Supplementary Oxygen

[James]

@James thanks for the invite to try and explain oxygen carrying capacity and oxygen-hemoglobin dissociation curves I have debated weighing in on this thread but avoided it thus far. When I have time later today I will try and write something understandable.

Thanks! Got an Intern?
Having flashbacks of spring 2020 when I tried to follow some ER and pulmonary ICU docs on youtube talking amongst themselves about treating covid patients on ventilators. Just too many things to look up, FiO2, PEEP, and on and on. Abandoned it after not too long as it wasn’t that useful.

 

[David]

I tried some Boost a couple of seasons ago and I'm sold. I keep a large can by my bed. If I take a few hits before bed, any time I get up or wake up I don't get the normal dull headache for the first couple of days. I also carry a small one ib my pocket when I'm skiing in case I can't catch my breath. In a week I use 1 big can & 2 or 3 small cans.

 

[Jwrags]

As promised earlier here is my attempt at explaining oxygen carrying capacity and how it relates to altitude, etc. Keep in mind I am not a pulmonary/critical care doc or an anesthesiologist who use this stuff every day. I have, however, studied this a lot in my training and career as well as managed many patients on a ventilator through the years. I live only a couple of hundred feet above sea level so have no experience managing patients in an oxygen deprived environment. Peter Hackett, who @James mentioned previously is definitely a guru of high altitude medicine and has an Everest summit to his credit.

First, let's talk about how much oxygen our body can carry. As most know, oxygen is carried in our blood by the hemoglobin in the red blood cells. There is a small amount of oxygen that is actually dissolved in the serum part of the blood, but very little. You can calculate the actual oxygen capacity in the blood with a formula: CaO2= (SaO2 x Hgb x 1.34) + .003(PaO2) CaO2 is the oxygen capacity, SaO2 is the saturation oxygen saturation of arterial blood, Hgb is the actual measured hemoglobin level, and PaO2 is the partial pressure of oxygen in the arterial blood. Unfortunately, all of these things need to be measured by a blood draw, and not a simple venous stick but an arterial blood draw. So it is not practical for everyday use. As can be seen by the formula, the overwhelming majority of oxygen carrying capacity comes from the hemoglobin. The .003(PaO2) represents the dissolved oxygen. If your hemoglobin is low or the saturation is low you will have much less oxygen available in your blood no matter how much oxygen you breathe in. If your saturations are high, i.e. 98-100%, breathing supplemental oxygen will do little to increase the content of oxygen in your blood.

The next important thing is the hemoglobin-oxygen dissociation curve, which demonstrates what impacts how the oxygen is actually delivered to the tissues. This is probably the most relevant thing relating to altitude.

This curve shows that hemoglobin is easily saturated in the beginning but becomes more difficult to carry more oxygen once the partial pressure of oxygen in the blood reaches around 60, under normal conditions. What can impact this is seen on the graph. When we are at altitude we tend to be more short of breath and breath faster because of the lower oxygen level in the air. By breathing faster we blow off our CO2 which gives us a respiratory alkalosis(increase pH) which shifts the curve to the left. This shift makes it more difficult for the hemoglobin to actually release the oxygen to the tissues. This is where Diamox comes in. It makes the body more acidotic, which combats the respiratory alkalosis associated with breathing at elevation, and shifts the curve back to normal or even to the right.

So now some of my personal conclusions about supplemental oxygen. The average healthy person who has a decent oxygen saturation will get minimal benefit from oxygen at the altitudes we are talking about here. Will taking a "hit" off the oxygen can help with quicker recovery at the bottom of a tough run or a hike for turns? Probably. Keep in mind that your hemoglobin desaturates very quickly. If you have a pulse oximeter put it on and hold your breath. It will likely go down just while sitting there before you have to breathe. Also look at how fast it comes back up once you do breathe. Staying on continuous oxygen or sleeping with it certainly will help you, while you are on it and may aid in tissue recovery/healing because of the increase in oxygen. It will have little effect once you take it off.

I hope this helps with understanding oxygen and oxygen delivery in the body. If some of the other docs on the forum have issues with what I wrote I am happy to edit for more accuracy.

 

[palikona]

I’m doing an experiment this month. I rented an O2 concentrator and am using it when I go from Denver to the high country: valleys of Summit and Eagle Counties, and some hiking around 11-12k.
Yesterday, we went to Frisco and hiked at about 9k. I did 40 mins of O2 at 2L/min on the ride up, 20 mins right after the easy hike, and 40 mins when we went back down. We were up for the whole day and with the O2 supplementation, I didn’t get the awful wooziness that I had been having these past few weeks when up there for the same amount of time (doing less exercise). No headache so far but sometimes it comes the afternoon of the day after (don’t get it).

 

[palikona]

So it worked to help me not feel woozy but I still got my normal post-exercise headache the day after (today) at 3pm. So frustrated that no one can pinpoint why this is happening.

 

[James]

So frustrated that no one can pinpoint why this is happening.

Who’s no one? Have you seen a doc experienced with altitude illness?

The why I would assume is genetics. Pinpointing exactly how could probably win a nobel prize. That’s not necessary though. and there’s likely some help available. It might just be you have to spend a whole day and night at 7k ft before going to 9k ft. Or renting one of those tents that simulates the lower oxygen availability at altitude by increasing. nitrogen.

What were you hoping to gain increasing oxygen on the way up to altitude? Can’t see how that would help acclimatize. I would think it would make it worse.

 

[Jwrags]

So it worked to help me not feel woozy but I still got my normal post-exercise headache the day after (today) at 3pm. So frustrated that no one can pinpoint why this is happening.

You actually do not know if it worked or what worked because you changed too many things at once.

 

[palikona]

Who’s no one? Have you seen a doc experienced with altitude illness?

The why I would assume is genetics. Pinpointing exactly how could probably win a nobel prize. That’s not necessary though. and there’s likely some help available. It might just be you have to spend a whole day and night at 7k ft before going to 9k ft. Or renting one of those tents that simulates the lower oxygen availability at altitude by increasing. nitrogen.

What were you hoping to gain increasing oxygen on the way up to altitude? Can’t see how that would help acclimatize. I would think it would make it worse.

Long story short, I’ve lived in Denver for 17 years, have spent lots of time at high altitudes (hiked 20 14ers, 25 13ers, typically ski once a week in Summit).

I noticed headaches 2 years ago that would regularly occur after a day skiing or hiking or exercising here in Denver as well. Strangely, they often did and still happen the day after doing something. I never had anything like this before 2 years ago.

I’ve seen a cardiologist, had tests done, seen a neurologist, had an MRI done, tried many migraine meds to see if they would help, and am seeing a hematologist right now. Two abnormalities were uncovered: I have a small/medium sized PFO in my heart that apparently 25% of the population has, and I have high hemoglobin. The cardiologist doesn’t think my headaches are because of the PFO but I am getting a second opinion soon.

My hemoglobin and hematocrit are genetically high (brother at sea level has same issue) so the hematologist is having me dump blood (250 ml every two weeks) till I get to “normal” levels. After that, I’ll have to do it regularly but likely every 3-4 months. He thinks that’s why I’m having headaches, but I’ve now been doing this for a couple of months, am about at the “normal” range, and my post-exercise headaches haven’t stopped at all. And at the end of the ski season, at the beginning of dumping blood, I noticed I was getting really tired at altitude. Well, that’s continued to get worse (recently I went up to Summit County for 2 day trips and each time I got woozy from just being at altitude). The hematologist said this can be a side effect of having dumped blood. So my experiment was to see if the supplementary O2 would help the wooziness. It did the day of, but I still got my typical headache the next day.

I’m not sure what I’m doing, as I’ve tried so much, with no luck in figuring out what is causing this, or if there’s a medicine that I can take when a headache comes on. None that my neurologist has suggested has helped consistently.

 

[Kneale Brownson]

My cardiologist was adamant that "dumping" was NOT the solution to my high numbers

 

[palikona]

My cardiologist was adamant that "dumping" was NOT the solution to my high numbers

Sigh. Really?
What was the solution? To move?

 

[Kneale Brownson]

I had to live below 6500 feet as opposed to the 10000 I'd been at the last dozen years

 

[James]

I’m not sure what I’m doing, as I’ve tried so much, with no luck in figuring out what is causing this, or if there’s a medicine that I can take when a headache comes on. None that my neurologist has suggested has helped consistently.

Sounds very frustrating. Seems to be a lot going on just at your resting altitude of roughly a mile. So I don’t think anyone’s anecdotal evidence of their situation really applies to you. Not that it would apply that much to anyone else.

I think you need a generalist who specializes in altitude illness who can then work with your specialists. You’re not that far from one of the foremost in the world in Dr Hackett. At the least he could recommend someone. I wouldn’t wait too long as he’s been at it for forty years.

Who knows, maybe the solution is to live between 7-8k feet if going to 9-13.5k ft for a couple days is the goal. No idea.

 

[Kneale Brownson]

Tom Hackett is a renowned orthopedic surgeon with Steadman Clinic in Vail. Don't know that he also deals in altitude issues.

I don't think there is a medication that would help after the fact. Diamox helped while I remained at altitude as long as I started it several days before visiting.

 

[James]

Tom Hackett is a renowned orthopedic surgeon with Steadman Clinic in Vail.

Dr Peter Hackett, Telluride

Dr. Peter Hackett — Institute For Altitude Medicine

www.highaltitudedoctor.org

 

[palikona]

Sounds very frustrating. Seems to be a lot going on just at your resting altitude of roughly a mile. So I don’t think anyone’s anecdotal evidence of their situation really applies to you. Not that it would apply that much to anyone else.

I think you need a generalist who specializes in altitude illness who can then work with your specialists. You’re not that far from one of the foremost in the world in Dr Hackett. At the least he could recommend someone. I wouldn’t wait too long as he’s been at it for forty years.

Who knows, maybe the solution is to live between 7-8k feet if going to 9-13.5k ft for a couple days is the goal. No idea.

I’ll look into talking with Dr Hackett. Thank you!

Just out of curiosity, does anyone here hike with a portable O2 concentrator in their pack as backup, in case symptoms like breathlessness or dizziness come on?

 

[Tricia]

So it worked to help me not feel woozy but I still got my normal post-exercise headache the day after (today) at 3pm. So frustrated that no one can pinpoint why this is happening.

Long story short, I’ve lived in Denver for 17 years, have spent lots of time at high altitudes (hiked 20 14ers, 25 13ers, typically ski once a week in Summit).

I noticed headaches 2 years ago that would regularly occur after a day skiing or hiking or exercising here in Denver as well. Strangely, they often did and still happen the day after doing something. I never had anything like this before 2 years ago.

I’ve seen a cardiologist, had tests done, seen a neurologist, had an MRI done, tried many migraine meds to see if they would help, and am seeing a hematologist right now. Two abnormalities were uncovered: I have a small/medium sized PFO in my heart that apparently 25% of the population has, and I have high hemoglobin. The cardiologist doesn’t think my headaches are because of the PFO but I am getting a second opinion soon.

My hemoglobin and hematocrit are genetically high (brother at sea level has same issue) so the hematologist is having me dump blood (250 ml every two weeks) till I get to “normal” levels. After that, I’ll have to do it regularly but likely every 3-4 months. He thinks that’s why I’m having headaches, but I’ve now been doing this for a couple of months, am about at the “normal” range, and my post-exercise headaches haven’t stopped at all. And at the end of the ski season, at the beginning of dumping blood, I noticed I was getting really tired at altitude. Well, that’s continued to get worse (recently I went up to Summit County for 2 day trips and each time I got woozy from just being at altitude). The hematologist said this can be a side effect of having dumped blood. So my experiment was to see if the supplementary O2 would help the wooziness. It did the day of, but I still got my typical headache the next day.

I’m not sure what I’m doing, as I’ve tried so much, with no luck in figuring out what is causing this, or if there’s a medicine that I can take when a headache comes on. None that my neurologist has suggested has helped consistently.

Dr Peter Hackett, Telluride

Dr. Peter Hackett — Institute For Altitude Medicine

www.highaltitudedoctor.org

This is a good resource.
Also, consider the Jewish hospital in Denver. They are world renowned for their pulmonary specialties.

Dr David Polaner was a doctor at the Jewish hospital. Now, he's in the state of Washington.

 

[palikona]

This is a good resource.
Also, consider the Jewish hospital in Denver. They are world renowned for their pulmonary specialties.

Dr David Polaner was a doctor at the Jewish hospital. Now, he's in the state of Washington.

Cool, thank you.

 

[dmp]

This is David Polaner. I've just joined the board after Trish sent a link to this thread. I don't have the time to go through a response to every post but a couple of things I will respond to. I think that Trish will also be posting an update of my old post from EpicSki on altitude adaptation.

First, palokona (if I am correct in assuming that you are from the Denver area)- you should see a physician at the altitude and travel medicine clinic at Univ. of Colorado. I know several of the physicians there, and can send you some names if you pm me. You don't say how high your hemoglobin is, but unless you have Chronic Mountain Sickness (unusual in people living continuously at less than 12,000ft, so not seen much outside the Andes) I don’t think that is likely to be the answer. You give an important piece of information, though, that you have a PFO. There is very good evidence that people with PFO are at increased risk of acute mountain sickness, and are worse at acclimatizing. The best paper explaining this is by Andy Lovering and full text is here. I worked with these guys on the AltitudeOmics expedition and they are first rate scientists. This may be at the root, or at least a major contributor to your problem, and if indicated that can be repaired in the cath lab without surgery. You can certainly try and contact Peter Hackett, who is indeed one of the foremost altitude physicians in the world, but Peter lives on the Western Slope so you probably won't be able to see him in person. I think that you need to be seen formally as a patient. Your little experiment with the oxygen concentrator might have meant something, because hypoxia does both increase intrapulmonary shunt (the amount of blood that bypasses the air sacs in the lungs where blood picks up oxygen) and also increases the blood pressure in the lung's circulation, which then shunts more blood across that patent foramen ovale so it never goes through the lungs in the first place. That will increase what is called venous admixture- the amount of unoxygenated blood that flows to the systemic circulation.

Re: the little cans of oxygen- they are really not effective because the oxygen is only in your lungs for seconds- that will raise your oxygen saturation but only help while you are breathing it (well, for a little while longer, but less than a minute). A waste of money better spent on more gear or high grade chocolate.

The comment that James made about genetics is spot on (unfortunately for my friends and colleagues Rob Roach and Coleen Julian, however, not Nobel material yet!) There are absolutely genetic mechanisms behind the ease or difficulty to acclimatization to altitude, and there are specific polymorphisms (gene variants) that are associated with good adaptation. There are even genetic differences that result in different adaptive mechanisms in highland natives in the Andes and Tibet. Anyone who wants a technical paper that summarizes a lot of what is known can look here.

Hope this is some help.

David

 

[David]

Just out of curiosity, does anyone here hike with a portable O2 concentrator in their pack as backup, in case symptoms like breathlessness or dizziness come on?

After pneumonia a few years ago I now carry a pocket Boost when I'm at altitude. But I live at 600'.

 

[palikona]

This is David Polaner. I've just joined the board after Trish sent a link to this thread. I don't have the time to go through a response to every post but a couple of things I will respond to. I think that Trish will also be posting an update of my old post from EpicSki on altitude adaptation.

First, palokona (if I am correct in assuming that you are from the Denver area)- you should see a physician at the altitude and travel medicine clinic at Univ. of Colorado. I know several of the physicians there, and can send you some names if you pm me. You don't say how high your hemoglobin is, but unless you have Chronic Mountain Sickness (unusual in people living continuously at less than 12,000ft, so not seen much outside the Andes) I don’t think that is likely to be the answer. You give an important piece of information, though, that you have a PFO. There is very good evidence that people with PFO are at increased risk of acute mountain sickness, and are worse at acclimatizing. The best paper explaining this is by Andy Lovering and full text is here. I worked with these guys on the AltitudeOmics expedition and they are first rate scientists. This may be at the root, or at least a major contributor to your problem, and if indicated that can be repaired in the cath lab without surgery. You can certainly try and contact Peter Hackett, who is indeed one of the foremost altitude physicians in the world, but Peter lives on the Western Slope so you probably won't be able to see him in person. I think that you need to be seen formally as a patient. Your little experiment with the oxygen concentrator might have meant something, because hypoxia does both increase intrapulmonary shunt (the amount of blood that bypasses the air sacs in the lungs where blood picks up oxygen) and also increases the blood pressure in the lung's circulation, which then shunts more blood across that patent foramen ovale so it never goes through the lungs in the first place. That will increase what is called venous admixture- the amount of unoxygenated blood that flows to the systemic circulation.

Re: the little cans of oxygen- they are really not effective because the oxygen is only in your lungs for seconds- that will raise your oxygen saturation but only help while you are breathing it (well, for a little while longer, but less than a minute). A waste of money better spent on more gear or high grade chocolate.

The comment that James made about genetics is spot on (unfortunately for my friends and colleagues Rob Roach and Coleen Julian, however, not Nobel material yet!) There are absolutely genetic mechanisms behind the ease or difficulty to acclimatization to altitude, and there are specific polymorphisms (gene variants) that are associated with good adaptation. There are even genetic differences that result in different adaptive mechanisms in highland natives in the Andes and Tibet. Anyone who wants a technical paper that summarizes a lot of what is known can look here.

Hope this is some help.

David

First of all, thank you Trish for sending the link to David.

And David, thank you for your insight. I will go to see someone at UC for sure. I will PM you.

Can you explain your statement: “Your little experiment with the oxygen concentrator might have meant something, because hypoxia does both increase intrapulmonary shunt (the amount of blood that bypasses the air sacs in the lungs where blood picks up oxygen) and also increases the blood pressure in the lung's circulation, which then shunts more blood across that patent foramen ovale so it never goes through the lungs in the first place. That will increase what is called venous admixture- the amount of unoxygenated blood that flows to the systemic circulation.”

Am I making the situation worse by using the supplementary O2?