PRENDERGAST: OXYGEN THERAPY IN PNEUMONIA

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OXYGEN THERAPY IN PNEUMOMA*

By D'ARCY PRENDERGAST, B.A., M.B., M.RC.P. (LoND.)

Toronto ..HE therapeutic use of oxygen goes back a g 'eat many years, almost to the days of Priestley and Lavoisier, who first prepared the gas, and showed that it is the vital principle of air. Just on account of its being such a vital principle it was used at first in all manner of diseases, with the hope that it would have the same stimulating effect in the body as it has in such chemical reactions as combustion. As the physiology of respiration and circulation became better known, the use of oxygen was put on a more rational basis, and was restricted to disturbances of respiration and circulation. The need for oxygen in these conditions was obvious, but the methods of administration were so muefficient, and usually still are even at the present day, that the results hoped for were not obtained, and this form of therapy fell into more or less disrepute. It seems to have been reserved largely for the last hours of patients dying of pneumonia, and was given then more for th. sake of feeling that everything possible was being done than with any hope of saving life. At that stage in the disease, and administered in the way it usually was, oxygen had no more effect than the hypodermics of strychnine given under similar circumstances. The reason for this unfortunate situation in regard to oxygen therapy has been the difficulty of checking up scientifically the actual effect of oxygen in the body after inhalation by the patient. In recent years some of this difficulty has been cleared up by the work of Iluerter, Van Slyke, Haldane, and others, in their investigations on arterial blood in normal and in diseased individuals. Previous to this there had been no means of ascertaining whether or not the oxygen content of the blood leaving the lungs was in reality being increased by the oxygen inhaled. Fraser, at St. Bartholomew's Hospital, has further simplified these investigations by showing that it is easy and safe to obtain blood * Read at the Section of Medicine, Academy of Medicine, Tor unto, Tuesday, Nov. .. 1927 samples by puncture of the femoral artery just below the inguinal ligament. Lack of oxygen in the body tissues may be due to one or more of several causes 1. There may be too little oxygen in the air, as at the great altitudes found in mountain climbing and flying. 2. There may be too little h.rnnoglobin available, as in an.mia and in poisoning by carbon monoxide. 3. There may be failure of circulation, as in heart disease, when the blood flow is too slow to keep up an adequate supply of oxygen to the
tissues.

In the types of cases exemplified by anmemia and heart failure the administration of oxygen will do no good. The lung is the only place where oxygen can enter the blood stream, and in these conditions the blood leaving the lungs is already carrying practically its full load. Increasing the amount of oxygen in the inspired air in these cases can only increase the amount of oxygen in the blood by forcing a little more of the gas into simple solution in the plasma. 4. Lastly, anoxa.mia may be due to abnormalities in the lung, preventing the blood from getting its proper supply of oxygen from the inspired air. Examples of such abnormalities are infarct, omdema, and pneumonia. In these cases the circulation is. adequate, or almost so, but the state of the alveoli interferes with the transfer of gases between blood and air. It would seem reasonable to suppose that if the oxygen in the alveolar air were increased it would be easier for the blood to become fully saturated in the short time it spends in the pulmonary circulation. Normally, blood leaves the lungs about 95 per cent saturated with oxygen. In severe cases of pneumonia the arterial saturation may sink below 80 per cent, or sometimes even below 70 per cent. There is considerable evidence to suggest that such a lack of oxygen may in itself be the cause of some of the more severe symp-

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THE CANADIAN MEDICAL ASSOCIATION JOURNAL war, is also very efficient. It is free from most of the drawbacks of the chamber method. The difficulty is that the patient who is really ill, and who needs it most, usually refuses to wear it. Even a normal person requires a little practice before feeling quite comfortable in any type of gas-mask. When there is any dyspn.a, as in the pneumonic patient, or in the healthy individual after exercise, a mask is usually intolerable. One can force the patient to wear it, as is sometimes done, but it is doubtful whether its value is not more than offset by the struggles against it. The remaining method is by the nasal tube, and taken all around it is, perhaps, the best for general use. It is not quite so efficient as either the chamber or the mask, but it is free from their disadvantages. It is rarely objected to by any patient, and is cheap and easy to set up anywhere. It consists simply of a long rubber tube leading from an oxygen tank and ending in a soft rubber catheter. This catheter is lubricated with vaseline, or better still with cocaine ointment, and is pushed back through the nostril to within half an inch of the posterior wall of the nasopharynx. In the average adult this point will be three inches from the tip of the nose. A strip of adhesive tape will fix the tube to the cheek so that it is not so likely to be inadvertently pulled out. It is an improvement to bubble the oxygen through hot water on its way to the patient. This warms the gas and saturates it with water vapour, doing away with the tendency to dry the throat, which is otherwise an annoying feature. Another improvement is the use of the headband suggested by Geoffrey Bourne in the Lancet of July 1, 1922. This holds the catheter more securely than adhesive plaster, and is more comfortable for the patient. The most common fault with this nasal tube method is in not giving the oxygen fast enough. The usual rate of five to ten bubbles a second from a half-centimetre tube amounts to less than a half litre of oxygen a minute. This is not enough to have any appreciable effect on the alveolar air. Most individuals can tolerate about four litres per minute. When no meter is supplied with the oxygen tank, the easiest rule is simply to have as high a rate of flow as the patient can bear. It does not matter whether he breathes through nose or mouth, as the oxygen

toms and dangers of pneumonia. As an example of such evidence, it was a common observation during the war that aviators returniiig from particularly high patrols, even those during which there had been no special strain or fighting, were irritable and confused. Again, Barcroft shut himself in an air-tight chamber in which the oxygen was sufficiently reduced to cause his arterial saturation to sink from the normal 95 per cent to 88 per cent. This is a very mild degree of anox.mia, but was enough to cause in him such symptoms as vomiting, vertigo, severe headache, .nd increased pulse rate. These results were eonf.rmed by Ilaldane and others in similar experiments. Another example of the effects of anox.mia is carbon monoxide poisoning. In severe cases, although the oxygen content of the blood may be restored to normal within a couple of hours, there may already be so much damage done to the central nervous system that the patient does not recover. He may live for several days, unconscious all the time, and sometimes showing epileptiform twitchings. There is then little doubt that anoxamia may be one of the serious factors of pneumonia, and that the administration of oxygen should be of value. The method of administration is, however, important. There is no doubt that the worst method is the one in most common use, i.e.,
a tube connecting an oxygen tank with a funnel

held loosely over the patient's face. For all the actual effect this has on the blood the funnel might almost as well be hanging out of the window. There arc three other methods in use, all very much better. The first is the nasal tube, the second is the Haldane mask, and the third is the oxygen chamber. Oxygen chambers used in different places vary in size from a small tent which just covers the patient's head, to a room-sized cabinet. This method is very officient as regards getting oxygen into the lungs, and has the great advantage of having no attachments to annoy the patient or embarrass his breathing. It has, however, several draw-backs. It is not easily available in the home. It tends to be hot. It is not easy to get at the patient to feed, or sponge him, or to apply mustard plasters. However, where oxygen chambers are in use the results reported have been very good. The Haldane mask, or one of the various modifications of it that have been devised since the

I.RENDERGAST: OXYGEN THERAPY IN PNRUMONJA is being delivered from the tube at the point where nose and mouth meet. In the, course of some unpubli shed experiments at St. Bartholomew's Hospit. 1, Hilton has found that at four litres per minute by the nasal tube the oxygen tension in the al veolar air is raised to 31 per cent or 240 mms.; about two and one-half times the normal amount The same observer found that six litres per niinutc by the Haldane mask raises the alveolar t nision to 650 mms., not very far from pure oxyg .n. Whether such extreme concentration is des irable is not certain. Some animals, such as 3anaries, can live apparently normal lives in pur oxygen, but Karsner working at the Carnegie Institute in Boston, found that in rabbits breat hing over 80 per cent oxygen for upwards of thr ee days there were definite inflammatory changes in the lungs. In a few cases treated by the .vriter at St. Bartholomew's Hospital, and at the Toronto General Hospital, by the nasal tubc method, the changes in the oxygen content of the arterial blood were as follows:
ARTERIA L SATURATION Itefore After

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Oxygen Oxygen 86% 91% 89 92 81 89 72 78 72 84 86 92 78 86 73.5 73 90 91 84 89 58 56 67 62 59 71

them moribund, when the treatment was started. Three cases, Nos. 8, 11, and 12, all moribund, and all with a very marked degree of anoxa.mia, failed to show any improvement in the blood. In all the remainder the anoxa.mia was at least partially relieved. Subjective improvement was hard to judge. Several of the cases volunteered the statement that they felt better, but most were rather noncommittal. It cannot be said whether or not any of the survivors owed their lives to the oxygen, but it is at least very possible. There are in fact no figures available anywhere to show the effect of oxygen therapy on the mortality of pneumonia. To be of any value such figures would have to cover long series of unselected cases in whom this type of treatment was made a routine. A word as to the cost of such treatment may be of interest. The nasal tube outfit costs practically nothing, and requires no attention that cannot be given by the most unskilled nurse or relative. The cost of the chamber or mask varies with the different types, but is not high when compared with the cost of other items of hospital apparatus. As the demand for this equipment increases it may be that the medical supply houses will keep them in stock and rent them as required. Commercial oxygen, which is practically chemically pure and is perfectly satisfactory, costs about two cents a cubic foot. Used continuously at four litres a minute this would amount to a little over four dollars a day. In the average case of pneumonia, in which the administration was started early and continued throughout the acute stage the total cost would

had marked vary from fifteen dollarsuse of oxygen In summing up the upwards. in pneuwere deeply monia the chief points are as follows wed by the 0 the oAema 1. There is both theoretical and experimental t was caused evidence that the administration of oxygen in c peripheral pneumonia should availablevalue. What little clinical evidence is be of supports this. [unchanged. )rovement in 2. The treatment should be started early, belungs might fore the anoxa.mia, which .Crequently occurs in severe cases, injures the central nervous systen.. amonia. No Cyanosis is not marked until the saturation is se:ies as to well below 80 per cent, and by this time irre.gen, as these parable damage may be done. .nd some of 3. The administration must be done efficiently.