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oxygen therapy

Inhalation therapy with molecular oxygen Indications: (also see home oxygen) 1) PaO2 =< 55 mm Hg 2) PaO2 =< 59 mm of Hg with clinical evidence of pulmonary hypertension, polycythemia or cor pulmonale [2] 3) SaO2 =< 88% at rest or with exercise 4) persistent polycythemia a) hemoglobin (Hgb) > 18 g/dL b) hematocrit (Hct) > 54% 5) recurrent cor pulmonale 6) severe hypoxemia 7) CNS symptoms induced by hypoxemia, reversed by oxygen 8) 15 hours of long-term oxygen therapy for patients with chronic lung disease & severe hypoxemia [10] * SaO2 not to exceed 94-96% with oxygen therapy [7] Contraindications: - palliatative oxygen no better than room air in terminally ill patients with pO2 > 55 mm Hg [4] - higher mortality with liberal use of supplemental oxygen in acutely ill patients [6] - SaO2 > 90-93% [7] Procedure: (for medical oxygen use) Guidelines: 1) continuous O2 is more useful than nocturnal O2. 2) reassess need for chronic O2 treatment after 3 months 3) fiO2 generally increases by 3% for each liter flow of O2 4) Venturi mask provides fine control of O2 delivery 5) use O2 sparingly in patients with increased pCO2 6) 100% O2 denitrogenates the lungs to provide an O2 reserve 7) conservative oxygen therapy is associated with lower mortality in the ICU (12% vs 20%) [5] - use lowest FiO2 to maintain SaO2 of 94-98% [5] 8) similar outcomes with low normal 80 mm Hg vs high normal 96 mm Hg PaO2 in patients with critical illness SIRS [9] Oxygen delivery systems (storage devices): 1) oxygen concentrator (least expensive) 2) oxygen cylinders (provide highest O2 flow rates) a) stationary H size cylinder (70 kg) b) portable steel size E cylinder (7 kg) on wheels 3) portable unit of liquid oxygen linked to a demand pulse oxygen-conserving device (most expensive) * video [8] Complications: (oxygen toxicity) 1) respiratory distress syndrome 2) risk increases when: a) FiO2 of 1.0 exceeds 24 hours b) FiO2 of 0.6 exceeds 72 hours 3) not amenable to treatment 4) patients generally succumb to lung failure 5) histopathology a) early exudative phase b) irreversible proliferative fibrotic phase 6) excess cardiac arrhythmias, lung injuries in hospitalized patients without hypoxemia [6]

Related

delivery of oxygen (DO2)

Specific

high-flow oxygen home oxygen hyperbaric oxygen

General

inhalation therapy

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 743, 763
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998
  3. Taha SK et al, Nasopharyngeal oxigen insufflation following preoxygenation using the four deep breath technique Anaesthesia 2006; 61:427 PMID: 16674614
  4. Abernethy AP et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. Lancet 2010 Sep 4; 376:784. PMID: 20816546
  5. Girardis M, Busani S, Damiani E et al Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit. The Oxygen-ICU Randomized Clinical Trial. JAMA. Published online October 5, 2016 PMID: 27706466 http://jamanetwork.com/journals/jama/article-abstract/2565306 - Ferguson ND Oxygen in the ICU. Too Much of a Good Thing? JAMA. Published online October 5, 2016 PMID: 27706469 http://jamanetwork.com/journals/jama/fullarticle/2565302
  6. Chu DK, Kim LH, Young PJ et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): A systematic review and meta-analysis. Lancet 2018 Apr 28; 391:1693. PMID: 29726345 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30479-3/fulltext - McEvoy JW. Excess oxygen in acute illness: Adding fuel to the fire. Lancet 2018 Apr 28; 391:1640 PMID: 29726326 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30546-4/fulltext
  7. Siemieniuk RAC, Chu DK, Kim LHY et al Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ 2018;363:k4169 PMID: 30355567 https://www.bmj.com/content/363/bmj.k4169
  8. Rengasamy S, Nassef B, Bilotta F et al Videos in Clinical Medicine. Administration of Supplemental Oxygen. N Engl J Med 2021; 385:e9. July 15. PMID: 34260838 https://www.nejm.org/doi/full/10.1056/NEJMvcm2035240
  9. Gelissen H, de Grooth HJ, Smulders Y et al. Effect of low-normal vs high-normal oxygenation targets on organ dysfunction in critically ill patients: A randomized clinical trial. JAMA 2021 Aug 31; [e-pub] PMID: 34463696 https://jamanetwork.com/journals/jama/article-abstract/2783810
  10. Ekstrom M et al. Long-term oxygen therapy for 24 or 15 hours per day in severe hypoxemia. N Engl J Med 2024 Sep 19; 391:977. PMID: 39254466 https://www.nejm.org/doi/10.1056/NEJMoa2402638