Purity of Oxygen versus Concentration of Oxygen Is there a clinical

Purity of Oxygen versus Concentration of Oxygen
Is there a clinical difference?
By John R. Goodman BS RRT
From time to time patients who are on oxygen 24 hours per day, 7 days per week
find themselves confused between the “purity” of oxygen and the “concentration”
of oxygen. Many times the terms are used interchangeably adding even further to
the confusion. One thing we know for sure…there is no such thing as “one size fits
all” when it comes to oxygen therapy at home. Of course, it took many, many
years of trial and error before this important observation came to be accepted by
the pulmonary community at large.
If we use the decade of the 60’s as the very beginning of our timeline for bringing
oxyen into the home, we have somewhere around 50 years of home oxygen
experience. Most patients of that era were most certainly on cylinder oxygen as the
oxygen concentrator and liquid oxygen were still a decade or more away from
widespread acceptance. Although oxygen cylinders for home use were big, heavy,
and difficult to store…they did provide oxygen that was rated at 99.99% pure.
Even the earliest liquid oxygen systems provided at least 99.0% pure oxygen at the
outlet. This was determined to be “medical grade” oxygen. Early oxygen
prescriptions were almost certainly written for 2 L/minute with little variation. A
rare pulmonary pioneer (like Dr. Tom Petty) might have instructed their patient to
increase their flow rate by 1 L/min. with activity, but generally you were on 2
L/min. under all conditions for as long as you were on oxygen.
This, no doubt, was due in large part to the very heavy belief in the “knocking out
hypoxic drive” theory that was very deeply believed by just about every
pulmonogist prescribing oxygen at that time. We have since debunked much of
this theory, at least in how prevalent or dangerous it really is. Another thing that is
easy to overlook is there was simply no affordable finger pulse oximeter available
at that time. Today (January 2014) we take for granted that a quick Google search
will yield a wide variety of very clinically solid oximeters at a reasonable price.
All oxygen patients can now carefully titrate their oxygen flow rates to keep them
well saturated under conditions of both rest and activity. A routine order from
your pulmonogist will have your oxygen company do an overnight oximetry study
to monitor your oxygen saturation while you sleep. In many cases a patient is
surprised to learn that they actually need more oxygen at night while they are
doing absolutely nothing, than they do when they are up and around during the
Check your sats periodically
A good home care respiratory therapist checking a saturation
Let’s take a minute to review liter flow of oxygen and the actual percentage of
oxygen that is delivered to the lungs. For a very long time now, pulmonary
clinicians have been following this guideline regarding this topic…for every one
liter of oxygen per minute the patient is receiving via nasal cannula, there is about
a 4% increase in the amount of oxygen (%) getting down to the lungs.
Remembering that the room air we breathe in and out every day has right at 21%
oxygen, it is simple math to continue up the scale as follows:
1 L/minute equals 25% oxygen.
2 L/minute equals 29% oxygen.
3 L/minute equals 33% oxygen.
4 L/minute equals 37% oxygen.
5 L/minute equals 41% oxygen.
6 L/minute equals 45% oxygen.
(None of these numbers is exact, but they are close enough for this illustration)
Flows above 6 L/minute via standard nasal cannula with just a bubble humidifier
are pretty difficult for most patients to tolerate 24 hours per day. At this point
either an expensive heated humidification system needs to be considered, or
perhaps the patient is advised to wear a simple oxygen mask. As underlying lung
disease progresses and higher flow rates become necessary, many patients consider
transtracheal oxygen for its improved comfort and efficiency.
Since these percentages are actually fractions, the medical abbreviation is FIO2,
where the (F) stands for fraction the (I) stands for inspired and of course the O2 is
for oxygen. So, altogether we get the fraction of inspired oxygen. The numbers
listed above assume that the source oxygen was of medical grade or 99+% pure.
So why does the FIO2 which starts out at near 100% at the (for example) the
cylinder outflow connection, drop all the way down to around 30% at 2L/min. by
nasal cannula? Well, there are a number of pretty sophisticated equations that do
actually explain what happens, but there is no reason to add to the confusion here.
It is just as simple (for a minute) to picture yourself with your nasal cannula set at
2 L/min. taking in a simple breath and exhaling normally. This is called your Tidal
Volume and although it differs widely based on sex, age, and height, we can give a
range of say 350-500cc per breath. So even though you may have 99+% oxygen
flowing out of the prongs of your nasal cannula….you are diluting it with several
hundred cc’s of room air that contains just 21% oxygen with every breath.
There are other factors such as your respiratory rate, and the difference in the time
it takes to inhale and exhale, and the amount of dead space taken up by your
mouth, nose and throat. But when we take all the variables into effect, the net
result is a very substantial decrease in your FIO2. As long as that 2 L/min keeps
your saturation in the normal range…you are good to go. The same holds true for
whatever flow rate is needed to keep your saturations normal.
When the very first concentrators were introduced to the market, they were very
big, very noisy, used a great deal of electricity, usually couldn’t generate any more
oxygen than 3 L/min, and last but not least could not generate the 99.9% “pure”
oxygen like oxygen cylinders and liquid oxygen systems produced. About this
time the term “purity” began to be used to describe the amount of oxygen that
could be manufactured or generated by this new revolutionary technology. This
purity figure was usually somewhere between 90 and 95%. I think we all would
agree that “purity” of oxygen is a heck of a lot easier to remember than Fraction of
Inspired Oxygen!
First generation concentrator Typical concentrator
Pt. flying with POC
Once the term stuck and came into common usage, it was here to stay.
Purity has always been inversely related to liter flow. That is, as liter flow went
up…oxygen purity (or the FIO2) dropped. It was true back in the 70’s and it is still
true today. The question is…what is the clinically acceptable lower limit to
purity? The answer is…WE DON”T KNOW! Some of the very latest models of
portable oxyen concentrators (POC’s) have been extensively studied and the
results published in respected peer reviewed journals. Depending on the variables,
the purity of at least one current POC was down around 87% with the range being
87-96%. The general opinion seems to be that it is not clinically significant. I
say…it only has to be clinically significant to you. Clearly we need to study this
scenario in detail and that takes time and money.
Lots of POC’s
to choose from
They may look similar
Good for the Goose Not so good for the
but they perform differently
What does this all mean? This means that what might work acceptably for one
patient, might not even be close for another patient. And to bring this full circle
you can see where pulmonologists and respiratory therapists like myself put so
much emphasis on using your pulse oximeters so that you are not just adequately
oxygenated to a saturation of somewhere a little north of 90%, but saturated to
whatever saturation is normal for where you live, work, and hopefully play. This
will be in the 96-98% range at or near sea level to between 94-97% here in Denver
or other cities at altitude. No one knows your body better than you. This is
especially true regarding your oxygen therapy. Ask questions, get on the treadmill
whenever you can, pay attention to nutrition, check into local pulmonary rehab
programs. Take control of the things you CAN control, but don’t ever let your
lung disease control you!
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