Professional Documents
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Lit Rev O2 TX in PX
Lit Rev O2 TX in PX
Lit Rev O2 TX in PX
Abstract
Oxygen therapy is a common intervention in health care worldwide; yet, despite universal use, it is evident
through poor practice that oxygen is often prescribed and administered injudiciously. It is proposed that
possibly an influencing culture presides, whereby oxygen is often poorly understood and uncertainty
regarding its use exists. It is unclear where the origins of this culture lie but exploring perceptions may
enlighten the problem. A review of the literature was undertaken to establish what is already known about
this elusive phenomenon. The paucity of any direct evidence regarding perceptions of oxygen directed the
review to utilize a critical interpretative synthesis (CIS). The aim of this study was to explore how
respiratory patients perceive oxygen therapy. A systematic search in Medline, Cinahl, Embase, British
Nursing Index and PsychInfo yielded 1514 studies of which 42 were selected to consider the review
question. The CIS allowed evidence from across studies to synthesize existing and new interpretations of
data related to patients perceptions of oxygen therapy. Synthetic constructs then informed the synthesizing
arguments, namely positive feeling safe, enabler and comforter; negative fear, oxygen versus self,
restriction and embarrassment; and impartiality mixed blessings. The findings are divergent, and at times
contradictory. There appears uncertainty among patients regarding the purpose and benefits of oxygen
therapy, though an underlying faith in health-care professionals is apparent. This faith seems to foster acceptance of a life-changing therapy, despite the impact, burden and incomplete understanding. There is a clear need
for further research regarding these elusive perceptions in order to improve clinical practice in respect of
oxygen.
Keywords
Oxygen, perceptions, critical interpretative synthesis, respiratory, patients, chronic respiratory disease
Introduction
Oxygen is one of the commonest therapeutic interventions in health care worldwide. Yet, despite the widespread use, problems regarding prescription and
administration exist,17 resulting in a significant burden for patients, carers and health care resources.
Poor practice regarding oxygen therapy, such as
inadequate assessment and poor follow-up, has been
uncovered in the United Kingdom.7 This led to major
changes in prescription and provision of domiciliary
oxygen therapy, principally the provision of clinical standards for initial assessment and subsequent
patient management.8 Despite implementation of
these changes, problems continue.9,10 It is unclear
1
Postgraduate Medical Institute, Faculty of Heath and Social
Care, Edge Hill University, Ormskirk, Lancashire, UK
2
Learning Services, Edge Hill University, Ormskirk, Lancashire,
UK
Corresponding author:
Carol Ann Kelly, Postgraduate Medical Institute, Faculty of Heath
and Social Care, Edge Hill University, St Helens Road, Ormskirk,
Lancashire, L39 4QP, UK.
Email: kellyc@edgehill.ac.uk
210
Exclusion criteria
Method
Meta-ethnography14 is an interpretative approach
that aims to make sense of what a collection of qualitative studies are saying rather than just narrating the
various findings. A variant of meta-ethnography, critical interpretative synthesis (CIS), has been developed
as a method to review large, diverse and complex
bodies of literature,15 allowing explicit integration
of qualitative and quantitative evidence through an
Search strategy
A systematic approach to searching, locating and
retrieving relevant literature was adopted (Centre for
Reviews and Dissemination (CRD), 2009). Medline
(19502014), Cinahl (19812014), Embase (1980
2014), British Nursing Index (19852014) and PsychInfo (18062014) and searched via Evidence
Search (www.evidence.nhs.uk) using key words oxygen therapy, chronic respiratory disease, COPD,
interstitial lung disease. No date or publication type
restrictions were applied.
Synonyms and term variants were searched and
combined using the Boolean OR (e.g. oxygen therapy OR O2 therapy). Different facets were combined
with the Boolean AND. Truncation (*) was utilized
to capture plurals and spelling variants (e.g. Oxygen
therap*). Advanced search operators for phrase
searching () were used to improve the focus. The
search was limited to English language, human and
adult studies as per inclusion criteria (Table 1).
To minimize publication bias, a wider Internet
and grey literature search was conducted; database
searches were supplemented with hand-searching
key journals and citation snowballing.16 Discussion with experts in the field, together with searching
key respiratory conference proceedings ensured
inclusion of contemporary literature not yet indexed
in databases.
211
Initially excluded on the grounds that no mention of perception of oxygen therapy identified
120
Exclusions following quality appraisal (including relevance):
Four patient studies further excluded: 1 involved lay carers; 2 focused on HCP perceptions of COPD no
4
oxygen; 1 practice focused no perceptions
Four studies of HCPs excluded: 1 did not specifically mention oxygen (related to COPD generically); 1 duplicate
4
publication of the same study (Considine, 2006); 2 did not relate to perception specifically
References list of excluded patient studies
Arne M, et al. COPD patients perspectives at the time of diagnosis: a qualitative study. Primary Care Respiratory Journal
2007:16(4):215221.
Boyle AH. Living with a spouse with chronic obstructive pulmonary disease: the meaning of wives experiences. Journal of
Nursing and Healthcare of Chronic Illness 2009; 1:273282.
Eastwood GM, et al. Patients and nurses perspectives on oxygen therapy: a qualitative study. Journal of Advanced Nursing
2009; 65(3):634641.
Elkington H, et al. The last year of life of COPD: a qualitative study of symptoms and services. Respiratory Medicine 2004;
98:439445.
HCP: health-care professionals; COPD: chronic obstructive pulmonary disease.
Quality assessment
A leading contention related to quality appraisal and
integrative reviews is whether studies should be
excluded on the grounds of poor quality.17,18 It is further
argued19 that assessment of qualitative research is an
interpretative act that requires informed reflective
thought rather than just a simple scoring system. Content and relevance of findings therefore was a key consideration and articles were quality appraised on their
own merit and within the context of the review question.
The diversity of studies warranted development of a
hybrid quality appraisal/data extraction sheet based on
criteria for disparate data as suggested by Hawker
et al.20 This identified various methodological strengths
and weaknesses without excluding studies of poorer
quality.21 Using Hawker et al.s protocol for assessment,
a score of 14 is assigned to each of 10 criterion
resulting in an accumulative score that indicated
the overall assessed methodological rigour of each
212
Mixed blessings
Embarrassment
Restriction
Fear
Comfort
Enabler
Feeling safe
Synthesising
argument
Compromise/trade-off
Knowledge and
understanding
Attitude of others
Changing body image
Shame
Guilt
Adaptation
Frustration
Complaints
Social isolation
Existing
Faith in
Keep alive
Symptom relief
Mastery
Placebo
Benefit
Synthetic construct
I had an extension of life; it can also save my life and . . . I dont know if Id be around if I didnt have it (p. 767).22
. . . without the oxygen I wouldnt have a life; The benefit is it is keeping me alive . . . (p. 18).23
After Im finished, I come back to the bedroom and take oxygen for about 10 minutes (p. 846).24
When you wake up and you get out of bed on a morning, I feel as if I have to use it straight away. (p. 792).25
Four RCTs2629 suggest that symptomatic benefit not entirely dependent on the literature and a placebo effect may play a role
Jones et al.s30 mixed methods observational study reported that 83% of 45 patients claimed benefit. When she goes to bed she hasnt got that
fear.31
I didnt realise things had got this bad.32
I knew that I would be on oxygen because Id seen my mother deteriorate . . . (p. 82).33
How can I face others . . . . They think that I am an addict (p. E5).34
Ive been on oxygen three years and I still get progressively worse. I dont know if that is my fault or the illness (p. 41).35
Doi36 questionnaire survey found four factors related to the psychological impact of LTOT: hopelessness; burden and misery, denial against
oxygen and dependency and anxiety.
. . . Im not the same person as I used to be and Im not going to be able to do the things I used to do and I havent been able to do the things I
used to do (p. 22).23
I used to dance and travel; then I was diagnosed with COPD and oxygen therapy, everything stops its like you are on a leash, tied to a
regimen (p. 606).37
. . . tied to that machine (p. 103).38
This thing [the oxygen tubing] was cutting into my ear this stupid thing here . . . it twists, twists, twists. I untwist it and it gets twisted again!
. . . I dont know if it does much good or not. I seem to get along without it just as good as with it (p. 315).39
. . . I dislike when people stare at me. They definitely think that I have been smoking myself to death . . . (p. 22).40
Well what are they gonna think with me walkin in with a blimmin great oxygen cylinder and what have you, (p. 112).38
Neri et al.41 survey found people were ashamed of being seen by passers-by (p. 800).
I feel like I have to do it because I smoked (p. 753).42
Earnest42 refers to physical adaption such as rigging vehicles with oxygen to enable fishing trips; running oxygen lines upstairs and ways of
mobilising equipment.
I am willing to put up with the nuisance for the benefit of oxygen; the burden does not mean much (pp. 767768).35
Neri et al.s41 survey reported that 51% of the 1504 patients included, understood that oxygen was given for low blood oxygen levels, whilst
38.5% believed it was for dyspnoea.
Cicutto and Brooks43 considered the value of health-care professional instruction regarding oxygen therapy 57% 353 COPD patients
identified the most common motivator as their healthcare provider told them to do it (p. 1543).
RCT: randomized controlled trial; COPD: chronic obstructive pulmonary disease; LTOT: long-term oxygen therapy.
Impartiality
Negative
perceptions
Positive
perceptions
Domain
213
Findings
The flow chart (Figure 1), adapted from PRISMA,44
provides a summary of the search outcome. At this
stage, articles were separated into two categories,
namely patients (42 studies) and health-care professionals (HCPs; 12 studies), with a total of 51 articles
(three articles being eligible for both). Results from
patients perceptions are reported here, results from
HCPs perceptions are reported in a companion paper.
The final selection of articles related to patient perception is summarized in Table 4.
Few studies directly addressing the research question
were evident therefore studies were selected on the basis
Positive perceptions
Three main synthesizing arguments were constructed
that reflected patients positive perceptions of oxygen
214
Methodology
Context
Adams23
Phenomenology Australia
Arnold et al.45
Qualitative
United
Kingdom
Berga,46
Qualitative
United
States
Booth et al.26
RCT
United
Kingdom
Borak et al.47
Prospective
Quantitative
Study
Poland
Bruera et al.48
Double-blind
RCT crossover
Canada
Bruera et al.29
RCT
United
States
Participants
Focus of study
215
Table 4. (continued)
Author Year
Methodology
Context
Participants
Cicutto et al.43
Mail Survey
Canada
353 (78%
response)
Clancy et al.33
Phenomenology United
Kingdom
Cornforda,25
Qualitative
United
Kingdom
Australia
Cullen and
Stiffler50
Meta-synthesis
United
States
Currow et al.51
Prospective
Quantitative
Australia
Demirel et al.52
Retrospective
Turkey
Case note
study &
patient review
Doi36
Survey
Japan
Focus of study
To explore
Some discussion of motivators
patients
for O2 use: value of HCP
instruction highlighted faith
perceptions of
in. No details of O2 status or
selfprescription.
management
Limited application to review
question.
10 hypoxic
To explore
O2 perceived as inevitable
patients
experiences of
decline. Memories of
prescribed
LTOT patients
experiences of others
LTOT and
& carers
(negative). 7 had very negative
their carers
views/2 positive.
Lay beliefs from Ambivalent findings: O2 as
24 patients on
patients on
O2 no
restricting vs. benefiting. Only
oxygen status.
domiciliary O2
7 of 24 patients took O2 >15
hours. Quite applicable to
review question.
17 Domiciliary To identify
Limited relativity. Poster only,
common
O2 no
so limited detail. Key themes
diagnosis
concerns and
of embarrassment, grief & loss
stated
problems with
and social isolation.
domiciliary O2
Contacted authors for more
detail initial response but no
further detail.
4 studies
LTOT, hypoxic
Limited different research
Joanna Briggs
patients
question. Four common
Institute
experiences of
themes (adaptation/
methodology
LTOT
restriction/self-management &
submission/dependency).
Data extrapolated from individual studies differed subtly.
Studies includeda
1239 community Relief of
Limited applicability. Conflicting
hospice
dyspnoea in
benefit/no benefit.
patients
palliative care
No oxygen status recorded.
Evaluate
Limited, focus on prescribing.
127 patients
indications for
16% reported fear of
with
continuous O2,
addiction. Subjective benefit
continuous O2
therapy
satisfaction and 77% felt improvement. Other
usage
23% no different or worse
majority O2 < 15 hours/day.
No correlation with hypoxia
level and usage though.
144 LTOT
Psychological
Tool used to measure negative
patients
impact of
attitudes Four factors
compared
chronic lung
revealed: hopelessness;
with no O2
disease and
burden & misery; denial
LTOT
against O2 and dependency
and anxiety. Bias may be
inherent because of predetermined phrases (p. 997).
(continued)
216
Table 4. (continued)
Author Year
Methodology
Context
Participants
Focus of study
Earnesta,42
Qualitative
United
States
27 hypoxic
COPD
patients on
LTOT
Patterns of
O2adherence
in hypoxic
COPD
Eaton et al.53
Audit
New
Zealand
405 SBOT
patients
Fraser et al.54
Phenomenology United
States
10 COPD
patients
oxygen status
not revealed
21 COPD
Explore fears of
patients no
death & dying
oxygen status
in COPD
reported
United
Kingdom
United
Kingdom
United
Kingdom
Gruffyd-Jones
et al.56
Prospective
observational
study
Hasson et al.57
Descriptive
qualitative
Netherlands 11 COPD
Gain insight why
patients
COPD patients
Purposeful
do not ask for
sample with &
help
without O2
N. Ireland
13 COPD
Explore the
Use of O2 for relief of symptoms
patients on
potential for
and attacks. Reliance on O2
psychological dependency
LTOT/LTOT
palliative care
discussed but no real data. All
NIV
in advanced
COPD
on LTOT but no blood
oxygen status.
(continued)
217
Table 4. (continued)
Author Year
Methodology
Context
Ingadottir and
Jonsdottir40
Iceland
Jaturapatporn
et al.22
Jones et al.30
Kampelmacher39
Lai et al.34
Lewis et al.28
Neri et al.a,41
ONeill et al.4
Participants
Focus of study
218
Table 4. (continued)
Author Year
Methodology
Context
Participants
Focus of study
United
Kingdom
45 patients on
LTOT vs. 41
controls
Efficacy of
assessment
LTOT and
education
United
Kingdom
Reinke et al.b,37
Grounded
theory
United
States
Ring and
Danielsona,59
Phenomenology Sweden
Ringbaek et al.5
Q Survey
Denmark
Canada
Robinson35
Phenomenology United
Kingdom
Uronis et al.61
SR & Metaanalysis
Australia
Williams38
Mixed Methods
United
Kingdom
219
Table 4. (continued)
Author Year
Methodology
Wrench32
Context
Participants
United
Kingdom
6 COPD
What is
students 5 had important to
O2
COPD
patients?
Phenomenology United
Kingdom
7 patients,
4 carers
Focus of study
Adaptation to
LTOT
RCT: randomized controlled trial; COPD: chronic obstructive pulmonary disease; LTOT: long-term oxygen therapy;O2: oxygen; FEV1:
forced expiratory volume in 1 second; SGRQ: Saint George Respiratory Questionnaire, BMI: Body Mass Index; HCP: health-care professional; PRN: when needed; NIV: non-invasive ventilation; SBOT: short burst oxygen therapy.
a
Studies included in Cullen and Stifflers meta-synthesis.
b
Studies also included in the review of HCPs perception.
No. of studies
7
8
23
11
15
11
9
5
9
10
7
14
11
12
9
9
8
3
5
4
8
Synthesising argument
Domain
Feeling safe
Positive perceptions
Enabler
Comfort
Fear
Negative perceptions
Embarrassment
Mixed blessings
Impartiality
Faith in
x
x
Keep Alive
Symptom relief
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Benefit
Mastery
x
x
x
Disease decline
x
x
Fear
Fear of dependency
x
x
x
x
x
x
x
x
x
Disappointment
Comfort
Placebo
Adams23
Arnold et al.45
Berg46
Booth et al.26
Borak et al.47
Bruera et al.27
Bruera et al.29
Cicuttoand Brooks43
Clancy et al.33
Cornford25
Crockett et al.49
Cullen and Stiffler50
Currow et al.48
Demirel et al.52
Doi36
Earnest42
Eaton et al.53
Fraser et al.39
Gardiner et al.55
Goldbart et al31
Gruffyd-Jones et al.56
Habraken et al.24
Hasson et al.57
Ingadottir and Josdottir40
Jaturapatporn et al.22
Jones et al.30
Kampelmacher et al.39
Lai et al.34
Lewis et al.28
Neri et al.a,41
ONeill et al.4
Peckham et al.58
Quantrill et al.27
Reinke et al.a,37
Ring and Danielson59
Ringbaek et al.5
Roberts et al.a,60
Robinson35
Uronis et al.61
Williams38
Williams et al.62
Wrench32
Enabler
Feeling safe
x
x
x
x
x
x
x
x
x
Restriction
x
x
x
x
Frustration
Author
Social isolation
Negative
Physical Complaints
x
x
x
x
x
Attitude of others
x
x
x
Embarrassment
x
x
x
Positive
x
x
x
x
Shame
Guilt
x
Adaptation
x
Mixed blessings
Impartiality
x
x
Compromise Trade-off
220
Knowledge understanding
221
Negative perceptions
Within the considered literature four major synthesizing arguments were constructed featuring negative
perceptions of oxygen therapy for patients: fear, oxygen versus self, restriction and embarrassment.
Fear: declining disease status; memories (of others); and
fear of dependency. Articles reported oxygen was symbolic of declining disease status or patients getting
worse.33,32,37,49 The initiation of oxygen therapy is
seen as a key milestone in the disease trajectory and
symbolizes declining health, one patient reported that
initially they thought they would get off it but then
accepting that this is the way its going to be and
analogy with a death sentence.49 This issue is quite
clearly linked with memories (of others), with one
patient reporting, I knew that I would be on oxygen
because Id seen my mother deteriorate.49 This association with death appears as a direct contradiction to
previous constructs of faith in and keep alive.22,23,34
222
223
Discussion
Although few studies specifically addressed the
review question, data extracted from existing literature allowed for illumination of patterns and construction of synthetic arguments concerning patients
perceptions of oxygen.
For many patients oxygen is regarded as a positive
therapy, a life-giving intervention, although it is not
clear whether this arises from patients expected benefits, or faith in HCPs. Juxtapose to this, patients
relate to removal or denial of oxygen as a sign of
impending death. This finding may be relevant
regarding why patients are often considered to
demand oxygen or resist removal of established
therapy.
It appears that patients understanding is often that
oxygen is commonly given for relief of dyspnoea.
Lack of rationale for oxygen prescription is apparent
throughout the literature and makes it impossible to
judge whether individuals require oxygen, or not. For
some, oxygen helps to control dyspnoea but whether
this is as a result of the sensation of air flow,63,64 cessation of exercise or a placebo effect is unclear. Studies have shown that comparing to room air, there are
no additional benefits of oxygen for the palliation of
dyspnoea.65 Likewise a Cochrane review66 gives no
firm conclusions regarding the efficacy of oxygen for
symptom relief. But regardless of why oxygen
relieves breathlessness it is clearly beneficial to
patients.
Although physiological benefit for hypoxaemic
patients cannot be disputed, for normoxic patients
there appears to be a definite placebo effect.65 Interestingly, Roberts et al.60 observed that although several patients in their last year of life were taking
morphine or an anxiolytic, none believed that these
had been prescribed for relief of dyspnoea, highlighting patients preconceived ideas regarding the
rationale for prescribed treatments and resultant
expectation.
224
contradictory views. There appears to be an uncertainty among patients with regards the purpose and
proposed benefits of oxygen therapy, though an
underlying faith in health-care professionals is
apparent. This faith seems to foster acceptance of
a life-changing therapy, despite the impact, burden
and incomplete understanding.
Although some enlightenment has emerged from
the literature there is a clear need for further research
regarding these elusive perceptions, from patients,
carers and health-care professionals viewpoints
in order to improve clinical practice in respect of
oxygen.
225
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.
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