British Thoracic Society Guideline

for oxygen use in healthcare and

emergency settings

Key messages for doctors

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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BTS guideline for oxygen use in adults in
healthcare and emergency settings: Overview
• Why have a guideline?
• Oximetry as the basis of the guideline
• Normal range of oximetry
• Effects of hypoxaemia – sudden onset and gradual onset
• Aims of oxygen treatment and its place in resuscitation
• Recommended target saturations – with rationale
• Oxygen Alert cards
• Prescribing oxygen
• Devices
• What device and flow to use
• Monitoring
Guideline and this lecture available on BTS website www.brit-thoracic.org.uk
12/05/2017
Oxygen - there is a problem
Published audits have shown that…
• 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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BTS guideline for oxygen use in adults
in healthcare and emergency settings

• The British Thoracic Society, together with 21 other

Societies and Colleges produced a multi-discipline
Guideline for emergency oxygen use in 2008

• This Guideline covers all aspects of emergency oxygen

use in pre-hospital care and in emergency hospital care

• It has been updated and expanded in 2017

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Basis of the BTS guideline:
Prescribing by target oxygen saturation

Keep the oxygen saturation

normal/near-normal for all
patients except pre-defined
groups who are at risk
from hypercapnic
respiratory failure

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What is normal and what is
dangerous?

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Normal Range for Oxygen saturation

Normal range for healthy young adults is

approximately 96-98% (Crapo AJRCCM, 1999;160:1525)

There is a slight fall with advancing age

A study of 871 subjects showed that age > 60 was associated with
minor SpO2 reduction of 0.4% (Witting MD et al Am J Emerg Med 2008: 26: 131-136)
An audit in Salford and Southend showed mean SpO2 of 96.7%
with SD 1.9 in 320 stable hospital patients aged >70 without lung
disease or heart failure (2 SD range 92.9 to 100%)
(O’Driscoll R et al Thorax 2008; 63(suppl Vii): A126)

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What is a “normal”
nocturnal oxygen saturation?
Healthy subjects in all age groups routinely
desaturate to an average nadir of 90.4%
during the night (SD 3.1%)

Gries RE et al Chest 1996; 110: 1489-92

*Therefore, be cautious in interpreting a single oximetry measurement

from a sleeping patient. Watch the oximeter for a few minutes if in any
doubt (if the patient is otherwise stable) because normal overnight
dips are of short duration.

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Effects of sudden hypoxaemia
(e.g Removal of oxygen mask at altitude or in a pressure chamber)

• Impaired mental function; Mean onset at SaO2 64%

No evidence of mental impairment above SaO2 84%

• Loss of consciousness at mean saturation of 56%

• Test Pilots in decompression chambers do not

experience breathlessness when the oxygen tension is
lowered, they make mistakes and then pass out
Akero A et al Eur Respir J. 2005 ;25:725-30
Cottrell JJ et al Aviat Space Environ Med. 1995 ;66:126-30
Hoffman C, et al. Am J Physiol 1946, 145, 685-692
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Clinical features of hypoxaemia
The effects are often non-specific
Depends if onset is chronic or acute
• Altered mental state

• Dyspnoea, cyanosis, tachypnoea, arrhythmias, coma

• Hyperventilation when PaO2 <5.3kPa (saturation <72%)

• Loss of consciousness ~ 4.3 kPa (saturation ~56%)

• Death approximately 2.7 kPa

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Assessment/Measurement of hypoxaemia

CYANOSIS - Often not recognised,

- Absent with anaemia

BLOOD GASES - PaO2 and SaO2

PaO2 = Arterial oxygen partial pressure in blood gas
specimen
SaO2 =Arterial oxygen saturation measured in blood gases

OXYGEN SATURATION - Easily measured by pulse oximetry

SpO2 is widely available
SpO2 = Oxygen saturation measured by pulse oximeter

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What happens at 9,000 metres
(approximately 29,000 feet) – it depends
Atmospheric pO2 5.7 kPa (< 1/3 sea level atmospheric oxygen tension)
PaO2 ~3.3 kPa Arterial Oxygen Saturation ~54%

SUDDEN ACCLIMATISATION
Passengers unconscious in
<60 seconds if depressurised Everest has been climbed without oxygen

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Why is oxygen used?

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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

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Fallacies regarding oxygen therapy
John B Downs MD Respiratory care 2003;48:611-20

THE FALLACY: “Routine administration of

supplemental oxygen is useful, harmless and
clinically indicated.”

THE FACTS
•Little increase in oxygen-carrying capacity if SpO2
is normal

•Renders pulse oximetry worthless as a measure of ventilation

•May prevent early diagnosis & specific treatment of

hypoventilation

The guideline only recommends supplemental oxygen

when SpO2 is below the target range.
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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
• Safeguarding the airway
• Enhancing circulating volume
• Correcting severe anaemia
• Enhancing cardiac output
• Avoiding/Reversing Respiratory Depressants
• Increasing Fraction of Inspired Oxygen (FIO 2)

• Establish the reason for Hypoxia and

treat the underlying cause (e.g Bronchospasm, LVF etc)

• Patient may need, CPAP or NIV or Invasive ventilation

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Defining safe lower and upper
limits of oxygen saturation

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What is the minimum arterial oxygen
level recommended in acute illness?
Target oxygen
Saturation
Critical care consensus guidelines Minimum 90%

Surviving sepsis campaign Aim at 88-95%

But these patients have intensive levels of nursing & monitoring

This guideline recommends a minimum

of 94% for most patients – combines
what is near normal and what is safe
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Exposure to high concentrations of
oxygen may be harmful • Harten JM et al J Cardiothoracic Vasc Anaesth
2005; 19: 173-5
• Kaneda T et al. Jpn Circ J 2001; 213-8
• Absorption Atelectasis even at FIO2 30-50% • Frobert O et al. Cardiovasc Ultrasound 2004; 2: 22
• Intrapulmonary shunting • Haque WA et al. J Am Coll Cardiol 1996; 2: 353-7
• Thomaon aj ET AL. BMJ 2002; 1406-7
• Post-operative hypoxaemia • Stub D et a;. Circulation 2015’; 131: 2143-50
• Risk to COPD patients • Helmerhorst HJ Crit Care Med 2015; 43: 1508-19
• Girardis M et al. JAMA 2016; 316: 1583-89
• Coronary vasoconstriction
• Increased Systemic Vascular Resistance
• 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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Some patients are at risk of CO2 retention
and acidosis if given high dose oxygen*
• Chronic hypoxic lung disease
• COPD
• Severe Chronic Asthma
• Bronchiectasis / CF
• Chest wall disease
• Kyphoscoliosis
• Thoracoplasty
• Neuromuscular disease
• Morbid obesity and OHVS (Obesity Hypoventilation Syndrome)

*Blood gases should be checked for all such patients if they need oxygen
*Target saturation range is 88-92% if CO2 level is elevated (or if it was high in the past)
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What is a safe lower Oxygen level in acute COPD?
OxyHaemoglobin Dissociation Curve
In acute COPD
pO2 above 6.7 kPa
or 50 mm Hg

SaO2
will prevent death
(SpO2 above about 85%)

Murphy R, Driscoll P, O’Driscoll R Emerg Med J 2001; 18:333-9 mmHg

PaO2

This guideline recommends a minimum saturation

of 88% for most COPD patients
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What is a safe upper limit of oxygen target range in
acute COPD patients who need oxygen therapy?
• 47% of 982 patients with exacerbation of COPD were hypercapnic on
arrival in hospital

• 20% had Respiratory Acidosis (pH < 7.35)

• 5% had pH < 7.25 (and were likely to need ICU care)

• Most hypercapnic patients with pO2 > 10 kPa were acidotic

(equivalent to oxygen saturation of above ~ 92%)
i.e. they had been given too much oxygen
Plant et al Thorax 2000; 55:550

RECOMMENDED UPPER LIMITS

Keep PaO2 below 10 kPa and keep SpO2 ≤ 92%
in acute COPD pending blood gas results
(Maintain target range 88-92% if hypercapnic)
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High concentration oxygen may double the risk of
death in acute exacerbations of COPD (AECOPD)

• 405 patients with presumed AECOPD were randomised to high

concentration oxygen or controlled oxygen (target range 88-92%)

• Mortality 9% on high concentration O2 V 4% on controlled O2

• Titrated oxygen treatment reduced mortality compared with high

flow oxygen by 58% for all patients (relative risk 0.42, 95%
confidence interval 0.20 to 0.89; P=0.02)

• Less acidosis and less hypercapnia on controlled oxygen therapy

Austin M et al BMJ 2010; 341: c5642
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Danger of Rebound Hypoxaemia
• If you find a patient who is severely hypercapnic due to
excessive oxygen therapy……

• Do NOT stop oxygen therapy abruptly

• The PaCO2 is very high which will cause low PAO2 as soon as
oxygen is removed as demonstrated by the Alveolar Gas
Equation (PAO2 ≈ PIO2 –PaCO2/RER )

It is safest to step down to 35% oxygen if the patient

is fully alert or call your Critical Care team to provide
mechanical ventilation if the patient is drowsy

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Use of target ranges

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Target Saturation Scheme
• O2 prescribed by target saturation

• Oxygen delivery device and flow are

changed if necessary to keep the SpO 2
in the target range

• Target oxygen saturation prescription

integrated into patient drug chart and
monitoring

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Recommended target saturations
The target ranges are a consensus agreement by the
guidelines group and the endorsing colleges and societies

Rationale for the target saturations is combination of what is

normal or near-normal and what is safe

Most patients 94 - 98%

Risk of hypercapnic respiratory failure 88 –

92%*
*Or patient specific saturation on Alert Card

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Safeguarding patients at risk of
type 2 respiratory failure
• Lower target saturation range for these patients (88-92%)

• Education of patients and health care workers

• Use of controlled oxygen via Venturi masks or 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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Oxygen Alert Cards and 24% masks can
avoid hypercapnic respiratory failure
associated with high flow oxygen masks
• Oxygen alert card (and a 24% Venturi mask) given to patients
admitted with hypercapnic acidosis with a PO 2 > 10kPa
• Patients instructed to show these to ambulance and A&E staff

After introduction of alert cards

• Use of 24% oxygen: 63% in Ambulance
94% in Emergency Department

Gooptu B, Ward L, Davison A et al. Oxygen alert cards and controlled oxygen masks:
Emerg Med J 2006; 23:636-8
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Prescribing Oxygen

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Oxygen prescription on paper chart
Model for oxygen section in hospital prescription charts

DRUG OXYGEN
(Refer To Trust Oxygen Policy)
Circle target oxygen saturation STOP DATE
88-92% 94-98% Other___

Starting device/flow rate________

Tick if saturation not indicated PHARM

(Saturation is indicated in almost all cases except for

palliative terminal care)
SIGNATURE / PRINT NAME DATE
ddmmyy

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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.

Hypoxaemia

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Oxygen prescription and Administration

• Clinician (usually a doctor) prescribes oxygen by

circling the desired oxygen saturation target range (or
by selecting a range in electronic prescribing)

• Nurses and PAMs* use appropriate devices and flow

rates to maintain saturation within the target range

*PAMs = Professions allied to medicine

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Oxygen use in palliative care
• Most breathlessness in cancer patients is caused by
specific issues such as airflow obstruction, infections or
pleural effusions and the main issue is to treat the cause

• Oxygen has been shown to relieve dyspnoea in

hypoxaemic cancer patients but not if PaO2 is >7.3 kPa
(saturation above about 90%)

• Morphine and Midazolam also relieve breathlessness and

are probably more effective

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Devices

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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 in the Guideline as
suitable for most patients with both
type I and II respiratory failure.
• 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.
• Comfortable and easily tolerated
• No re-breathing
• Low cost product
• Preferred by patients (vs simple mask)

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Venturi or Fixed Performance Masks (V)
• Aim to deliver constant oxygen
concentration within and between breaths.

• 24-40% Venturi Masks operate accurately

A 60% Venturi mask gives ~50% FIO2

• With TACHYPNOEA (RR >30/min) the

oxygen flow rate should be increased by
above the minimum flow rate shown on the
packaging - see next slide

• Increasing flow does not increase oxygen

concentration because it is a fixed dose
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device
 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

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 Operation of Venturi valve
Air

O2
O2 +
Air

Air

For 24% Venturi mask, the typical oxygen flow of 2 l/min gives a total gas flow of 51 l/min

For 28% Venturi mask, 4 l/min oxygen flow, gives a total gas flow of 44 l/min(Table 10.2)
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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)
• 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 humidified 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.

3 3

2 2

1 1

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
Oxygen outlet Air outlet when not in use
(Usually white) (usually black)
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What device and flow rate
should you use in each
situation?

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Many patients need high-dose oxygen
to normalize saturation
• Severe Pneumonia
• Severe LVF
• Major Trauma
• Sepsis and Shock
• Major atelectasis
• Pulmonary Embolism
• Lung Fibrosis
• Etc etc etc

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Oxygen use in specific illnesses
4 Major groups of patients
See Tables 1-4 and Charts 1-2 in BTS Emergency Oxygen Guideline

• Critical illness requiring high levels of supplemental oxygen

• Serious illness requiring moderate levels of supplemental

oxygen if a patient is hypoxaemic

• COPD and other conditions requiring controlled or low-dose

oxygen therapy

• Conditions for which patients should be monitored closely but

oxygen therapy is not required unless the patient is
hypoxaemic (This group includes most cases of chest pain, heart attacks, stroke
etc)

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Chart 1
Oxygen prescription for acutely hypoxaemic patients in hospital

•Is the patient critically ill Commence treatment with

(see Table 1 and section
8.10 in Guideline)
Yes reservoir mask or bag-valve
mask and manage as advised in
No Table 1

Is this patient at risk of hypercapnic respiratory failure

(Type 2 Respiratory Failure)?

YES NO
Target saturation is 88-92% whilst
awaiting blood gas results
Aim for SpO2 94-98%

Specific instructions are given for each category of patient depending on blood gas results etc
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 YES No known Risk
(Risk of CO2 Retention) of CO2 Retention

SpO2 ≤ 93%
Obtain ABGs

Yes No
CHECK ABGs

pH <7.35 pH > 7.35 PCO2 < 6.0 PCO2 >6.0 Monitor SpO2
and PCO2 > 6.0 and PaCO2 >6kPa
(Normal or or patient tiring Oxygen may not be
(Respiratory (Hypercapnia)
low) required
Acidosis) Prescribe target
or patient tiring range in case SpO2
falls

Seek immediate Treat with low flow nasal Seek immediate

senior review oxygen or lowest senior review
Consider NIV or strength Venturi mask Consider invasive
invasive ventilation that will keep SpO2 ventilation
between 88-92%

Treat with lowest FiO2 via Repeat ABG’s: Treat Treat urgently. Aim for Treat
Venturi mask or 1-2 l/ If Respiratory Acidosis appropriately SpO2 of 94-98% until appropriately
min nasal oxygen to keep ( pH <7.35 & PCO2>6.0) Seek aiming to keep immediate senior aiming to keep
SpO2 88-92% pending immediate senior review, SpO2 94-98% review. SpO2 94-98%
senior medical advice or consider NIV/ICU.
and repeat Also consider COPD
NIV or ICU admission Consider reducing FiO2
gases in 30-60 needing SpO2 88-92%
if PO2 > 8.0 kPa minutes
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Titrating Oxygen up and down
This table below 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

Seek medical advice

If reservoir mask required

seek senior medical input immediately
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FLOW CHART FOR OXYGEN ADMINISTRATION ON GENERAL WARDS IN HOSPITALS
See target saturation in the patient’s drug chart. Choose the most suitable delivery system and flow rate
Titrate oxygen up or down to maintain the target oxygen saturation
The table below shows available options for stepping dosage up or down.
The chart does NOT imply any equivalence of dose between Venturi masks and nasal cannulae.
Allow at least 5 minutes at each dose before adjusting further upwards or downwards
(except with major and sudden fall in saturation – falls ≥3% also require clinical review)
Once your patient has adequate and stable saturation on minimal oxygen dose, consider discontinuation of oxygen therapy.

Patients in a peri-arrest situation and critically ill patients should be given oxygen therapy at 15 l/min via reservoir mask or bag-
valve mask whilst immediate medical help is arriving.
(Except for patients with COPD with known oxygen sensitivity recorded in patient’s case notes and drug chart or in the Electronic
Patient Record (EPR): keep saturation at 88-92% for this sub-group of patients)
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 Monitoring patients

• Oxygen saturation and delivery system should be

recorded on the bedside monitoring chart or EPR

• Delivery devices and/or flow rates should be

adjusted to keep oxygen saturation in target range

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Key elements of an oxygen observation chart
*It is recommended that the 2017 NEWS chart should be used*

Respiratory Rate, Oxygen saturation and oxygen therapy

Clinical review required if saturation is outside target range

Target range: 94-98% 88-92% Other________

Respiratory Respiratory
Rate Rate

Oxygen Oxygen
Saturation % Saturation %

Oxygen Oxygen
Device or Air Device or Air

Oxygen flow Oxygen flow

rate L/min rate L/min

Your Your
Initials* Initials*

*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 2017 NEWS chart
when available

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Standard abbreviations for oxygen delivery devices
A Air

N Nasal Cannulae HFN High Flow Humidified Nasal Cannulae

V24 Venturi Mask 24% V28 Venturi Mask 28% V35 Venturi Mask 35%

V40 Venturi Mask 40% V60 Venturi Mask 60%

H28 Humidified O2 28% H40 Humidified O2 40% H60 Humidified O2 60%

RM Reservoir Mask SM Simple Face Mask TM Tracheostomy Mask

CPAP Continuous Positive NIV Non-Invasive

Airway Pressure Ventilation

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From the BTS Emergency Oxygen Guideline

To the patient
• Guideline agreed by the whole UK medical, nursing and AHP
community (endorsed by 23 Colleges and Societies)

• Medical and Nurse/Physio Champions in every Hospital Trust

• Clear prescription charts and monitoring charts in every

hospital

• Training packages on BTS website

• Audit tools on BTS website: audits.brit-thoracic.org.uk

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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) Prior to publication of 2008 Guideline

•48% in 2011 (156 Hospitals)
•55.1% in 2013 (151 Hospitals)
•57.5% in 2015 (181 Hospitals)

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2015 BTS Oxygen Audit
4083 patients on oxygen with prescribed target range

• 69% of SpO2 observations were within the target range

• 21.5% of SpO2 observations were above the target range

• 9.5% of SpO2 observations were below the target range

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Summary
1. Prescribe oxygen to a target saturation for each group of
patients
• 94 - 98% for most adult patients
• 88 - 92% if risk of hypercapnia
(or patient-specific target on alert card)

1. Administer oxygen to achieve target saturation

2. Monitor oxygen saturation and keep in target range

3. Taper oxygen dose and stop when stable

4. Audit your practice

5. All information on www.brit-thoracic.org.uk

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These slides are provided for use on a local basis – permission is
not request 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.