Sectional

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Proceedings of the Royal

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Society

of Medicine

Vol. XXXIII

section of Eberapeutics anb Pbarmacologw

President-Sir VWrILLIAM WILLCOX, K.C.I.E., C.B., C.M.G., M.D., F.R.C.P.Lond.
[March 12, 1940]

DISCUSSION ON THE INDICATIONS FOR OXYGEN THERAPY

AND METHODS OF ADMINISTRATION
Professor B. A. McSwiney pointed out that about 360 c.c. of the 500 c.c. of
air drawn in at an average breath reach the alveoli, 140 c.c. being required to fill the
air tubes (dead space air). The alveolar air must contain therefore more carbondioxide and less oxygen than the mixed expired air which consists of alveolar air plus
unchanged dead-space air which is expelled first on expiration.
The composition of the alveolar air in resting subjects at normal atmospheric
pressure is nearly constant. The alveolar air contains about 14% 02 and 5.6% Co2.
The air in the alveoli is separated from the blood in the capillaries by the walls
of the pulmonary epithelium and the endothelium of the capillary wall. The exchange
of gases takes place by a process of simple diffusion depending on the partial pressure
of the gases, the character of the membrane, and the solubility of the gase3.
Oxygen in the alveolar air is at a partial pressure of 100 mm.Hg, while that in
the venous blood is at 40 mm.Hg, consequently oxygen passes from the alveoli to the
blood. The carbon-dioxide in the venous blood is at a higher tension than the
alveolar carbon-dioxide, hence carbon-dioxide diffuses into the alveoli of the lungs.
The full oxygen combining power of haemoglobin in 100 c.c. of blood is 20 c.c.
As the blood is normally 95% saturated, 100 c.c. of arterial blood contains 19 c.c.
of oxygen combined with heemoglobin and 0 3 c.c. in solution, a total of 19-3 c.c. of
oxygen.
Oxygen want in the body from any cause is termed anoxia. Four types
are described: (a) Anoxic anoxia; (b) anaemic anoxia ; (c) stagnant anoxia;
(d) histotoxic anoxia.
In the first, the type seen in lung diseases, congenital heart diseases and at high
altitudes, the hawmoglobin is not saturated to the normal extent. This may be due
to alteration in the pulmonary epithelium or to a decrease in the partial pressure
of oxygen. In the second type, the oxygen capacity of the blood is reduced due
to a reduction in haemoglobin. In stagnant anoxia the oxygen content of the
arterial blood is normal, but a large part of the oxygen supply is delivered under
low pressure since the blood gives up a large proportion of its oxygen due to a slow
blood flow through the capillaries. In the fourth type oxygen cannot be taken up
and used by the cells.
Anoxic anoxia may be benefited by oxygen therapy. By increasing the percentage of oxygen in the alveolar air the partial pressure of the gas will be raised and
the oxygen content of the blood increased.
Recent work by Boothby and his co-workers at the Mayo Clinic suggests that the
administration of oxygen in high concentrations may be of benefit in other types of
anoxia.

JUNE-THERAP. 1

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Three different methods of oxygen administration for use in adults and older
children were described: (1) Nasal catheter; (2) nasal tubes; (3) masks.
It was shown that the efficiency of nasal catheters and nasal tubes was similar,
but that nasal tubes were more comfortable. With a flow of 4 litres a minute 33%
of oxygen may be obtained in the alveolar air.
The apparatus designed by Boothby, Lovelace and Bulbulian (1938) has many
advantages. In the first place by its use any desired concentration of oxygen between
that in air and practioally pure oxygen can be administered; secondly, the apparatus
is comfortable and can be worn for long periods; thirdly, the mask fits over the nose
so that the mouth is free for feeding and talking; finally, the apparatus is mechanicaUy
simple and easy to operate. With the B-L-B. inhalation apparatus it is possible
to obtain alveolar oxygen concentrations ranging from 45 to 90%.
The difficulty of operating oxygen tents was discussed, and it was considered that
these were only of value in institutions where facilities were available for maintaining
a proper service.
REFERENCES
BOOTHBY, W. M. (1938), Proc. Staff Meet., Mayo Clin., 13, 641.
BULBULIAN, A. H. (1938), ibid., 13, 654.
LOVELACE, W. R. (1938), ibid., 13, 646.

Professor R. V. Christie: In general, the onset of cyanosis is the most important

indication for oxygen therapy, but unfortunately while the relief of cyanosis with
oxygen may be spectacular in some cases, it is imperceptible in others. It is important
that the clinician should be able to recognize those cases likely to benefit from oxygen
and those who are not, but this will only be possible if he appreciates the symptoms
of anoxaemia and its dangers, and understands certain simple principles on which
oxygen therapy is based.
The first principle concerns the dangers of oxygen lack. The more harmful
anoxaemia is shown to be, the more important it is that oxygen should be given early
and efficiently. Anoxeemia, if very severe, may result in permanent damage to the
nervous system but, except in carbon-monoxide poisoning, this is rarely seen clinically.
Much more common and more important is the effect of oxygen lack on the heart.
There is ample evidence that the degree of anoxaemia often seen in bronchopneumonia,
phosgene poisoning, or acute heart failure, is sufficient to embarrass the heart of a
healthy individual, and in these conditions relief of anoxaemia by means of oxygen
may be a life-saving procedure. Since the cardiovascular system is the first to suffer,
any assessment of the effects of oxygen therapy should be based partly on careful
observation of the pulse: a reduction in the rate of the heart-beat or an improvement
in the quality of the pulse is an important indication of successful treatment.
The second principle is that hsemoglobin is almost completely saturated with oxygen
when exposed to ordinary inspired air, and therefore the administration of oxygen
to a healthy person does little to increase the quantity of oxygen taken up by the
blood. In an individual whose arterial blood is fully oxygenated in the lungs but
whose hands are blue because they are cold, or who has widespread cyanosis due to a
sluggish peripheral circulation, the administration of oxygen cannot be expected to
relieve the cyanosis. Again, when the blood passing through certain parts of the lung
is not aerated, the addition of oxygen to the air in the healthy parts of the lung will
have but little compensatory effect. For instance, in a case of lobar pneumonia
where the left lung is consolidated and the right unaffected, any cyanosis that is
present will be due to the flow of blood through the consolidated and unaerated left
lung. If oxygen is given it can only reach the blood passing through the solid left
lung by the very slow process of diffusion, and as the blood flowing through the
healthy right lung is already fully aerated, no amount of oxygen will supersaturate it.
On theoretical grounds therefore little relief of cyanosis can be expected from oxygen

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therapy where the anoxoemia is due to the flow of blood through consolidated lung,
and the same is true of other conditions, such as pneumothorax or massive collapse
of the lungs, where ventilation in parts of the lung is completely obliterated. Fortunately anoxaemia is seldom severe in these cases, since in the airless parts of the
lung the pulmonary circulation rapidly diminishes and in time is almost obliterated.
This latter phenomenon is well illustrated in the case of artificial pneumothorax
where, even with extensive collapse, cyanosis is seldom seen.
In bronchopneumonia or acute pulmonary cedema the situation is entirely different.
Here the patches of consolidation are small or minute, and it is a deficiency of
ventilation which causes anoxaemia. The quantity of air which enters the affected
areas is insufficient to oxygenate the blood passing through them and this deficiency
can be effectively overcome by enriching the inspired air with oxygen. The same is
true of other conditions such as asthma or emphysema where cyanosis is due to a
generalized underventilation of the blood in the lungfs. Oxygen, if properly given,
should compensate for underventilation and should efficiently relieve anoxoemia.
These generalizations can be restated in terms of physical signs; where moist
sounds are plentiful and widespread, anoxsemia is often severe and oxygen, if properly
given, should relieve cyanosis, but where added sounds are few or absent and bronchial
breathing or suppression of breath sounds are conspicuous, oxygen is usually of little
benefit.
The third principle is that lack of oxygen rarely, if ever, is the direct cause of
dyspnoea. While the majority of patients who are ill and who complain of dyspncea
are also cyanosed, this by no means proves that the one is the cause of the other.
Cyanosis is frequently said to be the cause of dyspnoea, not because of any proved
relationship, but because it seems reasonable to suppose that the impaired respiratory
function should be responsible for the respiratory symptoms. Nevertheless there is
no foundation for such a supposition. In uncomplicated anoxaemia, such as is seen
in carbon monoxide poisoning or when flying at very high altitudes, dyspncea
comparable to that in pneumonia or cardiac failure is never observed, although the
pilot may be incapacitated by oxygen want. Anoxaemia by its action on the carotid
sinus or gland may cause slight hyperventilation but not respiratory distress. It is
true that even mild exercise at high altitudes may cause dyspncea, but the evidence
available suggests that this is due to cardiac embarrassment and pulmonary congestion
rather than to any direct chemical stimulation. The practical bearing of these
observations is that in pneumonia and in other conditions where dyspnoea is primarily
due to an inflammatory lesion in the lung and not to cardiac failure, the relief of
anoxeemia cannot be expected to produce any reduction in respiratory rate. For this
reason, the use of the symptom dyspncea as an indication for oxygen therapy, or as a
criterion of the efficacy of oxygen, is fallacious in most cases.
The fourth principle is that if oxygen is to be given at all, it should be given more
or less continuously. The administration of oxygen for ten minutes in every two hours
to a patient who requires oxygen can only mean that he is denied the relief of
anoxeemia for nine-tenths of the time.
These are the general principles which decide the therapeutic indications for
oxygen therapy, and their application to disease is not difficult.
In severe bronchopneumonia, acute pulmonary oedema, and poisoning with the
lung-irritant gases, there is exudate scattered throughout the lungs, and anoxaemia,
which is frequently severe, can be relieved by oxygen. In this type of case, the
early and efficient administration of oxygen may be a life-saving procedure.
In lobar pneumonia, the therapeutic value of oxygen is in considerable dispute.
There is no good evidence that oxygen therapy lowers the mortality rate or shortens
the course of the disease, and even the relief of cyanosis is often imperceptible.
Where cyanosis is due to outspoken consolidation little relief from oxygen is to be
expected, but in the majority of patients with lobar pneumonia there are some areas

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where consolidation is incomplete, and in these areas the administration of oxygen

may be of some value. In other words, it is often impossible to state with certainty
that oxygen will be of no value in a case of lobar pneumonia. It is usually better
therefore to give oxygen a trial if the patient is cyanosed; if the patient dislikes
this procedure or if it prevents sleep, it should be discontinued for a while and only
given again if cyanosis increases. Fortunately, anoxaemia is seldom severe in lobar
pneumonia.
After a large pneumothorax, hydrothorax, or hcemothorax, cyanogis is usually
transient. If it persists, removal of air or fluid from the pleural cavity is indicated,
rather than the administration of oxygen.
Oxygen is of little or no value in the treatment of long-standing cyanosis such as
is seen in chronic heart failure or emphysema, and should be reserved for the acute
emergencies that frequently occur.
While the onset of cyanosis is the most important indication for oxygen therapy,
there are three groups of clinical conditions without cyanosis in which the administration of oxygen is claimed to be beneficial.
The first group is where cyanosis is masked by anaemia. The greater the degree of
anwemia the greater may be the anoxaemia without cyanosis, until, when the hsemoglobin falls to 30% the patient cannot be cyanosed although he may be suffering from
a very dangerous degree.of oxygen lack which can be relieved, partly at least, by
oxygen. This clinical picture of anaemia and anoxasemia without cyanosis is uncommon
except after operations on the lungs or wounds of the chest, but in these cases the
administration of oxygen may be of value although cyanosis is not demonstrable.
The second group concerns a recent innovation in oxygen therapy. Where
oxygen lack is due to a sluggish peripheral circulation and not to any deficiency of
oxygen in the haemoglobin it is possible to increase the amount of the gas in solution in
the plasma by the administration of 100% oxygen. This increase is small, and
the administration of pure oxygen requires special apparatus, but in view of. results
which have been obtained it seems possible that oxygen is of value in the treatment
of shock.
The third and last group concerns another recent innovation in oxygen therapy.
It is claimed that the inhalation of pure oxygen will facilitate the absorption of any
collection of gas which is trapped in the body. The administration of oxygen in
high concentrations is therefore advised in conditions such as air embolism, surgical
emphysema, and severe abdominal distension.
Dr. J. McMichael: Practical experience with the B-L-B mask.-My experience
of the B-L-B mask has only extended over six weeks, but during this time we have
had a large number of cases of bronchopneumonia through the acute medical wards
at Hammersmith Hospital. With two masks in use we have been able to treat the
most severe cases only, and in every case we administered 100% oxygen from the
beginning, and only reduced the concentration as the patients improved.
(1) Efficiency.-The high degree of efficiency of the method is beyond doubt.
One has only to see the disappearance of a mauve cyanosis and its replacement by a
healthy salmon-pink colour of the skin to appreciate this. Even in the most severe
cases it was invariably possible to bring about a decided improvement in colour.
One apparently moribund patient with extensive bilateral bronchopneumonia, with
exudation extending up towards the clavicles, improved immediately in colour and
was maintained in a good state as regards tissue oxygenation for three days before
he ultimately died of the effects of infection and sepsis.
(2) Technique of use.-While the mask is highly efficient and simple, it requires
watching.
(a) The regulation of oxygen fiow.-It is stated that so long as the bag is rising and
falling with respiration all is well and there is no need for a flow meter. My experience

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is that without a flow meter serious difficulties and even dangers may occur. In
one patient who was admitted unconscious with extensive bronchopneumonia and
severe cyanosis the mask was applied and the oxygen cylinder turned on. The bag
expanded and deflated with each respiration, but within a short time there was no
improvement in the cyanosis and the patient had a convulsion. In error, an empty
oxygen cylinder had been used, and the movements of the bag simply indicated rebreathing. This mistake is of course more likely to occur as a cylinder is running
out than at the beginning, but it must be kept in mind. Some form of simple flow
meter is undoubtedly essential, and a simple device is all that is needed for this purpose,
together with a pressure gauge on the oxygen cylinder to indicate the oxygen content.
(b) A flow meter has further advantages in that there need be no wastage of oxygen.
In many cases of severe cyanosis there seems to be considerable depression of respiration, and full benefits of high oxygen percentages may be achieved with an oxygen
flow somewhat less than that recommended in the instructions with the mask.

THE B-L-BWINHALATION APPARATUS.

(Block kindly lent by Messrs. A. Charles King, Ltd.. 33, Devonshire Street, W.1.)

(3) Toleration.-All patients in real need of oxygen have tolerated the mask well.
One or two restless and distressed cardiac patients have discarded the mask after
short periods, but in these the indications for oxygen therapy were less clear and the
benefits much less obvious. The mask allows complete freedom for fluid feeding of
the sick patient and does not in any way hinder expectoration.
We have not encountered any instances of severe nasal obstruction to limit the
use of the mask. An open mouth certainly diminished the benefits to be obtained.
In some seriously ill, cyanotic patients, the jaw drops and is difficult to close. In
such patients we have been able to obtain full benefits of the mask by placing a napkin
over the mouth. It has been our experience, however, that these patients have
invariably died. The wide-open mouth is a bad prognostic sign.

(4) Circulatory effects.-In cyanotic patients to whom the oxygen is given an

asphyxial rise of blood-pressure may be lowered. We have observed this several

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times. In itself this must considerably relieve the circulation, and it is often of
diagnostic aid in determining the cause of pulmonary exudation.
The effect on the electrocardiogram is less obvious. In one severely cyanotic
case with slight S-T depression no change resulted from oxygen administration.
(5) Indications other than pulmonary anoxia.-We have not yet had an opportunity
of giving oxygen in shocked patients. One patient with a mixed infection type of
pneumonia developed severe tympanites; this failed to respond to turpentine
enemata, pituitrin, and other better-known methods. She was given oxygen, and
within twelve hours was much more comfortable and the abdomen had completely
deflated in thirty-six hours. The benefits achieved by washing out inert gases are
certainly striking and give this new mask a further field of practical use.
The mask constitutes a most valuable addition to our therapeutic armamentarium.
Mr. J. E. H. Roberts, after congratulating the openers on their admirable papers,
said that from the point of view of the surgeon there were two types of patient in
whom cyanosis was not present although they were anoxaemic. One was the patient
who was anaemic from the loss of blood during an operation or from wounds,- and the
other was the anaemic patient in whom it was impossible by blood transfusion to raise
the haemoglobin to as high as 80% pre-operatively. Both these patients might need
oxygen although cyanosis was not seen.
Then there was the patient who had what might be called " psychical dyspncea"
post-operatively in whom there was probably inco-ordination between the diaphragmatic and costal movements. These patients were pacified and settled down
rapidly when given oxygen.
Deficient ventilation of the lung from interference with the movements of respiration such as occurred in thoracoplasty operations was also an indication for
oxygen therapy, as was deficient ventilation from stricture of the trachea, for instance
by a large goitre.