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Oxygen Therapy for Chronic Obstructive Pulmonary Disease Patients

Oxygen Therapy for Chronic Obstructive Pulmonary Disease Patients

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Published by shielphi
A literature review regarding the hypoxic drive and COPD
A literature review regarding the hypoxic drive and COPD

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Categories:Types, Research
Published by: shielphi on Jun 07, 2010
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03/08/2013

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Chronic Obstructive Pulmonary Disease, Carbon Dioxideretention and high Oxygen flows: A literature review.
 
Philip Shields RN Ba Nursing (Hons)
Introduction
 
This literature review was born from the author’s curiosity. The graduate nurse often encountersempirical and anecdotal accounts regarding the delivery of high flow Oxygen and its ability to “wipeout” the “hypoxic drive” in Carbon Dioxide (CO
2
) retaining Chronic Obstructive Pulmonary Disease(COPD) patients.This review will attempt to determine if this belief has an empirical grounding. The purpose of thisliterature review is to provide an understanding of current clinical modalities regarding Oxygen therapyfor non-exacerbated and exacerbated COPD CO
2
retaining patients with an emphasis on effective
 
oxygen application grounded in literature. The review has a general medical/surgical ward nurse focus.Although it is not the purpose of this literature review to detail anatomy and physiology, the review
 
will briefly define COPD to aid understanding, particularly focusing upon the condition’s cause andresultant systemic affects. An outline of “normal’ Partial Pressures of Oxygen (PaO
2
) and Carbondioxide (PaCO
2
) will be provided with reference to basic chemoreceptor operation.
 
Various non-invasive oxygen delivery devices encountered in a ward will be examined and their basicfunctionality explained.Endeavouring to understand the evolution of treatment for non-exacerbated CO
2
retaining patients
 
suffering from COPD, the review will explore a selection of the literature from the 1960’s to the present day in chronological order.The review will conclude with a summary of findings.
Method
 
The researcher used “Lib Explore’ which is a multi faceted database search engine available throughLa Trobe University’s library. A sub-set of relevant health databases nested into the user interface
 
allowed a systematic and focussed crawl by Lib Explore with every Boolean expression. A broadsearch was commenced using pulmonary keywords such as “COPD”, “CO
2
retention” and “hypoxicdrive”. During the broader search, keywords were also entered into the public search engine “Google”
 
to provide leads to articles that could be followed up later in Lib Explore. Examining the hundreds of responses it was realised that the search could be narrowed using keywords such as “Fraction of inspired” and “non-exacerbation” and COPD. The final narrowed searches used Boolean expressions
 
such as “non exacerbation” and “copd” and “passive” not “ventilation”.The selected literature was recorded in “end note” and tagged in a collection folder for sorting and later scrutiny. To enable multiplatform editing, the document was placed on "Google docs" and scrutinized
 
 by the Medical ward Nurse Unit manager and a masters in Nursing.
What is COPD?
 
Martini, (2005) states that COPD is an “umbrella” term that embraces three overlapping pulmonarydisorders, namely, Asthma, Bronchitis and Emphysema.
 Being progressive in aetiology, restricting airflow to the lungs and reducing alveolar expansion characterize this group.
 
 
 Asthma
 
This disorder restricts airflow across the bronchial tree by constricting the smooth muscle and producing oedema and swelling of the mucosa (Martini & Welch, 2005).Current research suggests production of mucus is accelerated in response to an auto-immune reaction to
 
an allergen. Asthmatics may have an accelerated growth, differentiation and recruitment of mast cells, basophils, eosinophils and B-cells, all of which are involved in humoral immunity, inflammation, andthe allergic response. In asthma, this arm of the immune response is possibly overactive (De Paz,
 
Esteban, Garcia, & Martinez, 2004).
 Bronchitis
 
Is an inflammation and swelling of the bronchial lining and is characterised by overproduction of mucous secretions. In time, these secretions will block the minor airways and decrease respiratoryefficiency. A great deal of research has been conducted exploring the role bacterial infections play in
 
the exacerbations of Bronchitis, including the role Enterobacteriaceae and Pseudomonas play in acuteexacerbations (Eller, Ede, Schaberg, & Niederman, 1998) . Patients with chronic bronchitis may haveheart failure resulting in systemic oedema and low oxygenation manifesting as cyanosis.
 Emphysema
 
Is characterised by the irreversible destruction of lung gas exchange surfaces within the alveoli. It iscaused by the inhalation of toxic gases and particles particularly from smoking. Individuals withchronic emphysema tend to exert large amounts of energy compensating for the loss of functioningtissue to maintain a relatively normal arterial Oxygen partial pressure (Martini & Welch, 2005).
Non-invasive oxygenation
 
It is not the intention of this literature review to describe physiology and chemoreceptor theory indetail. That having been stated, to understand the effect of non-invasive oxygen delivery in the chronicCOPD patient it is essential that “normal” operational parameters be outlined. Porth, (2005) states thatthe normal carotid arterial PaO
2
lies between 80 and 100 mm Hg and the arterial PaCO
2
is 35 to 45 mmHg in healthy individuals.
Three current theories
 
There is confusion in the literature regarding the breathing mechanism in COPD patients. In an article published in the “Medical Surgical nursing journal” Simmons and Simmons (2004) outline three predominant theories regarding breathing control in these individuals.
 
The authors explain the
hypoxic drive
as a process whereby the patient is triggered to breathe by virtueof increased acidity in Ph sensing peripheral chemoreceptors. They cite Whitnack (2001) who states inthe Adult acute care bulletin that this theory is all but disproven. Their description of the hypoxic drivehas elements of 
the
 
 Haldane effect 
 
whereby CO
2
replaces O
2
in haemoglobin.
The Haldane effect 
is thesecond most popular theory in the literature.The Ventilation/Perfusion (V/Q) mismatch theory is cited in the majority of the literature as the most plausible mechanism. V/Q matching is said to occur in alveoli when the capillary flow matchesventilation ensuring a 1:1 exchange of gases across the surface. A high mismatch is termed
deadspace
 
” and is present when more ventilation occurs than perfusion. The theory states that as COPD patients are given high flow oxygen the V/Q match changes due to long term vasoconstricted
 
capillaries dilating causing an increase in PaO
2
and PaCO
2
(Epstein & Singh, 2001). There is much
 
debate and confusion in the literature regarding the actual cause.Interestingly, Martini, (2005) observes that although Ph receptors react quickly to an initial change, if CO
2
 
levels are maintained over hours the receptors accept the level as “normal”. As a result, over time,the effect of the CO
2
receptors on the regulation of the breathing centre declines and these receptorscease to be a reliable regulator. Fortunately, the action of Oxygen receptors remains intact, correctly
 
responding to changes in O
2
levels.Martini (2005), notes that chronic COPD patients may be operating with an arterial Carbon Dioxidelevel between 50 and 55 MM Hg, their CO
2
receptors regarding this elevated range as “normal
 
operation” and thus providing regulation within this boundary.Martini (2005), observes that O
2
receptors are the only reliable breathing centre regulator in these patients.
Oxygen delivery devices
Strachan and Knoble, (2001) state that masks can be divided into two categories, fixed and variable.Both types of mask entrain (bring in) air from outside mixing with Oxygen. The Hudson mask andnasal cannula are examples of variable delivery devices as the resultant percentage of Oxygen (and air mixture) to the patient is dependent on variable parameters including the rate of breathing, position of the device and Oxygen flow rate.It can be seen that entrained air is not regulated in a variable device simply by looking at the holes in aHudson mask, thus, an accurate percentage of Oxygen can never be delivered.Strachan and Knoble (2001), observe that the percentage of entrained air can be minimised (andOxygen increased) by utilising a rebreather bag attachment to the Hudson mask.Fixed devices primarily used with COPD patients regulate entrained air via a rotating fenestratedadaptor and deliver a known percentage of Oxygen. The researchers state these devices are also usefulas a fixed reference prior to an accurate arterial blood gas measurement. These masks are suppliedwith a table showing the O
2
flow rate against entrained air setting with the resultant percentage of delivered Oxygen (Strachan & Noble, 2001).
Oxygen therapy in COPD patients
 
Medical and nursing anecdotal lore states that administering high flows of Oxygen to a COPD CO
2
retainer will reduce hypoxic drive thus eventually resulting in apnoea, the purpose of this review is toascertain if this belief has an empirical basis grounded in literature.The literature review commenced with the reviewer attempting to track the earliest mentioning of thehypoxic drive theory. What primarily emerged in the early literature was the fact that subjects were amixture of non-ventilated individuals who where exacerbated, non exacerbated, CO
2
and non CO
2
retainers.The earliest literature consistently named an increase of pulmonary dead space and an increase of arterial Carbon Dioxide as a problem when Oxygen low is increased.An example is the Lee and Read (1967), study. The researchers hypothesized that an increase inOxygen delivery to COPD patients may increase pulmonary dead space by reversing alveoli pulmonary

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