Picture: 10,600 ft in Loveland Ski basin parking lot...
Close to fifty years is a long time for drive to breathe 'myth' to be perpetuated
Mark Mangus replies:
question as to why the general medical pulmonologists seem to feel
that there could be a problem with too much oxygen and are hesitant to
approve a higher flow.
"You ask a very good question. I can't deny that there are a LARGE
number of physicians AND other health care professionals who still
adhere/clingto the 'myth' that "too much oxygen can cause those who
retain CO2 to stop breathing or to at least decrease their ventilation
enough to put them at risk for 'acute respiratory failure'".That is a
premise that was birthed out of our misunderstanding of how human beings
breathe going back to the late 1950's - early 1960's; hence why I call
it a 'myth'. It was based on what we NOW know to be fallacious
understanding of respiratory physiology and the mechanisms - - -
chemical and neurological - - - that drive breathing.In the 1990's
and on into this century, a mounting number of studies (some impressive
and audacious, done by the Japanese!) have attempted to invoke the
phenomenon - - - 'apnea' - cessation of breathing - - - in CO2-retaining
COPD'ers, several studies using subjects that were in full blown 'acute
respiratory failure' with extremely high CO2's, by having them breathe
80 % oxygen and higher. In not one instance have they been able to
stop one's breathing. In several studies, breathingINCREASED. The
fact of the matter is thatwe have only empiric, reproducible evidence
to show that the myth is NOT truewhile we have not a single shred of
reproducible or empiric evidence to support the 'myth'!
Close to fifty years is a long time for a 'myth' to be perpetuated. It
literally pervades ALL levels of health care training. You know the
old adage: "Tell a lie long enough and it becomes the reality, but not
necessarily the 'truth'." That sums up the gist of the debate.
Today, in most respiratory care training materials, it is taught as a
"historical misunderstanding" in contrast with the correct - - - and
scientifically verifiable - - - explanation.As evidenced by revisions
of recent textbooks by our nation's prominent pulmonologists (Barry
Make, Brian Tiep, Thomas Petty, to name a few)to include partial
revisions of the old 'myth' to work towards denying that it exists at
all. They are tiptoeing toward the truth while trying not to totally
upset the thinking ship of the greater medical community! While they
have not flatly said it's bogus, they are saying that even if it does
affect a rare individual , to practice using the 'just enough oxygen'
therapy approach - - - where they allow one's oxygen to be raised only
to above 88 %, but not above, say, 92 %,notonly robs those with
hypoxia and CO2-retention of a decent level of comfort,but it drives
them to right heart failure and an earlier death while robbing them of
considerable function and livelihood in the meantime.
The concern is mounting to such a degree that our NIH/NHLBI recently
initiated a long term study to evaluate (1) earlier intervention with
oxygen therapy when hypoxia below 92 % is FIRST detected, so as to
assess survival statistics and (2) to assess the affect on physical
function, right heart function and length survival by attempting to
correct hypoxia to a more "normal" level of >/= 94 % saturation.
Another fallacy that is being studied is the notion that detrimental
effects on function and the right heart are directly influenced by
"paO2" and NOT by "saturation". Yet, with more study of 'dynamic
hyperinflation' and the discovery that desaturation resulting from this
factor does NOT lower paO2 as much as it causes 'respiratory acidosis'
(increased CO2 with decreased pH) suggests that it is indeed saturation
and acidosis that is responsible for secondary pulmonary hypertension
and quicker onset right heart failure, while paO2 can be "adequate"
according to clinical evidence.When you see me responding to folks
who talk about their CO2 being elevated, or being CO2-retainers and they
are concerned about oxygen use, you will always see me asking about
their pH on their blood gas.That is because the pH is the ALL
IMPORTANT factor in whether or not we need to worry about what the CO2
is. A CO2 that is elevated in the presence of a pH that is equally
decreased spells trouble, regardless of what the oxygen is.The
saturation will ALWAYS be decreased with that combination. On the
other hand, a CO2 that is increased in the presence of a normal pH is
NOT a problem and saturation remains high/normal. Further, 99 % of
those who retain CO2 have a NORMAL pH, which is WHY there is NO fear
that they will breathe any different, much less worse, if given enough
oxygen to run their saturation up to 96 % and higher
The bottom line is that those clinicians who are still adamant about
restricting oxygen use by CO2-retainersare, (1) not informed/up to date
or (2) simply are not convinced of the evidence, so far. I am
confident that with the work going on and the voices in the wilderness,
like me, that we will come to a point when folks will slap their
foreheads and figure it out. Until then, you must do what your
conscience and your doctor agree is best for you. We know that the
likelihood of avoidable mishap exists as long as they withhold adequate
oxygen. But, it is the accepted standard by a large segment of the
medical community and we haven't convinced enough of the medical
community to act accordingly."
Mark W. Mangus, Sr. BSRC, RPFT, RRT
Pulmonary Rehabilitation
Christus Santa Rosa Health Care
San Antonio, TX
mark.mangus@christushealth.org
________________________________________________________________________________
Chronic Obstructive Pulmonary DiseaseA chronic condition that limits
activitiesChronic Obstructive Pulmonary Disease, or COPD, includes chronic bronchitis and emphysema, two lung diseases that often coexisthttp://ihcrp.georgetown.edu/agingsociety/pubhtml/copd/copd.html
.
Protect Your Lungs From Wildfire SmokeDoctor Offers Tips For Minimizing Side EffectsWhen wildfires are blazing -- and after threatened people have ensured their personal safety -- there are steps people can take to reduce the effects of smoke on their lungs and respiratory systems.http://www.my58.com/health/2592720/detail.html
roxlyngcd@comcast.net
Picture: 10,600 ft in Loveland Ski basin parking lot...
Close to fifty years is a long time for drive to breathe 'myth' to be perpetuated
Mark Mangus replies:
question as to why the general medical pulmonologists seem to feel
that there could be a problem with too much oxygen and are hesitant to
approve a higher flow.
"You ask a very good question. I can't deny that there are a LARGE
number of physicians AND other health care professionals who still
adhere/clingto the 'myth' that "too much oxygen can cause those who
retain CO2 to stop breathing or to at least decrease their ventilation
enough to put them at risk for 'acute respiratory failure'".That is a
premise that was birthed out of our misunderstanding of how human beings
breathe going back to the late 1950's - early 1960's; hence why I call
it a 'myth'. It was based on what we NOW know to be fallacious
understanding of respiratory physiology and the mechanisms - - -
chemical and neurological - - - that drive breathing.In the 1990's
and on into this century, a mounting number of studies (some impressive
and audacious, done by the Japanese!) have attempted to invoke the
phenomenon - - - 'apnea' - cessation of breathing - - - in CO2-retaining
COPD'ers, several studies using subjects that were in full blown 'acute
respiratory failure' with extremely high CO2's, by having them breathe
80 % oxygen and higher. In not one instance have they been able to
stop one's breathing. In several studies, breathingINCREASED. The
fact of the matter is thatwe have only empiric, reproducible evidence
to show that the myth is NOT truewhile we have not a single shred of
reproducible or empiric evidence to support the 'myth'!
Close to fifty years is a long time for a 'myth' to be perpetuated. It
literally pervades ALL levels of health care training. You know the
old adage: "Tell a lie long enough and it becomes the reality, but not
necessarily the 'truth'." That sums up the gist of the debate.
Today, in most respiratory care training materials, it is taught as a
"historical misunderstanding" in contrast with the correct - - - and
scientifically verifiable - - - explanation.As evidenced by revisions
of recent textbooks by our nation's prominent pulmonologists (Barry
Make, Brian Tiep, Thomas Petty, to name a few)to include partial
revisions of the old 'myth' to work towards denying that it exists at
all. They are tiptoeing toward the truth while trying not to totally
upset the thinking ship of the greater medical community! While they
have not flatly said it's bogus, they are saying that even if it does
affect a rare individual , to practice using the 'just enough oxygen'
therapy approach - - - where they allow one's oxygen to be raised only
to above 88 %, but not above, say, 92 %,notonly robs those with
hypoxia and CO2-retention of a decent level of comfort,but it drives
them to right heart failure and an earlier death while robbing them of
considerable function and livelihood in the meantime.
The concern is mounting to such a degree that our NIH/NHLBI recently
initiated a long term study to evaluate (1) earlier intervention with
oxygen therapy when hypoxia below 92 % is FIRST detected, so as to
assess survival statistics and (2) to assess the affect on physical
function, right heart function and length survival by attempting to
correct hypoxia to a more "normal" level of >/= 94 % saturation.
Another fallacy that is being studied is the notion that detrimental
effects on function and the right heart are directly influenced by
"paO2" and NOT by "saturation". Yet, with more study of 'dynamic
hyperinflation' and the discovery that desaturation resulting from this
factor does NOT lower paO2 as much as it causes 'respiratory acidosis'
(increased CO2 with decreased pH) suggests that it is indeed saturation
and acidosis that is responsible for secondary pulmonary hypertension
and quicker onset right heart failure, while paO2 can be "adequate"
according to clinical evidence.When you see me responding to folks
who talk about their CO2 being elevated, or being CO2-retainers and they
are concerned about oxygen use, you will always see me asking about
their pH on their blood gas.That is because the pH is the ALL
IMPORTANT factor in whether or not we need to worry about what the CO2
is. A CO2 that is elevated in the presence of a pH that is equally
decreased spells trouble, regardless of what the oxygen is.The
saturation will ALWAYS be decreased with that combination. On the
other hand, a CO2 that is increased in the presence of a normal pH is
NOT a problem and saturation remains high/normal. Further, 99 % of
those who retain CO2 have a NORMAL pH, which is WHY there is NO fear
that they will breathe any different, much less worse, if given enough
oxygen to run their saturation up to 96 % and higher
The bottom line is that those clinicians who are still adamant about
restricting oxygen use by CO2-retainersare, (1) not informed/up to date
or (2) simply are not convinced of the evidence, so far. I am
confident that with the work going on and the voices in the wilderness,
like me, that we will come to a point when folks will slap their
foreheads and figure it out. Until then, you must do what your
conscience and your doctor agree is best for you. We know that the
likelihood of avoidable mishap exists as long as they withhold adequate
oxygen. But, it is the accepted standard by a large segment of the
medical community and we haven't convinced enough of the medical
community to act accordingly."
Mark W. Mangus, Sr. BSRC, RPFT, RRT
Pulmonary Rehabilitation
Christus Santa Rosa Health Care
San Antonio, TX
mark.mangus@christushealth.org
________________________________________________________________________________
Chronic Obstructive Pulmonary DiseaseA chronic condition that limits
activitiesChronic Obstructive Pulmonary Disease, or COPD, includes chronic bronchitis and emphysema, two lung diseases that often coexisthttp://ihcrp.georgetown.edu/agingsociety/pubhtml/copd/copd.html
.
Protect Your Lungs From Wildfire SmokeDoctor Offers Tips For Minimizing Side EffectsWhen wildfires are blazing -- and after threatened people have ensured their personal safety -- there are steps people can take to reduce the effects of smoke on their lungs and respiratory systems.http://www.my58.com/health/2592720/detail.html
roxlyngcd@comcast.net