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COPD; Alpha-1 antitrypsin deficiency; Bronchitis - chronic; Chronic bronchitis; Emphysema
Lung function may eventually worsen to the point that patients may need to rely on supplemental oxygen provided through portable or stationary tanks.
Continuous Therapy. Continuous oxygen therapy (more than 15 hours a day) is the only treatment for emphysema that has been proven to prolong survival in certain patients. It also improves alertness, motor speed, and hand strength. Continuous oxygen therapy is usually recommended for patients with:
Ideally, the patient should receive enough oxygen to keep the oxygen level at 65 mm HG, but no less than 60 mm HG, or at an oxygen saturation level of at least 90%. Additional oxygen flow may be needed during sleep or exertion (physical activity).
About 40% of patients improve enough in 1 month to stop continuous treatment, although such patients should be observed closely. COPD frequently deteriorates, and patients need to restart oxygen therapy. Some patients worsen in spite of treatment, although at this point it is not possible to predict who is at risk for oxygen therapy failure. The addition of nitric oxide, a gas that dilates blood vessels, may offer additional benefits.
Intermittent Oxygen. Patients with less severe COPD who are not on permanent oxygen maintenance may need supplemental oxygen during specific circumstances:
Oxygen During Travel. People on continuous oxygen therapy who are traveling by plane should increase their oxygen by 1 - 2 liters per minute during the trip. Supplemental oxygen may be required during air travel for people on intermittent oxygen therapy if the trip is longer than 2 hours and they develop symptoms, or if they experience a drop in oxygen levels before traveling. People are not allowed to bring their own tanks on board an airplane; many airlines will provide oxygen if notified 48 - 72 hours in advance. It is important to note that aircraft cabins are actually pressurized to the equivalent of 8,000 feet above sea level. Such pressures could be potentially dangerous for people with severe COPD.
Unless they are bed-bound, patients usually use a combination of stationary and mobile oxygen systems.
Stationary Systems. The most common stationary oxygen system is the concentrator, an electrical device that pulls oxygen from the air. It weighs about 35 pounds and cannot be battery operated, so a patient can use only it at home.
Portable Units. Portable units containing electronic oxygen-conserving devices weigh only a few pounds and can provide up to 8 hours of oxygen. Some portable units weigh 6.5 lbs, with liquid oxygen supplies lasting 4 hours. Some weigh 9.5 lbs, with an oxygen supply lasting 8 hours when used at a flow rate of 2 liters per minute.
Compressed or Liquid Oxygen. Oxygen can be administered from large stationary tanks or small portable ones, either as compressed gas or liquid oxygen. A container of liquid oxygen lasts four times longer than compressed gas of the same weight and is easier to fill. Liquid oxygen is very beneficial for patients who want to maintain an active life, although the tanks require occasional venting to release pressure, and this wastes oxygen. They are also more expensive. In some areas, for example, a stationary liquid oxygen system costs $3,500 and a compressed oxygen tank costs $350.
Precautions. Supplemental oxygen is a fire hazard, and some hotels and residences do not allow its use. No one should smoke near an oxygen tank, and tanks should be stored safely, secured to a wall and away from heaters and furnaces.
Oxygen is usually administered in one of three ways: through a nasal canula, transtracheal catheter, or electronic demand device.
Nasal Canula. Using a nasal canula, oxygen is delivered through a long, slender plastic tube that runs from the oxygen tank to small plastic prongs that fit in the nostrils. The tube can be very long when attached to a stationary tank in order to accommodate walking throughout a house, or relatively short when attached to a portable unit.
A reservoir pouch is a recent innovation added to this device that provides an extra rush of oxygen when a patient starts to inhale. This method is inexpensive and easy to use, but some patients are embarrassed by its appearance under their noses.
Transtracheal Oxygen. Transtracheal oxygen is delivered directly into the windpipe (trachea) through a catheter tube implanted by a surgeon. The device is inconspicuous, and patient compliance is excellent. The initial cost is high, but over time expenses are reduced because of more efficient oxygen usage. Long-term complications may include infection, dislodgment, and blockage by mucus, which can be very serious. Complications of the procedure itself occur in 3 - 5% of cases and can include lung spasms and uncontrollable coughing.
Electronic Demand Devices. Electronic devices that sense the beginning of a breath and deliver a pulse of oxygen are also available, although they are complicated, expensive, and have a risk for mechanical failure. Newer units have a continuous flow bypass switch that allows delivery of oxygen if the battery runs down.
In emergency situations, oxygen may be delivered to the patient in various ways:
Noninvasive Positive Pressure Ventilation (NPPV). If the patient is able to breathe naturally, oxygen is delivered through a tube using a tightly fitted oxygen mask to maintain airway pressure during breathing. Some physicians now believe such devices should be first-line treatments (in addition to medications) for managing respiratory failure after an acute exacerbation. They allow the patient to communicate and drink fluids, and are much better tolerated than nose or throat tubes. They cannot be used on patients with rapidly deteriorating COPD, those who are uncooperative, or those with facial structures that do not allow the mask to seal tightly.
Intubation. When standard oxygen therapy does not meet a patient's needs, endotracheal intubation may be required to deliver high concentrations of oxygen. With intubation, a tube is inserted down through either the nose or the mouth, and oxygen is administered through the tube.
Mechanical Ventilation. In very serious cases such as acute respiratory failure, a mechanical ventilator can be used to take over the function of breathing. The primary goal of ventilation is to eliminate carbon dioxide and restore a balanced exchange of gases.
Most patients have a low tolerance for intubation, and the tubes are often removed prematurely due to discomfort. Patients may need painkillers, sedatives, or muscle relaxants.
There are also several complications that lead to the removal of breathing tubes:
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