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Breathlessness and oxygen therapy Rosemary Moore Physiotherapist B App Sc (Physio) Grad Dip Physio (Cardiothoracic) M Physio (Research) PhD Take home messages ● Oxygen is a drug used to treat low blood oxygen levels (hypoxaemia) ● Breathlessness does not always indicate hypoxaemia ● Oxygen is not a treatment for breathlessness Why do we breathe? Fuel: oxygen Waste: carbon dioxide (Lavoisier 18th century) “….. the body has practically no storage capacity for oxygen, but depends from moment to moment for its supply from the air” (Haldane 1919) Why might we feel breathless? ●demand and supply ●MANY possible causes of excessive breathlessness * excessive breathlessness not always associated with insufficient oxygen The oxygen transport pathway Respiratory Circulatory Muscles System (& organs) System Excessive Breathlessness: some investigations ● Lungs − Breathing tests (obstructive, restrictive lung problem) − Chest X-ray − CT scan ● Heart − ECG, angiogram, echocardiograph, 24 hour monitor ● Exercise tests ● Blood tests Dyspnoea ● perceived difficulty with breathing ● unpleasant urge to breathe (air hunger) ● breathing discomfort ● sensations of increased inspiratory work or effort, chest tightness, unsatisfied inspiration * Dyspnoea is not always associated with insufficient oxygen Cycle of deconditioning SOB on exercise deconditioning dyspnoea avoidance of exercise inactivity Hypoxaemia: investigations ● Arterial blood gases ● Pulse oximetry ● Exercise tests – eg. 6 minute walk test ● Oxygen therapy is a drug prescribed to treat hypoxaemia − according to guidelines (Australasian) − to achieve target oxygen saturation range Acute / emergency oxygen therapy ● In hospital, emergency departments, ambulance ● To correct hypoxaemia in severely ill patients ● Target range: − Australasian guidelines: SpO2 92% to 96% − or 88–92% in COPD / risk of hypercapnea (raised blood carbon dioxide level) Home oxygen therapy 3 main categories 1. Continuous (“Long Term Oxygen Therapy”) 2. Nocturnal oxygen therapy 3. Intermittent oxygen therapy − Exertional (ambulatory) oxygen therapy − Air travel − Palliative: terminal illness + severe dyspnoea + significant hypoxaemia − Acute/life threatening asthma + isolated area Home oxygen therapy 3 main categories 1. Continuous (“Long Term Oxygen Therapy”) 2. Nocturnal oxygen therapy 3. Intermittent oxygen therapy − Exertional (ambulatory) oxygen therapy − Air travel − Palliative: terminal illness + severe dyspnoea + significant hypoxaemia − Acute/life threatening asthma + isolated area Continuous oxygen therapy (LTOT) ● Indications: severe hypoxaemia at rest − PaO2 55 mmHg or − PaO2 56–59 mmHg + hypoxic organ damage: polycythaemia (blood test) heart (echocardiograph) ● Aim: PaO2 > 60 mmHg Continuous oxygen therapy (LTOT) ● At least 15 hours per day ● Stationary concentrator − +/- portable cylinders − ? portable concentrator ● Evidence: in COPD − improves survival − alleviates hypoxic organ damage Exertional (ambulatory) oxygen therapy ● Indication: − exercise induced hypoxaemia ● Australasian guidelines: may be considered if − O2 sat: 88% during exercise and − exercise tolerance or dyspnoea − Six minute walk tests Exertional (ambulatory) oxygen therapy ● For use during exertion ● Portable cylinders ● ? portable concentrator ● Evidence: not evidence based Oxygen therapy – Contraindications ● Normal oxygenation ● Sub-maximal therapy ● Current smoking − fire risk − reduced benefit ● Disinclination Oxygen therapy – Risks ● Safety − increased risk of falls − burns − death ● Incorrect flow − hypercapnea (raised blood carbon dioxide) ● Nasal discomfort Oxygen therapy – Barriers ● Difficulty with equipment − lack of portability − changing regulators ● Embarrassment Take home messages ● Oxygen is a drug used to treat low blood oxygen levels (hypoxaemia) ● Breathlessness does not always indicate hypoxaemia ● Oxygen is not a treatment for breathlessness References Getting started on home oxygen. Lung Foundation Australia HOME OXYGEN THERAPY GUIDELINES Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand. McDonald et al. Medical Journal of Australia, 2005; 182(12): 621-626. British Thoracic Society guidelines for home oxygen use in adults. Hardinge et al. Thorax 2015;70:i1–i43. ACUTE / EMERGENCY OXYGEN THERAPY GUIDELINES TSANZ oxygen guidelines for acute oxygen use in adults. “Swimming between the flags.” Beasley et al. Respirology 2015; 20: 1182-1191. BTS guidelines for emergency oxygen use in adult patients. O’Driscoll et al. Thorax 2008;63(Suppl VI):vi1–vi68. REVIEW ARTICLE Dyspnoea and oxygen therapy in COPD. Moore and Berlowitz. Physical Therapy Reviews, 2011; 16(1): 10-18. When you can’t breathe, nothing else matters