Nuts and Bolts Medicine: A Seemingly Trivial Cause of Hypoxia

George is in chronic respiratory failure, running 2 liters of oxygen through his nasal cannula every minute, day and night. His noisy old concentrator is down the hall somewhere and I have this constant worry that he will someday trip on the tubing.

A while back he got a cold that turned into a sinus infection. I was on vacation but he happened to have an appointment with his pulmonologist, who put him on doxycycline and prednisone. George’s oxygen saturation was lower than usual, but his chest was clear. The pulmonologist told him his COPD might just be getting slowly worse. The new medicines helped only a little, but he still had pain in his maxillary sinuses. George decided to call Galileo’s urgent care team and they agreed to switch him to amoxicillin, which has helped him many times before when he has had a sinus infection.

The amoxicillin cleared up his sinus pain, but his oxygen level kept dropping every time he even walked across the room. He had neither cough nor wheezing and he had not gained weight or developed any ankle swelling.

I saw him in a follow-up housecall the other day. At that moment his oxygen saturation was decent, but he told me he had had a mild stuffy nose for the past few weeks. He had taken a loratadine allergy pill once in a while and used his Flonase nasal steroid on and off the past month, because he was pretty sure he had started to be allergic to something.

I asked him to remove his oxygen cannula and inhale and exhale through his nose with his mouth shut. I did not feel any airflow and didn’t hear much either. All I heard was a very slight slurping sound.

“George, I think your nose is too congested for the oxygen to get through the way it should”, I told him. “Take the loratadine and the Flonase every single day and I think you’ll see your oxygen more steadily where we want it.”

I think I found a low tech explanation and remedy for his deteriorated oxygenation.

Only in a housecall…