A breath of fresh air
SummaryA new national guideline will provide clarity on emergency oxygen use in adults
The first national guideline for the emergency use of oxygen in adults has been published, with the aim of simplifying oxygen delivery and better protecting acutely ill patients. Developed by a working party and led by the British Thoracic Society (BTS), the guideline is published in the October 2008 issue of Thorax1, the journal of the BTS, and is supported by 22 professional societies and institutions.
Until now, most healthcare professionals have followed their own institution’s customary practice when administering oxygen therapy, and it is this lack of consistency and clear guidance that the BTS’ guideline aims to correct.
Oxygen is one of the most widely used drugs, and is used across the whole range of healthcare specialities. Oxygen is an extremely important drug because hypoxaemia can cause death during many medical emergencies and it is essential to protect patients from this risk by the rapid recognition of acute illness and hypoxaemia followed by the immediate provision of oxygen to hypoxaemic and critically ill patients.
The guideline recommends that oxygen is administered to patients whose oxygen saturation falls below the target saturation ranges (94-98% for most acutely ill patients and 88-92% for those at risk of type 2 respiratory failure with raised carbon dioxide level in the blood), and that those who administer oxygen therapy should monitor the patient and keep within those specified target saturation ranges.
Dr Ronan O’Driscoll, of the Department of Respiratory Medicine, Salford Royal University Hospital, one of the respiratory physicians who led the development of the guideline said: “The development of this landmark guideline is a vital step in the recognition of oxygen as a carefully targeted therapeutic agent. For the first time, delivery of oxygen will be controlled and monitored in accordance with the best available evidence, allowing patients to receive better, more effective care.”
The BTS’ Standards of Care Committee established a working party, in association with 21 other Societies and Colleges, to produce an evidence-based, up-to-date guideline for the UK. BTS President Prof Martyn Partridge said: “This guideline is a welcome step forward in the delivery of oxygen in many different settings, which should translate into even better care for acutely ill patients.”
Despite a widespread belief amongst medical staff, and patients, that oxygen relieves breathlessness, there is no evidence that oxygen has an effect on breathlessness if the blood oxygen level is normal. The guideline group advised that too much oxygen can prove harmful in patients with chronic lung diseases such as chronic obstructive pulmonary disease (COPD), and ‘blind’ oxygen therapy outside of critical illness might actually delay recognition of a patient’s deterioration by providing a false sense of reassurance based on high oximetry measurements.
Historically, oxygen therapy has been delivered via complex protocols, involving either unreliable clinical examination or taking blood from the arteries. The widespread use of oximeters, in both hospital and community settings, makes the controlled, adjustable use of oxygen and reliable monitoring of oxygen saturation levels possible for the first time. The guideline also recommends that pulse oximetry should be available in all locations where emergency oxygen is used.
The biggest changes that people will notice are as follows:
Oxygen therapy will be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease.
Nurses will make these adjustments without requiring a change to the prescription on each occasion.
Most oxygen therapy will be from nasal cannulae rather than masks.
Oxygen will not be given to patients who are not hypoxaemic (except during critical illness)
Pulse oximetry must be available at all locations where emergency oxygen therapy is used.
Oxygen will require a prescription in all situations except for the immediate management of critical illness.
To ensure widespread and accurate take-up of the guidelines, the BTS has taken the innovative step of identifying ‘oxygen champions’ in every hospital in the UK. The ‘oxygen champions’ will facilitate training and will disseminate the supportive educational materials and new standardised documentation for the prescription and monitoring of emergency oxygen use, which have also been developed. This aims to reduce the existing confusion around oxygen prescription and use in emergency settings and cut through the often-conflicting advice given in training and practice.
More information and an abbreviated copy of the BTS Guideline for Emergency Oxygen Use in Adult Patients for download are available on http://www.brit-thoracic.org.uk .