Dr.

Pangkuwidjaja P
Oxygen Transport

Ventilation
only one component of human ventilation

gases must be :
efficiently distributed to the alveoli
exchange with the pulmonary circulation
transported to and from the tissues
Oxygen Transport

Oxygen carried in the blood in two different states :

 in simple physical solution

 plasma
 erythrocyte intracellular fluid

 in reversible chemical combination with hemoglobin

Physically Dissolved Oxygen

Henry’s Law
the amount of oxygen that dissolves will be :
directly proportional to its solubility coefficient
inversely proportional to the temperature

Dissolved Oxygen (mL/dL) : PO2 x 0,003

Chemically Combined Oxygen
Hb is a conjugated protein
four linked polypeptide chains (globin portion)
combined with porphyrin complex
Heme
Fe++

When Hb is not carrying O2 (deoxygenated state)

four unpaired electrons
weak acid
 Reduced Hemoglobin (Hb-)

With complete oxygen binding

Hb-  HbO2 (Oxyhemoglobin)
 Oxygenated state
Oxygen Carrying Capacity of Hemoglobin
The total oxygen carried by each gram of Hb
1,34 mL/g

Hb saturation
the proportion of available Hb that is actually
carrying oxygen

HbO2 dissociation curve

the degree of Hb saturation is determined by its affinity
for oxygen at various partial pressures
Oxygen Content of the blood

The amount of oxygen in a given volume of blood

CaO2 = Chemically combined O2 + Dissolved O2

= Hb x SaO2 x 1,34 + PaO2 x 0,003

Calculation of oxygen delivery

DaO2 = CaO2 x CO
Factors affecting oxygen loading and unloading

pH
Temperature
The concentration of certain organic phosphate in erythrocyte
Variation in the chemical structure of Hb
P50
Oxygen Therapy

Indications

• Treatment or prevention of hypoxemia

 avoidance or resolution of tissue hypoxia
• Decrease the symptoms associated with chronic hypoxemia
• Prevent or minimize the increased cardiopulmonary work load
associated with compensatory responses to hypoxemia
Tissue hypoxia
exist when delivery of O2 is inadequate to meet
the metabolic demands of the tissues

Hypoxemia
A relative deficiency of O2 tension in the arterial blood
 Cause of Hypoxia
Cause Primary Indicator Mechanism Example
Harmful Physiologic Effect of Hypoxia

 Pulmonary vasoconstriction
 Cardiovascular workload
 Deleterious effect on myocardial function
 Impaired renal function
 Altered CNS function
 Anaerobic metabolism, lactic acid accumulation, and metabolic acidosis
Breathing circuits

1. Rebreathing
2. Non-rebreathing

• exhaled gases must be sequestered by one-way valves

• Inspired gases must be presented in sufficient volume and flow
 high peak flow rates and minute ventilation
General Performance Characteristic

Ideal :
Should deliver any desired FiO2 under all clinical conditions
Should be comfortable  for prolonged period

In clinical practice
FDO2
Stability of FiO2 under changing patient demand
 Oxygen therapy systems

Category Description FiO2 Examples

Variable-performance Provide only a portion Varies Nasal cannula

(Low-flow system) of inspired gas needs Nasal cath
Simple mask
Fixed-performance Meets the patient’s inspired Constant Air-entrainment
(High-flow system) flow needs mask (low FiO2)

Fixed-performance Meets the patient’s inspired Constant Leak-free non-

(Reservoir system) flow needs rebreathing
mask
 B
C

Patient’s flow

Device’s flow
Oxygen delivery devices
1. Low-flow system
• Nasal catheter
• Nasal cannulas

Simple available
easy to apply tolerable
inexpensive

Nasal passages must be patent

Flow rate 0.25 – 6 L/min  FiO2 0.24 – 0.44

> 4 L/min  mucosal drying
 humidified
Oxygen delivery devices
1. Low-flow system

• Simple face mask

Reservoir capacity 100 – 200 ml

Flow rate 5 – 12 L/min
Minimal flow 5 L/min
to ensure the mask volume is replenish with oxygen
to avoid CO2 accumulation and rebreathing
Approximate FiO2 delivered by simple face mask 

Flow rate ( L/min ) FiO2

5–6 0.40

6–7 0.50

7–8 0.60

 Based on normal ventilatory pattern

FiO2 0.4 – 0.6

Oxygen delivery devices
1. Low-flow system
• Partial rebreathing mask

Reservoir capacity 600 – 1000 ml

33% of exhaled volume fills the reservoir bag,
mixes with oxygen sources
Approximate FiO2 delivered by mask with reservoir bag 

Flow rate ( L/min ) FiO2

6 0.60
7 0.70
8 0.80
9 0.80 +
10 0.80 +

 Based on normal ventilatory pattern

FiO2 0.60 – 0.80

Oxygen delivery devices
1. Low-flow system

• Nonrebreathing mask

3 unidirectional valves
1 valve on each side
to permit the venting of exhaled gases
to prevent RA entraiment
1 valve between the mask and reservoir bag
to prevent exhaled gases from entering the bag
• Nonrebreathing mask

Flow rate 10 – 15 L/min

FiO2 0.80 – 0.90 +

If the total ventilatory needs are met without RA entrainment,

The rebreathing mask performs like a high-flow system

Safety valve : spring

Remove one of the unidirectional valve
to allow RA entrainment if needed to meet ventilatory demands
Factors affecting FiO2 delivery by low-flow
oxygen systems
Increases FiO2
• Higher O2 input
• Mouth-closed breathing
• Lower inspiratory flow
• Lower tidal volume
• Slow rate of breathing
• Small minute ventilation
• Long inspiratory time
• High I:E ratio
Decrease FiO2
• Lower O2 input
• Mouth-open breathing
• Higher inspiratory flow
• Higher tidal volume
• Fast rate of breathing
• Large minute ventilation
• Short inspiratory time
• Low I:E ratio
Oxygen delivery devices
2. High-flow system

• Ventury mask
Benoulli principle
Oxygen delivery devices
2. High-flow system

• Ventury mask

FiO2 varies
by altering the gas orifice or entrainment port size
fixed FiO2 model
variable FiO2 model
predictable
Independent of respiratory pattern
Monitoring Delivered Oxygen Concentration

Input
FDO2
Outcome
Physiologic result
PaO2
SaO2

By comparing input to outcome

 determine severity of the problem
 course of therapy
 equipment function
Selecting a delivery approach

No one best method

Decision  medical

‘ Three Ps ‘
Purpose
Patient
Performance
Purpose of oxygen therapy

  FiO2  to correct hypoxemia

  Hypoxic symptoms

 Minimizing cardiopulmonary work

Patient factors when selecting oxygen therapy equipment

 Severity/cause of hypoxia
 Patient age group
 Degree of consciousness/alertness
 Presence / absence of a tracheal airway
 Stability of the minute ventilation
Equipment performance

Vary in :
 Actual FDO2
 Stability of FiO2 under changing patient demands

The more critically ill the patient

 the greater the need for stable, high FDO2
Harmful effects of excessive oxygen

 Oxygen toxicity
 Oxygen-induced hypoventilation
 Retinopathy of prematurity
 Absorption atelectasis
 Depression of ciliary and/or leukocyte function
 Altered surfactant production / activity
Oxygen toxicity

Long-term exposure to high PO2

Congestion
Inflammation
Edema
 ENZYME DEFENSES

Superoxide dismutase
OXYGEN RADICALS
Glutathion peroxidase
Catalase
Superoxide anion
Hydrogen peroxide
Hydroxyl radical
ANTIOXIDANTS

Vit E
Vit C
Beta-carotene
Oxygen toxicity

Exposure time Physiologic response

(Hours)
0 – 12 Normal pulm. Function
Tracheobronchitis
Substernal chest pain

12 – 24 Decreasing vital capacity

24 – 30 Decreasing lung compliance
Increasing P(A-a)O2
Decreasing exercise PO2
30 – 72 Decreasing diffusing capacity

Jenkinson SG, Respir Care 28: 614-617, 1983

Oxygen toxicity

Clinical picture

Diffuse bronchopneumonia
Patchy infiltrates

alveolar exudate and consolidation

Low V/Q ratio
shunting
 O2
toxicity

Increased Increased
FiO2 shunting

Low
PaO2
 Factors altering development of O2 toxicity
Hastened onset or increased
severity
• Increased age
• Steroid administration
• Catecholamines
• Protein malnutrition
• Vitamin C, E or A
deficiency
• Trace metal deficiency
• Elevated serum iron
• Bleomycin or Adriamycin
• Hyperthermia
Delayed onset or decreased
severity
• Moderate O2 administration
• Adrenalectomy
• Endocrine exposure
• Prior lung damage
• Antioxidants
• Glutathion
• Hypothermia
• immaturity
Oxygen – induced hypoventilation

COPD
chronic hypoxemia and hypercapnia
ventilatory drive to CO2 is blunted
ventilatory drive by low O2

!!! Prevent hypoxia but avoid hypoventilation

Use low FiO2 (0.24 – 0.30)
PaO2 between 50 – 60 torr
Retinopathy of prematurity (ROP)
Retrolental fibroplasia

• Premature
• Low birth-weigh infant

Excessive blood oxygen level  Retinal vasoconstriction 

Necrosis of the blood vessels  Neovascularization 
Hemorrhage of new vessels  Scarring behind the retina 
Retinal detachment and blindness

• Keep the PaO2 below 80 torr

Absorption atelectasis

High FiO2 ( > 0.50 )  Nitrogen wash out

Reduced V/Q area

Oxygen will be absorbed into the blood faster than
ventilation can replace it
 the affected alveoli smaller  collapsed

Reopen collapsed alveoli

CPAP/PEEP
Hypoxic-related conditions that may improve with oxygen therapy

 Pulmonary hypertension
 Recurring congestive heart failure
 Chronic cor pulmonale
 Erythrocytosis
 Impaired cognitive process
 Nocturnal restlessness
 Morning headache
Oxygen delivery devices
2. High-flow system
• Aerosol mask and T piece with nebulizer or air-oxygen blender