Key messages from the British Thoracic Society Emergency Oxygen Guideline This presentation was last updated on 07/07/2010

BTS NURSES TRAINING SLIDES MAY 2010(V13) British Thoracic Society Guideline for emergency oxygen use in adult patients Endorsed by: Association of Respiratory Nurse Specialists Association for Respiratory Technology and Physiology British Association for Emergency Medicine British Cardiovascular Society British Geriatric Society British Paramedic Association Chartered Society of Physiotherapy General Practice Airways Group (GPIAG) Intensive Care Society Joint Royal Colleges Ambulance Liaison Committee Resuscitation Council (UK) Royal College of Anaesthetists Royal College of General Practitioners Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists (approved) Royal College of Physicians (London, Glasgow, Edinburgh) Royal Pharmaceutical Society of Great Britain Society for Acute Medicine O’Driscoll BR. Howard LS, Davison AG. Thorax 2008; 63 Suppl VI 2

Oxygen - there was a disagreement Chest Physicians Intensivists / Anaesthetists Emergency Medicine / A&E clinicians Ambulance teams

Important points to consider about oxygen therapy Oxygen is a life saving drug for hypoxaemic patients. (Patients whose oxygen levels are low) 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. cardiac / stroke) may also be harmed by too much oxygen 5 Only give as much as needed– no need for extra!

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 any prescription If there is a prescription, it is unusual for the patient to receive what is specified on the prescription

National BTS audit of oxygen use in 2008 99 UK Hospitals (Pre-Guideline) 14,830 patients audited on 712 hospital wards 2,597 patients were using oxygen (17.5%) 32% of patients who were using oxygen had some sort of written order for oxygen use. 10% had a prescription or oxygen order with a target saturation range

Oxygen is a drug and should be prescribed except in emergencies BTS NURSES TRAINING SLIDES MAY 2010(V13) Oxygen is a drug and should be prescribed except in emergencies Oxygen should be regarded as a drug (BNF 2010) 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 (BTS 2008)

Normal Oxygen saturation range in healthy adults SpO2 Saturation (measured by pulse oximetry) of O2 Daytime Sp02 96-98% * Transient dips in saturation are common during sleep (~84%)

Aims of emergency oxygen therapy To correct or prevent potentially harmful hypoxaemia To alleviate breathlessness (only if hypoxaemic) Oxygen has no effect on breathlessness if the oxygen saturation is normal

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

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 Giving Oxygen therapy Establish the reason for Hypoxia and treat the underlying cause (e.g Bronchospasm, LVF etc) Some patients may need specialist care!!

Oxygen therapy by first responders in critical illness See BTS 02 guideline section 8.10 Patients must not go without oxygen while waiting for a medical review Initial 02 therapy is reservoir mask 15litres (RM15) Once stable aim for 94-98% unless hospital policy requires identification of target range for all patients COPD patients who are critically ill should have the same 02 therapy until blood gases have been obtained and may need controlled oxygen therapy

Prescribing to a Target Saturation range BTS NURSES TRAINING SLIDES MAY 2010(V13) Prescribing to a Target Saturation range O2 will be prescribed in order to keep Sp02 within a specified range for individual patients (like an Insulin “BM sliding-scale chart”) Target oxygen saturation prescription integrated into patient drug chart and monitoring Oxygen delivery device and flow administered and changed if necessary to keep the SpO2 in the target range 13

Patients will be initially prescribed a target saturation from those below 94-98% - most patients 88-92% - COPD or C02 retaining patients ( see list below) 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 Target saturations should be reviewed and changed if required

Exposure to high concentrations of oxygen also Exposure to high concentrations of oxygen also may be harmful to non COPD patients See examples below Lung collapse even at FIO2 30-50% Intrapulmonary shunting Post-operative hypoxaemia Coronary vasoconstriction Increased Systemic Vascular Resistance Reduced Cardiac Index Possible reperfusion injury post MI Worsens systolic myocardial performance Oxygen therapy INCREASED mortality in non-hypoxic patients with mild-moderate stroke This guideline recommends an upper limit of 98% for most patients. Combination of what is normal and safe

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 Use of oxygen alert cards Issue of personal Venturi masks to high-risk patients

OXYGEN ALERT CARD Name: ______________________________ I am at risk of type II respiratory failure with a raised CO2 level. Please use my % Venturi mask to achieve an oxygen saturation of _____ % to _____ % during exacerbations Use compressed air to drive nebulisers (with nasal oxygen a 2 l/min). If compressed air not available, limit oxygen-driven nebulisers to 6 minutes.

Who does what ? Nurses HCAs / Student nurses Write starting device Start O2 and ensure target achieved straight away Titrate O2 to keep in range Sign drug chart every drug round Monitor O2 minimum 4 hourly. Record Sp02 & delivery device Wean off 02 if clinically stable Codes to be written on obs chart and initialled Doctors Prescribe O2 Circle Target Saturation Write starting device Sign drug chart Cross O2 off drug chart after successful weaning HCAs / Student nurses Monitor O2 minimum 4 hourly. Record Sp02 and delivery device Codes recorded on obs chart and initialled Inform nurses when Sp02 outside target range

Target saturation prescribing Most hospitals do not prescribe a target saturation unless the patient is on oxygen. Some hospitals (especially those with electronic prescribing) are routinely prescribing a target saturation for all patients but patients only receive oxygen if the saturation is below the target. Medical review is then required.

Oxygen prescription chart Model for oxygen section in hospital prescription charts DRUG OXYGEN (Refer To Trust Oxygen Policy)   Circle target oxygen saturation 88-92% 94-98% Other___ Starting device/flow rate________ PRN / Continuous PHARM Tick if saturation not indicated (Saturation is indicated in almost all cases except for palliative terminal care) SIGNATURE / PRINT NAME DATE ddmmyy 08 12 18 22 * Saturation is indicated in almost all cases except for palliative terminal care

Monitoring & Starting Oxygen therapy Record Sp02 before starting 02 therapy where possible If Target Sp02 94-98% Choose mask & % or flow rate to achieve Target Sp02 Repeat blood gases are not be needed If Target Sp02 88-92% Start with 28% Venturi mask then titrate up to achieve Target Sp02 Blood gases needed after 30-60 mins If ‘Other’ Sp02 prescribed - start as directed by doctor Monitor Sp02 for first 5 mins and then monitor patient Sp02 minimum 4 hourly. Record delivery devices on obs chart

Example of an oxygen observation chart Respiratory Rate, Oxygen saturation and oxygen therapy Clinical review required if saturation is outside target range Continuous Oxygen / PRN / Not on oxygen therapy Target range: 88-92% 94-98% Other_____ Respiratory Rate Oxygen Saturation % Device or Air Oxygen flow rate L/min Your Initials* Codes for recording oxygen delivery on observation chart A Air. (Patient not requiring oxygen therapy) AX Measurement on air for a patient who is on PRN Oxygen therapy AW Measurement on air for a patient who is being weaned off oxygen but not yet discontinued on chart N Nasal Cannulae SM Simple mask V24 Venturi 24% V28 Venturi 28% V35 Venturi 35% V40 Venturi 40% V60 Venturi 60% H28 Humidified oxygen at 28% (“Quatro” or similar device) (also H 35, H40, H60) RM Reservoir Mask TM Tracheostomy Mask CP Patient on CPAP system NIV Patient on NIV system OTH Other device *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 (unless the oxygen prescription is part of a timed protocol

Maintaining the Target saturation Nurses must use the mask escalator (see next slide) Masks and flow rates 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 rates to ensure target Sp02 is achieved E.g. 2 Ltr nasal cannula may change to 35% Venturi mask Always monitor Sp02 for 5 mins after any change in 02 therapy to ensure target Sp02 is achieved .

BTS NURSES TRAINING SLIDES MAY 2010(V13) Titrating Oxygen up and down using the mask escalator This table below shows APPROXIMATE conversion values. Venturi 24% (blue) 2-4l/min OR Nasal specs 1L Venturi 28% (white) 4-6 l/min OR Nasal specs 2L Venturi 35% (yellow) 8-10l/min OR Nasal spec 4L Venturi 40% (red)10-12l/min OR Simple face mask 5-6L/min Venturi 60% (green) 15l/min OR Simple face mask 7-10L/min Reservoir mask at 15L oxygen flow If reservoir mask is required, seek senior medical input immediately

Titrating 02 up or down in Target saturation range 94-98% Increase 02 if Sp02 is lower than Target Sp02 on chart Decrease 02 if Sp02 is higher than Target Sp02 on chart Monitor Sp02 for 5 mins at every change Document Sp02 after 5 mins on chart If 02 increased, Medical assessment needed and blood gases may be required If 02 decreased NO blood gases needed No need to inform doctor if clinically stable Ensure change is documented in patient record

Titrating 02 up or down in Target saturation range 88-92% or OTHER Increase 02 if Sp02 is lower than Target Sp02 on chart Decrease 02 if Sp02 is higher than Target Sp02 on chart - Monitor Sp02 for 5 mins at every change Document Sp02 after 5 mins on chart If 02 increased blood gases after 1 hour (show doctor results) - If 02 decreased NO blood gases needed No need to inform doctor if clinically stable Ensure change is documented in patients record

Stopping 02 therapy for all patients Stop 02 if patient stable and Sp02 is within range on 2 consecutive observations - Patient will already be weaned to low dose 02 Stop 02 & monitor Sp02 for 5mins & document If stable document continue on air for 1 hour monitoring Sp02 Document Sp02 at end of hour on chart. If stable doctor should cross off 02 on drug chart If saturation falls on stopping oxygen, then re-start the previous dose If acute deterioration or if Sp02 fall outside of the target range oxygen should be re-started and the patient should have an immediate medical review

When to use the Target saturation not indicated box (To be used if pulse Oximetry not needed) - Some patients may be on oxygen, however 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

Devices to use

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.

Nasal Cannulae (N) Recommended for most patients. 2-6L/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 Can eat Preferred by patients (Vs simple mask) Low cost product

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 (although packaging may say 2-10L)

Venturi or Fixed Performance Masks (V) Aims to deliver constant oxygen concentration within and between breaths. With TACHYPNOEA (RR >30/min) the oxygen supply should be increased by 50% Increasing flow does not increase oxygen Concentration Good masks for patients with raised C02 (patients with a target of 88-92%)

Humidified Oxygen (H) Tracheostomy 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 ) N.B There is little evidence for humidification in routine oxygen therapy

Oxygen Flow Meter The centre of the ball indicates the correct flow rate. The ball must sit either side of the line. This diagram illustrates the correct setting of the flow meter to deliver a flow of 2 litres per minute

Check your knowledge What monitoring is needed when starting 02 therapy? 2 What should you do if the patient’s saturation is lower than the Target Sp02 prescribed in the 94-98% group? 3 What should you do if the patient’s saturation is lower than the Target Sp02 prescribed in the 88-92%? 4 What should you do if the patient’s Sp02 is higher than the Target saturation prescribed in both groups? When do you consider stopping Oxygen therapy ? How do you stop 02? What scenario do you use high flow 02 therapy and seek immediate medical review? 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 Sp02 94-98% Choose mask & % or flow rate to meet Target Sp02 No blood gases needed If Target Sp02 88-92% Start with 28% Venturi mask then titrate up to meet Target Sp02 Blood gases after 30-60 mins Monitor Sp02 for first 5 mins and then monitor patient Sp02 minimum 4 hourly.

Answer to Question 2 What to do if Oxygen level (SpO2 ) is lower than prescribed target SpO2 of 94-98% ? If Sp02 less than 90% urgent medical review required ( according to Track & Trigger OR Early warning system) Step up oxygen therapy immediately Monitor Sp02 for 5 mins after each change up & record on chart Inform doctor that pt is unstable & monitor according to clinical condition

Answer to question 3 What to do if saturation is lower than prescribed Target Sp02 of 88-92% ? As per EWS seek immediate medical review Step up oxygen as per escalator immediately Monitor Sp02 for 5 minutes & record on obs chart Blood gases must be taken within 1 hour of increase in 02 therapy to check for C02 increase ( Doctor to review blood gases)

Answer to question 4 What to do if Saturation is higher than the Target Sp02 in both groups ? Wean oxygen down using mask escalator by; 1. Reducing oxygen flow and/or 2. Change delivery device Monitor Sp02 for 5mins & record on chart If stable remain on lower oxygen Document in notes and obs chart

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

Answer to question 6 How do you stop oxygen ? Stop 02 and monitor SpO2 for 5 minutes If stable document and monitor SpO2 for one hour on air If saturation remains within prescribed target range on air stop 02 If oxygen is stopped the doctor should cross it off on the drug chart unless local policy and/or mEWS system requires target range for all patients If Target SpO2 not maintained resume original 02 therapy and consider stopping 02 at a later stage Document changes in medical notes

Answer to question 7 When do you use high amounts of 02 and seek urgent medical review ? Cardiac arrest and other critical illness. If a patient with target range of 94-98% deteriorates <85% See Track & Trigger / Early Warning System. Get urgent medical review whilst giving high amounts of oxygen ( Reservoir mask should be used)

Oxygen prescribing Summary Oxygen is a life saving drug Oxygen must be prescribed Doctors will prescribe Target saturation Prescription will be written on Oxygen section on drug chart Nurses will choose mask and &/flow rate to achieve Target Saturation Nurses can titrate Oxygen up & down & record on obs chart Nurses can wean patients off oxygen Oxygen must be monitored minimum four hourly Nurses must sign drug chart every drug round