Manual of Healthcare Procedures | SKSU | 2024

OXYGENATION

Oxygen is essential for sustaining life. The cardiovascular and the respiratory systems
are responsible for supplying the body’s oxygen demands. Blood is oxygenated through the
mechanisms of ventilation, perfusion, and the transport of respiratory gases (Potter, Perry, Ross-
Kerr, & Wood, 2010).

Respiration is optimal when sufficient oxygenation occurs at the cellular level and when
cellular waste and carbon dioxide are adequately removed via the bloodstream and lungs. If this
system is interrupted — for example by lung tissue damage, inflammation or excess mucus in
the airways, or impairment of ventilation — intervention is required to support the client and
prevent the condition from worsening or, potentially, to prevent death from occurring (Perry,
Potter, & Ostendorf, 2014).

Oxygen is the most frequently used medication in emergency medicine, and when
used appropriately in the treatment of hypoxemia (an inadequate supply of oxygen in the arterial
blood), it potentially saves lives (Kane, Decalmer, & O’Driscoll, 2013). This chapter describes the
principles of oxygen therapy, the causes and management of hypoxia (the reduction of oxygen
supply at the tissue level), and the optimal use of oxygen therapy and treatment modalities.

Learning Objectives
• Describe the principles of oxygenation
• Understand the functions and limitations of pulse oximetry
• Describe the causes of hypoxia
• Identify when oxygen therapy is needed
• Describe the management of hypoxia
• List hazards, precautions, and complications of oxygen therapy
• Describe how to perform oral suctioning

MAINTAINING RESPIRATION OF PATIENT

The air we breathe is made up of various gases, 21% of which is oxygen. Therefore, a
patient who is receiving no supplemental oxygen therapy is still receiving oxygen from the
air. This amount of oxygen is adequate provided that the patient’s airway is not compromised and
there is sufficient hemoglobin in the blood. The cardiovascular system must also be intact and
able to circulate blood to all body tissues. If any of these systems fail, the patient will
require supplemental oxygen to increase the likelihood that adequate levels of oxygen will reach
all vital body tissues necessary to sustain life.

Oxygen in the Blood

Hemoglobin (Hgb) holds oxygen in reserve until the metabolic demands of the body
require more oxygen. The Hgb then moves the oxygen to the plasma for transport to the
tissues. The body’s demand for oxygen is affected by activity, metabolic status, temperature, and
level of anxiety. The ability of Hgb to move the oxygen to the tissues depends on a number of
factors, such as oxygen supply, ventilatory effectiveness, nutrition, cardiac output, hemoglobin
level, smoking, drug use, and underlying disease. Any one of these factors
can potentially impede the supply and transport of oxygen to the tissues.

Measurement of Oxygen in the Blood

The vast majority of oxygen carried in the blood is attached to hemoglobin and can be
assessed by monitoring the oxygen saturation through pulse oximetry (SpO2).The target range

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for oxygen saturation as measured by blood analysis (SaO2), such as arterial blood gas, is 92%
to 98% for a normal adult. Arterial blood gas (ABG) is the analysis of an arterial blood sample to
evaluate the adequacy of ventilation, oxygen delivery to the tissues, and acid-base balance status
(Simpson, 2004). For patients with COPD, the target SaO2 range is 88% to 92% (Alberta Health
Services, 2015; British Thoracic Society, 2008; Kane et al., 2013). Only about 3% of the oxygen
carried in the blood is dissolved in the plasma, which can be assessed by looking at the partial
pressure of oxygen in the blood through blood gas analysis (PaO2). The normal PaO2 of a
healthy adult is 80 to 100 mmHg. The SpO2 is more clinically significant than the PaO2 in
determining the oxygen content of the blood.
Oxygen is considered a medication and therefore requires continuous monitoring of the
dose, concentration, and side effects to ensure its safe and effective use (Alberta Health Services,
2015). Oxygen therapy may be indicated for hypoxemia and hypoxia.

PULSE OXIMETRY

Oxygen saturation, sometimes referred to as ‘‘the fifth vital sign,” should be checked by pulse
oximetry in all breathless and acutely ill patients (British Thoracic Society, 2008). SpO2 and
the inspired oxygen concentration should be recorded on the observation chart together with
the oximetry result. The other vital signs of pulse, blood pressure, temperature, and
respiratory rate should also be recorded in situations where supplemental oxygen is required.

Pulse oximetry is a painless, non-invasive method to monitor SpO2 intermittently

and continuously. The use of a pulse oximeter is indicated in patients who have, or are at
risk for, impaired gaseous exchange or an unstable oxygen status.

OXYGEN SOURCES

How oxygen is supplied will depend on the client’s setting. In an acute care setting,
oxygen is delivered directly to the client via a wall oxygen outlet. Oxygen tubing is attached to a
flow meter which are attached to green oxygen outlets. In home and long-term care facilities,
clients may use oxygen concentrators or portable oxygen tanks.

Types Additional Information/ Description

Oxygen Supply Outlets In inpatient settings, rooms are equipped with wall-
mounted oxygen supply outlets that are nationally
standardized in a green color, whereas air outlets are
standardized with a yellow color. Oxygen flow meters
are attached to the green oxygen outlets, and then
the oxygenation device is attached to the flow meter.
An oxygen flow meter consists of a glass cylinder
containing a steel ball with an opening through which
oxygen from the supply source is injected through an
adapter. This adapter is commonly referred to as a
“tree” because of its appearance. Oxygen is turned
on, and the flow rate of oxygen is controlled by
turning the green valve on the side of the glass
Figure 47. Oxygen flow meter cylinder. The flow rate is set according to the location
of a steel ball inside the cylinder and the numbered
lines on the glass cylinder. For example, in Figure
9.3.1 the flow rate is currently set at 2 liter per minute
(L / min). It is essential to implement safety
precautions whenever oxygen is used.

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Portable Oxygen Tanks Portable oxygen tanks are commonly used when
transporting a client to procedures within the hospital
or to other agencies. See Figure 9.3.2 for an image
of a portable oxygen tank.
Oxygenation devices are connected to the tank in a
similar manner as the wall-mounted oxygen flow
meter. It is crucial for nurses and transporters to
ensure the tank has an adequate amount of oxygen
for use during transport, is turned on, and the
appropriate flow rate is set.

Figure 48. Portable oxygen tank

Oxygen Concentrators Instead of oxygen tanks, oxygen concentrators are
commonly used by clients in their home environment.
See Figure 9.3.3 for an image of a home oxygen
concentrator.
Oxygen concentrators are also produced in portable
sizes that are lightweight and easy for the client to
use while travelling and mobile in the community.
Oxygen concentrators work by taking the 21%
concentration of oxygen in the air, running it through
a molecular sleeve to remove the nitrogen and
concentrating the oxygen to a 96% level, thus
producing between 1 and 6 liters per minute of
oxygen.
Oxygen concentrators may provide pulse flow or
continuous flow. Pulse flow only occurs on inhalation,
whereas continuous flow delivers oxygen throughout
Figure 49. Oxygen Concentrator the entire breath cycle. Pulse versions are the most
lightweight because oxygen is provided only as
needed by the client.

TYPES OF OXYGEN TUBING AND EQUIPMENT

Types Additional Information/ Description
Nasal-cannula (low-flow system) Nasal cannula consists of a small-bore tube
connected to two short prongs that are
inserted into the nares to supply oxygen
directly from a flow meter or through
humidified air to the client. It is used for short-
or long-term therapy (i.e., COPD patients), and
is best used with stable clients who require low
amounts of oxygen.
Advantages: Can provide 24% to 40% O2
(oxygen) concentration. Most common type of
oxygen equipment. Can deliver O2 at 1 to 6
litres per minute (L/min). It is convenient as the
client can talk and eat while receiving oxygen.
May be drying to nares if level is above 4
L/min. Easy to use, low cost, and disposable.
Limitations: Easily dislodged, not as effective if a
Figure 50. Client with a nasal cannula client is a mouth breather or has blocked
nostrils or a deviated septum or polyps. Nasal
dryness can occur.

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Simple face mask (low-flow system) A mask fits over the mouth and nose of the client
and consists of exhalation ports (holes on the
side of the mask) through which the client
exhales CO2 (carbon dioxide). These holes
should always remain open. The mask is held
in place by an elastic around the back of the
head, and it has a metal piece to shape over
the nose to allow for a better mask fit for the
client. Humidified air may be attached if
concentrations are drying for the client.
Advantages: Can provide 40% to 60%
O2 concentration. Flow meter should be set to
deliver O2 at 6 to 10 L/min. Used to provide
moderate oxygen concentrations. Efficiency
depends on how well mask fits and the
patient’s respiratory demands. Readily
Figure 51. Simple Face Mask available on most hospital units. Provides
higher oxygen for patients.
Disadvantages: Difficult to eat with mask on.
Mask may be confining for some clients, who
may feel claustrophobic with the mask on.
NOTE: exhalation ports / holes/ vents on the
sides of the mask must be open to allow for
gas exchange.
Non re-breather mask (high-flow Consists of a simple mask and a small reservoir
system) bag attached to the oxygen tubing connecting
to the flow meter. With a re-breather mask,
there is no re-breathing of exhaled air. It has a
series of one-way valves between the mask
and the bag and the covers on the exhalation
ports. On inspiration, the patient only breathes
in from the reservoir bag; on exhalation, gases
are prevented from flowing into the reservoir
bag and are directed out through the
exhalation ports.
Advantages: With a good fit, the mask can
deliver between 60% and 80% FiO2 (fraction
of inspired oxygen). The flow meter should be
set to deliver O2 at 10 to 15 L/min. Flow rate
must be high enough to ensure that the
reservoir bag remains partially inflated during
inspiration.
Disadvantages: These masks have a risk of
suffocation if the gas flow is interrupted. The
bag should never totally deflate. The client
should never be left alone unless the one-way
Figure 52. Non-rebreather mask valves on the exhalation ports are
removed. This equipment is used by
respiratory therapists for specific short-term,
high oxygen requirements such as pre-
intubation and patient transport. They are not
available on general wards due to: 1. the risk
of suffocation, 2. the chance of hyper-
oxygenation, and 3. their possible lack of

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humidity. The mask also requires a tight seal

and may be hot and confining for the client.
The mask will interfere with talking and eating.
Face tent (low-flow system) The mask covers the nose and mouth and does
not create a seal around the nose.
Advantages: Can provide 28% to 100% O2 Flow
meter should be set to deliver O2 at a
minimum of 15 L/min. Face tents are used to
provide a controlled concentration of oxygen
and increase moisture for clients who have
facial burn or a broken nose, or who are are
claustrophobic.
Disadvantages: It is difficult to achieve high
levels of oxygenation with this mask…but
sometimes this is the only option

Figure 53. Face tent

Venturi mask (high-flow system) High-flow system consisting of a bottle of sterile
water, corrugated tubing, a drainage bag,
air/oxygen ratio nebulizer system, and a mask
that works with the corrugated tubing. The
mask may be an aerosol face mask,
tracheostomy mask, a T-piece, or a face tent.
The key is that the flow of oxygen exceeds the
peak inspiratory flow rate of the client, and
there is little possibility for the client to breathe
in air from the room
Advantages: The system can provide 24% to
60% O2 at 4 to 12 L/min. Delivers a more
precise level of oxygen by controlling the
specific amounts of oxygen delivered. The
port on the corrugated tubing (base of the
Figure 54. Venturi mask mask) sets the oxygen concentration. Delivers
humidified oxygen for patient comfort. It does
not dry mucous membranes.
Disadvantages: The mask may be hot and
confining for some clients, and it interferes
with talking and eating. Need a properly fitting
mask. Nurses may be asked to set up a high-
flow system. In other instances, respiratory
therapists may be responsible for regulating
and monitoring the high-flow systems.
Oxygen concentrator aka nebulizer / Concentrates oxygen from the wall source up to
humidifier (high flow system) 100%. Delivers humidified oxygen for
patient comfort and to reduce risk of drying out
mucous membranes.

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Figure 55. Nebulizer

High flow oxygen therapy (HFT) Oxygen delivery system that has the ability to
deliver high flows of oxygen -up to 60 L/min.
concentrated up to 100%. Oxygen that
is warmed to body temperature.
Humidity to promote mucociliary clearance
continuous flow and positive airway pressure
delivery.

Figure 56. High Flow nasal cannula

ORAL SUCTIONING
The purpose of oral suctioning is to maintain a patent airway and improve oxygenation by
removing mucous secretions and foreign material (vomit or gastric secretions) from the mouth
and throat (oropharynx). Oral suction is the use of a rigid plastic suction catheter, known as a
yankauer, to remove pharyngeal secretions through the mouth (Perry et al., 2014). The suction
catheter has a large hole for the thumb to cover to initiate suction, along with smaller holes along
the end, which mucous enters when suction is applied. The oral suctioning catheter is not used
for tracheotomies due to its large size.

Oral suctioning is useful to clear secretions from the mouth in the event a patient is
unable to remove secretions or foreign matter by effective coughing. Patients who benefit the
most include those with CVAs, drooling, impaired cough reflex related to age or condition, or
impaired swallowing (Perry et al., 2014).

Safety considerations:
• Avoid oral suctioning on patients with recent head and neck surgeries.
• Use clean technique for oral suctioning.

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• Know which patients are at risk for aspiration and are unable to clear secretions
because of an impaired cough reflex. Keep supplies readily available at the bedside and
ensure suction is functioning in the event oral suctioning is required immediately.
• Know appropriate suctioning limits and the risks of applying excessive pressure or
inadequate pressure.
• Avoid mouth sutures, sensitive tissues, and any tubes located in the mouth or nares.
• Avoid stimulating the gag reflex.
• Always perform a pre- and post-respiratory assessment to monitor patient for
improvement.
• Consider other possible causes of respiratory distress, such as pneumothorax,
pulmonary edema, or equipment malfunction.
• If an abnormal side effect occurs (e.g., increased difficulty in breathing, hypoxia,
discomfort, worsening vital signs, or bloody sputum), notify appropriate health care
provider.

Steps Additional Information

1. Assess patient need for suctioning Baseline respiratory assessment, including an

(respiratory assessment for signs of O2 saturation level, can alert the health care
hypoxia), risk for aspiration, and provider to worsening condition.
inability to protect own airway or clear Signs and symptoms include obvious excessive
secretions adequately, which may lead secretions; weak, ineffective cough; drooling;
to upper airway obstruction. gastric secretions or vomit in the mouth; or
gurgling sounds with inspiration and
expiration. Pooling of secretions may lead to
obstruction of airway. Suctioning is required
with alterations in oxygen levels and with
increased secretions.

2. Explain to patient how the procedure This allows patient time to ask questions and
will help clear out secretions and will increase compliance with the procedure.
only last a few seconds. If appropriate, Minimizes fear and anxiety.
encourage patient to cough. Encourage the patient to cough to bring
secretions from the lower airways to the upper
airways.

3. Position patient in semi-Fowler’s This facilitates ease of suctioning. Unconscious

position with head turned to the side. patients should be in the lateral position.

4. Perform hand hygiene, gather supplies, This prevents the transmission of

and apply non-sterile gloves. Apply microorganisms.
mask if a body fluid splash is likely to Supplies include a suction machine or suction
occur. connection, connection tubing, non-sterile
gloves, yankauer, water and a sterile basin,
mask, and clean towel.
Suctioning may cause splashing of body fluids.

5. Fill basin with water. Water is used to clear connection tubing in

between suctions. Fill basin with enough water
to clear the connection tubing at least three
times.

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Fill sterile container with sterile water

6. Attach one end of connection tubing to This prepares equipment to function effectively.
the suction machine and the other end
to the yankauer.

Suction container

7. Turn on suction to the required level. Suction levels for adults are 100-150 mmHg on
Test function by covering hole on the wall suction and 10-15 mmHg on portable
yankaeur with your thumb and suction units. Always refer to hospital policy for
suctioning up a small amount of water. suction levels.

8. Remove patient’s oxygen mask if Always be prepared to replace the oxygen if

present. Nasal prongs may be left in patient becomes short of breath or has
place. Place towel on patient’s chest. decreased O2 saturation levels.
The towel prevents patient from coming in
contact with secretions.

14. Insert yankauer catheter and apply Movement prevents the catheter from suctioning
suction by covering the thumb hole. to the oral mucosa and causing trauma to the
Run catheter along gum line to the tissues.
pharynx in a circular motion, keeping Coughing helps move secretions from the lower
yankauer moving. Encourage patient to airways to the upper airways.
cough. Apply suction for a maximum of 10 to 15
seconds. Allow patient to rest in between
suction for 30 seconds to 1 minute.

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Insert yankauer and apply suction by

covering the thumb hole

10. If required, replace oxygen on patient Replace oxygen to prevent or minimize hypoxia.
and clear out suction catheter by Clearing out the catheter prevents the
placing yankauer in the basin of water. connection tubing from plugging.

Clear suction tubing with water

11. Reassess and repeat oral suctioning if Compare pre- and post-suction assessments to
required. determine if intervention was effective.

12. Reassess respiratory status and This identifies positive response to suctioning
O2 saturation for improvements. Call for procedure and provides objective measure of
help if any abnormal signs and effectiveness.
symptoms appear.

13. Ensure patient is in a comfortable This promotes patient comfort.

position and call bell is within reach.
Provide oral hygiene if required.

14. Clean up supplies, remove gloves, and Cleanup prevents the transmission of
wash hands. Document procedure microorganisms. Documentation provides
according to hospital policy. accurate details of response to suctioning and
clear communication among the health care
team.

Data source: Perry et al., 2014; Potter et al., 2010

Other Special Considerations for Oral Suctioning:

• Review the protocol at your health authority prior to initiating any high-flow oxygen
systems, and consult your respiratory therapist.
• In general, nasal prongs and a simple face mask (low-flow oxygen equipment) may be
applied by a health care provider. All other oxygen equipment (high-flow systems) must
be set up and applied by a respiratory therapist.
• For patients with asthma, nebulizer treatments should use oxygen at a rate greater than
6 L/min. The patient should be changed back to previous oxygen equipment when
treatment is complete.

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• Oxygenation is reduced in the supine position. Hypoxic patients should be placed in an

upright position unless contraindicated (e.g., if they have spinal injuries or loss of
consciousness).
• In general, for most patients with COPD, target saturation is 88% to 92%. It is important
to recognize COPD patients are at risk for hypercapnic respiratory failure.
• Check the function of the equipment and complete a respiratory assessment at least
once each shift for low-flow oxygen and more often for high-flow oxygen.
• In acutely ill patients, oxygen saturation levels may require additional ABGs to regulate
and manage oxygen therapy.
• Oxygen saturation levels and delivery equipment should be documented on the patient’s
chart.

INCREASING OXYGEN IN THE LUNGS

The use of oxygen delivery systems is only one component to increasing oxygen to the
alveolar capillary bed to allow for optimal oxygenation to the tissues. Additional methods to
increase oxygen saturation levels in the body include (Perry et al., 2014):
▪ Maintaining satisfactory airway
▪ Optimizing oxygen-carrying capacities (hemoglobin levels)
▪ Reversing any respiratory depressants
▪ Using invasive or non-invasive ventilation when necessary
▪ Treating airflow obstruction with bronchodilators and sputum-clearing techniques
▪ Treating pulmonary edema as required

APPLYING AND TITRATING OXYGEN THERAPY

Safety Considerations:
• Perform hand hygiene.
• Check room for additional precautions.
Introduce yourself to patient.
• Check patient’s name band to confirm identification.
• Explain process to patient.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Apply principles of asepsis and safety.
• Disclaimer: Always review and follow your hospital policy regarding this specific skill.

PROCEDURE ON APPLYING AND TITRATING OXYGEN THERAPY

Steps Additional Information

1. Complete respiratory Assess need for O2: check SaO2 level with a pulse
assessment for hypoxia. oximetry device.
SaO2 should be greater than Assess for underlying medical conditions or alternate
92% unless otherwise stated by causes of hypoxia (cardiovascular).
the physician. The goal is to use
the least amount of oxygen to
maintain levels between 92%
and 98%.

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2. If a patient requires oxygen Oxygen is initially started at a low concentration (2 L/min)

therapy, choose an oxygen using nasal prongs. Then the flow is titrated up to
delivery system based on your maintain oxygen saturation of 92% or greater.
patient’s requirements. Selection of delivery system is based on the level of
oxygen support required (controlled or non-controlled),
the severity of hypoxia, and the disease process. Other
factors include age, presence of underlying disease
(COPD), level of health, presence of an artificial airway,
and environment (home or hospital).
Significant decreases to O2 saturation levels or large
increases to maintain O2 saturation should be reported
promptly to responsible health care provider.

3. Once oxygen is applied, Hypoxia should be reduced or prevented. O2 levels

reassess your patient in 5 should be between 92% and 98%.
minutes to determine the effects Assess vital signs, respiratory and cardiovascular
on the body. systems, and level of consciousness. Assess and
implement additional treatments for hypoxia if
appropriate.
Reassess your patient if signs and symptoms of hypoxia
return.

4. If required, adjust O2 levels. Changes in O2 percentages should be in 5% to 10%

increments.
Patients should be reassessed (respiratory assessment
including O2 saturations) after 5 minutes following any
changes to oxygenation levels.
Changes in litre flow should be in 1 to 2 L increments.
Consider changing O2 delivery device if O2 saturation
levels are not maintained in target range.
Slow, laboured breathing is a sign of respiratory failure.

5. If hypoxia continues, contact Patient may require further interventions from the
respiratory therapist or respiratory therapist or most responsible health care
physician for further orders provider.
according to agency protocol. Signs and symptoms of respiratory deterioration include
increased respiratory rate, increased requirement of
supplemental oxygen, inability to maintain target
saturation level, drowsiness, decrease in level of
consciousness, headache, or tremors.

Data source: British Thoracic Society, 2008; Perry et al., 2014

Other Special considerations for Oxygenation:

• The underlying condition causing hypoxia must be treated to manage and improve
patient outcomes. For example, if hypoxia is caused by pneumonia, additional treatment
for hypoxia may include antibiotics, increased fluid intake, oral suctioning, position
changes, and deep breathing and coughing exercises.
• If a patient has COPD, check physician order for the amount of required oxygen and the
expected saturation level. In general, COPD patients receive 1 to 2 L/min (Kane et al.,
2013).
• Once oxygen saturation levels are within normal range, perform a respiratory
assessment every two to four hours to monitor need for supplemental oxygen.

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• When using oxygen therapy, assess the patient’s skin where the oxygen device comes
in contact with the patient. The nose, chin, and ears may have skin breakdown due to
the irritation of the tubing on the skin. Oxygen therapy tends to cause drying effects to
the nares and mouth. To prevent the drying effect, consider increasing fluid intake (if not
contraindicated). Perform frequent mouth care and apply humidification if the patient is
receiving more than 4 L/min (Perry et al., 2014).

CAUTIONS WITH OXYGEN THERAPY

Oxygen therapy supports life and supports combustion. While there are many benefits
to inhaled oxygen, there are also hazards and side effects. Anyone involved in the administration
of oxygen should be aware of potential hazards and side effects of this medication. Oxygen
should be administered cautiously and according to the safety guidelines listed below.

Table on Oxygen Safety Guidelines for Home and Hospital

Guideline Additional Information

1. Oxygen is a medication. Remind patient that oxygen is a medication and should

not be adjusted without consultation with a physician
or respiratory therapist.

2. Storage of oxygen cylinders When using oxygen cylinders, store them upright,
chained, or in appropriate holders so that they will not
fall over.

3. No smoking Oxygen supports combustion. No smoking is permitted

around any oxygen delivery devices in the hospital or
home environment.

4. Keep oxygen cylinders away Keep oxygen delivery systems at least 1.5 metres from
from heat sources. any heat source.

5. Check for electrical hazards in Determine that electrical equipment in the room or
the home or hospital prior to home is in safe working condition. A small electrical
use. spark in the presence of oxygen will result in a serious
fire. The use of a gas stove, kerosene space heater,
or smoker is unsafe in the presence of oxygen. Avoid
items that may create a spark (e.g., electrical razor,
hair dryer, synthetic fabrics that cause static
electricity, or mechanical toys) with nasal cannula in
use.

6. Check levels of oxygen in Check oxygen levels of portable tanks before

portable tanks. transporting a patient to ensure that there is enough
oxygen in the tank.

7. ABGs should be ordered for all High concentrations of oxygen therapy should be
critically ill patients on oxygen closely monitored with formal assessments (pulse
therapy. oximetry and ABGs).

Data source: British Thoracic Society, 2008; Perry et al., 2014

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PRECAUTIONS AND COMPLICATIONS OF OXYGEN THERAPY

Oxygen is essential to life, but as a drug it has both a maximum positive benefit and an
accompanying toxicity effect. The toxic effects from oxygen therapy can occur based on the
condition of the patient and the duration and intensity of the oxygen therapy.

For example, with normal lung function, a stimulation to take another breath occurs when
a patient has a slight rise in PaCO2. The slight rise in PaCO2 stimulates the respiratory centre in
the brain, creating the impulse to take another breath. In some patients with a chronically high
level of PaCO2, such as those with chronic obstructive pulmonary disease (COPD), the stimulus
and drive to breathe is caused by a decrease in PaO2. This is called a hypoxic drive. When
administering oxygen to patients with known CO2 retention, watch for signs of hypoventilation, a
decreased level of consciousness, and apnea.

Oxygen therapy can have harmful effects, which are dependent on the duration and
intensity of the oxygen therapy.

Table on Precautions and Complications of Oxygen Therapy

Complications Precautions

Oxygen-induced If patients with a hypoxic drive are given a high concentration of

hypoventilation/ oxygen, their primary urge to breathe is removed and hypoventilation
hypoxic drive or apnea may occur. It is important to note that not all COPD
patients have chronic retention of CO2, and not all patients with CO2
retention have a hypoxic drive. It is not commonly seen in clinical
practice.
Never deprive any patient of oxygen if it is clinically indicated. It is
usually acceptable to administer whatever concentration of oxygen is
needed to maintain the SpO2 between 88% and 92% in patients
with known chronic CO2 retention verified by an ABG.

Absorption About 80% of the gas in the alveoli is nitrogen. If high concentrations
actelectasis of oxygen are provided, the nitrogen is displaced. When the oxygen
diffuses across the alveolar-capillary membrane into the
bloodstream, the nitrogen is no longer present to distend the alveoli
(called a nitrogen washout).
This reduction in alveolar volume results in a form of collapse called
absorption atelectasis. This situation also causes an increase in the
physiologic shunt and resulting hypoxemia.

Oxygen toxicity Oxygen toxicity, caused by excessive or inappropriate supplemental

oxygen, can cause severe damage to the lungs and other organ
systems. High concentrations of oxygen, over a long period of time,
can increase free radical formation, leading to damaged
membranes, proteins, and cell structures in the lungs. It can cause a
spectrum of lung injuries ranging from mild tracheobronchitis to
diffuse alveolar damage.
For this reason, oxygen should be administered so that appropriate
target saturation levels are maintained.
Supplemental oxygen should be administered cautiously to patients
with herbicide poisoning and to patients receiving bleomycin. These
agents can increase the rate of development of oxygen toxicity.

Data source: British Thoracic Society, 2008; Perry et al., 2014.

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