Part 2: First you tell me I have lung disease …
Now You Tell Me I Have Pulmonary Hypertension!
by John R. Goodman, BS RRT
This 2-part article was written to give you a better understanding of Pulmonary Hypertension and how it develops in patients with chronic lung disease.
Part 2: Pulmonary Hypertension (PH) Defined
our pressures will help dictate your treatment plan. For some patients, certain medications known to directly lower the pressure in the lungsmay be given. For some patients blood thinners may be prescribed. In others, calcium channel blocking agents may improve symptoms. Ultimately, for some patients with very severe PH, a lung transplant may be the only hope.
And There Is Hope!
The vast majority of PH in patients with COPD are in the mild to moderate category. Severe PH is seen in less than 5% of patients with COPD. Currently, there is no clinical test or examination finding that accurately identifies PH in patients with COPD. All of the treatment options mentioned are used to treat a particular component of PH. There is one therapy however that has been shown to decrease, and even reverse, the progres- sion of PH in many patients. What is this therapy? It’s as plain as the nose on your face or at least the nasal can- nula in that nose. Long term oxygen therapy works at reversing the very problem we described in Part 1 of this article (The Pulmonary Paper, July/August 2011). Remember, the very small pulmonary arteries constrict due to the body compensating for low blood oxygen levels. By administering supplemental oxygen to patients with PH, we can begin to reverse the mechanism
responsible for all that follows. Not only can oxygen therapy slow down or even reverse the progression of PH, oxygen has been shown to be the only drug (yes, I said drug) ever scientifically proven to increase survival! That means if you wear your oxygen as prescribed by your doctor, you will live longer than patients who either can’t or won’t wear their oxygen.
The Centers for Medicare and Medicaid Services (CMMS) estimates that there are roughly 1.2 million patients who (should) use oxygen 24 hours a day at home. By far the most common device for administering oxygen is the nasal cannula. The nasal cannula is simple
and inexpensive, but it is also very uncomfortable and inefficient.
So in reality, the problem with oxygen therapy is somewhat complex. We know beyond any shadow of a doubt about the survival benefits of oxygen therapy, especially when combined with an organized exercise program such as Pulmonary Rehabilitation programs. Neuropsychiatric function is also improved with oxygen therapy. When I am teaching new patients about the benefits of oxygen therapy, I will usually tell them that oxygen itself is not life support … but it sure as hell is supporting life!
A Quick Review
left: This 26-year-old patient (the author’s niece) had PPH and received two different lung transplants in an eight-year period.
A quick review of where this little discussion has taken us is in order before we can move on. The story of PH goes something like this. Lung disease (or some other entity) causes a chronic low blood oxygen scenario (hypoxemia) to develop. Through a variety of compen- satory mechanisms, the body attempts to “fix” the problem by constricting the small blood vessels in the lungs and perhaps causes changes in the viscosity (thickness) of the blood by producing and releasing more red blood cells into the blood. The combined effect causes the right side of the heart to have to work harder and harder. If left untreated, this can lead to right ventricular hyper- trophy (enlargement), and finally right heart failure.Depending on the specific cause of the hypoxemia, a wide variety of drugs with different actions may be prescribed. Ultimately if the PH is severe and persistent enough, a lung transplant may be the only treatment left to the patient. Of all the “drugs” that might be prescribed by the doctor, the most important is undoubtably oxygen. But, oxygen delivered via standard nasal cannula is difficult to wear on a 24/7 basis as ordered by the physician. A reasonable question there- fore would be: Are there other delivery devices for oxygen therapy? And the answer is, of course there are. Please remember the end-point we all seek as clinicians is true compliance with the oxygen prescription. The original plastic nasal cannula was patented in 1956, although some primitive cannulas were available as early as the 1930s. Oxygen masks have been available since before the turn of the century.
But This Is 2011!
Certainly oxygen delivery devices have improved and evolved over the past half century, haven’t they? We know the nose hasn’t changed in the past 55 years, and there are just so many ways you can skin a cat. Over this time period a pretty good number of new generation nasal cannulas have been introduced to the market. Different types of plastics, better anatomic designs, lighter weights, different colors and a number of devices such as the OxyArm, have been introduced to patients in an attempt to improve comfort and compliance.
But the very bottom line is that with all the best efforts of the oxygen industry, compliance with oxygen via nasal cannula is still sub-optimal. Very classic studies on compliance have proven that the vast majority of patients who are on oxygen 24/7 are only willing or able to wear their nasal cannula for about 18 hours per day. In effect, losing the benefits of their therapy for six or so hours per day. Is there a way to insure 24 hour per day compliance? Probably not with conventional non-invasive oxygen
delivery devices. If however, you can make a patient either more comfortable, or less self-conscious about going out in public wearing their oxygen, you should be able to improve compliance, and as an extra bonus, improve quality of life by getting patients out of the house and into the mainstream of life again.
Combining Oxygen and Eyeglasses
We have already discussed the discomforts associated with the use of a nasal cannula. Much of this due is to the fact that the cannula must be worn with the prongs in the nose, and the tubing draped, lariat-style, over the ears. Now imagine you also must wear glasses to see, read and just get around in general. Wearing both glasses and a nasal cannula at the same time is very uncomfortable for patients. In fact, we know many patients will take their nasal cannula off to give their nose and ears a rest.
Above right: Oxy-View™ glasses allow this patient more mobility, signifi- cantly improving her quality of life.
Above left: Alice from NY says, “Since I have been wearing my Oxy-View™ glasses, friends and family think I’ve stopped using oxygen because the cannula line across my face and under my chin is gone. They are so comfortable
I forget I have it on.”
A few years ago, an ingenious new method of delivering oxygen was developed that found a way to combine the dual necessities of needing to wear oxygen with needing to wear glasses. This product is called Oxy-View™ eyeglass wear. The frames of the glasses are hollow. Oxygen up to 5 liters per minute can flow through the frame and into the nose via two small, discreet prongs or “J-hooks.” Your oxygen tubing is usually connected from behind your head, so it can be almost completely camouflaged.
Finally, we can briefly discuss the most efficient method for oxygen delivery, transtracheal oxygen therapy (TTOT). TTOT involves the insertion of a very small flexible catheter directly into the windpipe or trachea.
There are many, many benefits asso- ciated with TTOT.
You may want to talk to your pulmonologist to see if it may be a good option for you. You can visit the website at www.tto2.com for more information too.
Remember oxygen is a drug. It is almost certainly the most important drug you are taking. It will be one of the most important therapies your doctor employs to treat pulmonary hypertension should it develop. Many bogus oxygen therapies can be found on line. An educated patient is an empowered patient!
For more information, please visit www.ph association.org or call the PHA Toll Free Patient-to- Patient Support Line, 1-800-748-7274.
PAH Medication Assistance Program
Tracleer® (bosentan) is used in people with pulmonary arterial hypertension to improve their exercise ability and to decrease worsening of their condition. Its maker, Actelion, is sponsoring the Tracleer Patient Coupon Program – to help you pay no more than$10 per month for Tracleer. The company is contribut- ing up to $10,000 annually for every person who uses the drug. For more information, visit www.tracleer.com on the Internet.
You would not be eligible for their program if your prescription is paid for by the government (Medicare, Medicaid, VA, Tricare or Indian Health Services) or if youJohn Goodman RRT is Executive Vice President of Technical/ Professional Services at Transtracheal Services, Denver, CO, who says “All You Need Is Love!”live in Massachusetts, Puerto Rico or where it is prohibited by law.