What is the treatment for acute worsening of hypoxia in a patient on home oxygen (O2) therapy, with a history of pulmonary hypertension and pulmonary fibrosis, now requiring increased oxygen supplementation from 3 liters to 12 liters?

From the Guidelines

For acute worsening of hypoxia in a patient with pulmonary hypertension and pulmonary fibrosis who has increased oxygen requirements from 3L to 12L, immediate hospitalization and high-flow oxygen therapy to maintain an oxygen saturation of 94-98% is crucial. The patient's condition necessitates careful management to prevent further deterioration and potential mortality. Given the patient's history of pulmonary hypertension and pulmonary fibrosis, it is essential to aim for an oxygen saturation target of 94-98% or the highest possible if these targets cannot be achieved, as recommended by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1.

Key considerations in the management of this patient include:

• High-flow oxygen therapy to achieve the desired oxygen saturation levels
• Potential use of non-invasive ventilation such as BiPAP if oxygen therapy alone is insufficient
• Administration of intravenous corticosteroids to reduce inflammation, particularly if an acute exacerbation of pulmonary fibrosis is suspected
• Initiation of broad-spectrum antibiotics to cover potential infection while awaiting culture results
• Use of diuretics like furosemide if fluid overload is contributing to the patient's condition
• Continuation of current vasodilator therapy for pulmonary hypertension management and consideration of intensification under specialist guidance

A comprehensive diagnostic workup should be performed, including:

• Arterial blood gases
• Complete blood count
• Comprehensive metabolic panel
• Cardiac enzymes
• Chest imaging
• Possibly CT pulmonary angiogram to rule out pulmonary embolism

This approach addresses the acute hypoxemia while investigating underlying causes, recognizing that acute deterioration in these patients can be life-threatening and requires prompt, multidisciplinary intervention.

From the Research

Treatment of Acute Worsening of Hypoxia

• The patient's condition, with a history of pulmonary hypertension and pulmonary fibrosis, requires careful management of hypoxia, as stated in 2.
• Oxygen therapy can be delivered by variable or fixed rate devices, and non-invasive ventilation, with the possibility of tracheal intubation and mechanical ventilation if the patient deteriorates, as mentioned in 2.
• The treatment of pulmonary hypertension caused by hypoxic lung disorders aims to reduce pulmonary vascular resistance and improve right ventricular function, with approved medications including prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors, as discussed in 3.

Management of Acute Hypoxemic Respiratory Failure

• Non-invasive ventilatory support and high-flow nasal oxygen can be used as first-line treatment for acute hypoxemic respiratory failure, as stated in 4.
• High-flow nasal oxygen and helmet noninvasive ventilation are promising techniques for first-line treatment of severe patients, but no conclusive evidence recommends a single approach over others in case of moderate-to-severe hypoxemia, as mentioned in 4.
• The AARC Clinical Practice Guideline recommends aiming for an oxygen saturation range of 94-98% for most hospitalized patients and promoting early initiation of high-flow oxygen, as discussed in 5.

Comparison of Non-Invasive Ventilation and High-Flow Oxygen Therapy

• A non-randomized retrospective analysis compared non-invasive ventilation and high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure, finding no difference in the occurrence of severe hypoxemia during intubation, as stated in 6.
• However, the study found that non-invasive ventilation was associated with higher pulse oximetry values during preoxygenation and fewer patients with severe hypoxia among those with moderate-to-severe hypoxemia, as mentioned in 6.