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Supplemental oxygen

Some patients with obstructive lung diseases have trouble getting enough oxygen by breathing normally. For these patients, a prescription for supplemental oxygen should be seriously considered. Supplemental oxygen may be useful or necessary in some cases even though it may be needed only for a few hours a day for a few months. Some patients may need oxygen when flying or at high altitude.

Patients must have a prescription from a doctor for oxygen therapy in order to get it. The prescription will include how much oxygen a patient should have and how often. Patients may need supplemental oxygen during certain activities, such as sleeping or exercising, or they may need it all of the time.

While various techniques can help improve breathing, when correctly administered, oxygen may help resolve problematic symptoms like disconcerting shortness of breath, chest pain and low pulse/oximeter readings. Supplemental oxygen can be dangerous when certain safety precautions aren't followed. Always use oxygen as directed by one's physician.

Rationale for use

Using supplemental oxygen is not a step backward nor an admission of failure. It is a palliative treatment to prevent the heart muscle from overworking. Supplemental oxygen can relieve the distressing symptom of dyspnea (shortness of breath).1 Dyspnea is not lethal but patients who are able to control it are more comfortable and perhaps able to tolerate additional immunopathology while lung inflammation is resolving.

Oxygen therapy may help a patient feel better, sleep better, be more alert, and be in a better mood. Patients may be able to carry out your daily activities without feeling as tired or as short of breath and may have less intercostal pain.

According to an |e-medicine article on sarcoidosis, supplemental oxygen should be provided to all patients prior to hospital care. So, ask your doctor for a trial of home oxygen to attempt to avoid a deterioration that might possible lead to a hospital stay, if possible.

For just the same reason as you will eventually be able to recover some of the lung function you thought was irreversibly lost, the bacterial die-off will often (maybe usually) make breathing difficulties worse before they get better. Whenever I talk with a physician about healing from sarcoidosis, I try and remember to remind the physician to make bottled oxygen available to the patient.

Trevor Marshall, PhD

Caution to patients with pulmonary fibrosis

Sarcoidosis patients with extensive pulmonary fibrosis should be aware that they may experience ongoing bouts of pulmonary immunopathology – which includes extreme shortness of breath – as the fibrotic collagen remodels. Remodelling occurs as the vitamin D metabolites normalize, for much the same reason as arthritic joints recover during the several years of Phase Three.

Those who have been on 24/7 oxygen should be encouraged to keep the concentrator handy for a year or two into Phase Three, out of an abundance of caution.

Evaluating need

When the lungs are not perfusing oxygen well, as evidenced by a low oxygen saturation level, the heart beats faster to compensate. The use of supplemental oxygen is deemed warranted by Medicare standard when the oxygen saturation level falls below 90% by pulse oximeter. Insurance companies often follow that guideline to determine if they will pay for oxygen.

It may be advantageous for patients who meet that standard to also have the more invasive blood gases measurement via arterial puncture. This will determine the amount of oxygen a person can safely receive. Patients who have obstructive lung disease may retain too much carbon dioxide, which can suppress respiration, when they get too much oxygen. Most people with Th1 inflammation of the lungs have restrictive lung disease, not obstructive, and can use higher levels of oxygen. The only way to determine this is through testing.

Working with one's physician

When determining if a patient needs oxygen, a physician will typically ask the patient to perform an activity of daily living which requires the most exertion. This usually involves walking some distance or climbing stairs. Some doctors will even have the patient walk outside in cold weather to be sure the oxygen level remains okay under those conditions.

During that time the patient wears a pulse oximeter on their finger and the nurse or doctor will note the oxygen level during different activities. Patients will not be expected to exert yourself beyond your limits. When a patient becomes breathless and the oxygen level falls, the test is over.

The determining factor at least in the United States is an oxygen saturation level that falls below 90%. This figure has been determined by Medicare and most insurance companies follow this guideline to determine if they will reimburse the cost of oxygen.

A doctor can order oxygen even if the patient doesn't meet this criteria and may do so if the oxygen saturation is borderline but the insurer has no obligation to pay for it. In that case a patient may have to pay out-of-pocket.

When being evaluated for oxygen need, patients are advised to time their antibiotics administration such that they are experiencing their immunopathology at its strongest.

When I got home oxygen equipment, it was my primary care physician who agreed to prescribe oxygen. I described how my ability to use my chest muscles was okay early in the morning, but as the day progressed and my strength waned, breathing became progressively more difficult. My husband verified, and thank goodness my PCP had compassion to write the order.

Maybe if you discuss using oxygen as needed, when your chest muscles are weak, the PCP will have the logic and compassion to order it. I used oxygen as needed, and that was usually from noon-time on, but not at night. Perhaps if the doctor realizes your use of oxygen will be just a long-term coping tool, he will be comfortable ordering it, since it requires a doctor's prescription. A brief summary of the Medicare guidelines for covering supplemental oxygen are here.

Belinda, MarshallProtocol.com

Obtaining oxygen

In the United States

Any physician can prescribe oxygen. The prescription will indicate the rate of oxygen flow needed. In the United States, oxygen is highly regulated by the Centers for Medicare and Medicaid Services, the Food and Drug Administration, and the U.S. Department of Transportation. The requirements for medical coverage are different for different insurance carriers. Private insurance is likely to have less stringent requirements than Medicare.

In Canada

The oxygen funding available in each of Canada's Provinces requires meeting certain program criteria. Information regarding initial and long-term oxygen funding is available from one's local Medigas Praxair supplier or by contacting the Department of Veterans Affairs, Regional/Municipal Social Assistance Programs or one's private insurance carrier.

Types of supplemental oxygen

Supplemental oxygen is dispensed several ways. The oxygen system that is right for any given patient depends on the amount of oxygen being used and the level of activity.

Typically, a prescription provides for combination of an oxygen concentrator and portable tanks. A medical equipment provider delivers the equipment to one's home and returns regularly to replenish portable oxygen tanks. The provider also checks and maintains equipment in one's home. The provider can also be expected to educate on how to use the equipment and provide patients with a supply of tubing, cannulas, masks and humidifiers as needed.

Oxygen concentrator

An oxygen concentrator is an electric device that concentrates the oxygen that is already in the air. The advantages of this delivery system is that it costs less and is easier to maintain, primarily because it doesn't need refilling. But the oxygen concentrator is about the size of a bedside table, which makes it non-portable.

This oxygen is stored in the container and given back to patients through a mask or cannula. Patients are advised to always have a backup cylinder of oxygen with them at all times in the event of a power failure.

Compressed oxygen

Some oxygen is supplied in a metal cylinder under pressure. This compressed oxygen does not need electrical power to operate like an oxygen concentrator does. Compressed oxygen cylinders are heavier than liquid oxygen containers. Small cylinders and wheeled carts are available so that patients can move around while using compressed oxygen. The stem of a compressed oxygen cylinder must be protected from damage. Cylinders should always be stored in an upright position and secured so that they do not fall over.

Liquid oxygen

Liquid oxygen is kept very cold in an insulated container. Liquid oxygen warms and turns into a breathable gas when it is released from the container. Liquid oxygen takes up less space than compressed oxygen, so it is more portable. Patients can refill small, lightweight liquid oxygen tanks from a big tank kept at home. Liquid oxygen may cost more than other oxygen systems.

One's liquid oxygen supply may not last as long as compressed oxygen because it can evaporate. Liquid oxygen is very cold and may burn the skin if it spills. Keep liquid oxygen containers in an upright position. Secure the container when travelling so that it does not tip.

Faulty equipment

I had a recent scare. I was dropped off at the hospital to visit my mother (with my O2 tank). I stopped at the coffee kiosk and my O2 wasn't working! It was very early in the morning and I was alone and didn't know what to do. I remembered that the pulmonary therapists said I could get O2 from rehab in an emergency, so I slowly walked to rehab. When I got there I took my O2 saturation and it was 68% with 132 bpm heart rate.

I went in and told the first therapist that I needed O2, that it was an emergency! Jennifer got me O2 ASAP. When my sats returned, we tried to figure out what happened to my tank. No luck - it was not frozen, but it wasn't flowing O2 either. With great trepidation she loaned me an O2 tank, so I could walk upstairs and visit my mother!

After an hour visit, my O2 started working, so I returned the rehab tank much to Jennifer's delight! When I was picked up, we drove directly to medical supply for a new O2 tank! What a scare! I was reminded of my limitations, once again!

Sue Lyons, MarshallProtocol.com

I shared with the doc my power company experience. He suggested, and signed a form, for me to submit to the power company since I'm on oxygen. One still has to pay their bill, but if you're late you won't be cut off. Additionally, if there's a power outage, you are designated as one to be powered up first.

ToniD, MarshallProtocol.com

Danger of dependency?

Patients do not become physically dependent on oxygen. The process of oxygen transport into the circulatory system is inhibited by the anatomical changes of the disease process. Changes in the lung anatomy are usually progressively worse causing a greater need for oxygen. Patients with obstructive lung disease cannot simply turn up the oxygen. Patients with restrictive lung disease can use oxygen on the highest setting if needed to relieve shortness of breath.

As lung function improves, there is the possibility of psychological dependence on oxygen, especially if anxiety is a symptom. However, patients will become less physically dependent on oxygen as your lung inflammation resolves and oxygen is more easily exchanged in the pulmonary tissues.

Patient experiences

When the medical equipment folks came to my home to take the oxygen that I no longer needed, they were flabbergasted that I was fine without it now. They said that never happens.

Belinda, MarshallProtocol.com

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Notes and comments

References

1 Bateman NT, Leach RM ABC of oxygen. Acute oxygen therapy. BMJ. 1998;317:798-801.
Last modified: 01.02.2012
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