Handbook of Oxygen Therapy Kapil Zirpe, Atul P Kulkarni, Subhal B Dixit, Shilpushp Bhosale, Khalid Ismail Khatib
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
Abscess, intracranial 112
Academia, workup of 86fc
Acetazolamide 86
Acid-base disorders 80, 81t
Acidemia 129
Acidosis 56, 80
Activator protein 117
Acute respiratory distress syndrome 28, 40, 81, 134, 136
Adenosine triphosphate 51, 124, 125
Adrenergic drugs 129
Aerobic metabolism 123
Air 10, 12, 18
emboli 111
entrainment, adjustment of 96
separation unit 3, 6, 23, 30
Albumin correction 83
Alkalemia 85
management of 87fc
Alkalosis 80
Alveolar gas equation 49
Alveolar hypoventilation 51, 71
Alveolar membrane 71
Alveolar septum 116
Alveolar-arterial gradient 49, 71
Alveolar-capillary membrane 129
Ambient light 78
Analeptics 84
Anemia 72, 78
acute blood loss 111
Anemic anoxia 62
Anemic hypoxia 51, 123, 130
Anesthesia 28
Angiogenesis inducers 125
Anion gap 86
concept of 84f
high 86
Anoxic anoxia 61
Anxiety 84
Arterial blood gas 71, 80, 80t, 82
analysis 80
Arterial carbon dioxide tension 61
Arterial insufficiency 112
Atelectasis 28
Avagadro's law 17
Barbeau test 76
Barometric otitis 113
Barotrauma 113
Beer-Lambart law 73
Bernoulli's principle 95
Bicarbonate 80
conservation 83f
Bilevel positive airway pressure 41
Biphosphoglycerate 66
Bleomycin 132
glucose 80
oxygen content of 50
plasma 64
pressure, monitoring systolic 76
Bohr effect 60, 66
Boyle's law 110
Brain injury, traumatic 134, 135
Bubble humidifier 100
Burns 79
Capillary transit time 70
Carbon dioxide 10, 12, 18, 47, 55, 57, 67, 69, 80, 93
Carbon dioxide dissociation curve 57f
Carbon dioxide retention 5557
Carbon dioxide, pressure of 67
Carbon monoxide 67
Carbon monoxide antagonism 110
Carbon monoxide exposure 129
Carbon monoxide hemoglobin dissociation curve 67f
Carbon monoxide poisoning 28, 51, 111
Carbonic acid 85
Carboxyhemoglobin 73, 110
Cardiopulmonary illness, acute 28
Catecholamine 84
Central nervous system 71, 113, 133
Cerebral hypoxia 126
Cerebrospinal fluid 56
Chamber attendants, risk to 113
Chest trauma 28
Chloride responsive 87
Chloride unresponsive 87
Chronic obstructive pulmonary disease 30, 32, 52, 57, 81, 105, 130, 131, 134, 135
Cilia, function of 99
Cirrhosis 81
myonecrosis 111
perfringens 111
Cold-water humidifier 100
Compartment syndromes 112
Compression injury 112
Conservative oxygen therapy 52
Continuous positive airway pressure 41
Convective oxygen transport 59
Corneal abrasions 79
Coronary vasoconstriction 52
COVID-19 40, 103
pandemic 3, 16
Crush injury 112
Cryogenic air separation unit 3, 4fc
Cryogenic fractional distillation method 23f, 28
Cryogenic liquid 22
cylinders 25
medical oxygen 22
Cyanide poisoning 51
Cyclopropane 12, 18
components of 16
connections 36
handling of 36
identification of 18
testing of 17
transportation of 36
Cytochrome oxidase 51
Cytopathic hypoxia 62
Cytotoxic hypoxia 124
Dead space ventilation 71
Decompression sickness 111
Deoxyhemoglobin 51, 73
Dephlogisticated air 22
Deployable oxygen concentration system 3, 5
Depression 71
Diabetic ketoacidosis 84
Diameter index safety system 11, 11f, 25, 26
Diarrhea 86
severe 81
Diffusion capacity, measurement of 70
Diffusive oxygen transport 62
Diphosphoglycerate 60, 61, 66, 67
Disposable probes 75t
Domiciliary oxygen therapy 38
Dual lumen cannula barbs 26f
Duplex vacuum pump 14f
Dysrhythmias 77
Ear 113
Electrical interference 78
Endotracheal tube 99
Enterocutaneous fistulas 86
Entonox 12
Enzymes, function of 116
Erythropoietin 125
Ethylene 18
glycol 84
External flow control valve 25
Face mask
partial rebreather 93, 93f
simple 93
Fetal hemoglobin 67
Fick's law 48, 62, 69
Fire hazard analysis, components of 37b
Fire triad 35f
Flickering lights 78
Flow control knob 26f
Fluid responsiveness 76
Gamma-amino butyric acid 116
Gas 8, 10, 12, 18
bubble size reduction 110
exchange, physiology of 47
gangrene 111
Gene expression, regulation of 125
Glucose transporters 125
Glutamic acid 116
Glycolytic enzymes 125
Guillain-Barré syndrome 130
Haldane effect 58, 60
Hazard analysis 36
Headache 118
Hearing loss, idiopathic acute sensory 112
Heart failure, chronic 72
Heat and moisture exchanger filter 100
Helium 18
Hemodynamic therapy, goal-directed 63
Hemoglobin 59, 64, 88, 123
capacity of 70
low 51
molecule 59f
S 77
saturation of 129
structure of 59f
Henry's law 64, 110
High-flow nasal cannula 96, 97f, 101, 103, 107
oxygen therapy 104f
High-flow nasal oxygen 101
High-flow systems 91fc, 131
Histotoxic hypoxia 51, 62, 129, 131
Hormones 84
Humidification 99, 105
devices, types of 100
physiology 99
risks of 101
system 100
Humidifiers, heated 100
Humidity 99
Hyperalimentation 86
Hyperbaric oxygen 129
therapy 28, 109
mechanism of action of 110
Hyperbaric therapy 109
Hyperbilirubinemia 78
Hypercapnia 56, 81
Hypercapnic respiratory failure 53, 105
Hypercarbia 129
Hyperchloremic metabolic acidosis 85
Hyperoxemia 76
Hyperoxia 123, 133
effects of 127
Hyperoxic acute lung injury 116
Hyperoxic states 129
Hyperthermia 129
Hypotension 81
Hypothyroidism 129
Hypoventilation 49, 130
Hypovolemia 77
Hypoxemia 51, 56, 84, 128
cause of 49
effects of 123
etiology of 49, 49t
Hypoxemic hypoxia 51, 123, 130
Hypoxia 123, 125, 128
adaptation to 124
effects of 123
type of 61, 130
Hypoxic episode 123
Hypoxic hypoxia 130t
Hypoxic ischemic encephalopathy 134, 135
Hypoxic respiratory failure 105
Hypoxic tissues 129
Industrial oxygen 5
Inflammatory lung disease, chronic 96
Infrared interference 78
Inspired oxygen, fraction of 136
Intensive care unit 12, 40
Keratinization 99
Kidneys 83f
Krogh's cylinder model 62
Kyphoscoliosis 71
Lambert-Eaton syndrome 130
Liberal oxygen therapy 52
Liquid medical oxygen 24, 42
tank 14, 24, 24f
Liquid oxygen 20, 23, 24, 30
benefits of 28
cryogenic production of 23f
cylinders 28
dewars 27
limitations of 28
plant 23
storage tanks 28
Lung 55, 113
primary function of 47
Mechanical ventilation 84
Medical air 14
components of 14
Medical gas
cylinders 16, 18t, 21
pipeline system 8, 22
components of 9f
Medical oxygen 5, 22, 40
Medical piped gas structure 8
Metabolic acidosis 8385
causes of
hyperchloremic 85
normal anion gap 85b
high anion gap 85b
Metabolic alkalosis 87t
Metabolic disorders 80
Metaplasia 99
Metastasis 126
Methanol 84
Methemoglobin 73
Methemoglobinemia 129
Mitochondria 59
Monoplace chambers 109, 109f
Motion artifacts 78
Multiplace hyperbaric chamber 110f
Myasthenia gravis 130
Myocardial infarction 118
Myocardial ischemia 126, 134
Nail polish 78
Nasal cannula 92
Nasal catheter 92, 92f
Nasal low-flow oxygen, long-term 100
Nasal mucosa 99
Near-infrared spectroscopy 51
Necrotizing fasciitis 111
Neoangiogenesis 126
Neuroepithelial bodies 124
Neurointensive care, management in 135
Neuromuscular weakness 71
Neuronal cells 124
Nitric oxide synthase 125
Nitrogen 18, 110
Nitrous oxide 10, 12, 18
Nocturnal oxygen therapy trial 30
Noninvasive ventilation 100, 103
Nonrebreather mask 94, 94f, 106
Non-ST-segment elevation myocardial infarction 134, 135
Nuclear magnetic resonance spectrometry 51
Obstructive sleep apnea 32
Optimal oxygenation target 126
Oxygen 3, 10, 12, 18, 22, 23, 35, 59, 62, 64, 94, 134
audit 40, 41
basic facts of 1
binding capacity 61
artificial 63
hemoglobin based 63
cascade 48f
consumption 50, 62, 129
content 50, 61
diffuses 69
diffusion of 69
ecosystem 40
enrichment, causes of 36b
extraction ratio 62
gas cylinders, sizes of 18t
hazards of 35, 36t
increased delivery of 110
leaks 38
manifold design 13
overzealous 136
partial pressure of 56
pressure gradient 129
production technologies 5, 6t
regulator 37f
requirement 40
sources 29t
species, reactive 116
stewardship program 40, 41
storage 37
targets 53, 121, 134t
transfer of 59
utilization of 59, 91
Oxygen concentrator 3, 5, 5fc, 6, 29, 30, 32, 33f, 34
advantages of 34
components of 32
disadvantages of 34
home users of 34
types of 32, 33t
Oxygen cylinder 36
filling 43
storage of 36
Oxygen delivery 36, 37, 50, 61t
devices 91, 131t
equipment 22
systems 12, 89
Oxygen therapy 35, 97, 99, 128, 130, 134, 137
cardinal goal of 51
devices 131
goals of 51, 52, 128
guidelines 132t
hazards 133
humidification of 99
long-term 28
monitoring of 45
physiology of 45
role of 130t
targeted 132
Oxygen toxicity 113, 115
diagnosis 116
differential diagnosis 119
pathophysiology of 115, 117f
prognosis 119
severe cases of 115
signs of 118t
symptoms of 118t
treatment 119
Oxygen transport 37, 59
and delivery 128
Oxyhemoglobin 51, 73
dissociation curve 60, 60f, 61t, 64, 65, 65f, 66, 66f, 66t
Paraquat toxicity 132
Peripheral oxygen saturation 57
Peripheral pulses 80
Persistent hypoxia 127
Pin index system 11, 12, 17
Piped gas system, components of 8
Plasma membrane 125
Pneumonia 28
Pneumothorax 28
Portable fill connector 26f
Portable liquid oxygen dewar 25
Portable oxygen concentrator 30, 31, 33f
Positive end-expiratory pressure 96, 104
Post-cardiac arrest 119
Postextubation 106
Postischemic dysfunction 126
Preoxygenation 106
Pressure 18
control system 24f
gauge 26f
injuries 79
swing adsorption 6, 12, 32, 43
plant 3, 4
Pressurized oxygen cylinder 29, 30
Progesterone 84
Pro-inflammatory cytokines 116
Protein-gas binding rate 70
Pseudomonas aeruginosa 101
Pulmonary blood flow 69
Pulmonary capillaries 69
Pulmonary edema 28, 84
Pulmonary embolism 28, 84
Pulmonary function test 116
Pulmonary hypertension 128
Pulmonary shunt 130
Pulmonary toxicity 133
Pulse oximeter
components of 75
principle of 75f
signals 78b
Pulse oximetry 73, 76
advantages of 76b
applications of 76
Radiation injury, chronic 111
Radio frequency identification 43
Red blood cell 85
Reflectance oximetry 75
Refractory osteomyelitis 111
Renal tubular acidosis 86
Reperfusion injury 126
Reservoir systems 131
Respiratory alkalosis, causes of 84b
Respiratory centre 55
Respiratory drive 57
Respiratory failure 81, 92
Respiratory rate 105
Safety regulations 110
Safety system 10, 11
Salicylates 84
Sepsis 78, 136
electric 79
septic 78
Shunt, left-to-right 71
Sickness impact profile score 31
Sinuses 113
grafts and flaps 111
irritation 79
pigmentation 78
Sleep apnea 106
Stagnant anoxia 61
Stagnant hypoxia 51, 123, 131
Staphylococcus aureus 101
Stationary oxygen concentrator 33f
Stationary unit 25, 26f
components of 26f
ST-elevation myocardial infarction 134
Stroke 119, 134, 135
Sulfhemoglobin 73
Supplemental oxygen 135
gradient, effect of 49
Thermal injury, acute 112
Tissue oxygenation, measures of 51
Toxic effects 115
Toxins 84
Tracheostomy 99
Transmission oximetry 75
Transtracheal oxygen catheter 94, 95f
Tumor angiogenesis 126
Tyrosine hydroxylase 125
Uremia 84
Urinary chloride 85
Vacuum 10
insulated evaporator 24
pressure swing adsorption plant 3, 4
system 13
Vacuum-insulated evaporator 24f
Valve service units 8, 9f, 10, 11f
Venous blood gas 80t
Vent valve 26f
Ventilation 58
Venturi devices, color-coded 96f
Venturi mask 95, 95f, 96
functionality 95f
Venturi principle 95f
Volatile acids 82
Vomiting 81
Ward vacuum unit 14f
Wound healing 111
Zone valves 10
Chapter Notes

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Handbook of Oxygen Therapy
Handbook of Oxygen Therapy
Editors Kapil Zirpe MD (Chest) FCCM FICCM Head Department of Neuro Critical Care Ruby Hall Clinic, Grant Medical Foundation Pune, Maharashtra, India Subhal B Dixit MD (Med) IDCCM FCCM FICCM FICP Director Department of Critical Care Sanjeevan Hospital Pune, Maharashtra, India Atul P Kulkarni MD (Anesthesiology) FISCCM PGDHHM FICCM Professor and Head Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Homi Bhabha National Institute Mumbai, Maharashtra, India Associate Editors Shilpushp Bhosale DM (Critical Care Medicine) Fellowship Pediatric Critical Care (Canada) Professor Division of Critical Care Medicine Department of Anesthesiology Critical Care and Pain Tata Memorial Centre Homi Bhabha National Institute Mumbai, Maharashtra, India Khalid Ismail Khatib MD (Medicine) FICCM FICP Professor Department of Medicine SKN Medical College Pune, Maharashtra, India Forewords Ashish K Khanna, BD Kadam
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Handbook of Oxygen Therapy
First Edition: 2022
Printed at:
Contributors Foreword
Oxygen is a much-utilized ‘medication’ in the inpatient environment. Whether the operating room, the intensive care unit or other acute care areas, most have access to this easily available agent. In fact, oxygen is the one thing that we turn to as a reflex action, whenever our patients are in a crisis. However, oxygen is also a drug, and like all other pharmacological interventions has a therapeutic window and potential adverse effects. Most commonly, we end up placing patients who leave the post-anesthesia care unit (PACU) or the emergency room or ICU on a few liters of oxygen for comfort or to keep their oxygen saturation numbers looking satisfactory. This practice is rather dangerous and may mask respiratory distress, specifically hypoventilation in situations where spontaneously breathing patients have an inadequate respiratory drive and with no measures of ventilation to guide therapy. Similarly, the use of high-inspired oxygen in ventilated ICU patients has the potential for free radical damage and absorption atelectasis, both often missed because of subtle early presentation. The need to understand, physiology, pharmacology, physics, and delivery of oxygen in a precise manner is paramount for improving patient outcomes. Unfortunately, there is a paucity of education around the use of this life-saving agent, even though all of us use it nearly every single day, we work in the hospital.
It is a pleasure to see this the first edition of the Manual of Oxygen Therapy, edited by three stalwarts in critical care and acute care medicine. I have known the editors, Dr(s) Kapil Zirpe, Subhal Dixit, and Atul P Kulkarni through their work in the field, and tremendous contributions to the Indian Society of Critical Care Medicine (ISCCM). It is not a surprise to me that they have put together an excellent compilation of authors and knowledge areas in this manual. The text itself is nicely divided into four sections that range from handling medical oxygen as a gas, monitoring the use of oxygen in the context of the physiology of gas exchange, delivery devices, toxicity, and therapy for individualized disease states. This will serve as a source of ready reference for the experienced clinicians, and a rich textbook for the medical students and trainees in medicine or paramedical fields. My very best wishes to this team, and congratulations on publishing this much-needed work that will benefit all of us.
Ashish K Khanna
Associate Professor, Vice-Chair for Research
Director, Perioperative Outcomes and Informatics Collaborative (POIC)
Department of Anesthesiology, Section on Critical Care Medicine
Wake Forest University School of Medicine
Atrium Health Wake Forest Baptist Medical Center
Winston-Salem, NC, USA 27106
It gives me great pleasure to write foreword for Manual of Oxygen Therapy. All the contributors to this book are critical care specialists, who deal with oxygen day-in and day-out.
They have put all their experience in this book and made it of practical utility than theoretical knowledge.
Oxygen is abundant in the atmosphere. We realize its importance only when it is most necessary for our survival. In my experience, I realized why oxygen is called Pranavayu in most of the vernacular languages, you remember it when you need it in your life.
After visiting Leh, I realized that even when walking for 10 steps, my colleagues and I cannot breathe easily. This was my first experience of hypoxia. It feels as though someone is trying to stop your breathing. It can be treated with oxygen inhalation and adequate bed rest. This is when you realize the importance of oxygen.
A second experience, I had was with Corona epidemic. The press reported that elderly people were giving up their oxygen beds for the sake of a young person. This was because oxygen was in short supply and patients were running from pillar to post of every hospital to get oxygen beds to save themselves or their relatives. Oxygen audit came into existence after this episode. Everyone realized oxygen was the most important resource in dealing with Corona epidemic.
If we look at the history of oxygen, we realize that oxygen was discovered by Carl Wilhelm Scheele in 1771 and named by Antoine Lavoisier as oxygen. Oxygen is atomic number 8. It is a highly reactive nonmetal oxidizing agent. It is present in the earth's atmosphere to the tune of 20.95%. Its stable compound is a di-oxygen molecule. Oxygen is used as therapy when it is supplied as a supplement to breathe in addition to air for hypoxemia. It can be utilized in various formats such as home oxygen therapy, hyperbaric oxygen therapy, hospital-based oxygen therapy, and extracorporeal membrane oxygenation (ECMO). It is an essential medicine classified by WHO. Normally, saturation of oxygen in the body is to the tune of 94–96%, however in COPD patients, it can be 88–92%. One can start oxygen at saturation of less than 90% and stop the same above 96%. Yes, there are contraindications to oxygen therapy such as paraquat poisoning, bleomycin, aspiration, and sepsis to avoid hyperoxia. Its pathophysiological effects include absorption atelectasis, airway inflammation, CNS effects, CO2 retention, pulmonary vascular and systematic vasoconstriction when given more than demand. Hence oxygen therapy is to be used judiciously for saving a patient's life.
The present manual on oxygen therapy is a comprehensive effort to delineate various aspects of oxygen therapy. Dr Kapil Zirpe, Dr Subhal B Dixit, Dr Atul P Kulkarni, and their colleagues have certainly made a valuable contribution to society with this effort.
Section 1 of this book deals with the basics of oxygen purity, storage distribution, and safety of oxygen. With multiple incidents of fires in hospitals claiming lives, safety becomes the most critical aspect. It is equally important to distribute oxygen to multiple wards and the ICU to justify oxygen usage.
Section 2 of the book talks about the physiological effects of oxygen therapy and the basics of gas exchange. This gives us insights into oxygen therapy. It also speaks about targets in oxygen therapy and preventing oxygen toxicity. This section will enable physicians to use oxygen as a pharmaceutical agent with the appropriate understanding of its limitations and implications, including interpretation of blood gas analysis, oxygen dissociation curves, and monitoring by pulseoxymetry and its limitations.
Section 3 describes various oxygen delivery systems. During COVID epidemic, role of high flow oxygen therapy became the therapy of choice. Before this mode was underutilized. It is explained in this chapter how to use various delivery systems, ranging from a nasal catheter to intubation and ventilator in a graduated manner, without creating unnecessary and unsupervised oxygen toxicity.
Final section 4 describes the effect of hypoxia on various organ systems and how to revert it by using oxygen therapy. The mechanism of this therapy is described in detail. Oxygen therapy has to be utilized in light of underlying comorbidity and underlying lung or any other systematic disorder. Normal versus diseased lung ventilation for hypoxemia is different. Furthermore diseases such as ARDS, COPD, myocardial infarction, and stroke will change various aspects of oxygen therapy.
Thus this book will be a one-stop guide for oxygen therapy in a variety of disorders for physicians. This book should be a reference book in every place where oxygen therapy is being delivered as it will guide physicians to get optimal results from oxygen therapy. I congratulate editors and team for this wonderful venture.
BD Kadam
Professor Medicine Emeritus
BJ Government Medical College
Pune, Maharashtra, India
Chairman, COVID-19 Task Force, Pune Division
Master Teacher Awardee By Association of Physicians of India (API)
Dear Friends, it gives us great pleasure in presenting to you this Manual of Oxygen Therapy. Ongoing COVID-19 pandemic has brought up number of respiratory issues. Many of us are unaware of administrative hard-work that is required, the detailed planning this entails in getting a small innocuous looking cylinder at the patient's bedside. Many doctors who are normally not called upon to provide oxygen therapy to patients in their routine clinical activities were forced to look after patients who were not only sick, but were requiring high fraction of inspired oxygen, during this unusual situation. Although oxygen therapy may be common in the various settings in hospital, it is used quite rarely at home under normal circumstances. The pandemic- forced patients to use oxygen at home, when clinicians were forced to discharge patients on oxygen therapy.
We felt that there is a lack of a source which will provide detailed information about how oxygen is stored, how it piped to the bedside of the intended recipient and how it should be administered. This manual of oxygen therapy is our attempt to provide this, and other information regarding its appropriate use, devices which are used deliver oxygen to the patient and complications associated with oxygen therapy. Thus, our main purpose in writing this manual was to spread knowledge among non-acute care practicing clinicians, critical care trainee and paramedics. This book will be a good source of ready reference.
While preparing the table of contents, we have tried to cover topics ranging from differences between industrial and medical gas, medical gas pipeline designs physiology gas exchange, to oxygen therapy targeted towards specific diseases. The contributions have come from experts in the subject and from all corners of India.
This book is user-friendly and provides information in structured manner. We hope the readers will enjoy reading this book as much as loved planning, designing and writing it. It is also our fervent hope that it proves handy in day-to-day practice of the busy clinicians, juniors and seniors alike.
Best wishes!
Kapil Zirpe
Subhal B Dixit
Atul P Kulkarni