration

possible 95% to 100% by means other than intubations or mechanical, at liter flow of 10 to 15 L/min.

VENTURI MASKIt delivers oxygen concentration varying from 24%

to 40% or 50%at flow rate of 4 to 5 lit /min. The venturi mask has wide tubing and colour coded jet adaptors that correspond to a precise oxygen concentration and flow rate

Trans tracheal deliveryThis is used for oxygen dependent clients. Oxygen is delivered through a small, narrow plastic cannula surgically inserted through the skin directly into trachea.a collar around the neck holds the catheter in place. Advantage-with the method client requires less oxygen (0.5 to 2 L/ min) as 5ml of saline twice or thrice a day.

face tents: it can be used for clients who cannot tolerate masks. these provide 30% to 50% oxygen concentration at a flow rate of 4 to 8 L/ min. nurse should frequently of flow is delivered directly to lungs. The nurse keeps the catheter patent by injecting 1.5 ml of normal saline with it. Moving a cleaning rod in and out and then reinjecting 5ml of saline twice or thrice a day.

VETILATORSIn medicine, mechanical ventilation is a

method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows. There are two main divisions of mechanical ventilation: invasive ventilation and non-invasive ventilation.There are two main modes of mechanical ventilation within the two divisions: positive pressure ventilation, where air (or another gas mix) is pushed into the trachea, and negative pressure ventilation, where air is essentially sucked into the lungs

OXYGEN CONCENTRTIONThe exact oxygen concentration being delivered is usually difficult to know for this reason it can best assessed by the flow rate (FiO2) and by the type of mask being used to the patient. The fiO2 required to be delivered based upon the acuteness of illness and the severity of the hypoxemia. One must avoid a high fiO2 for prolonged period to avoid toxicity.

SOURCE OF OXYGENCompressed gas cylinders continues to be used in hospitals in our country. Piped system with wall outlets from the central sourceis made available in large hospitals. A knowledge about the cylinders, regulators, flow meters and the pressure guage is much important for the nurses for an efficient role

Application and duration It can be used as a short term measure, for example during

an operation or critical illness (often in the setting of an intensive care unit). It may be used at home or in a nursing or rehabilitation institution if patients have chronic illnesses that require long-term ventilatory assistance. Owing[clarification needed] to the anatomy of the human pharynx, larynx, andesophagus and the circumstances for which ventilation is required then additional measures are often required to secure the airway during positive pressure ventilation to allow unimpeded passage of air into the trachea and avoid air passing into the esophagus and stomach. Commonly this is by insertion of a tube into the trachea which provides a clear route for the air. This can be either an endotracheal tube, inserted through the natural openings of mouth or nose or a tracheostomy inserted through an artificial opening in the neck. In other circumstances simple airway maneuvres, an oropharyngeal airway or laryngeal mask airway may be employed. If the patient is able to protect their own airway and non-invasive ventilation or negative-pressure ventilation is used then a airway adjunct may not be needed

Types of ventilatorsNegative pressure ventilationThis exerts the negative pressure on the

external chest; which in turn decreases the intra thoracic pressure during inspiration and allows the air to flow into the lungs., thereby filling its volume. These are mainly used in clients with neuro muscular conditions

Advantage-easy to use and doesn’t require intubation

Disadvantage- unsuitable for patients who require frequent ventilation changes

METHODS OF OXYGEN DELIVERYNasal cannula:It is the most common inexpensive method used to administer oxygen to client. it delivers a relatively low concentration of oxygen (24% to 45%)at flow rate of 2-6 l/mt.But this is not in use nowadays. In these days nasal prongs are used.

Positive pressure ventilationThese inflates the lungs by exerting pressure on the airways, forcing the alveoli to expand during inspiration. Expiration occurs passively which further includes cycled ventilatiors, pressure cycled ventilators and volume cycled ventilators

Modes in ventilators CMV- continous mandatory volume without allowances for spontaneous

breathing ACV- assist control ventilation; where assisted breaths are followed by

controlled breaths IMV- intermittent mandatory ventilation; are those which mixes controlled

breath and spontaneous breaths. PSV- pressure support ventilation; this is where the patient has the complete

control over all the aspects of his/her breaths except the pressure limits HIGH FREQENCY VENTILATION- where mean airway pressure is maintained

constantly and hundreds of tiny breaths are delivered /min. CPAP- continous positive airway pressure; spontaneous ventilation with

continous positive airway pressure . this ventilator is adjunct and is used only with spontaneous ventilation. i.e the patient breaths spontaneously through the ventilator at an elevated baseline pressure throughout the breathing cycle.

SIMV-synchorinized intermittent mandatory ventilation; a present a minimum number of breaths are synchronously delivered to the patient but the patient may also take spontaneous breaths of various volume. Note how the inspiratory and expiratory pressure differ between spontaneous and ventilator breaths.

PEEP-positive and expiratory pressure; airway pressure with varying levels of positive and expiratory pressure. Note that at he end of the expiration, the airway is not allowed to return to zero.

face mask:The simple face mask delivers oxygen concentrations from 40% to 60%at flow rate of 5 to 8L/min respectively.The face mask is sub divided into two types namely:Rebreather mask:In rebreather mask the oxygen the oxygen reservoir bag that is attached allows the client to rebreath the exhaled air in conjunction with oxygen.thus it increases FiO2(fractional oxygen of inspired air) by recycling expired oxygen. Non breather mask:It delivers the highest oxygen concentration possible 95% to 100% by means other than intubations or mechanical, at liter flow of 10 to 15 L/min.

ADVANCE OXYGEN THERAPY

ADVANCE OXYGEN THERAPY

HYPERBARIC OXYGEN THERAPY

ADVANCE

OXYGEN THERAPY

OZONE THERAPY

.Venturi mask:It delivers oxygen concentration varying from 24% to 40% or 50%at flow rate of 4 to 5 lit /min. the venturi mask has wide tubing and colour coded jet adaptors that correspond to a precise oxygen concentration and flow rate.