Oxygen therapy, also referred to as supplemental oxygen, is the use of oxygen as medical treatment. Supplemental oxygen can also refer to the use of oxygen enriched air at altitude. Acute indications for therapy include hypoxemia (low blood oxygen levels), carbon monoxide toxicity and cluster headache. It may also be prophylactically given to maintain blood oxygen levels during the induction of anesthesia. Oxygen therapy is often useful in chronic hypoxemia caused by conditions such as severe COPD or cystic fibrosis. Oxygen can be delivered via nasal cannula, face mask, or endotracheal intubation at normal atmospheric pressure, or in a hyperbaric chamber. It can also be given through bypassing the airway, such as in ECMO therapy. Oxygen is required for normal cellular metabolism. However, excessively high concentrations can result in oxygen toxicity, leading to lung damage and respiratory failure. Higher oxygen concentrations can also increase the risk of airway fires, particularly while smoking. Oxygen therapy can also dry out the nasal mucosa without humidification. In most conditions, an oxygen saturation of 94–96% is adequate, while in those at risk of carbon dioxide retention, saturations of 88–92% are preferred. In cases of carbon monoxide toxicity or cardiac arrest, saturations should be as high as possible. While air is typically 21% oxygen by volume, oxygen therapy can increase O2 content of air up to 100%. The medical use of oxygen first became common around 1917, and is the most common hospital treatment in the developed world. It is currently on the World Health Organization's List of Essential Medicines. Home oxygen can be provided either by oxygen tanks or oxygen concentrator.
Medical uses
Oxygen is widely used by hospitals, EMS, and first-aid providers in a variety of conditions and settings. A few indications frequently requiring high-flow oxygen include resuscitation, major trauma, anaphylaxis, major bleeding, shock, active convulsions, and hypothermia.
Acute conditions In context of acute hypoxemia, oxygen therapy should be titrated to a target level based on pulse oximetry (94–96% in most patients, or 88–92% in people with COPD). This can be performed by increasing oxygen delivery, described as FIO2(fraction of inspired oxygen). In 2018, the British Medical Journal recommended that oxygen therapy be stopped for saturations greater than 96% and not started for saturations above 90 to 93%. This may be due to an association between excessive oxygenation in the acutely ill and increased mortality. Exceptions to these recommendations include carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax. Oxygen therapy has also been used as emergency treatment for decompression sickness for years. Recompression in a hyperbaric chamber with 100% oxygen is the standard treatment for decompression illness. The success of recompression therapy is greatest if given within four hours after resurfacing, with earlier treatment associated with a decreased number of recompression treatments required for resolution. It has been suggested in literature that heliox may be a better alternative to oxygen therapy. In the context of stroke, oxygen therapy may be beneficial as long as hyperoxic environments are avoided. People receiving outpatient oxygen therapy for hypoxemia following acute illness or hospitalization should be re-assessed by a physician prior to prescription renewal to gauge the necessity of ongoing oxygen therapy. If the initial hypoxemia has resolved, additional treatment may be an unnecessary use of resources.
Chronic conditions Common conditions which may require a baseline of supplementary oxygen include chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema. Patients may also require additional oxygen during acute exacerbations. Oxygen may also be prescribed for breathlessness, end-stage cardiac failure, respiratory failure, advanced cancer, or neurodegenerative disease in spite of relatively normal blood oxygen levels. Physiologically, it may be indicated in people with arterial oxygen partial pressure PaO2 ≤ 55mmHg (7.3kPa) or arterial oxygen saturation SaO2 ≤ 88%. Careful titration of oxygen therapy should be considered in patients with chronic conditions predisposing them to carbon dioxide retention (e.g., COPD, emphysema). In these instances, oxygen therapy may decrease respiratory drive, leading to accumulation of carbon dioxide (hypercapnia), acidemia, and increased mortality secondary to respiratory failure. Improved outcomes have been observed with titrated oxygen treatment largely due to gradual improvement of the ventilation/perfusion ratio. The risks associated with loss of respiratory drive are far outweighed by the risks of withholding emergency oxygen, so emergency administration of oxygen is never contraindicated. Transfer from the field to definitive care with titrated oxygen typically occurs long before significant reductions to the respiratory drive are observed.
Contraindications There are certain situations in which oxygen therapy has been shown to negatively impact a person's condition.
Oxygen therapy can exacerbate the effects of paraquat poisoning and should be withheld unless severe respiratory distress or respiratory arrest is present. Paraquat poisoning is rare, with about 200 deaths globally from 1958 to 1978. Oxygen therapy is not recommended for people with pulmonary fibrosis or bleomycin-associated lung damage. ARDS caused by acid aspiration may be exacerbated with oxygen therapy according to some animal studies. Hyperoxic environments should be avoided in cases of sepsis.
Adverse effects In some instances, oxygen delivery can lead to particular complications in population subsets.
In infants with respiratory failure, administration of high levels of oxygen can sometimes promote overgrowth of new blood vessels in the eye leading to blindness. This phenomenon is known as retinopathy of prematurity (ROP). In rare instances, people receiving hyperbaric oxygen therapy have had seizures, which has been previously attributed to oxygen toxicity. There is some evidence that extended HBOT can accelerate development of cataracts.
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