Oxygen therapy is a common intervention in modern day healthcare on a global basis, but as ODriscoll et al. (2011), highlight, it is marred with poor practices primarily because it is in many instances prescribed and administered imprudently. In consequence, it results in potentially worse outcomes, especially for respiratory patients, including an increase in mortality rates, particularly in a pre-hospital setting (Perrin et al., 2011). Having contributed to patient deaths, the use of oxygen in both chronic and acute settings is currently recognized as a major area that needs improvement. Essentially, when used for therapeutic purposes, it is often regarded as a drug, and its prescription and administration is dependent on the condition of the patient, care settings, as well as the acuity. For respiratory purposes, oxygen is in most instances prescribed for treating hypoxemia, as either chronic or acute therapy, but the condition that is being treated determines the duration and concentration of the oxygen being administered.
Benefits of Oxygen Therapy
For COPD patients in a clinical and prehospital setting, oxygen therapy is advantageous. For instance, it prolongs life for COPD patients undertaking long-term oxygen therapy (LTOT), especially those with severe cases of hypoxemia (Croxton & Bailey, 2006). However, the patient should use it for at least 15 hours on a daily basis. For example, the average survival in COPD patients under LTOT for at least 18 hours a day is two times compared to COPD patients not subjected to the oxygen therapy. Besides, it reduces COPD complications by eliminating complications that would otherwise lead to low quality of life, including pulmonary hypertension, cor pulmonale, which is a form of heart failure, as well as secondary polycythemia. Oxygen therapy reduces these complications by stabilizing pulmonary hypertension, decreasing arrhythmias, which refers to the irregular heart rhythms, reducing instances of secondary polycythemia, as well as preventing myocardial ischemia, which refers to the lack of oxygen to the heart. Also, it lowers and relieves instances of dyspnea, which is the shortness of breathing, as well as other symptoms that are related to COPD, such as depression, dizziness, and fatigue.
Furthermore, oxygen therapy increases exercise tolerance, which is one of the most crucial aspects of managing COPD. Regular physical exercises increase the survivability of COPD patients. It has been established that many patients with COPD have poor exercise tolerance, and thus, oxygen therapy is vital for improving their tolerance to exercise (Emter et al., 2003). For this reason, oxygen therapy during exercises improves endurance, heightens performance, as well as diminishing a sensation of breathlessness. It also makes it safer for COPD patients to travel by air because they suffer severe instances of hypoxemia in such cases. It also helps manage erectile dysfunction, which is frequently encountered by male COPD patients with low oxygen levels. For example, Aasebo (1993) highlights that 42% of the patients who received LTOT experienced a reversal of their sexual impotence after just a month. For this reason, oxygen therapy has significant advantages for COPD patients in an inpatient and pre-hospital setting.
Dangers of Oxygen Therapy
For paramedic uses, especially for chronic obstructive pulmonary disease (COPD) patients in prehospital settings, oxygen usage, is thus, a contentious issue. Essentially, it is often recommended that it is wise to control oxygen with fixed inspired oxygen Fi0.28 (Joosten et al., 2007). According to Perry and Williams (2008), the restriction is often intended to prevent instances of carbon dioxide retention, which would otherwise lead to hypercapnia respiratory failure. First reports of oxygen-induced carbon dioxide were first reported in the first half of last century. For instance, in 1937, Barach made an observation that patients who had been treated with oxygen developed a state of irrationality and stupor when they were aroused, and in 1941, he observed that there was a profound disturbance of mental functionality in patients who suffered from a long-term anoxaemia after they had inhaled 50% oxygen. Barach ascribed these adverse effects to the sudden change in cerebral oxygen tension. It was in 1949 that Donald attributed to the negative effects as due to retention of carbon dioxide. In essence, Donald noted that after 12 hours of oxygen therapy PaCO2 of a patient who had severe emphysema rose to 12 mmHg, and subsequently lapsed into a coma, but after the therapy was withdrawn, he recovered abruptly, with his PaCO2 dropping to 60 mmHg. Donald attributes this neurological effect to hypoventilation due to the removal of the anoxic stimulus to breath. In effect, he suggested that oxygen therapy should be administered in an intermittent manner to prevent carbon dioxide retention. Massaro, Katz, and Luchsinger (1962) pointed out that the higher the concentration of oxygen, the more PaCO2 was released in the patients system.
There are dangers associated with uncontrolled oxygen administration to patients with acute exacerbation of severe COPD primarily because it induces hypercapnia, and it should be noted that the level of hypoxemia can be used as a predictor for the subsequent development of hypercapnia. In essence, uncontrolled oxygen administration leads to an early initial decrease in minute ventilation, characterized with an elevation of PaCO2. However, uncontrolled oxygen administration in acute exacerbation of severe COPD has a limited effect on instances of minute ventilation, and for this reason, the total increase of PaCO2. In rare occasions will a pediatric or COPD patient encounter an apneic response in decompensated patients that are approaching a hypercapnic coma.
Following Donalds case report, further studies that were conducted in the 1950s described some cases where hypercapnia developed, particularly in COPD patients after administration of oxygen therapy. In essence, the adverse effects that were found included muscle0twitching, headache, coma, and even in some cases, it resulted in death (Westlake, Simpson & Kaye, 1955). As such, it was established that COPD patients had a high risk of developing carbon dioxide retention from the administration of oxygen therapy, mainly caused by hypoventilation.
Also, oxygen therapy also induces pulmonary intoxication, usually referred to as the Smith Effect. For instance, Gerschman et al. (1954) suggested that oxygen administration derived free radicals, resulting in pathological changes, such as hemorrhage, edema, inflammation, alveolar, hyalinization and thickening of alveolar membranes, as well as fibrin deposition. Besides, specific cell damage is usually caused by the free radicals that are present in the form of hydrogen peroxide and superoxide. Even though antioxidant enzymes, for example, catalase, glutathione peroxide, as well as superoxide dismutase protect the patients body from the free radicals, in instances of hyperoxic conditions, the production of these radicals is increased leading to saturation of these enzyme systems, which results in the escape of the free radicals. Hyperoxia is a condition whereby oxygen therapy results in more oxygen in the system than required.
Additionally, oxygen therapy also leads to central nervous system (CNS) toxicity. For instance, Bert articulated that CNS toxicity occurs at pressures of >3 atmospheres, but at lower pressures, hyperoxia increases the formation of oxygen free radicals in the brain, which subsequently induces cerebral vasoconstriction that is associated with the reduction of cerebral blood flow. For pediatric patients, oxygen therapy also causes increased instances of retinopathy of prematurity in children, which is known as retrolental fibroplasia. It is mainly caused by the disorganized growth of premature retinal vessels, which is accelerated by supplemental oxygen exposure after oxygen therapy, even though it is not the single causative agent. What is of serious concern is the increased adverse pulmonary sequelae with higher oxygen for children.
Besides, oxygen therapy causes a potential to delay the recognition of psychological deterioration. For instance, Downs (2003) highlighted that there is a propensity that intrapulmonary right-to-left will worsen, significantly leading to shunting of blood due to progressive deterioration of the disease. However, it is only after the shunt has achieved some degree that it is reflected as low oxygen saturation, which may delay treatment and detection of an unstable patient.
Protocols and Solutions
Various protocols exist to avoid hypoxemia in conditions where oxygen is breathed at higher than normal partial pressures, including neonatal care and hyperbaric medicine. Oxygen therapy should only be administered by competent staff who have specifically be trained for the purpose of oxygen administration. Besides, oxygen saturation, as well as the delivery system need to be recorded on a chart, which should be checked with the oximetry results (ODriscoll et al., 2008). The oxygen delivery devices along with the flow rates should be adjusted to keep the saturation in the target range. Additionally, oxygen should be signed on the drug chart for each drug round (ODriscoll et al., 2008). Besides, the target saturation should be written on the drug chart. To control the dangers associated with oxygen therapy, controlling oxygen flow rates for pediatric and COPD patients is vital so as to obtain the appropriate oxygen saturation levels through the pulse oximetry instead of providing a fixed concentration of the oxygen.
There are various advantages of oxygen therapy, such as increased quality of life, improved sex, and social life, as well as reduced complications and symptoms. However, there are also dangers of oxygen therapy such as hypercapnia and hyperoxia. In essence, patients that are most susceptible to oxygen-induced hypercapnia are primarily those who associated with severe hypoxemia. However, administration of high-flow oxygen concentrations in oxygen therapy has been associated with adverse effects, such as cardiovascular and CNS toxicity, which leads to various complications, which in some instances could lead to death. As such, it is vital to observe guidelines and protocols while administering oxygen for COPD and pediatric patients in the pre-hospital and in-patient settings to avoid adversities. There are dangers of uncontrolled administration of oxygen, including hyperoxia and hypercapnia, which should be corrected via controlled oxygen therapy It is vital to observe various protocols including recording that oxygen has been administered primarily because it is a drug Besides, only qualified personnel should be able to administer oxygen therapy.
Aasebo, U., et. al. (1993).Reversal of sexual impotence in male patients with COPD and hypoxemia with LTOT. J Steroid Biochem Mol Biol, 46(6), 799-803.
Croxton, T. L., & Bailey, W. C. (2006). Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. American journal of respiratory and critical care medicine, 174(4), 373-378.
Downs, J. B. (2003). Has oxygen administration delayed appropriate respiratory care? Fallacies regarding oxygen therapy. Respiratory Care, 48(6), 611-620.
Emtner, M., Porszasz, J., Burns, M., Somfay, A., & Casaburi, R. (2003). Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients. American journal of respiratory and critical care medicine, 168(9), 1034-1042.
Joosten, S. A., Koh, M. S., Bu, X., Smallwood, D., & Irving, L. B. (2007). The effects of oxygen therapy in...
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