Oxygen therapy

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Oxygen therapy
Simple face mask.jpg
A person wearing a simple face mask
Clinical data
Other namessupplemental oxygen, enriched air
AHFS/Drugs.comFDA Professional Drug Information
Routes of
administration
inhaled
Drug classmedical gas
ATC code
Identifiers
CAS Number
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  • none
UNII
Chemical and physical data
FormulaO2

Oxygen therapy, also known as supplemental oxygen, is the use of oxygen as medical treatment.[1] Acute indications for therapy include hypoxemia (low blood oxygen levels), carbon monoxide toxicity and cluster headache. It may also be prophylactically given to maintain blood oxygen levels during the induction of anesthesia.[2] Oxygen therapy is often useful in chronic hypoxemia caused by conditions such as severe COPD or cystic fibrosis.[3][1] Oxygen can be delivered via nasal cannula or face mask, or via high pressure conditions such as in endotracheal intubation or hyperbaric chamber.[4][5] It can also be given through bypassing the airway, such as in ECMO therapy.

Oxygen is required for normal cellular metabolism.[6] However, excessively high concentrations can result in oxygen toxicity, leading to lung damage and respiratory failure.[2][7] Higher oxygen concentrations can also increase the risk of airway fires, particularly while smoking.[1] Oxygen therapy can also dry out the nasal mucosa without humidification.[1] In most conditions, an oxygen saturation of 94–96% is adequate, while in those at risk of carbon dioxide retention, saturations of 88–92% are preferred.[1][8] In cases of carbon monoxide toxicity or cardiac arrest, saturations should be as high as possible.[1][8] While air is typically 21% oxygen by volume, oxygen therapy can increase O2 content of air up to 100%.[7]

The medical use of oxygen first became common around 1917, and is the most common hospital treatment in the developed world.[1][9][10][11] It is currently on the World Health Organization's List of Essential Medicines.[11] Home oxygen can be provided either by oxygen tanks or oxygen concentrator.[1]

Medical uses

Oxygen piping and regulator with flow meter, for oxygen therapy, mounted in an ambulance

Oxygen is widely used by hospitals, EMS, and first-aid providers in a variety of conditions and settings. A few indications frequently requiring high-flow oxygen include resuscitation, major trauma, anaphylaxis, major bleeding, shock, active convulsions, and hypothermia.[12][13]

Acute conditions

In context of acute hypoxemia, oxygen therapy should be titrated to a target level based on pulse oximetry (94–96% in most patients, or 88–92% in people with COPD).[12][8] This can be performed by increasing oxygen delivery, described as FIO2(fraction of inspired oxygen). In 2018, the British Medical Journal recommended that oxygen therapy be stopped for saturations greater than 96% and not started for saturations above 90 to 93%.[14] This may be due to an association between excessive oxygenation in the acutely ill and increased mortality.[8] Exceptions to these recommendations include carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax.[14]

Oxygen therapy has also been used as emergency treatment for decompression sickness for years.[15] Recompression in a hyperbaric chamber with 100% oxygen is the standard treatment for decompression illness.[15][16][17] The success of recompression therapy is greatest if given within four hours after resurfacing, with earlier treatment associated with a decreased number of recompression treatments required for resolution.[18] It has been suggested in literature that heliox may be a better alternative to oxygen therapy.[19]

In the context of stroke, oxygen therapy may be beneficial as long as hyperoxic environments are avoided.[20]

People receiving outpatient oxygen therapy for hypoxemia following acute illness or hospitalization should be re-assessed by a physician prior to prescription renewal to gauge the necessity of ongoing oxygen therapy.[21] If the initial hypoxemia has resolved, additional treatment may be an unnecessary use of resources.[21]

Chronic conditions

Common conditions which may require a baseline of supplementary oxygen include chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema. Patients may also require additional oxygen during acute exacerbations. Oxygen may also be prescribed for breathlessness, end-stage cardiac failure, respiratory failure, advanced cancer, or neurodegenerative disease in spite of relatively normal blood oxygen levels. Physiologically, it may be indicated in people with arterial oxygen partial pressure PaO
2
≤ 55mmHg (7.3kPa) or arterial oxygen saturation SaO
2
≤ 88%.[22][23][24]

Careful titration of oxygen therapy should be considered in patients with chronic conditions predisposing them to carbon dioxide retention (e.g., COPD, emphysema). In these instances, oxygen therapy may decrease respiratory drive, leading to accumulation of carbon dioxide (hypercapnia), acidemia, and increased mortality secondary to respiratory failure.[25] Improved outcomes have been observed with titrated oxygen treatment largely due to gradual improvement of the ventilation/perfusion ratio.[26] The risks associated with loss of respiratory drive are far outweighed by the risks of withholding emergency oxygen, so emergency administration of oxygen is never contraindicated. Transfer from the field to definitive care with titrated oxygen typically occurs long before significant reductions to the respiratory drive are observed.

Contraindications

There are certain situations in which oxygen therapy has been shown to negatively impact a person's condition.[27]

Adverse effects

In some instances, oxygen delivery can lead to particular complications in population subsets.

Alternative medicine

Some practitioners of alternative medicine have promoted "oxygen therapy" as a cure for many human ailments including AIDS, Alzheimer's disease and cancer. According to the American Cancer Society, "available scientific evidence does not support claims that putting oxygen-releasing chemicals into a person's body is effective in treating cancer", and some of these treatments can be dangerous.[34]

Physiologic Effects

Oxygen supplementation has a variety of physiologic effects on the human body. Whether or not these effects are adverse to a patient is dependent upon clinical context. Cases in which an excess amount of oxygen is available to organs is known as hyperoxia.[35] While the following effects may observed with noninvasive high-dose oxygen therapy (i.e., not ECMO), delivery of oxygen at higher pressures is associated with exacerbation of the following associated effects.

Absorption atelectasis

It has been theorized that oxygen therapy may promote accelerated development of atelectasis (partial or complete lung collapse), as well as denitrogenation of gas cavities (e.g., pneumothorax, pneumocephalus).[36][37] This concept is based on the idea that oxygen is more quickly absorbed compared to nitrogen within the body, leading oxygen-rich areas that are poorly ventilated to be rapidly absorbed, leading to atelectasis.[36] It is thought that higher fractions of inhaled oxygen (FIO2) is associated with increasing rates of atelectasis in the clinical scenario.[38] In clinically healthy adults, it is believed that absorption atelectasis typically does not have any significant implications when managed properly.[39]

Airway inflammation

In regard to the airway, both tracheobronchitis and mucositis have been observed with high levels of oxygen delivery (typically >40% O2).[40] Within the lungs, these elevated concentrations of oxygen have been associated with increased alveolar toxicity (coined the Lorrain-Smith effect).[35] Mucosal damage is observed to increase with elevated atmospheric pressure and oxygen concentrations, which may result in the development of ARDS and possibly death.[41][42]

Central nervous system effects

Decreased cerebral blood flow and intracranial pressure (ICP) have been reported in hyperoxic conditions, with mixed results regarding impact on cognition.[43][44][45][46] Hyperoxia as also been associated with seizures, cataract formation, and reversible myopia.[47]

Hypercapnea

Among CO2 retainers, excess exposure to oxygen in context of the Haldane effect causes decreased binding of deoxyhemoglobin to CO2 in the blood.[48] This unloading of CO2 may contribute to the development of acid-base disorders due to the associated increase in PaCO2 (hypercapnea). Patients with underlying lung disease such as COPD may not be able to adequately clear the additional CO2 produced by this effect, worsening their condition.[49] In addition, oxygen therapy has also been shown to decrease respiratory drive, further contributing to possible hypercapnea.[37]

Immunological effects

Hyperoxic environments have been observed to decrease granulocyte rolling and diapedesis in specific circumstances in humans.[50] In regard to anaerobic infections, cases of necrotizing fasciitis have been observed to require fewer debridement operations and have improvement in regard to mortality in patients treated with hyperbaric oxygen therapy.[51] This may stem from oxygen intolerance of otherwise anaerobic microorganisms.

Oxidative Stress

Sustained exposure to oxygen may overwhelm the body's capacity to deal with oxidative stress.[52]  Rates of oxidative stress appears to be influenced by both oxygen concentration and length of exposure, with general toxicity observed to occur within hours in certain hyperoxic conditions.[53]

Reduction in erythropoiesis

Hyperoxia is observed to result in a serum reduction in erythropoietin, resulting in reduced stimulus for erythropoiesis.[54] Hyperoxia at normobaric environments does not appear to be able to halt erythropoiesis completely.[54]

Pulmonary vasodilation

Within the lungs, hypoxia is observed to be a potent pulmonary vasoconstrictor, due to inhibition of an outward potassium current and activation of inward sodium current leading to pulmonary vascular muscular contraction.[55] However, the effects of hyperoxia do not seem to have a particularly strong vasodilatory effect from the few studies that have been performed on patients with pulmonary hypertension.[56][57] As a result, an effect appears to be present but minor.[56][57]

Systemic vasoconstriction

In the systemic vasculature, oxygen serves as a vasoconstrictor, leading to mildly increased blood pressure and decreased cardiac output and heart rate. Hyperbaric conditions do not seem to have a significant impact on these overall physiologic effects.[58][46] Clinically, this may lead to increased left-to-right shunting in certain patient populations, such as those with atrial septal defect. While the mechanism of the vasoconstriction is unknown, one proposed theory is that increased reactive oxygen species from oxygen therapy accelerates the degradation of endothelial nitric oxide, a vasodilator.[59][46] These vasoconstrictive effects are thought to be the underlying mechanism helping to abort cluster headaches.[60]

Dissolved oxygen in hyperoxic conditions may make also a significant contribution to total gas transport.[61]

Storage and sources

Oxygen can be separated by a number of methods (e.g., chemical reaction, fractional distillation) to enable immediate or future use. The main methods utilized for oxygen therapy include:

  1. Liquid storage – Liquid oxygen is stored in insulateded tanks at low temperature and allowed to boil (at a temperature of 90.188 K (−182.96 °C)) during use, releasing gaseous oxygen. This method is widely utilized at hospitals due to high oxygen requirements. See Vacuum Insulated Evaporator for more information on this method of storage.
  2. Compressed gas storage – Oxygen gas is compressed in a gas cylinder, which provides a convenient storage method (refrigeration not required). Large oxygen cylinders hold a volume of 6,500 litres (230 cu ft) and can last about two days at a flow rate of 2 litres per minute (LPM). A small portable M6 (B) cylinder holds 164 or 170 litres (5.8 or 6.0 cu ft) and weighs about 1.3 to 1.6 kilograms (2.9 to 3.5 lb).[62] These tanks can last 4–6 hours with a conserving regulator,[clarification needed] which adjust flow based on a person's breathing rate. Conserving regulators may not be effective for patients who breathe through their mouth.[clarification needed]
  3. Instant usage – The use of an electrically powered oxygen concentrator[63] or a chemical reaction based unit[64] can create sufficient oxygen for immediate personal use. These units (especially the electrically powered versions) are widely used for home oxygen therapy as portable personal oxygen. One particular advantage includes continuous supply without need for bulky oxygen cylinders.

Hazards and risk

Highly concentrated sources of oxygen also increase risk for 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 that are relatively inert under normal conditions. Fire and explosion hazards exist when concentrated oxidants and fuels are brought together in close proximity, although an ignition event (e.g., heat or spark) is needed to trigger combustion.[65]

Concentrated oxygen will allow combustion to proceed rapidly and energetically.[65] 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 oxygen systems requires special training to ensure that ignition sources are minimized.[65] Highly concentrated oxygen in a high-pressure environment can spontaneously ignite hydrocarbons such as oil and grease, resulting in a 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 only apply to pure oxygen; any concentration significantly higher than atmospheric (approximately 21%) carries a potential ignition risk.

Some hospitals have instituted "no-smoking" policies which can help keep ignition sources away from medically piped oxygen. These policies do not eliminate the risk of injury among patients with portable oxygen systems, especially among smokers.[66] Other potential sources of ignition include candles, aromatherapy, medical equipment, cooking, and deliberate vandalism.

Delivery

Various devices are used for oxygen administration. 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) which controls the flow at a measured rate (e.g., litres per minute [LPM]). The typical flowmeter range for medical oxygen is between 0 and 15 LPM with some units capable of obtaining up to 25 LPM. Many wall flowmeters using a Thorpe tube design are able to be dialed to "flush" oxygen which is beneficial in emergency situations.

Low-dose oxygen

Many people only require slight increases in inhaled oxygen, rather than pure or near-pure oxygen.[67] These requirements can be met through a number of devices dependent on situation, flow requirements, and personal preference.

A nasal cannula (NC) is a thin tube with two small nozzles inserted into a person's nostrils. It can provide oxygen at low flow rates, 1–6 litres per minute (LPM), delivering an oxygen concentration of 24–40%.[68]

There are also a number of face mask options, such as the simple face mask, often used at between 5 and 10 LPM, capable of delivering oxygen concentrations between 35% and 55%.[68] This is closely related to the more controlled air-entrainment masks, also known as Venturi masks, which can accurately deliver a predetermined oxygen concentration from 24 to 50%.[68]

In some instances, a partial rebreathing mask can be used, which is based on a simple mask, but features a reservoir bag, which can provide oxygen concentrations of 40–70% at 5–15 LPM.

Demand oxygen delivery systems (DODS) or oxygen resuscitators deliver oxygen only when the person inhales or the caregiver presses a button on the mask (e.g., nonbreathing patient).[69] These systems greatly conserve oxygen compared to steady-flow masks, and are useful in emergency situations when a limited supply of oxygen is available and there is a delay in transporting the person to higher care.[69] Due to utilization of a variety of methods for oxygenation requirements performance differences arise.[70] They are very useful in 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 person's lungs, for which some systems employ safety valves. These systems may not be appropriate for people who are unconscious or in respiratory distress because of the required respiratory effort.

High flow oxygen delivery

For patients requiring high concentrations of oxygen, a number of devices are available. The most commonly utilized device is the non-rebreather mask (or reservoir mask). Non-rebreather masks draw oxygen from attached reservoir bags with one-way valves that direct exhaled air out of the mask. If flow rate is not sufficient (~10L/min), the bag may collapse on inspiration.[68] This type of mask is indicated for acute medical emergencies. The delivered FIO2 (Inhalation volumetric fraction of molecular oxygen) of this system is 60–80%, depending on oxygen flow and breathing pattern.[71][72]

Another type of device is a humidified high flow nasal cannula which enables flows exceeding a person's peak inspiratory flow demand to be delivered via nasal cannula, thus providing FIO2 of up to 100% because there is no entrainment of room air.[73] This also allows the person to continue to talk, eat, and drink while still receiving therapy.[74] This type of delivery method is associated with greater overall comfort, improved oxygenation, and respiratory rates compared with face mask oxygen.[75]

In specialist applications such as aviation, tight-fitting masks can be used. These masks 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 into their lungs for gaseous exchange to take place. Systems for delivery vary in complexity and cost, starting with a basic pocket mask adjunct which can be used to manually deliver artificial respiration with supplemental oxygen delivered through a mask port.

Many

Pin-indexed Oxygen Regulator for portable D-Cylinder, usually carried in an ambulance's resuscitation kit

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