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Oxygen Supplementation Part 1

Avir Mitra, MD and Neda Frayha, MD
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We provide supplemental oxygen all the time. But how often do we really understand the physiology behind what we’re doing, or the different modalities we have available to us? Dr. Avir Mitra, Clerkship Director of Emergency Medicine at the Icahn School of Medicine at Mount Sinai Beth Israel in New York, joins Neda for a conversation about O2 supplementation, mechanical airway support, and the tools we have to oxygenate and ventilate our patients. 

 

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Chris -

Dr. Mitra made a comment mid-way through this piece about over-use of oxygen potentially leading to someone losing their respiratory drive. Though he didn't mention COPD explicitly, this is usually what people are referring to when they mention the "hypoxic drive theory" that we are probably all familiar with. I'm curious whether there is now any evidence to actually support a decrease in breathing as the cause for hypercapnia with use of high levels of oxygen in people with COPD. When I looked into the literature on this years ago, I couldn't find much but what I did find were old studies that seemed to suggest that while the CO2 does go up with high levels of oxygen being given to people with COPD, that the mechanism has nothing to do with losing respiratory drive:

“By the fifteenth minute of O2 inhalation the PaO2 averaged 225 +/- 23 mmHg, and it was concluded that despite the removal of the hypoxic stimulus of O2 inhalation, the activity of the respiratory muscles remained great enough to maintain VE at nearly the same degree as that while breathing room air.”
Source: Aubier M, Murciano D, Milic-Emili J, et al. Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure. Am Rev Respir Dis 1980;122(5):747-54.

“O2-induced hypercarbia does not indicate a failure of respiratory control mechanisms in the maintenance of PaCO2 homeostasis.”
Source: Dick CR, Liu Z, Sassoon CS, et al. O2-induced change in ventilation and ventilatory drive in COPD. Am J Respir Crit Care Med 1997;155(2):609-14.

Neda F., MD -

Hi Chris. I've emailed Dr. Mitra to ask for his input. Since he's working in EM in NYC, I'm sure he has many other things demanding his attention right now, but we'll keep you posted when we hear back from him. In the meantime, I found two resources that I found helpful and that speak to your point. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682248/ and Hippo Education friend Dr. Salim Rezaie's generally excellent blog, Rebel EM: https://rebelem.com/is-too-much-supplemental-o2-harmful-in-copd-exacerbations/

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Hippo Primary Care RAP Written Summary February 2020 764 KB - PDF

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