How can I balance CO2 and Oxygen Levels?

#1 Dee

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22 November 2010 - 11:22 AM

Q. How can I balance CO2 and Oxygen levels?

Getting too much O2 and CO2 ?? I started my question like this because I have trouble helping my husband thru this dilemma. When he has too much CO2 his brain is telling him to breath faster and get more O2, now his lungs really does not need O2 because he has too much CO2 right???

Now I got startled the other night when his breathing went way too fast like his O2 went down to 71 and his heart was 130. I called the Ambulance they came and they put his O2 unto 10Litres I told her my husband was a CO2 retainer and she proceeded to tell me I was not giving my husband his Ventalin right he needed a chamber, little did she know that the chamber was not something my husband wanted at that time. He does use the chamber when he needs ventolin. They never turned down the O2 until 45 minutes later.

Fred's C02 was 91 we proceeded to put on his BiPap for 15 hrs a day. The next day is was 71 and is still going down.

What can I do to get the two balanced out. Fred is on O2 most of the time at 1.5 liters sometimes he turns it up to 2.0litres

I hope I explained this right??? Basically I worry about CO2 a lot. He went into a Coma after his LVRS and I will never forget that. Fred has end stage Emphysema he was a smoker and worked underground for 28 years. He quit smoking 4 years ago. I just want Fred with me for as long as I can hang on to him. He no longer works. He retired.

Thanks a million

A. Hi Mitch,

First, you did a pretty good job of providing enough information for me to figure out a few things to suggest to help (I hope) allay some of your concern. BUT, in the process, I want to express some concerns that "I" have in view of the information you provided.

To be sure I have his scenario correct, please correct me if any of the following is not applicable or accurate. He has (probably stage IV - GOLD) severe COPD such that he retainsCO2. Without knowing what his corresponding pH is with the CO2 levels you report, I cannot ascertain how 'acutely' his respiratory failure (technical term) actually is. He was a coal miner? (You said he worked underground for 28 years, so I presume he was a miner and likely mining coal. Correct?) As with many miners, he also smoked, giving him a double-whammy of COPD. That explains his severe gas exchange defect and the CO2 retention. Now, folks who retain CO2 BUT, balance it with retention of "bicarbonate" (a buffering substance in the blood) are said to exhibit "chronic respiratory failure", a necessary and desirable 'compensation action of the body. We say that they have "compensated" for the retained CO2. How much and how well they have compensated for the retained CO2 is indicated by the pH and the bicarbonate, both components of blood gas measurements. When he is 'stable', or in his 'steady state', his pH will be in the normal range or slightly elevated AND his bicarbonate will be significantly above normal. These two components match up to the elevated CO2 to determine if he is 'OK' at any given moment. You also report that he has had LVRS. But, you don't relate WHEN he had it done. So it is difficult to ascertain where he is in his disease state and progression in view of having had the procedure. BUT, that said, folks who have LVRS tend to decline back to their 'pre-LVRS' pulmonary function by four years, though MANY continue to do well for many more years beyond four. With his history, I wouldn't be surprised if he has returned to his pre-LVRS state at this point, especially in view of the fact that he seems to be severely retaining CO2.

Now, one point I want to make is that there is not a "balance" relationship between O2 and CO2, per se, as you seem to put it. So, any notion you may have developed about too much oxygen being a problem is misplaced for several reasons. But, the bottom line is he surely DOES need oxygen and probably more than you have thought in the past, or than some of his health care professionals may think, even now. There IS a long-standing belief that giving too much oxygen to a CO2-retainer will cause them to retain even more CO2 which will then decrease their 'drive to breathe', causing them to quit breathing, even to the point of dying from it. There is no empiric evidence that such thing happens. And indeed, today, the growing sentiment is that the theory was misbegotten AND to practice the withholding of adequate oxygen from folks who retain CO2 in an effort to avoid decreasing their drive to breathe is bad medicine and leads to very predictable problems as time goes by, including premature death from more rapid disease progression. In the meantime, the deprivation of adequate oxygen reduces their ability to function and move around so that they worsen more rapidly than they would if given adequate oxygen, despite CO2 retention. And their ability to achieve any level of 'comfort' within their breathing difficulties is severely impaired, if not impossible.

In folks with normal lung function, as CO2 goes up, they are stimulated to breathe more to try to 'blow it off' to reduce it back towards normal. This mechanism is thought to be defective and suppressed in folks who retain CO2. But, in actuality, we do NOT observe that to be the case when we investigate the phenomenon in studies. So, in one respect, you are correct that his rising CO2 DOES make him try to breathe more. But, to think that he should receive less O2, or that his lungs don't need the additional O2 is where your notion goes awry. He indeed DOES need the extra oxygen for reasons that are too intricate to try to explain here. But, suffice it to say that he indeed SHOULD turn his O2 up, especially if you observe his pulse oximeter measurement of saturation to drop below 88 - 90 % for any significant amount of time. 71 % on the oximeter is critically low and very dangerous if left untreated. Consider that the oxygen level in venous blood - - - after the body has extracted all the oxygen it needs and is sending the blood back to the lungs to pick up more oxygen again - - - is 75 %. At 71 %, his lungs are sending out blood that is so poorly oxygenated that there is little to none to supply the body. Remember that oxygen saturation measured by pulse oximetry is a measurement of the "arterial" content of oxygen. As such it is what is going out into the body to feed it its necessary quantity of oxygen in order to continue functioning. At 71 %, the body becomes starved for oxygen very quickly!

Now, he has some degree of "acute respiratory failure" which is 'superimposed' upon his "chronic respiratory failure". How much he has is not ascertainable without knowing the pH of his blood that goes with those secerely elevated CO2's (the 91 that then dropped to a still, very elevated 71. Normal is 35 - 45, 40 being absolute normal.) Only a blood gas ca measure pH, as oximetry, while being directly affected by pH does not give any indication of what it is. You said that he uses BiPAP and increased to15 hours a day to get his CO2 to drop to the 71 it dropped to. That tells me that he was in fairly profound "ACUTE" respiratory failure. The BiPAP was a godsend and also effective as evidenced by his significant decrease in CO2. It would be invaluable to know what his "steady state" CO2 is. But, that can ONLY be measured when he is feeling as good as he can, in view of his disease severity and requires doing a blood gas test.

In any case, you have the tools to support him as best you can to help him breathe better and to "keep him around" as long as you can. With his BiPAP and oxygen and proper and judicious use of each, he can better normalize his O2 and CO2 than he would be able to without them. I hope you are 'bleeding-in' oxygen to his BiPAP when he is using it - - - and at a flow that is much higher than 2. As well, I would bet that he needs much more than 1.5 to 2 liters ox oxygen even when at rest, though I can't be fully confident of that knowing only what I've learned from your post. At the very least, when he gets up and moves around, his oxygen flow requirement is likely at least 5 or 6 or more in order just to keep his saturation while moving around in the mid-80 % range. Only measurements while he is walking around and for at least 90 seconds or more of movement can verify or refute that speculation.

Another point that comes to mind is what inhaled medications he may be using. I hope that Ventolin is not the ONLY medication he is inhaling. While a spacer IS the best thing to help him get the most out of it, that drug alone is not near enough for the stage of disease he is in. Ventolin should ONLY be a rescue medication for him and a "pick-me-up" as a preparation to walk or exert or exercise. He should be on one of the long-acting forms (LABA) of the class from which Ventolin comes - - - like Formoterol or Salmeterol. He should also be on a long-acting anticholinergic medication. Spiriva is the only one at this time, though there may be other ones coming onto the market around the world. He likely would benefit from an inhaled cortisteroid, like Fluticasone or Beclomethasone or one of a few others that are widely used. Many folks take a combination inhaled drug mixture of these medications. Advair and Symbicort are two that are widely used here in the USA. Depending upon where one lives outside the states, they may have different brand names, though they are still combinations of the same generic LABA and cortisteroid. One of those combined drug preparations plus Spiriva 'should' be his "maintenance" medication treatment regimen with the Ventolin used "when needed" beyond those medications.

If he is already using a combination drug plus Spiriva AND he is still severely retaining CO2and exhibiting hypoxia as you describe, then I'm afraid he is about as severe as he can get. In that case, the BiPAP for as many hours of the day as he feels is helpful is likely his best treatment. And, as I said before, he should be putting oxygen flow into the BiPAP system when he is using it, as well.

Lastly, while his situation seems so severe AND he undoubtedly abhors getting up and moving around and making his breathing much harder as a result, he nevertheless would benefit greatly from putting himself through that misery to try to move and even exercise (walk) as much as possible as doing so will improve his breathing ability, his muscle condition and tone and ultimately reduce his demand for oxygen and his over-production of CO2. This is NOT an easy thing that I recommend. And, if he is past a point where he is willing to try to improve, I would understand perfectly, as he seems about as severe as one can get.

I wish you both the best and success in improving his situation.

Mark Mangus, Sr. BSRC, RRT, RPFT, FAARC


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