How Long do I Need to Use Nocturnal Oxygen?

Nocturnal Oxygen: Is it Still Necessary?

Dr. Mahler:

I am writing to ask you if I should continue nocturnal oxygen during sleep. A few months ago I had a flare-up of COPD and was in the hospital for 3 nights. I am feeling better and have resumed all of my previous activities. The hospital doctor said to use oxygen at a setting of 2 with activities and during sleep. However, my breathing is fine when I go shopping and do laundry, and I have not been using the portable oxygen system for the past 2 weeks. However, I am afraid to stop the oxygen during sleep at night even though I don’t think that I really need it. What should I do?

Janet from Silver Springs, MD

Dear Janet:

Your situation is quite common. Someone with COPD can get a respiratory infection, and then need to use oxygen when discharged from the hospital. Oxygen is prescribed when the oxygen saturation level is 88% or below at rest, with walking, and’or when sleeping. Many doctors recommend use of oxygen during sleep if it is also needed with walking activities.

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

I assume that the oxygen supply company provided both a portable system (for activities) and a concentrator (for sleep).

At your next appointment, I suggest that you ask your health care provider to measure your saturation level at rest and while walking in the hallway for at least 2 minutes. This will determine whether you will need to use oxygen at rest and during activities.

To check whether you require oxygen during sleep, your health care provider can order a test called nocturnal oximetry. This system (shown above) measures your oxygen saturation while you sleep breathing room air (not using oxygen that evening) and records the results on a computer chip. You return the device the next day and the results can be viewed on a computer screen and/or printed on paper.  Generally, if your oxygen saturation is consistently above 88% during sleep, then you should be able to stop nocturnal oxygen.

I hope this information is helpful.

Best wishes,

Donald A. Mahler, M.D.

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.

Sincerely,

Donald A. Mahler, M.D.

Chronic Bronchitis OR Emphysema?

Hello, Dr. Mahler:

I have mild/moderate COPD.  I know both Emphysema and Chronic Bronchitis are covered under this term and the treatment is virtually identical,  but I do want to know which primarily I have.  My nurses and doctor refuse to tell me,  do you think this is because they don’t know?  I have only ever had a chest x-ray.   Do I have the right to insist please?

I am smoking and my sats are often very low 90’s and even go as low as 90.   Also I have a severe symptom which is not being able to keep up with my peers on the flat.   Are these both down to smoking as they claim,  or could there be some other cause please?

Thank you very much.

Adele from Manchester, United Kingdom

Dear Adele,

Thanks for your query. The diagnosis of COPD requires breathing tests, whereas a chest x-ray may only suggest this medical problem.

With chronic bronchitis, the person coughs up mucus from the chest most days (at least for 3 months) over at least 2 years.  If you do this, then you do have chronic bronchitis. With emphysema, the main symptom is shortness of breath with activities. A breathing test called the diffusing capacity is lower than normal in those with emphysema.  Some individuals may have components of both chronic bronchitis and emphysema.

It is possible that your doctor may not know the answer to your question if he/she has not ordered pulmonary function tests (PFTs) – commonly called breathing tests.  I suggest that you ask your doctor about ordering these tests.

Views of the inside of a normal breathing tube on left and of chronic bronchitis on the right. Note the white-yellow mucus lining the inside of the airway in chronic bronchitis.

Views of the inside of a normal breathing tube on left and of chronic bronchitis on the right. Note the white-yellow mucus lining the inside of the airway in chronic bronchitis.

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

Microscopic view of the air sacs (alveoli) in the top right showing emphysema (destruction and enlargement).

It is likely that your breathing difficulty is due to COPD, although heart disease may also cause someone to be short of breath. PFTs are “key” to make sure of the correct diagnosis. If you do have COPD, it is  likely that “not being able to keep up with peers” is due to the narrowing of  your breathing tubes. The narrowing makes it hard to get all of the air out of your lungs when you exhale, and the “trapped air” affects the  ability of your breathing muscles (the diaphragm) to work properly.

On left: Normal size of lungs. On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.

On left: Normal size of lungs.
On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.

I encourage you to quit smoking and to ask your doctor whether inhaled bronchodilator medicine(s) may help you breathe easier  assuming PFTs do show narrowing or obstruction. This information and much more are available in my book COPD: Answers to Your Questions (published February 2015) which is presented on my website.

Best wishes,

Donald A. Mahler, M.D.

Low Oxygen Level

My Oxygen Level was only 72%

Dear Dr. Mahler:

I recently had an incident where I did not feel well and checked my O2 level to find it at 72. I felt very short of breath, extremely shallow breaths and had a stinging pain in my head. Had been reading and had gone to the restroom. I had been fine while just sitting and reading. Was on steady flow not on pulse. I have oximeter checked frequently and it is always spot on. Found and corrected the issue immediately but do not know how long I had had levels below 90 before I realized I was not feeling well. Could my organs or brain been affected? At what level does damage to the organs and or brain occur?
Thanks
Cindy from El Paso, TX

Dear Cindy,

Sorry to hear of your problem, but at least it was temporary.

It is impossible to know if you had any damage to your brain or other parts of your body with the low oxygen level. However, based on your description, I believe that it is highly unlikely that you suffered any permanent effect. Our bodies are remarkable and adapt to brief periods of low oxygen by increasing breathing and increasing heart rate in an effort to compensate. It sounds like your body sent you signals of this problem as you became “very short of breath” and had a “stinging pain in the head.” Your experience is a good example of how we need to pay attention to the signals that our body sends to our brain. The challenge is to know when the message is urgent like “I can’t breathe,” and then we need to respond as you did, OR we just ignore the signal and hope that it goes away.

To answer your second question, remember that the goal of breathing oxygen is to maintain an oxygen saturation level of 90 – 92%. This is measured by a machine placed on your finger called a pulse oximeter.

pulse oximeter that measures oxygen saturation

pulse oximeter that measures oxygen saturation

 

 

 

 

 

Although a normal oxygen saturation level if 95% or higher, the cells in our body work fine if we are at 90%. I suspect that when your doctor ordered oxygen for you, he/she picked the flow rate (usually 1 – 4 liters/min) based on measurements from the oximeter. Usually, the nurse or technician adjusts the flow rate of oxygen at rest and during walking to achieve a saturation in the low 90s. Hopefully, your doctor, or nurse, will check you oxygen levels periodically as things can change.

Finally, even though you are using oxygen, I encourage to stay as active as possible.

Best wishes,

Donald A. Mahler, M.D.

My Breathing is Worse… What Should I Do?

Breathing is Worse Requires Medical Assessment

Dear Dr. Mahler:

I am 72 years old and take Advair twice a day for my COPD. About 5 weeks ago my arm swelled up, and my primary care doctor thought it was due to an insect bite. She prescribed an antibiotic. When it did not get better, I saw my oncologist who diagnosed that the swelling was due to a blockage in my armpit because my previous breast cancer had spread to the lymph glands. I just completed 4 weeks of radiation treatments.

I am writing to you because my breathing has been worse for the past month or so. I went to the Emergency Room two weeks ago to be checked out. A CT scan was normal except for emphysema. There was no blood clot to my lungs. What should I do? I am using albuterol 2 -3 times per day, but it really doesn’t help much. I do take Ativan every couple of days because I have been feeling anxious.

Linda from Montpelier, VT

Dear Linda:

Sorry to hear about the cancer recurrence.

Regarding your shortness of breath, it is important to have breathing tests done and your oxygen saturation checked to see if these results show any changes. Without this information, it is impossible to know if your breathing is worse because of your COPD or another reason, such as anemia, anxiety, being out of shape (reduced physical activity while you were receiving your radiation treatments, and possible heart disease. All of these conditions are common causes for chronic breathing difficulty.

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

Spirometry performed to assess why Breathing is Worse

Woman performing breathing test.

 

 

 

 

 

 

Sincerely,
Donald A. Mahler, M.D.