Oxygen takes the breath away: old sting, new setting

Management of Chronic Neuromuscular Respiratory Failure in the Intensive Care Unit

In this seminar we describe the critical care management of patients with chronic neuromuscular diseases (cNMD). Determination of the acuity of the critical illness and trajectory of illness in the setting of cNMD is necessary to guide decision making. Systemic complications of critical illness, cardiac support needs, and peri-intubation considerations may be affected by underlying diagnosis. Mechanical ventilatory support, whether noninvasive or invasive, requires redefinition of the goals of ventilation on a patient-by-patient basis. Mode and approach to invasive ventilation and liberation to noninvasive ventilation versus tracheostomy have limited evidence, but potential clinical approaches are reviewed.

Oxygen-induced hypercapnia: physiological mechanisms and clinical implications

Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. The risk of hypercapnia is not restricted to COPD only; it has also been reported in patients with morbid obesity, asthma, cystic fibrosis, chest wall skeletal deformities, bronchiectasis, chest wall deformities, or neuromuscular disorders. However, the risk of hypercapnia should not be a deterrent to oxygen therapy in hypoxemic patients with chronic lung diseases, as hypoxemia may lead to life-threatening cardiovascular complications. Various mechanisms leading to the development of oxygen-induced hypercapnia are the abolition of ‘hypoxic drive’, loss of hypoxic vasoconstriction and absorption atelectasis leading to an increase in dead-space ventilation and Haldane effect. The international guideline recommends a target oxygen saturation of 88% to 92% in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and other chronic lung diseases at risk of hypercapnia.  Oxygen should be administered only when oxygen saturation is below 88%. We searched PubMed, EMBASE, and the CINAHL from inception to June 2022. We used the following search terms: “Hypercapnia”, “Oxygen therapy in COPD”, “Oxygen-associated hypercapnia”, “oxygen therapy”, and “Hypoxic drive”. All types of study are selected. This review will focus on the physiological mechanisms of oxygen-induced hypercapnia and its clinical implications.

Mechanical Ventilation

Mechanical ventilation is the second most frequently performed therapeutic intervention after treatment for cardiac arrhythmias in intensive care units today. Countless lives have been saved with its use despite being associated with a greater than 30% in-hospital mortality rate. As life expectancies increase and people with chronic illnesses survive longer, artificial support with mechanical ventilation is also expected to rise. In one survey, over half of senior internal medicine residents reported their training on mechanical ventilation as inadequate, whereas the majority of critical care nurses reported having received no formal education on its use. Technological advances resulting in the availability of sleeker ventilators with graphic waveform displays and new modes of ventilation have challenged the bedside clinicians to incorporate this new data along with evidenced-based research into their daily practice. A review of current thoughts on mechanical ventilation and weaning is presented.

Light-dependent oxygen consumption in bacteriochlorophyll-serine-treated melanoma tumors: on-line determination using a tissue-inserted oxygen microsensor

Successful application of anticancer therapy, and especially photodynamic therapy (PDT) mediated by type II (PDTII) processes, depends on the oxygen content within the tumor before, during and after treatment. The high consumption of oxygen during type II PDT imposes constraints on therapy strategies. Although rates of oxygen consumption and repletion during PDTII were suggested by theoretical studies, direct measurements have not been reported. Application of a novel oxygen sensor allowed continuous and direct in situ measurements (up to a depth of 8-9 mm from the tumor surface and for several hours) of temporal variations in the oxygen partial pressure (pO2) during PDT. Highly pigmented M2R mouse melanoma tumors implanted in CD1 nude mice were treated with bacteriochlorophyll-serine (Bchl-Ser; a new photodynamic reagent) and were subjected to fractionated illumination (700 < lambda < 900 nm) at a fluence rate of 12 mW cm-2. This illumination led to total oxygen depletion with an average consumption rate of 7.2 microM(O2) s-1. Spontaneous reoxygenation (at an average rate of 2.5 microM(O2)/s) was observed during the following dark period. These rates are in good agreement with theoretical considerations (Foster et al., Radiat. Res. 126, 296, 1991 and Henning et al., Radiat. Res. 142, 221, 1995). The observed patterns of oxygen consumption and recovery during prolonged periods of light/dark cycles were interpreted in terms of vasculature damage and sensitizer clearance. The presented data support the previously suggested advantages of fractionated illumination for type II photodynamic processes.