Nate,

Marc is spot on...  Respiratory therapists are geared towards treating folks with COPD...  so it's not their fault.  Few if any have ever had any training in treating cluster headaches, and even fewer have been exposed to aerospace or aviation physiology…  but they do know damaged lungs required special attention. 

As an example, there are more than a few folks out there with asthma and cluster headaches...

Nothing...  I mean nothing is worse or more frustrating for these folks who have found that oxygen therapy works well in aborting their cluster headaches, than to have an attack of both at the same time.

Imagine not having the breath to blow out a candle in front of your face due to an asthma attack and having the beast gouging your eye out at the same time…   Knowing the oxygen therapy would stop the pain and not being able to use it because of the asthma attack is very frustrating.

The folks with both conditions who manage to get their pulmonologist and neurologist in the same room at the same time and lock the door until they come out with a protocol to treat attacks of both at the same time are very fortunate.

It turns out the basic protocol is very simple...  Treat the asthma attack first...  It can kill you...  Then treat the cluster headache…  you may want to die but the condition will not kill you. 

The best trick I've seen in this area is to pump the nebulizer containing the bronchodilator with 100% oxygen...  the flow rate is not all that great, but it does jack up the SpO2 (Oxygen saturation or Dissolved Arterial Oxygen) enough to keep the cluster headache from going ballistic...  Then when the "pipes" clear enough to take a full breath of air and expel it without resistance, crank up the oxygen regulator to a minimum of 15 liters/minute or as high as 25 liters/minute and beat back the cluster headache.

If you want to convert your respiratory specialist to your way of thinking, your first approach is to use reason along with some basic respiratory physiology to make sure he or she understands it is not just elevating the oxygen levels (hyperoxia) to stimulate cerebral vasoconstriction that makes the abort with oxygen therapy happen, it is also requires reducing the CO2 levels (hypocapnia) by using flow rates that support hyperventilation to the point you reach and sustain respiratory alkalosis until the abort.  This is essential in effective oxygen therapy as reduced CO2 levels also act as a very powerful cerebral vasoconstrictor.   

Tell the respiratory therapist you need enough lung ventilation to reduce SpCO2 (Carbon Dioxide (CO2) saturation or Dissolved CO2) levels below normal to achieve respiratory alkalosis and abort the cluster headache attack.  It is also very safe.  So safe, the US Navy makes pilots breathe 100% oxygen from takeoff to touch down and they’ve been doing it for well over 60 years.  I can recall many times when we were scheduled for night operations and it was hairy scary dark, we would preflight and man-up our jets 5 minutes early so we could strap on the 100% oxygen to improve our night vision.

As you sit there reading this, it takes a minute volume of 20 to 22 liters of air ventilating the lungs just to maintain your SpCO2 levels in the normal range (Minute Volume = volume of air (or O2) inhaled in one minute).  Climbing three flights of stairs or walking at a fast pace will command a respiration rate or minute volume of lung ventilation equal to 50 to 53 Minute Liters...  Hmmm that means you need a flow rate of 50 to 53 liters/minute…

Once you understand this basic principle of respiratory physiology, you'll realize using a non-rebreathing mask with a constant flow regulator set to ≤15 liters/minute is a recipe for disaster if you have any physical activity during your cluster headache attack…  Flow rates this low with a non-rebreathing mask are not going to provide sufficient lung ventilation to regulate CO2 levels and CO2 levels will build... 

When that happens…  the abort with oxygen therapy is not possible…  you loose…   and the beast wins because elevated CO2 levels act as a very powerful cerebral vasodilator!

In short, if you're dancing the cha-cha or the tarantella two-step with a high Kip-level attack, you're generating more CO2 than normal due to the physical activity and that will require a greater minute volume of lung ventilation to maintain normal CO2 levels...   And… you'll need even more lung ventilation than that if you want to reduce blood CO2 levels below normal to achieve respiratory alkalosis to abort the attack...

If necessary, take your O2PTIMASK and high flow regulator or demand valve and a cylinder of oxygen to your next meeting with the respiratory therapist and demonstrate you won't fall on your ass using this method of oxygen therapy. 

I may have fallen on my face a time or two trying to convert a big batch of margaritas or too many rum & cokes into urine  …  but I've never passed out from using this method of oxygen therapy and I've used it since 2005 on every hit and every shadow, and I sucked down copious amounts of 100 oxygen on every flight for over 3000 hours total flight time...  and still brought the jet back for a safe landing on the ship…

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I also stand while using this method of oxygen therapy as this gives the diaphragm a full range of motion to better ventilate the lungs.  Sitting hunched over with your elbows on your knees is the worst possible position to be in during oxygen therapy.  It causes too much residual breath to be trapped in the lungs and when this happens, that residual breath builds up with higher levels of CO2 and that in turn elevates the partial pressure of CO2 in the arterial blood.  When that happens the elevated SpCO2 level negates the vasoconstrictive effect of hyperoxia putting you between a rock and a hard place as that makes the oxygen therapy ineffective or the abort last far too long…  and that is a real bummer.

If you feel uncomfortable standing during oxygen therapy, sit upright like your music or choir director used to tell you to do, or sit in a recliner leaning back to take any pressure off the abdomen and diaphragm.

Soooo… the motto is very simple, “When using oxygen therapy to abort a cluster headache, Oxygen is your friend and CO2 is your enemy.” 

That makes hyperventilating on 100% oxygen until you achieve and sustain respiratory alkalosis essential if you want to achieve a fast abort. 

I can hear the wheels turning now…  How do I know if I’ve achieved respiratory alkalosis?

The answer is really very simple…  Your body will tell you….  Respiratory alkalosis is accompanied by symptoms called paresthesia…  That would be a tingling or prickling sensation (slight pins and needles feeling) of the fingertips, face, lips, and back of the neck accompanied by a slight dizziness.

Is paresthesia dangerous?  No…  As you are creating this condition intentionally by hyperventilating, and effects of respiratory alkalosis are relatively short lived, the symptoms of paresthesia will clear in less than a minute as soon as you slow the respiration rate to allow CO2 levels to build back towards normal.

Regarding refill costs...  My E-size cylinders refill for $20 and my M-size cylinders refill for $30.  My guess is $35 to $45 to refill an H-size oxygen cylinder...

I average 20 to 25 aborts per M-size cylinder so that makes my cost per abort $1.20 to $1.50...   and that's a heck of a lot less than the imitrex cost per abort and there are no side effects save for a feeling confidence that you'll gain in knowing you control the beast...  and not the other way around.

Take care,

V/R, Batch