Asthma and O2 therapy

- somewhat controversial
- bottom line: give O2 if in resp distress (incr WOB or incr resp rate), dc when improved
- O2 is a mild bronchodilator
if in respiratory distress give O2, patient almost always benefits
- different opinions: give O2 when sat< 95, or when sat <90
- not necessary to try to get a sat of 100, can dc O2 when Resp rate improves

The child described in the vignette is presenting with a significant exacerbation of his reactive airway disease. Data obtained from sampling the capillary blood gas demonstrate that the patient still is ventilating well. This information is gleaned from the finding of a low Pco2, which would be expected in a person who has an increased respiratory rate, and the compensatory elevated pH that documents a respiratory alkalosis. The pulse oximetry reading of 94% demonstrates reasonable oxygenation. However, the capillary blood gas is a poor method of determining oxygen saturation because it is obtained after the blood already has begun to go through the tissues.

The use of supplemental oxygen in the patient who has status asthmaticus is somewhat controversial. Initially, it was thought that oxygen should not be administered to these patients because the oxygen might suppress their hypoxic drive, which could result in respiratory arrest. However, it has been demonstrated that this does not occur in asthmatic children, and it has also been shown that oxygen is a mild bronchodilator. Thus, patients who have low pulse oximetry readings should receive supplemental oxygen, although the exact oximetry reading at which it should be administered has not been determined. Some recommend oxygen supplementation for patients whose pulse oximetry readings are below 95%; others do not initiate therapy until the readings reach 90%. The patient who has an increased respiratory rate and work of breathing  almost always benefits from supplemental oxygen. The National Heart,Lung, Blood Institute guidelines for asthma recommend oxygen for anyone who has significant hypoxia and patients who have forced expiratory volume in 1 second or peak expiratory flow rates less than 50% of predicted. Obtaining pulmonary  function studies is difficult in children during an asthma exacerbation. Because oxygen has virtually no adverse effects, its use is recommended in affected children, such as the boy described in the vignette.

Oxygen therapy should be administered until the patient's respiratory rate improves. There is no reason to maintain an oxygen saturation of 100%, and it is inappropriate to wait until the oxygen saturation falls below 92% in a patient who is showing signs of respiratory distress. It is not appropriate to wait until existing respiratory distress worsens before beginning oxygen administration.

Routine measurement of arterial blood gases is not recommended because such evaluations are associated with complications and are quite painful, and changes in oxygen saturation can be monitored via pulse oximetry.

The illustrated oxygen saturation curve demonstrates that Pao2 can vary greatly, depending on the patient's pH. A patient who is experiencing a moderately severe exacerbation of asthma would have an elevated pH, which would shift the curve up and to the left, giving a falsely elevated value. In contrast, a severe exacerbation with an acidotic pH would result in a shift down and to the right, obscuring a lower Pao2.

AAAAI Initiatives: Update on pediatric asthma: promoting best practice. Available at:
default.stm Lemanske RE Jr, Green CG. Asthma in infancy and childhood. In: Middleton
E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds.
Allergy: Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book,
Inc; 1998:877-900
National Asthma Education Program, Expert Panel Report II. Guidelines
for the Diagnosis and Management of Asthma. Bethesda, Md: US Department
of Health and Human Services, Public Health Service, National Institutes
of Health; 1997:No. 97-4051