Dirty Little Secrets About
Oxygen
What you never knew…but
should!
Oxygen is arguably one of the most
frequently utilized drugs in modern
healthcare, but is often
administered to patients at
caregivers’ discretion with scant
evidence as to its efficacy or safety.
- Respiratory Care Journal, 2013
This is a discussion of current,
published recommendations on
oxygen delivery and practices. I
am in no way suggesting that
today’s discussion replace
physician orders or CPG’s.
There are risks associated with both hypoxemia
and hyperoxaemia, which underlie the importance
of prescribing oxygen only if required, and to
within a target oxygen saturation range.
-Thoracic Society of Australia and New Zealand Oxygen Guidelines for acute oxygen use in adults
Respirology, 2015.
How are we doing?
•
Oxygen is a commonly used drug in the
clinical setting and unquestionably saves
lives. However, it’s use must be carefully
considered. Like any drug, it may cause
harm when used inappropriately.
•
Overall the practice of prescribing oxygen
therapy is poor.
There is an entrenched culture of routine and
indiscriminate administration of highconcentration oxygen to acutely ill patients.
This culture must change…if we are to
improve the practice and minimize harm in
vulnerable patient groups.
•
•
- Acute Oxygen therapy: a review of prescribing and delivery practices. International
Journal of COPD, 2016.
A major shift is occurring in the use of
oxygen therapy…based on the
recognition that routine administration
of high-concentration of oxygen has the
potential to cause harm.
-Acute use of oxygen therapy, Australian Prescriber, 2015
•
Currently published recommendations are
that oxygen should be prescribed and
maintained within a target range:
•
•
COPD and others at risk for hypercapnia: 88-92%
Other acute medical conditions: 92-96% (94-98%)
- Acute oxygen therapy: a review of prescribing and delivery practices.
International Journal of COPD 2016
It is important to target all
healthcare professionals involved in
medical oxygen therapy and not
individual groups such as doctors
- A New oxygen prescription produces real improvements in
therapeutic oxygen use. BMJ Quality Improvement Reports, 2014
Every year incidents relating to oxygen use are
reported to the National Patient Safety Agency.
Between 2004-2009, 281 serious incidents were
identified as a result of inappropriate oxygen
therapy. Of these 75 were associated with
prescribing issues; nine may have directly caused
a patient’s death and 35 may have contributed to
death. The NPSA concluded these deaths may
have been prevented with better oxygen
prescribing practices.
It’s time for a radical rethink!
Too much oxygen has been shown to worsen
ventilation-perfusion mismatch, promote
absorption atelectasis, and cause
vasoconstriction increasing systemic vascular
resistance, thus reducing blood flow to
tissues in need. It is known to worsen
hypercapnic respiratory failure and delay
recognition of clinical deterioration.
- Implementation of a Titrated Oxygen Protocol in the Out of Hospital Setting. Prehospital
Disaster Medicine, 2014
We should aim to get the right
amount of oxygen to the right
patient at the right time; the mantra
of individualized medicine.
-Oxygen therapy in anaesthesia, the yin and the yang of O2. British
Journal of Anaesthesia, 2013
The essence of this guideline can be
summarized simply as a requirement for
oxygen to be prescribed according to a target
saturation range and for those who
administer oxygen therapy to monitor the
patient and keep within the target saturation
range.
-BTS Guideline for emergency oxygen use in adult patients. Thorax, 2008
Low Flow Oxygen Devices
Nasal Cannula
•
May use up to 6
L/min.
•
1st Liter brings up to
24%, each additional
liter adds
approximately 4%.
Extension tubing NOT
recommended in
patient rooms
•
Low Flow Oxygen Devices
Simple Mask
•Liter flow ranges 6-10
liters
•Never run below 6
L/min. (CO2 Increase)
•Do not add bubble
bottle.
•May not be an option
for patients with high
minute volume.
Low Flow Oxygen Devices
Non- Rebreather
•Liter Flow: 15+ (flush
is fine)
•Make sure the bag
stays inflated even
during inspiration.
•Not always adequate
for high minute
ventilation.
Oxygen Devices
Oxymizer
•Liter flow range: up to
15.
•Reservoir provides a
higher FiO2.
•Option for patients
who need more O2
than standard cannula
but don’t tolerate a
mask
•Call Respiratory.
Oxygen Devices
Venturi Mask
•Provides higher FiO2,
utilizes venturi device.
•Venturi device (holes) must
not be occluded.
•Can be adapted to a trach
mask.
•A short term option for
procedures for trach
patients normally on a
Misty-Ox
•Call Respiratory for
assistance.
Oxygen Devices
Misty-Ox
•High flow device
•Can provide specific
FiO2 and humidity.
•Requires Oxygen to be
analyzed.
•Utilizes an aerosol
mask or trach mask
•Call Respiratory for
assistance.
Oxygen Devices
High Flow Nasal
Cannula
•Liter Flows up to 50
L/min.
•FiO2 range 21-100%
•Great option for high
minute ventilation
needs.
•Great for patients who
don’t tolerate a mask
or BiPAP.
•Call Respiratory.
Questions?