MODULE
Oxygen Therapy in Severely ill
COVID 19 Patients
OBJECTIVES
I. Revise criteria for severe COVID 19
II. Define indications for O2 therapy in COVID 19
III. Explain different O2 Delivery Systems
IV. Revise indications for intubation and Mechanical Ventilation
in COVID 19 Patients
Severity Classification of Covid-19
WHO Illness Definition
Severity
Non - Severe Absence of any criteria for severe or critical COVID – 19
SEVERE COVID - O saturations < 90% on room air,
2 RR
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> 30, use of accessory muscles, inability
to complete sentences. In paeds, severe
chest wall indrawing, grunting, cyanosis,
danger signs (lethargy, reduced levels of
consciousness, inability to breastfeed
CONT’
WHO Illness Definition
Severity
Critical COVID – ARDS, Sepsis, Septic shock or other
19 conditions that would normally require
the provision of life – sustaining therapies
such as mechanical ventilation ( non –
invasive or invasive or vaso pressor
therapy)
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Who Needs Oxygen?
I. Severe Acute Respiratory disease(Severe Pneumonia)
II. Critical illness
a. ARDS
b. Sepsis
c. Septic Shock
d. MOD
FEATURES OF SARI INDICATIVE OF
O2 THERAPY
Adult or adolescent
I. Dyspnoea
II. Tachypnoea RR >30
III. Cyanosis
IV. Hypoxaemia
a. SPO2 <90 if patient is hemodynamically stable
b. SPO2 <94 if pregnant
c. SPO2 <94 with emergency signs of airway, breathing or
cardiovascular compromise
FEATURES OF SARI INDICATIVE OF
O2 THERAPY
Children
I. Respiratory distress
a. Grunting
b. Chest indrawing
c. Nasal flaring, intercostal/subcostal recession, accessory
muscle use
d. Lethargic, inability to breast feed or drink
CONT’
I. Tachypnoea
a. < 2 months: ≥ 60;
b. 2–11 months: ≥ 50;
c. 1–5 years: ≥ 40.
d. Hypoxaemia, SPO2 < 94%
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SARI BY IMAGING
I. Ground glass opacities
II. Bilateral infiltrates
III. Dense consolidations
IV. B –lines +/- subpleural consolidations on ultrasound
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COVID 19 SEVERITY SCORING
I. The COVID-19 Severity Scoring Tool is a guide to inform
clinical decision making.
II. It is NOT intended for use as a replacement for clinical
decision making or diagnostic investigations
III. Also note that that O2 saturations may be lower in patients
with chronic lung disease: clinical discretion will be needed in
many cases
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SUSPECTED COVID-19 SEVERITY SCORING
Name Age M F
STARTHERE
`
ASK
Comorbidities:
Hypertension
Score – circle only Diabetes
those that apply COPD/Asthma
>2 comorbidities TB
or Current smoker
Comorbidities Immunocompromised 2 Immunocompromise:
or HIV/AIDS
Cardiovascular disease Severe malnutrition
Chronic steroid use
ASSESS Immune-suppressing
medication
Ongoing cancer treatment
Score – circle only
those that apply
With help 1
Mobility
Stretcher 2
Diffi culty breathing or
Assessment 3
Unresponsive
35 2
Temperature
38.5 3
45 2
Pulse
110 3
9 2
Respiratory rate 20 - 27 2
28 4
90 4
Systolic BP
160 2
SCORE
Add all those circled
to give patient’s total:
8 or more points 5-7 points 0-4 points
Less likely to need
Probably needs
mechanical ventilation. Less likely to need Oxygen
mechanical ventilation
Likely needs Oxygen
PULSE OXIMETRY
I. Pulse oximeters should be available
in all settings caring for patients
with SARI.
II. SpO2 reflects the oxygen saturation
of Hb in the arterial blood:
a. most oxygen is bound to Hb in
the blood for delivery to tissues
b. normal value is >95 (at sea level).
III. Clinical signs are not reliable
indicators of hypoxaemia.
PULSE OXIMETRY
Finger clip probes Ear probes
Benefits Limits
Accurate Requires a pulsatile signal – challenging with motion or poor
perfusion
Fast Does not measure ventilation (pCO2)
False readings can be seen with abnormal Hb or CO poisoning
Easy to use Remember to remove nail polish if present!
All pictures © WHO/S Mardel
WHERE IS THIS OXYGEN FROM?
I. Oxygen systems must consist of an oxygen source, or production
combined with storage.
II. The appropriate choice of oxygen source depends on many factors,
including: the amount of oxygen needed at the treatment centre;
the available infrastructure, cost, capacity and supply chain for
local production of medicinal gases; the reliability of electrical
supply; and access to maintenance services and spare parts, etc
NB: Only high quality, medical-grade oxygen should be given to
patients.
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OXYGEN SOURCES
Pressure swing adsorption
Cylinders Manifold systems Concentrators Oxygen plants Liquid oxygen
• Very common • Cylinder based • Mobile • Do not require • Space
• Mobile but • Require supply chain • Do not require supply chain requirements
can be heavy • Require facility to supply chain • Require • Requires facility
• Require high have piping • Require electricity to have piping
pressure • Relatively low electricity • Require • Supply chain
compressor maintenance • Require maintenance • Suitable for
for filling • Difficult to repair maintenance • May need piping larger facilities
• Require • Capable of filling
supply chain cylinders
• Photos: PATH/Mike Ruffo, Lisa Smith
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OXYGEN THERAPY: NASAL CANNULA
I. Indicated for low flow, low
percentage supplemental
oxygen
II. Delivers FiO2 25 up to 45%
Oxygen
III. Flow rate 1 – 6 L/min
IV. Patient must wear a face
mask
OXYGEN THERAPY: SIMPLE O2 MASK
I. Indicated for higher percentage
supplemental oxygen
II. Delivers FiO2 up to 35 – 60 %
III. Flow rates 6 – 10 L/min
IV. Patient must wear a mask
OXYGEN THERAPY: VENTURI MASKS
I. Indicated for more precise titration
of percentage of Oxygen
II. Delivers FiO2 25 – 60%
III. Flow rates 4 -8 L/min
IV. Patient must wear a mask
V. O2 flow rate device specific
4 – 15 L/min
OXYGEN THERAPY: O2 MASK WITH
NRB
I. Indicated for high percentage FiO2
II. Delivers FiO2 80 – 100%
III. Flow rates 10 – 15 L/min
IV. Caution with aerosolised droplet spread with
high flow O2
V. Humidification may be used but equipment
is a potential site of contamination
OXYGEN THERAPY: HIGH FLOW NASAL
CANULA (HFNC)
I. Indicated for high flow, high
FiO2
II. Delivers FiO2 up to 100%
III. Flow rates up to 60L/Min
IV. Can provide pressure support and
PEEP as a result of high
V. Can provide adequately warmed
humidified gas
OXYGEN DELIVERY SYSTEMS
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CPAP/BiPAP
I. CPAP Provides a continuous positive pressure in a spontaneously breathing
patient via a tight fitting mask
II. A device with a capability to provide positive is required for CPAP, e.g
Ventilator, Neonatal CPAP machines etc
III. Indications
a. ARDS
b. COPD/Asthma
c. Pneumonia/PCP
d. Pulmonary Oedema
e. Heart Failure
IV. BiPAP Provides a continuous positive pressure during both
inspiration(pressure support) and expiration(PEEP)
MONITORING OXYGEN/HYPOXIA
I. Clinical signs
a. Hypoxic patient is likely to be
i. Distress, Cyanotic, anxious, restless, confused, altered level of consciousness
II. Pulse Oximetry
III. Blood gas analyzer
a. Measures O2 saturation from an arterial blood sample
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PRONING
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CONCLUSIVE EVIDENCE FROM
VARIOUS ICUs
I. Patients with moderate to severe ARDS appear to have
responded well to invasive ventilation in the prone position,
leading to prone ventilation being recommended in
international guidelines for the management of COVID-19.
II. Early use of prone ventilation in patients with moderate to
severe ARDS to improve oxygenation and reduce mortality
when compared with conventional supine ventilation.
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WHAT ABOUT THE TRADITIONAL
SUPINE POSITION?
I. The traditional supine position adopted by patients lying in
hospital beds has long been known to be detrimental to their
underlying pulmonary function:
a. Over-inflation of the ventral alveoli and atelectasis of the
dorsal alveoli (due to an increased trans-pulmonary pressure
gradient)
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CONT’
I. Compression of alveoli secondary to direct pressure from the
heart and the diaphragm being pushed cranially by the intra-
abdominal contents.
II. V/Q Mismatch – As dorsal alveoli are preferentially perfused
due to the gravitational gradient in vascular pressures they
are poorly ventilation and highly perfused which manifests as
hypoxaemia
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CONT’
I. Given the improvement in mechanically ventilated patients, it
has been postulated that adopting the prone position for
conscious COVID-19 patients requiring basic respiratory
support, may also benefit patients in terms of improving
oxygenation, reducing the need for invasive ventilation and
potentially even reducing mortality
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DOCUMENTED BENEFITS OF PRONING
I. Given the physiological benefits, prone positioning should
apply to all patients regardless of whether they are intubated
or not, the potential benefits include:
a. Improved VQ matching and reduced hypoxaemia
(secondary to more homogeneous aeration of lung and
ameliorating the ventral-dorsal trans-pulmonary pressure
gradient)
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CONT’
I. Reduced shunt (perfusion pattern remaining relatively
constant while lung aeration becomes more
homogenous)
II. Recruitment of the posterior lung segments due to
reversal of atelectasis
III. Improved secretion clearance
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PRONE VENTILATION
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CONT’
ZIKOMO KWAMBIRI
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