Type of patients/ persons and related devices to supply Medical Oxygen in human body

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Various devices are used for administration of oxygen. In most cases, the oxygen will first pass through a pressure regulator, used to control the high pressure of oxygen delivered from a cylinder (or other source) to a lower pressure. This lower pressure is then controlled by a flowmeter, which may be preset or selectable, and this controls the flow in a measure such as litres per minute (lpm). The typical flowmeter range for medical oxygen is between 0 and 15 lpm with some units able to obtain up to 25 liters per minute. Many wall flowmeters using a Thorpe tube design are able to be dialed to "flush" which is beneficial in emergency situations.

   

Supplemental oxygen

Many patients require only a supplementary level of oxygen in the room air they are breathing, rather than pure or near pure oxygen, and this can be delivered through a number of devices dependant on the situation, flow required and in some instances patient preference.

A nasal cannula (NC) is a thin tube with two small nozzles that protrude into the patient's nostrils. It can only comfortably provide oxygen at low flow rates, 2–6 litres per minute (LPM), delivering a concentration of 24–40%.

There are also a number of face mask options, such as the simple face mask, often used at between 6 and 12 LPM, with a concentration of oxygen to the patient of between 28% and 50%. This is closely related to the more controlled air-entrainment masks, also known as Venturi masks, which can accurately deliver a predetermined oxygen concentration to the trachea up to 40%.

In some instances, a partial rebreathing mask can be used, which is based on a simple mask, but featuring a reservoir bag, which increases the provided oxygen rate to 40–70% oxygen at 5 to 15 LPM.
Non-rebreather masks draw oxygen from an attached reservoir bags, with one-way valves that direct exhaled air out of the mask. When properly fitted and used at flow rates of 10-15 LPM or higher, they deliver close to 100% oxygen. This type of mask is indicated for acute medical emergencies.

Demand valves or oxygen resuscitators deliver oxygen only when the patient inhales, or, in the case of an apnic (non-breathing) victim, the caregiver presses a button on the mask. These systems greatly conserve oxygen compared to steady-flow masks, which is useful in emergency situations when a limited supply of oxygen is available and there is a delay in transporting the patient to higher care. They are very useful in performing CPR, as the caregiver can deliver rescue breaths composed of 100% oxygen with the press of a button. Care must be taken not to over-inflate the patient's lungs, and some systems employ safety valves to help prevent this. These systems may not be appropriate for unconscious patients or those in respiratory distress, because of the effort required to breathe from them.

High flow oxygen delivery

In cases where the patient requires a flow of up to 100% oxygen, a number of devices are available, with the most common being the non-rebreather mask (or reservoir mask), which is similar to the partial rebreathing mask except it has a series of one-way valves preventing exhaled air from returning to the bag. There should be a minimum flow of 10 L/min. The delivered FIO2 of this system is 60-80%, depending on the oxygen flow and breathing pattern. High flows of warmed and humidified air/oxygen blends can also be delivered via a nasal cannula, allowing the patient to continue to talk, eat and drink while still receiving the therapy.
In specialist applications such as aviation, tight fitting masks can be used, and these also have applications in anaesthesia, carbon monoxide poisoning treatment and in hyperbaric oxygen therapy

Positive pressure delivery

Patients who are unable to breathe on their own will require positive pressure to move oxygen in to their lungs for gaseous exchange to take place. Systems for delivering this vary in complexity (and cost), starting with a basic pocket mask adjunct which can be used by a basically trained first aider to manually deliver artificial respiration with supplemental oxygen delivered through a port in the mask.

Many emergency medical service and first aid personnel, as well as hospitals, will use a bag-valve-mask (BVM), which is a malleable bag attached to a face mask (or invasive airway such as an endotracheal tube or laryngeal mask airway), usually with a reservoir bag attached, which is manually manipulated by the healthcare professional to push oxygen (or air) in to the lungs. This is the only procedure allowed for initial treatment of cyanide poisoning in the UK workplace.

Automated versions of the BVM system, known as a resuscitator or pneupac can also deliver measured and timed doses of oxygen direct to patient through a facemask or airway. These systems are related to the anaesthetic machines used in operations under general anaesthesia that allows a variable amount of oxygen to be delivered, along with other gases including air, nitrous oxide and inhalational anaesthetics.

As a drug delivery route

Oxygen therapy can also be used as part of a strategy for delivering drugs to a patient, with the usual example of this being through a nebulizer mask, which delivers nebulizable drugs such as salbutamol or epinephrine into the airways by creating a vapor-mist from the liquid form of the drug.

Filtered oxygen masks

Filtered oxygen masks have the ability to prevent exhaled, potentially infectious particles from being released into the surrounding environment. These masks are normally of a closed design such that leaks are minimized and breathing of room air is controlled through a series of one-way valves. Filtration of exhaled breaths is accomplished either by placing a filter on the exhalation port, or through an integral filter that is part of the mask itself. These masks first became popular in the Toronto (Canada) healthcare community during the 2003 SARS Crisis. SARS was identified as being respiratory based and it was determined that conventional oxygen therapy devices were not designed for the containment of exhaled particles. Common practices of having suspected patients wear a surgical mask was confounded by the use of standard oxygen therapy equipment. In 2003, the HiOx80 oxygen mask was released for sale. The HiOx80 mask is a closed design mask that allows a filter to be placed on the exhalation port. Several new designs have emerged in the global healthcare community for the containment and filtration of potentially infectious particles. Other designs include the ISO-O2 oxygen mask, the Flo2Max oxygen mask, and the O-Mask. The use of oxygen masks that are capable of filtering exhaled particles is gradually becoming a recommended practice for pandemic preparation in many jurisdictions.

Because filtered oxygen masks use a closed design that minimizes or eliminates inadvertent exposure to room air, delivered oxygen concentrations to the patient have been found to be higher than conventional non-rebreather masks, approaching 99% using adequate oxygen flows. Because all exhaled particles are contained within the mask, nebulized medications are also prevented from being released into the surrounding atmosphere, decreasing the occupational exposure to healthcare staff and other patients.

Contraindications


Many EMS protocols indicate that oxygen should not be withheld from any patient, while other protocols are more specific or circumspect. However, there are certain situations in which oxygen therapy is known to have a negative impact on a patient’s condition.

Oxygen should never be given to a patient who is suffering from paraquat poisoning unless they are suffering from severe respiratory distress or respiratory arrest, as this can increase the toxicity. (Paraquat poisoning is rare — for example 200 deaths globally from 1958 to 1978). Oxygen therapy is not recommended for patients who have suffered pulmonary fibrosis or other lung damage resulting from bleomycin treatment.

High levels of oxygen given to infants causes blindness by promoting overgrowth of new blood vessels in the eye obstructing sight. This is retinopathy of prematurity (ROP).

Oxygen has vasoconstrictive effects on the circulatory system, reducing peripheral circulation and was once thought to potentially increase the effects of stroke. However, when additional oxygen is given to the patient, additional oxygen is dissolved in the plasma according to Henry's Law. This allows a compensating change to occur and the dissolved oxygen in plasma supports embarrassed (oxygen-starved) neurons, reduces inflammation and post-stroke cerebral edema. Since 1990, hyperbaric oxygen therapy has been used in the treatments of stroke on a worldwide basis. In rare instances, hyperbaric oxygen therapy patients have had seizures. However, because of the aforementioned Henry's Law effect of extra available dissolved oxygen to neurons, there is usually no negative sequel to the event. Such seizures are generally a result of oxygen toxicity, although hypoglycemia may be a contributing factor, but the latter risk can be eradicated or reduced by carefully monitoring the patient's nutritional intake prior to oxygen treatment.

Oxygen first aid has been used as an emergency treatment for diving injuries for years. Recompression in a hyperbaric chamber with the patient breathing 100% oxygen is the standard hospital and military medical response to decompression illness. The success of recompression therapy as well as a decrease in the number of recompression treatments required has been shown if first aid oxygen is given within four hours after surfacing.

There are suggestions that oxygen administration may not be the most effective measure for the treatment of decompression illness and that heliox may be a better alternative

 

Chronic obstructive pulmonary disease

Care needs to be exercised in patients with chronic obstructive pulmonary disease, such as emphysema, especially in those known to retain carbon dioxide (type II respiratory failure). Such patients may further accumulate carbon dioxide and decreased pH (hypercapnation) if administered supplemental oxygen, possibly endangering their lives. This is primarily as a result of ventilation–perfusion imbalance. In the worst case, administration of high levels of oxygen in patients with severe emphysema and high blood carbon dioxide may reduce respiratory drive to the point of precipitating respiratory failure, with an observed increase in mortality compared with those receiving titrated oxygen treatment. However, the risk of the loss of respiratory drive are far outweighed by the risks of withholding emergency oxygen, and therefore emergency administration of oxygen is never contraindicated. Transfer from field care to definitive care, where oxygen use can be carefully calibrated, typically occurs long before significant reductions to the respiratory drive.

A 2010 study has shown that titrated oxygen therapy (controlled administration of oxygen) is less of a danger to COPD patients and that other, non-COPD patients, may also, in some cases, benefit more from titrated therapy

  Fire risk

Highly concentrated sources of oxygen promote rapid combustion. Oxygen itself is not flammable, but the addition of concentrated oxygen to a fire greatly increases its intensity, and can aid the combustion of materials (such as metals) which are relatively inert under normal conditions. Fire and explosion hazards exist when concentrated oxidants and fuels are brought into close proximity; however, an ignition event, such as heat or a spark, is needed to trigger combustion. A well-known example of an accidental fire accelerated by pure oxygen under pressure occurred in the Apollo 1 spacecraft in January 1967 during a ground test; it killed all three astronauts. A similar accident killed Soviet cosmonaut Valentin Bondarenko in 1961.

Combustion hazards also apply to compounds of oxygen with a high oxidative potential, such as peroxides, chlorates, nitrates, perchlorates, and dichromates because they can donate oxygen to a fire.

Concentrated O2 will allow combustion to proceed rapidly and energetically. Steel pipes and storage vessels used to store and transmit both gaseous and liquid oxygen will act as a fuel; and therefore the design and manufacture of O2 systems requires special training to ensure that ignition sources are minimized. Highly concentrated oxygen in a high-pressure environment can spontaneously ignite hydrocarbons such as oil and grease, resulting in fire or explosion. The heat caused by rapid pressurization serves as the ignition source.

For this reason, storage vessels, regulators, piping and any other equipment used with highly concentrated oxygen must be "oxygen-clean" prior to use, to ensure the absence of potential fuels. This does not apply only to pure oxygen; any concentration significantly higher than atmospheric (approximately 21%) carries a potential risk.

Hospitals in some jurisdictions, such as the UK, now operate “no-smoking” policies, which although introduced for other reasons, supports the aim of keeping ignition sources away from medical piped oxygen. Other recorded sources of ignition of medically prescribed oxygen include candles, aromatherapy, medical equipment, cooking, and unfortunately, deliberate vandalism. Smoking pipes, cigars and cigarettes are of special concern. This does not entirely eliminate the risk of injury with portable oxygen systems, especially if compliance is poo

Oxygen therapy while on aircraft


In the United States, most airlines restrict the devices allowed on board aircraft. As a result passengers are restricted in what devices they can use. Some airlines will provide cylinders for passengers with an associated fee. Other airlines allow passengers to carry on approved portable concentrators. However the lists of approved devices varies by airline so passengers need to check with any airline they are planning to fly on. Passengers are generally not allowed to carry on their own cylinders. In all cases, passengers need to notify the airline in advance of their equipment.

Effective May 13, 2009, the Department of Transportation and FAA ruled that a select number of portable oxygen concentrators are approved for use on all commercial flights. The list of approved portable oxygen concentrators includes the Respironics EverGo, the Invacare XPO2, the Invacare Solo 2 and others.
FAA regulations require larger airplanes to carry D-cylinders of oxygen for use in an emergency.

Breathing Oxygen


A diving cylinder, scuba tank or diving tank is a gas cylinder used to store and transport high pressure breathing gas as a component of a scuba set. It provides gas to the scuba diver through the demand valve of a diving regulator.

Diving cylinders typically have an internal volume of between 3 and 18 litres (0.11 and 0.64 cu ft) and a maximum pressure rating from 200 to 300 bars (2,900 to 4,400 psi). The internal cylinder volume is also expressed as "water capacity" - the volume of water which could be contained by the cylinder. When pressurised, a cylinder carries a volume of gas greater than its water capacity because gas is compressible. 600 litres (21 cu ft) of gas at atmospheric pressure is compressed into a 3-litre cylinder when it is filled to 200 bar. Cylinders also come in smaller sizes, such as 0.2, 1.5 and 2 litres, however these are not generally used for breathing, instead being used for purposes such as Surface Marker Buoy, drysuit and buoyancy compensator inflation.

Divers use gas cylinders above water for many purposes including storage of gases for oxygen first aid treatment of diving disorders and as part of storage "banks" for diving air compressor stations. They are also used for many purposes not connected to diving. For these applications they are not diving cylinders.

The term "diving cylinder" tends to be used by gas equipment engineers, manufacturers, support professionals, and divers speaking British English. "Scuba tank" or "diving tank" is more often used colloquially by non-professionals and native speakers of American English. The term "oxygen tank" is commonly used by non-divers when referring to diving cylinders; however, this is a misnomer. These cylinders typically contain (atmospheric) breathing air, or an oxygen-enriched air mix. They rarely contain pure oxygen, except when used for rebreather diving, shallow decompression stops in technical diving or for in-water oxygen recompression therapy. Breathing oxygen at depths greater than 20 feet (6.1 m)(equivalent to a partial pressure of oxygen of 1.6 ATA) can result in oxygen toxicity, a highly dangerous condition that can trigger seizures and thus lead to drowning.


Nitrox refers to any gas mixture composed (excluding trace gases) of nitrogen and oxygen; this includes normal air which is approximately 78% nitrogen, 21% oxygen, and 1% other gases, primarily argon.

However, in scuba diving, nitrox is normally differentiated and handled differently from air. The most common use of nitrox mixtures containing higher than normal levels of oxygen is in scuba, where the reduced percentage of nitrogen is advantageous in reducing nitrogen uptake in the body's tissues and so extending the possible dive time, and/or reducing the risk of decompression sickness (also known as the bends).


Enriched Air Nitrox, nitrox with an oxygen content above 21%, is mainly used in scuba diving to reduce the proportion of nitrogen in the breathing gas mixture. Reducing the proportion of nitrogen by increasing the proportion of oxygen reduces the risk of decompression sickness for the same dive profile, or allows extended dive times without increasing the need for decompression stops for the same risk. Nitrox is not a safer gas than compressed air in all respects; although its use can reduce the risk of decompression sickness, it increases the risk of oxygen toxicity and fire, which are further discussed below.

Breathing nitrox is not thought to reduce the effects of narcosis, as oxygen seems to have equally narcotic properties under pressure as nitrogen; thus one should not expect a reduction in narcotic effects due only to the use of nitrox. Nonetheless, there are people in the diving community who insist that they feel reduced narcotic effects at depths breathing nitrox. This may be due to a dissociation of the subjective and behavioral effects of narcosis. However, it should be noted that because of risks associated with oxygen toxicity, divers tend not to utilize nitrox at greater depths where more pronounced narcosis symptoms are more likely to occur. For a reduction in narcotic effects trimix or heliox, gases which also contain helium, are generally used by divers.

There is anecdotal evidence that the use of nitrox reduces post-dive fatigue, particularly in older and or obese divers; however a double-blind study to test this found no statistically significant reduction in reported fatigue. There was, however, some suggestion that post dive fatigue is due to sub-clinical decompression sickness (DCS) (i.e. micro bubbles in the blood insufficient to cause symptoms of DCS); the fact that the study mentioned was conducted in a dry chamber with an ideal decompression profile may have been sufficient to reduce sub-clinical DCS and prevent fatigue in both nitrox and air divers. In 2008, a study was published using wet divers at the same depth and confirmed that no statistically significant reduction in reported fatigue is seen.

Further studies with a number of different dive profiles, and also different levels of exertion, would be necessary to fully investigate this issue. For example, there is much better scientific evidence that breathing high-oxygen gases increase exercise tolerance, during aerobic exertion. Though even moderate exertion while breathing from the regulator is a relatively uncommon occurrence in scuba, as divers usually try to minimize it in order to conserve gas, episodes of exertion while regulator-breathing do occasionally occur in sport diving. Examples are surface-swimming a distance to a boat or beach after surfacing, where residual "safety" cylinder gas is often used freely, since the remainder will be wasted anyway when the dive is completed. It is possible that these so-far un-studied situations have contributed to some of the positive reputation of nitrox.

Safety and Precautions


The NFPA 704 standard rates compressed oxygen gas as nonhazardous to health, nonflammable and nonreactive, but an oxidizer. Refrigerated liquid oxygen (LOX) is given a health hazard rating of 3 (for increased risk of hyperoxia from condensed vapors, and for hazards common to cryogenic liquids such as frostbite), and all other ratings are the same as the compressed gas form.


Oxygen gas (O2) can be toxic at elevated partial pressures, leading to convulsions and other health problems. Oxygen toxicity usually begins to occur at partial pressures more than 50 kilopascals (kPa), or 2.5 times the normal sea-level O2 partial pressure of about 21 kPa (equal to about 50% oxygen composition at standard pressure). This is not a problem except for patients on mechanical ventilators, since gas supplied through oxygen masks in medical applications is typically composed of only 30%–50% O2 by volume (about 30 kPa at standard pressure). (although this figure also is subject to wide variation, depending on type of mask).

At one time, premature babies were placed in incubators containing O2-rich air, but this practice was discontinued after some babies were blinded by the oxygen content being too high.

Combustion and other hazards

Highly concentrated sources of oxygen promote rapid combustion. Fire and explosion hazards exist when concentrated oxidants and fuels are brought into close proximity; however, an ignition event, such as heat or a spark, is needed to trigger combustion. Oxygen itself is not the fuel, but the oxidant. Combustion hazards also apply to compounds of oxygen with a high oxidative potential, such as peroxides, chlorates, nitrates, perchlorates, and dichromates because they can donate oxygen to a fire.

Concentrated O2 will allow combustion to proceed rapidly and energetically. Steel pipes and storage vessels used to store and transmit both gaseous and liquid oxygen will act as a fuel; and therefore the design and manufacture of O2 systems requires special training to ensure that ignition sources are minimized.The fire that killed the Apollo 1 crew in a launch pad test spread so rapidly because the capsule was pressurized with pure O2 but at slightly more than atmospheric pressure, instead of the 1⁄3 normal pressure that would be used in a mission.

Liquid oxygen spills, if allowed to soak into organic matter, such as wood, petrochemicals, and asphalt can cause these materials to detonate unpredictably on subsequent mechanical impact. As with other cryogenic liquids, on contact with the human body it can cause frostbites to the skin and the eyes.
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