10 Jun, 09 | by John Offen
“He’s on the throne,” called Mrs Tonks from within the small cottage. “On the phone. How long will he be?” queried my mentor?”. “Not the phone, the throne. He’s on the commode” she laughing good naturedly. By the time we reached the living room, Mr Tonks was ensconced in his threadbare easy chair puffing like a steam train. His blue tinged hands reached anxiously for his nasal cannula, and he sucked deeply at the meagre 2 litres of domiciliary oxygen which oozed from the concentrator behind his chair. It was minutes before he was able to utter a word. He looked deadbeat, like he had just finished a marathon, rather than moved a few feet from the commode to his chair. I found this man’s desperate struggle to breath after so little excursion shocking, and resolved to find out more about oxygen therapy. I started with a recent article in Nursing Standard about the use of domiciliary oxygen. I also found a Cochrane review that summarised the evidence base for domiciliary oxygen use.
The following day we visited another couple afflicted by respiratory failure. Mr Little and his wife lived in a beautiful village house overlooking a lake, but Mr Little had pulmonary fibrosis, a serious disease where the alveoli and lung tissues become damaged and scarred. Whilst we took a blood sample from Mr Little, his wife wheezed and coughed distressingly. “I have emphysema,” she gasped. Mr little was getting used to using a permanent oxygen supply, and clear plastic pipes snaked across the plush carpets. He started telling me that he had been given conflicting advice on how long to use his oxygen each day. One nurse had thought that it should not be used for more than 15 hours per day, whilst the GP had suggested using it 24 hours per day. Did I know which was right? Pre-armed with my recent reading, I prepared to explain that research had shown that mortality in patients with severe hypoxaemia was reduced if oxygen was used for more than 15 hours per day, but Mrs Little was to quick. “He won’t know – he’s only a student,” she scolded her husband abruptly. I felt slighted. OK I was only a student, but I had been taught to read and appraise evidence, and to try to apply it in the real world, and here I was at last doing it for real, only to be told that knowledge was the preserve of the experienced. I felt pleased that I had looked at the research, and this empowered me to promote best practice, but was reminded that sometimes it is not what you know, but who you are that carries weight.
Notes on evidence base
The Nursing Standard Article was:-
Lynes D and Kelly C (2009) Domiciliary oxygen therapy: assessment and management. Nursing Standard. 23 (20) 50-56
The 15 hours guideline emanates from the following research paper:
Medical Research Council (1981) Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981 (1) 681–5.
A broader review of the evidence base can be found in:-
Cranston JM, Crockett A,Moss J, Alpers JH. (2005) Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001744.