I am Using Oxygen at Night. Do I need Oxygen when I Sleep?

Do I Still Need to Use Oxygen at Night during Sleep?

Dear Dr. Mahler:

About a year ago my primary care doctor ordered oxygen at night when I sleep. I guess that my oxygen level was low in the office, but my level was not monitored during sleep. She really didn’t explain things very clearly except that she said to use oxygen at 2 liters/minute rate.  I really can’t tell any difference using oxygen during the night or when I wake up.  Last May my husband and I went away to Maine for our anniversary and I didn’t take the oxygen concentrator with me.  I felt fine and now only use oxygen a few nights each month when I feel a little tired. What do you think? I am 73 years  and have moderate COPD according to my doctor, but never had complete breathing tests.

Silvia from Newport, RI

Dear Silvia:

Insurance companies and the Centers for Medicare and Medicaid (CMS) have specific criteria (levels) for when they will pay for oxygen for an individual.  The oxygen level is usually

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

determined by a device that goes on your finger called an oximeter.  This measures the percentage of oxygen carried by the protein hemoglobin found in red blood cells.  The device sends wave lengths through the finger and a sensor determines the saturation of oxygen. This is abbreviated SpO2.

Diagram of oximeter to determine whether someone requires oxygen at night

The top piece of the oximeter emits light waves that pass through through the finger. The bottom piece has a sensor. Absorption of light differs between blood loaded with oxygen and blood lacking oxygen.

You qualify for using oxygen if your SpO2 is 88% or less.  If you level was 88% or below in the office a year ago, that would qualify you for using oxygen 24/7, not just at night. Did your doctor recommend using oxygen all of the time or just to use oxygen at night?

The decision to prescribe oxygen in the office or clinic should only be considered when you are being treated with optimal medical therapy.  In brief, this means:

  1. Not smoking
  2. Use of both types of inhaled bronchodilators (called beta-agonists and muscarinic antagonists) that work by different mechanisms (ways) to relax muscle around the breathing tubes. Available long-acting dual bronchodilators include Anoro (a dry powder) and Stiolto (a mist) used once daily in the morning.
  3. In a stable condition.

Different studies show that from 27 – 70% of those with COPD with awake SpO2 90-95% may experience substantial drops in oxygen levels during sleep. However, the consequences of these drops in oxygen (called desaturation) is unclear. These drops may contribute to more awakenings (arousals) during sleep which could lead to sleep fragmentation.

I suggest that you ask your doctor to recheck your oxygen saturation in the office.  If it is 88% or less, then you should be using oxygen all of the time. If it is 89% or higher, then it would be helpful to monitor your SpO2 when you sleep at home not using oxygen. This can determine if you have frequents drops in your SpO2 and can help guide a decision on whether you do or don’t need oxygen at night during sleep.


Donald A. Mahler, M.D.

Inhaled Corticosteroids and Pneumonia

Stopping Inhaled Corticosteroids Reduces Pneumonia

Background: Inhaled corticosteroids are an inhaled form of prednisone which reduces inflammation. Inhaled corticosteorids are approved  by the US Food and Drug Administration (FDA) to treat those with COPD in combination with a long-acting beta2-agonist bronchodilator. The names of these medications are: Advair; Symbicort; and Breo.

Studies show that these medications make it easier to breathe and reduce the chances of an exacerbation (worsening of shortness of breath, increased coughing, and/or more mucus) usually due to a chest infection. However, there is an increased risk of pneumonia in those with COPD who use Advair, Symbicort, or Breo.

Study Findings: In the November 2015 issue of CHEST (volume 148; pages 1177-1183) Samy Suissa, Ph.D., and colleagues examined health insurance information in over 103,000 individuals with COPD who used inhaled corticosteroids in the Quebec province of Canada from 1990 through 2009. Some of these stopped thier use during the study period.

The main finding was that stopping inhaled corticosteroids was associated with a 37% decrease in the rate of serious pneumonia (either requiring hospitalization or death from pneumonia).

My Comments: Both you and your health care provider should consider expected benefits and possible risks of any medication that you take. The findings of this study highlight the concern of the increased risk of pneumonia in someone taking inhaled corticosteroids and shows a decreased risk when inhaled corticosteroids are stopped.

In my practice, I advise someone with COPD to stop the medication containing an inhaled corticosteroid IF he/she has had pneumonia. I caution the individual that stopping the medication may make their breathing worse, and make sure that the person is taking both classes of different bronchodilators to improve breathing.

As always, I encourage you to discuss your individual situation with you health care provider.


Highlights from European Respiratory Society Congress

September 26 – 30, 2015, in Amsterdam

One of the highlights of the International Congress was a session on improving outcomes in those with COPD. A major emphasis was on the current goals of treatment:

  1. Reduce shortness of breath – which can generally be measured in a few weeks of starting a new inhaled bronchodilator medication
  2. Reducing the risk of an exacerbation (worsening of symptoms usually due to a chest infection) – this requires at least six months to assess.
David Singh, M.D., from University of Manchester in UK

David Singh, M.D., from University of Manchester in UK

Dr. David Singh of Manchester, United Kingdom, spoke about optimizing bronchodilation (opening the airways). He quoted one study that showed that most patients with COPD were still short of breath with activities after being started on a single long-acting  bronchodilator (Primary Care Respiratory Journal, year 2011, volume 20, page 46). He then discussed the role of using two different bronchodilators in a single inhaler to get the greatest benefit. In the US, there are two approved dual bronchodilators in a single inhaler – Anoro Ellipta and Stiolto Respimat. The evidence suggests that two bronchodilator medications that work in different ways can provide better stability in keeping the breathing tubes open longer. This means that it should be easier to breathe for those with COPD and should have a better quality of life.


Dr. Marc Miravitlies of the University Hospital in Barcelona, Spain, discussed both daytime and nighttime shortness of breath (medical word is dyspnea) in those with COPD. Studies show that many

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

individuals who have COPD wake up due to breathing difficulty. Also, poor sleep is considered a risk factor for having an exacerbation (worsening of shortness of breath and/or coughing up yellow-green mucus). Bronchodilators that work throughout the night should help if the sleep problem is due to COPD, but will not help if there is another cause like sleep apnea.

Dr. Neil Barnes, Medical Head of GlaxoSmithKline pharmaceutical company, spoke about the benefits and side effects of using inhaled corticosteroids (prednisone like medication). He emphasized that inhaled corticosteroids combined with long-acting beta-agonist bronchodilator (in US: brand names are Advair, Symbicort, and Breo) are widely prescribed, but should primarily be used in those who have had two or more exacerbations (worsening of symptoms) in the past year OR one exacerbation in the past year that required treatment in the hospital. A major concern about the use of

Neil Barnes, M.D., Medical Head of GalxoSmithKline pharmaceutical company

Neil Barnes, M.D., Medical Head of GlaxoSmithKline pharmaceutical company

inhaled corticosteroids is the risk of developing pneumonia.



My Comment: Each year at medical conferences there is growing research interest in helping those with COPD. Novel therapies are being evaluated in addition to improving inhaled bronchodilators. All of us need to promote greater public awareness of COPD and encourage the National Institute of Health, various professional organizations, and pharmaceutical companies to increase research funding.

What are the stages of COPD?

Dear Dr. Mahler:

I have moderate, or Stage 2, COPD according to my doctor. However, I don’t understand what the stages mean. Will I  go on to the next stage? How many stages are there? Overall, I am doing pretty good. I am 63 years old and still work 30 hours a week at a convenience store. In the summer I work outside to keep our property in good shape and attractive. Thanks for answering this.

Leo from Bennington, VT

Dear Leo:

The stages of COPD are based on breathing tests.  FEV1, or the forced expiratory volume in one second, is how much air you can exhale (blow out) in one second. The breathing tests should be performed after inhaling a quick acting bronchodilator (albuterol. is usually used).

The forced expiratory volume in one second (FEV1) is shown in the figure.

The forced expiratory volume in one second (FEV1) is shown in the figure.


The FEV1 value is then compared with what is expected, or predicted, for your age, sex, and height. This final value is called post-bronchodilator FEV1 percent predicted. This approach has been used for a long time even though we have major discussions at medical meetings about changing from using breathing test results to using the severity of symptoms (breathing difficulty and coughing).

There are four stages of COPD shown here.

  1.     Mild                         FEV1 80 percent predicted or higher
  2.     Moderate              FEV1 50 – 79 percent predicted
  3.     Severe                    FEV1 30 – 49 percent predicted
  4.     Very severe          FEV1 below 30 percent predicted

It is important to remember that the stages are based on how your lungs are working and not on how you feel or your breathing difficulty. Your stage of COPD may actually get better if you start taking one or more inhaled bronchodilator medications. It is also possible that your COPD will remain stable and you will stay in the moderate stage for a long time. On the other hand, breathing tests may get worse in those with COPD, particularly if you continue to smoke cigarettes or inhale irritants (dust, fumes, fibers) in the air.

It is great that you are active, and I encourage you to continue to lead a healthy life style. Let me know if you have further questions.


Donald A. Mahler, M.D.



Asthma and COPD Overlap Syndrome

Hot Topic at Respiratory Meetings – Asthma and COPD Overlap

Discussions about those individuals who have features of both asthma and COPD is a “hot topic” at medical meetings. It is important to understand this overlap, or combination, because different medications are used to treat asthma and to treat COPD (see below My Comment).

In a medical article published on-line on August 20, 2015, in the journal CHEST, Dr. Cosio and colleagues from Spain identified individuals who were considered to have both asthma and COPD. This is called asthma-COPD overlap syndrome and abbreviated ACOS.

The authors studied 831 patients diagnosed as having COPD. To identify those who also had asthma, they measured improvements in breathing tests after someone inhaled albuterol (a quick acting bronchodilator) and  examined blood tests that are usually positive in those with asthma,

Main Findings: 15% of the group were considered to have both asthma and COPD (ACOS). They were predominantly male (82%) and 63% were taking an inhaled corticosteroid medicine.

Circles show overlap between asthma and COPD. COPD includes chronic bronchitis and emphysema.

Circles show overlap between asthma and COPD. COPD includes chronic bronchitis and emphysema.

My Comment: Why is this important to you? The main reason is that inhaled corticosteroid medications are used to reduce inflammation (redness and swelling) in the breathing tubes in those with asthma. Rather, different types of inhaled bronchodilators are used to treat  those with COPD. Inhaled corticosteroids should be used to treat COPD mainly for those who have experienced frequent episodes of worsening of COPD usually due to a chest infection (called an exacerbation). One concern about use of inhaled corticosteroids in the treatment of COPD is an increased risk of pneumonia.

With any medication, there needs to be consideration of expected benefit and possible risk. You may wish to discuss this topic with your healthcare provider.