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British Thoracic Society Guideline for
oxygen use in healthcare and
emergency settings
Key messages for nurses
and PAMs (Professions Allied to Medicine)
12/05/2017
This presentation was last updated on 12/05/2017
BTS guideline for oxygen use in adults in healthcare
and emergency settings is endorsed by
Association of British Neurologists
Association of Chartered Physiotherapists in Respiratory Care
Association of Palliative Medicine
Association of Respiratory Nurse Specialists
Association for Respiratory Technology and Physiology
British Association of Stroke Physicians
British Geriatric Society
College of Paramedics
Intensive Care Society
Joint Royal Colleges Ambulance Liaison Committee
Primary Care Respiratory Society UK
Resuscitation Council (UK)
Royal College of Anaesthetists
The Royal College of Emergency Medicine
Royal College of General Practitioners
Royal College of Nursing (endorsement until April 2020)
Royal College of Obstetricians and Gynaecologists
Royal College of Physicians London
Royal College of Physicians of Edinburgh
Royal College of Physicians and Surgeons of Glasgow
Royal Pharmaceutical Society
The Society for Acute Medicine
O’Driscoll BR et al Thorax 2017; 72: Suppl 1 i1-i89
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Important points to consider about
oxygen therapy
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Oxygen is a life saving drug for hypoxaemic patients.
(Patients whose oxygen levels are low)
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Giving too much oxygen is unnecessary as oxygen cannot be stored
in the body
3
COPD patients (and some other patients) may be harmed by too much
oxygen as this can lead to increased carbon dioxide (C02) levels
4
Other patients (e.g. myocardial infarction) may also be harmed by
too much oxygen
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Only give as much as needed– no need for extra!
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Oxygen (02)
What’s the problem?
Published audits have shown:
• Doctors and nurses have a poor understanding of how oxygen should be used
• Oxygen is often given without a prescription
(In the 2015 BTS audit, 42% of hospital patients using oxygen had no prescription)
• If there is a prescription, patients do not always receive what is specified on the
prescription
• Where there is a prescription with target range, almost one third of patients are
outside the range
(9.5% of SpO2 results below target range and 21.5% above target range in 2015 BTS audit)
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National BTS audits of oxygen use 2008-2016
14% of UK hospital patients were using oxygen
Percent of patients using oxygen who had an oxygen prescription
during BTS audits:
• 32%
in 2008 (99 Hospitals)
• 48%
in 2011 (156 Hospitals)
Prior to publication of 2008 Guideline
• 55.1% in 2013 (151 Hospitals)
• 57.5% in 2015 (181 Hospitals)
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Oxygen is a drug and should be
prescribed except in emergencies
• Oxygen should be regarded as a drug (BNF 2016)
• Oxygen must be prescribed in all situations
(except for the immediate management of critical illness in accordance
with BTS guidelines) (NPSA Oct 2009)
• Oxygen should be prescribed to achieve a target saturation (Sp02)
which should be written on the drug chart or electronic prescription
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Normal Oxygen saturation range in healthy adults
SpO2 Saturation (measured by pulse oximetry) of O2
HEALTHY ADULTS
Daytime
Sp02 96-98%
*Transient dips in saturation are common during sleep (~84%)
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Aims of emergency oxygen therapy
• To correct potentially harmful hypoxaemia
• To alleviate breathlessness (only if hypoxaemic)
Oxygen has not been proven to have any consistent effect
on the sensation of breathlessness in non-hypoxaemic patients.
Benefit has been found with use of a hand-held fan and consider
use of opioids for patients with malignancy or other causes of
chronic severe breathlessness.
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Many patients need high-dose oxygen
to normalize saturation
• Severe Pneumonia
• Severe LVF
• Major Trauma
• Sepsis and Shock
• Lung collapse
• Pulmonary Embolism
• Lung Fibrosis
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Oxygen therapy is only ONE element of
resuscitation of a critically ill patient
The oxygen carrying power of blood may be increased by
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Safeguarding the airway
Enhancing circulating volume
Correcting severe anaemia
Enhancing cardiac output
Avoiding/reversing respiratory depressants
Giving Oxygen therapy
Establish the reason for hypoxaemia and treat the underlying cause (e.g
Bronchospasm, LVF etc)
• Some patients may need specialist care!!
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Oxygen therapy by first
responders in critical illness
See BTS 0xygen guideline section 8.10
• Patients must not go without oxygen while waiting for
a medical review
• Initial 02 therapy is reservoir mask at 15 litres/minute (RM15)
• Once stable aim for SpO2 94-98% or patient-specific target range
• COPD patients who are critically ill should have the same oxygen therapy
until blood gases have been obtained and may then need controlled
oxygen therapy or non-invasive or invasive ventilation
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Prescribing to a Target Saturation range
• Oxygen will be prescribed in order to keep Sp02
within a specified range for individual patients
• Target oxygen saturation prescription is
integrated into the patient’s drug chart and
bedside monitoring
• Oxygen delivery device and/or flow should be
changed if necessary to keep the SpO2 in the
target range
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Patients will be initially prescribed a
target saturation as shown below
• 94-98% Most patients (Those not at risk of CO2 retention)
• 88-92% COPD or C02 retaining patients:
Chronic hypoxic lung disease
COPD
Severe Chronic Asthma
Bronchiectasis / CF
Chest wall disease
Kypho-scoliosis
Neuromuscular disease
Obesity hypoventilation
• Other
Some patients with oxygen sensitivity may require a different lower
target range such as 85-90%
Target saturations should be reviewed and changed if required.
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Exposure to high concentrations of
oxygen may be harmful
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• Harten JM et al J Cardiothoracic Vasc Anaesth 2005; 19:
Absorption Atelectasis even at FIO2 30-50%
173-5
Intrapulmonary shunting
• Kaneda T et al. Jpn Circ J 2001; 213-8
Post-operative hypoxaemia
• Frobert O et al. Cardiovasc Ultrasound 2004; 2: 22
• Haque WA et al. J Am Coll Cardiol 1996; 2: 353-7
Risk to COPD patients
• Thomaon aj ET AL. BMJ 2002; 1406-7
Coronary vasoconstriction
• Stub D et a;. Circulation 2015’; 131: 2143-50
Increased Systemic Vascular Resistance
• Helmerhorst HJ Crit Care Med 2015; 43: 1508-19
• Girardis M et al. JAMA 2016; 1583-89
Reduced Cardiac Index
Possible reperfusion injury post MI
Increased CK level in STEMI and increased infarct size on MR scan at 3 months
Worsens systolic myocardial performance
Association of hyperoxaemia with increased mortality in several ITU studies
• This guideline recommends an upper limit of 98% for most patients
• Combination of what is normal and safe
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Safeguarding patients at risk of
type 2 respiratory failure
• Lower target saturation range for these patients (usually 88-92%)
• Education of patients and health care workers
• Use of controlled oxygen via Venturi masks and low flow nasal O2
• Use of oxygen alert cards
• Issue of personal Venturi masks to high-risk patients
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OXYGEN ALERT CARD Name: _____________________________________________ I have a chronic respiratory condition and I am at risk of having a raised carbon dioxide level in my blood during flare‐ups of my condition (exacerbations) Please use my ______% Venturi mask to achieve an oxygen saturation of _____ % to _____ % during exacerbations of my condition
Use compressed air to drive nebulisers (with nasal oxygen a 2 l/min)
If compressed air is not available, limit oxygen‐driven nebulisers to 6 minutes
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Who does what?
Doctors
(and other prescribers)
• Prescribe O2 target range
for ALL patients
Nurses / Physios
HCAs / Student nurses
• Document starting device/flow
• Monitor O2 minimum 4 hourly
• Start O2 and ensure target
achieved quickly
• Record SpO2 and delivery
device
• Titrate O2 to keep in range
• Codes recorded on obs chart
and initialled
• Usually 94-98% or 88-92%
• Specify starting device
• Provide advice to nurses if
the clinical condition of the
patient changes
• Adjust the target range if
the patient’s condition alters
(e.g. new hypercapnia)
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• Sign drug chart every drug round
(nurses, not physios)
• Inform nurses when SpO2
outside target range
• Monitor O2 minimum 4 hourly.
• Record SpO2 & delivery device
Wean off 02 if clinically stable
• Codes to be written on obs chart
and initialled
Target saturation prescribing
• It is recommended that all patients are routinely prescribed
a target saturation on admission to hospital.
• This is so that the right target range will be used if the
patient deteriorates and correct NEWS section is used.
• Patients will only receive oxygen if the saturation is below
the target. Medical review required when this happens.
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Oxygen prescription chart
Model for oxygen section in hospital prescription charts
*Saturation is indicated in almost all cases except for palliative terminal care.
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Example of electronic prescription
*Electronic prescribing
can be linked to electronic
bedside observations to
calculate EWS/NEWS
automatically according
to oxygen target range.
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Monitoring & starting oxygen therapy
Record SpO2 before starting oxygen therapy where possible.
(Do NOT take oxygen off an acutely unwell patient to obtain a reading on air)
If target saturation is 94-98%
• Choose mask and/or flow rate to achieve target saturation
• Repeat blood gases are not needed for these patients if within target range
If target saturation is 88-92%
• Start with nasal cannulae at 1-2 l/minute or 28% Venturi mask then titrate up to achieve the
target saturation
• Blood gases are needed after 30-60 mins
If ‘Other’ Sp02 prescribed - start as directed by doctor
Monitor SpO2 for first 5 mins and then monitor patient SpO2 minimum 4 hourly.
Record delivery device and flow on observations chart.
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Core content of an oxygen observation chart
*All changes to oxygen delivery systems must be initialled by a registered nurse or equivalent.
If the patient is medically stable and in the target range on two consecutive rounds, report to a
registered nurse to consider weaning off oxygen.
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Example of 2016 NEWS chart if available
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Standard abbreviations for oxygen delivery devices
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Maintaining the Target saturation
• Nurses must use the oxygen escalator (see next slide)
• Masks and flow rate should be changed up or down to ensure target saturation
range is met as quickly as possible
• Nurses do not need to use each step of the escalator and can change devices
and/or flow rate to ensure target SpO2 is achieved
e.g. 2 Litre nasal cannula may change to 35% Venturi mask
Always monitor SpO2 for 5 mins after any change in oxygen therapy
to ensure target saturation is achieved
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Titrating Oxygen up and down using the mask escalator
This table shows approximate conversion values.
Venturi 24% (blue) 2‐3 l/min
OR
Nasal cannulae 1L Venturi 28% (white) 4‐6 l/min
OR
Nasal cannulae 2L
Venturi 35% (yellow) 8‐12 l/min OR
Nasal cannulae 4L
Venturi 40% (red) 10‐15 l/min OR
Nasal cannulae or Simple face mask 5‐6L/min
Venturi 60% (green) 15 l/min
OR
Simple face mask 7‐10L/min
Reservoir mask at 15L oxygen flow
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If reservoir mask is required, seek senior medical input immediately
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Titrating oxygen up or down in
Target saturation range 94-98%
Increase oxygen if SpO2 is lower than target range
Decrease oxygen if SpO2 is higher than target range
• Monitor SpO2 for 5 mins at every change
• Document SpO2 on chart after 5 mins
• If oxygen therapy is increased, medical assessment is needed and
blood gases may be required
• If oxygen therapy is decreased for a stable patient, blood gases are NOT needed
No need to inform doctor if clinically stable
Ensure change is documented in patient record
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Titrating 02 up or down in Target
saturation range 88-92% or other
Increase oxygen if SpO2 is lower than target range
Decrease oxygen if SpO2 is higher than target range
- Monitor SpO2 for 5 mins at every change
- Document SpO2 on chart after 5 mins
- If oxygen therapy is increased, take blood gases after 30-60 minutes
(show doctor results)
- If oxygen therapy is decreased for a stable patient, blood gases are NOT needed
No need to inform doctor if clinically stable
Ensure change is documented in patients record
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Stopping oxygen therapy for stable patients
Stop 02 if patient stable and Sp02 is within range on 2 consecutive observations
• Patient will usually be weaned to low dose oxygen by this time
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Stop supplemental oxygen & monitor Sp02 for 5mins & document this in the chart
If Sp02 remains stable, continue on air for 1 hour monitoring Sp02
Document Sp02 on chart at end of hour
If stable at one hour, the patient is weaned off oxygen and continues regular obs
• If saturation falls on stopping oxygen, then re-start the previous dose
If cases of acute deterioration or if Sp02 fall outside of the target
rang despite re-starting oxygen therapy, the patient should have an
immediate medical review
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When to use the Target saturation not indicated box
(To be used for patients who do not benefit from pulse oximetry monitoring)
• Some patients may be on oxygen for conditions where it is inappropriate to
continue with observations.
• A tick in the box means no oxygen observations
• Qualified nurses must still sign the drug chart each round
This may apply to patients for
• Palliative care
• Symptom control in last days of life
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Devices to use
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High Concentration Reservoir Mask (RM)
• Non re-breathing Reservoir Mask
• Critical illness / Trauma patients
• Post-cardiac or respiratory arrest
• Delivers O2 concentrations
between 60 & 80% or above
• Effective for short term treatment
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Nasal Cannulae (N)
• Recommended for most patients.
• 1-6L/min gives approx 24-50% FIO2
• FIO2 depends on oxygen flow rate and
patient’s minute volume and inspiratory
flow and pattern of breathing.
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Comfortable and easily tolerated
No re-breathing
Patient can eat and drink
Preferred by patients (Vs simple mask)
Low cost product
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Venturi or fixed performance masks (V)
• Aims to deliver constant oxygen concentration within
and between breaths.
• The minimum oxygen flow is displayed.
With TACHYPNOEA (RR >30/min) the oxygen flow
should be increased by 50% - see next slide
• Increasing flow does not increase oxygen
concentration, it is a fixed dose device
• Good device for patients with raised C02 (patients with
a target of 88-92%)
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24% Venturi ‐ 2 L/min ‐ Use 3 l/min if RR >30
28% Venturi ‐ 4 L/min ‐ Use 6 l/min if RR >30
35% Venturi ‐ 8 L/min ‐ Use 12 l/min if RR >30
40% Venturi ‐ 10 L/min ‐ Use 15 l/min if RR >30 60% Venturi ‐ 15 L/min ‐ Change to RM if 60% Venturi is not sufficient 12/05/2017
Simple face mask (SM)
(Medium concentration, variable performance)
• Used for patients with type I respiratory
failure
• Delivers variable O2 concentration between
35% & 60%
• Low cost product
• Flow 5-10 L/min
Flow must be at least 5 L/min to avoid CO2
build up and resistance to breathing
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Humidified Oxygen (H)
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Tracheostomy
Bronchiectasis
Cystic Fibrosis patients
Physiotherapists may advise humidification
Patients on High flow whisper CPAP
Humidification may be provided by cold or warm humidifiers
( H24, H28, H35 etc.)
The illustration shows a cold humidifier delivering 28% oxygen at 5 l/min flow.
N.B. There is little evidence for humidification in routine oxygen therapy.
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Tracheostomy mask (TM)
• “Neck breathing patients”
• Adjust oxygen flow to maintain target
saturation
• Prolonged oxygen use requires
humidification
• Patients may also need suction
to remove airway mucus
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High flow nasal oxygen (HFN)
• High flow nasal oxygen using specialised
equipment may be used as an alternative to
reservoir mask treatment in patients with acute
respiratory failure without hypercapnia
• It is mostly used in Intensive Care Units, High
Dependency Units and other specialised areas
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Oxygen flow meter
The centre of the ball indicates the correct flow rate.
The ball must be centred on the
line.
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This diagram illustrates the correct
setting of the flow meter to deliver
a flow of 2 litres per minute.
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Beware of air outlets
They may be mistaken for oxygen outlets
Use a cover for air outlets or else remove the flow meter for air when not in use
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Oxygen outlet
(Usually white)
Air outlet
(usually black)
Oxygen prescribing Summary
• Oxygen is a life saving drug
• Oxygen must be prescribed (in emergencies, give immediately, record later)
• Doctors will prescribe a target saturation range for all patients
• Prescription will be written in oxygen section of drug chart or EPR
• Nurses will choose device and flow rate to achieve target saturation
• Nurses can titrate oxygen up & down & record on obs chart (Medical review is
required after up-titration of oxygen)
• Nurses can wean stable patients off oxygen
• Oxygen must be monitored minimum four hourly
• Nurses must sign drug chart for oxygen at every drug round
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Check your knowledge
1
What monitoring is needed when starting oxygen therapy?
2
What should you do if the patient’s saturation is lower than the target range prescribed in
the 94-98% group?
3
What should you do if the patient’s saturation is lower than the target range prescribed in
the 88-92% group?
4
What should you do if the patient’s Sp02 is higher than the target saturation range
prescribed in both groups?
5
When do you consider stopping oxygen therapy?
6
How do you stop oxygen therapy?
7
What scenario do you use high flow oxygen therapy and seek immediate medical review?
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Answers at end of presentation
Answer to question 1
What monitoring is needed when starting 02 therapy ?
Record Sp02 before starting 02 therapy where possible
If target range is 94-98%
• Choose mask and flow rate to meet target range
• No blood gases needed
If target range is 88-92%
• Start with 1-2 litres nasal oxygen or 28% Venturi mask then titrate up to
meet target range
• Check blood gases after 30-60 mins
Monitor Sp02 for first 5 mins and then monitor Sp02 on chart minimum 4 hourly
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Answer to question 2
What to do if oxygen level (SpO2) is lower than
prescribed target range of 94-98% ?
• If Sp02 less than 90% urgent medical review required
• Step up oxygen therapy immediately
• Monitor Sp02 for 5 mins after each change up & record on chart
• Inform doctor that patient is unstable & monitor according to clinical condition
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Answer to question 3
What to do if saturation is lower than prescribed target
range of 88-92% ?
• Seek immediate medical review
• Step up oxygen immediately as per oxygen escalator slide
• Monitor Sp02 for 5 minutes & record on obs chart
• Blood gases must be taken within 1 hour of increase in oxygen therapy
to check for C02 increase
(Doctor to review blood gases)
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Answer to question 4
What to do if Saturation is higher than the target range
in both groups?
• Wean oxygen down using oxygen escalator by:
1.
2.
Reducing oxygen flow and/or
Change delivery device
• Monitor Sp02 for 5mins & record on chart
• If stable remain on lower oxygen
• Document in notes and obs chart
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Answer to question 5
When do you consider stopping oxygen therapy?
• When the patient is clinically stable and has maintained target SpO2 on
low dose 02 therapy for 2 sets of observations
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Answer to question 6
How do you stop oxygen ?
•
Stop oxygen (as per previous slide) and monitor SpO2 for 5 minutes
•
If stable at 5 mins, document this and monitor SpO2 for one hour on air
•
If saturation remains within prescribed target range on air stop 02
•
If Target SpO2 not maintained, resume original 02 therapy and consider
stopping 02 at a later stage
•
Document changes in bedside observation charts or electronic records
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Answer to question 7
When do you use high amounts of oxygen and seek
urgent medical review ?
• Cardiac arrest and other critical illness
• If a patient with target range of 94-98% deteriorates <85%
• See unit Track & Trigger / Early Warning System / NEWS rules
• Get urgent medical review whilst giving high amounts of oxygen
(Reservoir mask should be used)
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These slides are provided for use on a local basis – permission is not required to use these and additional material may be added depending on local circumstances.
The BTS Guidelines for oxygen use in adults in healthcare and emergency settings should be acknowledged and referenced as follows:
O’Driscoll BR et al Thorax 2017; 72: Suppl 1 i1‐i89
Healthcare providers need to use clinical judgement, knowledge and expertise when deciding whether it is appropriate to apply recommendations for the management of patients. The recommendations cited here are a guide and may not be appropriate for use in all situations. The guidance provided does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.
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