1. Oxygen lead for London Respiratory Team, NHS London
How the rational use of oxygen can improve patient safety, health outcomes and reduce waste
Craig Davidson
Oxygen lead for London Respiratory Team, NHS London

2. Two faces of oxygen therapy

3. Oxygen use in England >85,000 people receive oxygen at home
It costs C £120, 000,000 (2011)
(30% up on 2006, 10% total cost COPD)
Historically service/cost placed in community
Patients often do not understand why provided or how to use
23-43% don’t use or don’t need
(Commissioning toolkit, DH)
Up to 51% continue to smoke (v < 15% Canada)

4. Rationale of home oxygen
Long term oxygen therapy (LTOT)
primarily to extend life
improve QOL (cognition & sleep)
c 15 hrs/day, downside :dependency & reduced mobility
Other forms of Home oxygen service (HOS)
for alleviation symptoms
primarily hypoxia and breathlessness on exertion
better ambulatory devices new contract
potentially expensive

5. LTOT use to prolong life
Long time ago
before recognition overlap syndromes (OSA/OHS & COPD) and treatment (CPAP/NIV)
not stratified for smoking
benefit small, delayed & limited number of patients (<300)
no benefit in less severe hypoxia
Goreka 1997
MRC

6. Responsible prescribing : smoking and LTOT
Smoking cessation as treatment
2 in 3 domestic fires in homes with O2 result of smoking
1 in 4 die
Risk can be predicted
Better to not start than to remove

7. BTS Guideline for emergency oxygen use in adult patients
35% patients receive O2 in ambulance/ED
18% ward patients treated with O2
prescribing rare
adjusting and removing even rarer
Development raised PCO2 increases mortality

8. Prescribing Oxygen
Oxygen is a drug and must be prescribed
It should be prescribed to a specific saturation range
Device and flow rate should be adjusted to achieve target
> 1 increase in oxygen dose requires medical review
Oxygen is not indicated unless patient hypoxaemic or in an emergency
For most acutely ill patients the target range is 94-98%
For patients at risk of CO2 retention the target is %
Disorders which increase risk of CO2 retention:
COPD
Cystic fibrosis
Bronchiectasis
Chest wall deformity
Neuromuscular disease
Obesity hypoventilation
In an emergency all patients should receive high flow oxygen
Designed by the Oxygen Steering Group July 2009
Reference:

9. Oxygen & hypercapnic RF
2011 BTS audit : 2500 cases hypercapnic respiratory failure receiving NIV
Respondents asked was hypercapnia O2 induced
Overall 21% oxygen toxicity
Ambulance 29% v in hospital 62%
Only 10% took action to prevent in future
eg O2 alert card, person specific protocol (PSP)

10. LAS already implemented change

11. Delivery devices

12. Targeted O2 in AECOPD
Mortality 9% in usual care v 2% controlled therapy NNH 14 (RR 0.42)
High flow increases
Mortality (2-4,000 avoidable deaths per year)
LOS
Need for NIV
HDU admission
Campbell 1967, Denniston 2002, Joosten 2007, Robinson 2001, Plant 2000, Wijesinghe 2009
National Patient Safety Awards 2011 Patient Safety in Clinical Practice Award (Health Service Journal and Nursing Times)

13. London Clinical Oxygen Network 2012
Christine Mikelsons (Royal Free Hospital)
Glenda Esmond (Central London Community Healthcare)
Karen Spooner (Community Pharmacy NCL)
Debbie Roots
(St Georges Hospital)
Anne Crawford (ONEL)
Belinda Krishek (Chief Pharmacist ONEL)
Enfield
Waltham Forest
Barnet
Redbridge
Irem Patel (Imperial College Hospitals)
Beryl Bevan (Chief Pharmacist ONWL)
Will Man (Brompton & Harefield)
Harrow
Havering
Barking & Dagenham
Haringey
Brent
Matthew Hodson (Homerton Hospital)
loren.Ateli (PCT)
Barbara Brese (Chief Pharmacist EL&C)
Camden
Ealing
Isling-
ton
Hammer
smith &
Fulham
West-
minster
City & Hackney
Newham
Tower
Hamlets
Hounslow
Kensing
ton & Chelsea
Hillingdon
South-
wark
Greenwich
Bexley
Lewisham
Lambeth
Richmond & Twickenham
Wandsworth
NHS London
Jim Pursell (HOS Lead)
Craig Davidson (COG Chair, London Respiratory Team)
Sonia Colwill (Director of Quality and Prescribing Bromley BSU)
Lynn McDonnell (Ambulatory lead)
Sally Hickman (Greenwich & Bromley)
Bromley
Kingston
Tuck-Kay Loke (Croydon University Hospital)
Nikki Davies (Croydon)
Neil Roberts (Primary care Contracting SWL)
Sutton & Merton
Croydon 13

14. BTS medical leads for O2
LRT has (so far) enrolled 23 consultants across London
Work with them
Universal prescription of O2
Leadership in protecting patients
Push to develop quality O2 assessments
Support RNS & therapists who, most often, involved in initiation of LTOT
(70% following admission)
Link with GPs, CCGs & community services

15. One of aims LCON : promote coordination between hospitals and community
Graham Delves

16. Summary Hospitals need to take a lead in protecting patients
supervising new starters
reaching out to community
controlling waste

17. (Lack of) Effect of palliative oxygen in relief of breathlessness in patients with refractory dyspnoea Lancet :784-93