Is The Use Of Oxygen A Placebo?
Forgetting to use it could be the difference between passing and failing a Sport First Responder test.
It has a wide range of uses in an emergency care setting, especially when dealing with your athletes in an acute injury or emergency.
Using supplemental oxygen therapy has been a major part of Sport First Responder courses over the years with various reasons for application including:
- Shock prevention
- Cardiac Arrest
- Anaphylaxis
- Carbon Monoxide poisoning
- Asthma
However recently I have been hearing rumblings, the use of oxygen may be on it’s way out as an intervention and I recently worked with a sport med doctor who doesn’t use oxygen and downplayed its effectiveness.
But this practice is so hard grained into us, that with pretty much every patient we see in an emergency setting, they get oxygen.
But do we really need it in all cases?
Why The Use Of Oxygen
The biggest reason oxygen is used in these emergency scenarios is to prevent hypoxemia, which is a decreased level of oxygen in the blood, which then leads to hypoxia (oxygen supply which is insufficient to support life).
However there is also a risk of using too much oxygen which results in hyperoxia (too much oxygen in the system), if oxygen therapy is not used properly it can lead to complications, which also depends on the condition your patient is dealing with.
It turns out that hypoxia (which is determined by using a pulse oximeter) is the only evidence based reason to give oxygen to a patient.
The other reasons are based on the assumption that it will help prevent hypoxia and relief of symptoms in an emergency setting.
Shock
I’m sure we all remember what shock is from our time in college, but there is more than one type of shock and we should all be familiar with the various types.
Medical shock is the type we are mainly worried about as opposed to emotional or psychological shock resulting from a traumatic experience or an emotional event.
When someone is suffering from or going into shock, the body is redirecting blood to service the internal organs and keep them alive, which is why you will often see the persons skin turn pale, cool and clammy.
The extremities are not getting the blood supply they’re used to.
But within the classification of “medical shock” there are further classifications of types of shock:
- Anaphylactic
- life threatening allergy to a substance
- Caridiogenic
- failure of the heart to pump sufficient blood to the body, usually occurs with cardiac arrest
- Hypovolemic
- lack of blood in the body
- Neurogenic
- failure of the nervous system to control the size of blood vessels causing dilation, common with head and spine injuries
- Respiratory
- the lungs fail to get sufficient oxygen into the bloodstream, common with breathing emergencies, respiratory arrest
- Septic
- intake of a poison causes blood vessels to dilate
Within the license of a Sport First Responder we would treat all of these types of shock the same way, by putting the patient on oxygen at a 10L flow along with keeping them warm.
In the case of someone having a heart attack (caridogenic shock) there are studies showing the use of oxygen in the first 12 hours may be unwarranted, however would still be appropriate for the sport first responder or until the patient reaches the hospital.
But in some cases with angina attack, oxygen can help with pain relief.
This is also because in the stressful environment of being a first responder, to determine exactly when it is appropriate to administer oxygen (signs of dyspnea or heart failure), so would more efficient to give it to everyone until arrival at hospital.
Common breathing emergencies like breathlessness or asthma should only be treated with oxygen if there is hypoxia present, this is one of those areas where we have always put oxygen on a patient .
In dealing with traumatic injuries that would typically cause hypovolemic shock a study showed that only half of adult trauma patients actually required the use of oxygen in pre-hospital care, yet it was still being administered to everyone.
When it comes to using oxygen therapy for shock it looks like a bit of a mixed bag as to when it’s appropriate to use it and when it is not.
However our Sport First Responder guidelines at this point still say that oxygen should be used to either help prevent or to deal with shock.
Photo by: Offutt Air Force Base
Strokes, COPD And Other Emergencies
I know these aren’t typically seen in the Sport First Responder setting but it’s still important information to know in case you ever have to deal with it.
Again, these are all instances where oxygen would always be put on a patient having an emergency.
New research is showing us that it may not be the best approach.
In patients having an acute COPD (Chronic Obstructive Pulmonary Disease) we have always been told that high flow oxygen is the method to treat the situation.
Studies have shown that using reduced flow oxygen actually decreased the risk of mortality by 58% (1) and leads to worse clinical outcomes. (2)
Using oxygen with someone who is suffering a stroke is also coming under skepticism even though it too has always been promoted as an acute therapy. I’ve used it on patients several times because of the recommendations.
But newer studies are saying that unless there is hypoxia present, the use of oxygen should be avoided (although it is also referring to the first 24 hours of hospitalization).
The same article points out that unless hypoxia is present with a pregnant woman or someone experiencing breathlessness, oxygen should be avoided.
However there is still hope for our friend Oxygen.
Someone with carbon monoxide poisoning should still be given Oxygen. It reduces the level of carbon monoxide in the blood in 40 min compared to 4-5 hours just breathing regular air.
Even though studies have started to question the use of oxygen in emergency settings, it is still imperative to stick to your local guidelines when responding to an emergency with your athletes. Most of the studies outlined in this post were based on the reading of gas exchange in the bloodstream using a pulse oximeter. Your average Sport First Responder probably doesn’t have one of these in their kit, so it is ALWAYS better to err on the side of caution. Another caveat for the use of oxygen (that I have seen first hand at emergency scenes) is distracting your patient. Having a mask on that is delivering oxygen brings some comfort to a patient, especially with breathing emergencies. I’m not sure it could be considered a placebo effect, but it definitely helps to calm a patient down. The point of this post wasn’t to tell you not to use oxygen anymore, you most certainly should. It was more just to make you aware that there could be changes coming down the road and the next time you re-certify, things might be a little different. In the meantime continue using your O2 cylinders and keep those athletes safe.
References:
1. Ntoumenopoulos G. Using titrated oxygen instead of high flow oxygen during an acute exacerbation of chronic obstructive pulmonary disease (COPD) saves lives. Journal Of Physiotherapy [serial on the Internet]. (2011), [cited September 12, 2016]; 57(1): 55. Available from: MEDLINE with Full Text.
2.Cameron L, Pilcher J, Weatherall M, Beasley R, Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgraduate Medical Journal [serial on the Internet]. (2012, Dec), [cited September 12, 2016]; 88(1046): 684-689. Available from: CINAHL Complete.
In my work as a hypnotherapist, the concept of the placebo effect fascinates me. In Bruce Lipton’s book, The Biology of Belief, he discusses this phenomenon in depth and eventually comes to the conclusion that the mind is stronger than the material body.
In my work as a scuba instructor and emergency first responder, oxygen is always at hand during a dive day. The placement of the mask on the subject does seem to have a relaxing effect, and of course, if the diver had the potential of experiencing decompression sickness, breathing 100% oxygen helps to flush residual nitrogen out of the tissues.
In addressing the placebo effect with oxygen, it seems that the application of the mask is a signal to the patient that they are receiving aid. It’s a physical touch-point beyond the words of the responder to let them know that they are not alone.
Great point Dan, I think part of it is the signalling of aid and physical touch point. It’s not to say that O2 doesn’t still have a therapeutic value, we may just overuse it a bit.
I wonder if oxygen application as a placebo could help cure or alleviate the effects of traumas that don’t require oxygen as a first response treatment. Your article brings up a valid point that more research may be warranted for first response cases.
Has anyone used oxygen in a massage therapy setting?
I’m not aware of any oxygen use in a massage setting, other than if there was a medical emergency, or someone who has COPD and brings an oxygen tank with them. Would be interesting to find out though.
I am of the mind that the oxygen mask itself brings comfort to a patient experiencing any one of the emergencies. When I experienced anaphylactic shock, the EMTs offered an oxygen mask before I entered the ambulance. I rejected the oxygen because I am stubborn.
Are the issues with oxygen that you’ve listed a matter of the quantity of oxygen given?
It depends on the situation, COPD yes. In the other cases it depends on the oxygen saturation in the bloodstream. That’s where the pulse oximeter comes into play as it reads the amount of oxygen in the blood, so when it dips too low would then be appropriate to give oxygen. In other cases some of the studies showed that O2 made no difference.
I never knew oxygen can be useful in those kinds of setting. This is definitely new to me. God forbid I will be in any of the situation but I would consider trying oxygen. Thank you!
Great article about the use of oxygen in emergency scenarios and its possible placebo effect. If it helps the patient calm down, obviously I think that’s a good thing. As more information comes out on the topic, I’ll be curious to see where this goes.
Interesting post! I have always seen the oxygen mask as a go to in most types of injury or emergency. I like to see that the data is changing and new methods may result to give higher health success rates.
I can see how the oxygen mask on people may act as a placebo when panic is occurring. I sure could of used a tank on that 14er hike I did last week!
Placebo effect is the best effect! In trauma work with near drowning or near death experiences, asthma and lack of oxygen (including choking) as well as panic attacks – neurobiologically work with SRT (self regulation therapy) and imagining getting all the oxygen you need actually has the body respond WITH increased oxygen flow/ease of breathing. I don’t have asthma anymore after 35 years of it as a result of this work and the placebo effect that the mind creates. Having oxygen available as well as having the suggestion “imagine having all the air you need… filling your lungs easily and effortlessly” or “imagine breathing in the best deep breath of ocean/mountain/fresh air effortless” – as they imagine it will actually help their physical breathing pathways facilitate more oxygen flow (including from an O2 mask/tank). Pretty cool right? Great post on this!
Like so many other treatments, I see your point regarding the possible overuse of oxygen. The pulse oximeter is a quick way to see if it is truly warranted, and as noted, in a lot of circumstances, it doesn’t hurt and it can have a calming effect on the patient being treated as well. Personally, I breathing pure oxygen when I get the chance… nice article in which you approach the topic from a number of directions.