Used to treat tissue hypoxia

Improve oxygen supply

Reduce the work of breathing
Potential to improve medical outcomes
and save lives if used appropriately
Can cause harm if used inappropriately
Main indication is the presence of tissue
hypoxia

Because of
1. Arterial hypoxaemia (inadequate
oxygen content)
2. Failure of oxygen- haemoglobin
transport system
 Defined as oxygen saturation < 90% or
arterial tension pO2 < 60 mmHg
Caused by
Impaired gas exchange in the lung
Alveolar hypoventilation
Shunt that allows venous blood into
the arterial circulation

An arterial blood gas helps discriminate

these possibilities
Occurs because of the failure of the
Oxygen-haemoglobin transport system

1. Reduced oxygen carrying capacity in the

blood
e.g. anaemia, carbon monoxide
poisoning
2. Reduced tissue perfusion
e.g. shock
 No evidence of benefit in acute coronary
syndrome or stroke
Some potential for harm
Oxygen causes coronary vasoconstriction
and reduces coronary blood flow
Associated with reduced survival in minor
and moderate stroke
Not indicated in normoxic patients with
drug overdoses or metabolic acidosis
 Paco2 during oxygen administration as a
function of Paco2 before oxygen treatment.

Rodrigo G J et al. Chest 2003;124:1312-1317

2003 by American College of Chest Physicians

 Acute exacerbation of COPD is common
May present with hypoxia
May have chronic elevation of CO2
(>45mmHg)
Natural tendency is to relieve hypoxia
But oxygen can increase CO2 and reduce
pH
Acute ventilatory failure is notorious
complication
defined: hypercapnia and acidaemia
 Chronic ventilatory failure
Acute exacerbations of COPD
Rare in stable COPD
Obstructive sleep apnoea
Obesity hypoventilation syndrome
Neuromuscular disease,
kyphoscoliosis
?Others
Degree of hypoxia at presentation is
better predictor than initial hypercapnia
 Previous acute ventilatory failure on oxygen
CO2 >45mmHg, pH <7.35 and O2
>70mmHg (spontaneous ventilation on
supplemental inspired O2)
Chronic ventilatory failure(any inspired O2)
CO2 >45mmHg with
COPD, OSA, Central Sleep Apnea, Obesity
Hypoventilation Syndrome
Previous acute ventilatory failure
pH<7.35 and CO2 >45
 History incomplete or unavailable
Old clinical notes not available
Arterial blood gases not feasible or
available
GCS reduced
 Oxygen saturation should be monitored
with pulse oximetry
at least as frequently as other vital signs
Clearly documented with inspired
oxygen concentration
 88-92% for all patients with or at risk or
hypercapnic respiratory failure
94-98% for all other patients
Special considerations for some poisons
e.g. carbon monoxide, paraquat,
bleomycin
 Prevention of acute respiratory failure
caused by excessive supplemental oxygen
Minimise risk of acute ventilatory
failure/respiratory acidosis
Identify and manage acute ventilatory
failure
Identify population at risk
Controlled oxygen therapy
Reassess and titrate O2 to target saturation
PLUS any one of the following?
Chronic lung disease e.g.: COPD (or
suspected)
Obesity (visual assessment)
Home O2 or CPAP/Bi-level PAP
GCS <15
O2 Alert- eMR alert or Caution with O2
card
Neuromuscular disorder
oBP < 100 mmHg systolic

oTrauma call

oSevere sepsis

If any exclusion use another pathway

Aim for O2 saturation 94-98%
REDUCE oxygen to 28%
o2L/min nasal prongs NP or
oVenturi mask VM 28%(yellow)

If Target sat already achieved

on room air or 2 L/min NP or VM <= 28%
oContinue current inspired O2
 Oxygen saturation (SpO2) monitoring
Venous Blood Gases (VBG)
when initial bloods collected
Caution with Oxygen stickers
in observation + medication charts
Drive nebulisers with Air
(continue nasal O2)
On O2 2 L/min, 28%
If O2 93% change to
1L/min via nasal prongs
or 24% VM (blue)
repeat step 3 on lower O2
If O2 88-92%
Target achieved
Continue current FiO2 until medical
review
IfO2 < 88%
Increase O2 to target SpO2
Urgent Medical review
Arterial Blood Gases (ABG) collection
On O2 1 L/min, 24%
If O2 93% change to
Remove oxygen
(leave on room air)
repeat step 3 on room air
If O2 88-92%
Target achieved
Continue current FiO2 until medical review
check VBG
IfO2 < 88%
Increase O2 to target SpO2
Urgent Medical review
Arterial Blood Gases (ABG) collection
On room air
If O2 93%
Continue on room air until medical
review
If O2 88-92%
Target achieved
Continue on room air until medical
review
If O2 < 88%
Increase O2 to target SpO2
Urgent Medical review
Arterial Blood Gases (ABG) collection
Including any of:

Acute breathlessness
Decreasing conscious state
Oxygen saturation < 88% and falling
Oxygen requirements increasing
pH>7.35 and pCO2 <45mmHg
Not acute ventilatory failure
Reduce FiO2 if possible

pH<7.35 or pCO2 > 45mmHg

Acute ventilatory failure possible
Do ABG
CO2 <45mmHg
Not acute ventilatory failure
Reduce FiO2 if possible

CO2 > 45mmHg

Acute ventilatory failure possible
Check ABG pH and pO2
 pO2>70 mmHg
Reduce FiO2 if possible
pO2 55 70 mmHg
Target achieved
Prescribe current FiO2
pO2 < 55 mmHg
Increase FiO2 to target SpO2
Senior review

Assess response with ABG

pH < 7.35 and CO2 > 45
Acute Respiratory Acidosis
Consider NIV
check GCS
Senior review
Assess response with ABG
 Can be managed with Non-Invasive
Ventilation (NIV)
But increased
LOS
Morbidity
ICU/HDU admissions
Hospital resources
May correct rapidly when inspired
oxygen reduced
Doctor prescribe
Maintain current inspired oxygen
Target current range O2 saturation
Change Clinical Review criteria for SpO2 to
< 88%
Document in ED flowchart and notes if CO2
elevated or Acute Respiratory Acidosis
Drive nebulisers with Air (continue nasal O2)
 Defined by:
CO2 retention
acidosis
Complications:
Narcosis
Respiratory failure
Death
Outcomes:
Mechanical ventilation
Cardiac arrhythmia
ICU admission
Subsequent complications
 Measure O2 saturations

If O2 sats >92% no O2 required

If sats 85 to 92% 2 litres O2 nasal prongs,

monitor sats and measure ABGs

If sats <85% high flow O2 and titrate to

keep sats >92% and measure ABGs
[Beasley et al Thorax 2007]
 No O2 sats monitor available

Suspect severe hypoxaemia

Administer 2-3 litres O2 nasal

prongs
[Beasley et al Thorax 2007]
High concentration oxygen therapy delays
recognition of clinical deterioration

Low concentration oxygen therapy

allows deterioration to be detected earlier,
and gives more time to intervene before
life- threatening situation develops

[Beasley et al Thorax 2007]

 Flow rates, masks
Venturi masks with known inspired
O2
NIV with known inspired O2
CPAP
Inspired O2 meters
CO2 meters
 Coloured wrist band
Clear prescription for O2 in med records
identifying acute resp acidosis risk with
excessive O2
Warning label on medical record and
med chart
CAUTION WITH OXYGEN! I have Chronic Respiratory
Disease

O
My Carbon Dioxide can be
raised
2 ALERT Do NOT give me High Flow
Oxygen!
TURN CARD OVER Low Flow Only < 28%
FOR INSTRUCTIONS Department of Respiratory
Medicine Liverpool Hospital
 Venturi mask 50% O2 back titrate SaO2
to 92%
Caution with O2 ID and/or alert on
EDIS/PASS Venturi 28% and SaO2 92%
ABGs performed within 20 mins of
starting supplemental O2
Patient receives
1. Caution With Oxygen ID card
2. Venturi O2 mask (28%)
3. Information leaflet
4. Instruction to give ID card and mask to
Ambulance Officers or ED staff on
presentation
In addition
Alert in eMR
Entry in Caution With Oxygen Register