British Thoracic Society Guideline for oxygen use in

British Thoracic Society Guideline for oxygen use in healthcare and emergency settings Key messages for nurses and PAMs (Professions Allied to Medicine) 12/05/2017 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 i 1 -i 89 12/05/2017

Important points to consider about oxygen therapy 1 Oxygen is a life saving drug for hypoxaemic patients. (Patients whose oxygen levels are low) 2 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 (C 02) levels • Other patients (e. g. myocardial infarction) may also be harmed by too much oxygen 5 Only give as much as needed– no need for extra! 12/05/2017

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 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 Sp. O 2 results below target range and 21. 5% above target range in 2015 BTS audit) 12/05/2017

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) • 48% in 2011 (156 Hospitals) Prior to publication of 2008 Guideline • 55. 1% in 2013 (151 Hospitals) • 57. 5% in 2015 (181 Hospitals) 12/05/2017

Oxygen is a drug and should be prescribed except in emergencies • Oxygen should be regarded as a drug (BNF 2016) • 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 (Sp 02) which should be written on the drug chart or electronic prescription 12/05/2017

Normal Oxygen saturation range in healthy adults Sp. O 2 Saturation (measured by pulse oximetry) of O 2 HEALTHY ADULTS Daytime Sp 02 96 -98% *Transient dips in saturation are common during sleep (~84%) 12/05/2017

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. Benefit has been found with use of a hand-held fan and consider use of opioids for patients with malignancy or other causes of chronic severe breathlessness. 12/05/2017

Many patients need high-dose oxygen to normalize saturation • Severe Pneumonia • Severe LVF • Major Trauma • Sepsis and Shock • Lung collapse • Pulmonary Embolism • Lung Fibrosis 12/05/2017

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 hypoxaemia and treat the underlying cause (e. g Bronchospasm, LVF etc) • Some patients may need specialist care!! 12/05/2017

Oxygen therapy by first responders in critical illness See BTS 0 xygen guideline section 8. 10 • Patients must not go without oxygen while waiting for a medical review • Initial 02 therapy is reservoir mask at 15 litres/minute (RM 15) • Once stable aim for Sp. O 2 94 -98% or patient-specific target range • COPD patients who are critically ill should have the same oxygen therapy until blood gases have been obtained and may then need controlled oxygen therapy or non-invasive or invasive ventilation 12/05/2017

Prescribing to a Target Saturation range • Oxygen will be prescribed in order to keep Sp 02 within a specified range for individual patients • Target oxygen saturation prescription is integrated into the patient’s drug chart and bedside monitoring • Oxygen delivery device and/or flow should be changed if necessary to keep the Sp. O 2 in the target range 12/05/2017

Patients will be initially prescribed a target saturation as shown below • 94 -98% Most patients (Those not at risk of CO 2 retention) • 88 -92% COPD or C 02 retaining patients: 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 range such as 85 -90% Target saturations should be reviewed and changed if required. 12/05/2017

Exposure to high concentrations of oxygen may be harmful • • • Harten JM et al J Cardiothoracic Vasc Anaesth 2005; 19: Absorption Atelectasis even at FIO 2 30 -50% 173 -5 Intrapulmonary shunting • Kaneda T et al. Jpn Circ J 2001; 213 -8 Post-operative hypoxaemia • Frobert O et al. Cardiovasc Ultrasound 2004; 2: 22 • Haque WA et al. J Am Coll Cardiol 1996; 2: 353 -7 Risk to COPD patients • Thomaon aj ET AL. BMJ 2002; 1406 -7 Coronary vasoconstriction • Stub D et a; . Circulation 2015’; 131: 2143 -50 • Helmerhorst HJ Crit Care Med 2015; 43: 1508 -19 Increased Systemic Vascular Resistance • Girardis M et al. JAMA 2016; 1583 -89 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 12/05/2017

Safeguarding patients at risk of type 2 respiratory failure • Lower target saturation range for these patients (usually 88 -92%) • Education of patients and health care workers • Use of controlled oxygen via Venturi masks and low flow nasal O 2 • Use of oxygen alert cards • Issue of personal Venturi masks to high-risk patients 12/05/2017

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 12/05/2017

Who does what? Doctors (and other prescribers) • Prescribe O 2 target range for ALL patients • Usually 94 -98% or 88 -92% • Specify starting device • Provide advice to nurses if the clinical condition of the patient changes • Adjust the target range if the patient’s condition alters (e. g. new hypercapnia) 12/05/2017 Nurses / Physios HCAs / Student nurses • Document starting device/flow • Monitor O 2 minimum 4 hourly • Start O 2 and ensure target achieved quickly • Record Sp. O 2 and delivery device • Titrate O 2 to keep in range • Codes recorded on obs chart and initialled • Sign drug chart every drug round (nurses, not physios) • Monitor O 2 minimum 4 hourly. • Record Sp. O 2 & delivery device Wean off 02 if clinically stable • Codes to be written on obs chart and initialled • Inform nurses when Sp. O 2 outside target range

Target saturation prescribing • It is recommended that all patients are routinely prescribed a target saturation on admission to hospital. • This is so that the right target range will be used if the patient deteriorates and correct NEWS section is used. • Patients will only receive oxygen if the saturation is below the target. Medical review required when this happens. 12/05/2017

Oxygen prescription chart Model for oxygen section in hospital prescription charts *Saturation is indicated in almost all cases except for palliative terminal care. 12/05/2017

Example of electronic prescription *Electronic prescribing can be linked to electronic bedside observations to calculate EWS/NEWS automatically according to oxygen target range. 12/05/2017

Monitoring & starting oxygen therapy Record Sp. O 2 before starting oxygen therapy where possible. (Do NOT take oxygen off an acutely unwell patient to obtain a reading on air) If target saturation is 94 -98% • Choose mask and/or flow rate to achieve target saturation • Repeat blood gases are not needed for these patients if within target range If target saturation is 88 -92% • Start with nasal cannulae at 1 -2 l/minute or 28% Venturi mask then titrate up to achieve the target saturation • Blood gases are needed after 30 -60 mins If ‘Other’ Sp 02 prescribed - start as directed by doctor Monitor Sp. O 2 for first 5 mins and then monitor patient Sp. O 2 minimum 4 hourly. Record delivery device and flow on observations chart. 12/05/2017

Core content of an oxygen observation chart *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. 12/05/2017

Example of 2016 NEWS chart if available 12/05/2017

Standard abbreviations for oxygen delivery devices 12/05/2017

Maintaining the Target saturation • Nurses must use the oxygen escalator (see next slide) • Masks and flow rate 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 rate to ensure target Sp. O 2 is achieved e. g. 2 Litre nasal cannula may change to 35% Venturi mask Always monitor Sp. O 2 for 5 mins after any change in oxygen therapy to ensure target saturation is achieved 12/05/2017

Titrating Oxygen up and down using the mask escalator This table shows approximate conversion values. Venturi 24% (blue) 2 -3 l/min OR Nasal cannulae 1 L Venturi 28% (white) 4 -6 l/min OR Nasal cannulae 2 L Venturi 35% (yellow) 8 -12 l/min OR Nasal cannulae 4 L Venturi 40% (red) 10 -15 l/min OR Nasal cannulae or Simple face mask 5 -6 L/min Venturi 60% (green) 15 l/min OR Simple face mask 7 -10 L/min Reservoir mask at 15 L oxygen flow 12/05/2017 If reservoir mask is required, seek senior medical input immediately

Titrating oxygen up or down in Target saturation range 94 -98% Increase oxygen if Sp. O 2 is lower than target range Decrease oxygen if Sp. O 2 is higher than target range • Monitor Sp. O 2 for 5 mins at every change • Document Sp. O 2 on chart after 5 mins • If oxygen therapy is increased, medical assessment is needed and blood gases may be required • If oxygen therapy is decreased for a stable patient, blood gases are NOT needed No need to inform doctor if clinically stable Ensure change is documented in patient record 12/05/2017

Titrating 02 up or down in Target saturation range 88 -92% or other Increase oxygen if Sp. O 2 is lower than target range Decrease oxygen if Sp. O 2 is higher than target range - Monitor Sp. O 2 for 5 mins at every change - Document Sp. O 2 on chart after 5 mins - If oxygen therapy is increased, take blood gases after 30 -60 minutes (show doctor results) - If oxygen therapy is decreased for a stable patient, blood gases are NOT needed No need to inform doctor if clinically stable Ensure change is documented in patients record 12/05/2017

Stopping oxygen therapy for stable patients Stop 02 if patient stable and Sp 02 is within range on 2 consecutive observations • Patient will usually be weaned to low dose oxygen by this time • • Stop supplemental oxygen & monitor Sp 02 for 5 mins & document this in the chart If Sp 02 remains stable, continue on air for 1 hour monitoring Sp 02 Document Sp 02 on chart at end of hour If stable at one hour, the patient is weaned off oxygen and continues regular obs • If saturation falls on stopping oxygen, then re-start the previous dose If cases of acute deterioration or if Sp 02 fall outside of the target rang despite re-starting oxygen therapy, the patient should have an immediate medical review 12/05/2017

When to use the Target saturation not indicated box (To be used for patients who do not benefit from pulse oximetry monitoring) • Some patients may be on oxygen for conditions where 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 in last days of life 12/05/2017

Devices to use 12/05/2017

High Concentration Reservoir Mask (RM) • Non re-breathing Reservoir Mask • Critical illness / Trauma patients • Post-cardiac or respiratory arrest • Delivers O 2 concentrations between 60 & 80% or above • Effective for short term treatment 12/05/2017

Nasal Cannulae (N) • Recommended for most patients. • 1 -6 L/min gives approx 24 -50% FIO 2 • FIO 2 depends on oxygen flow rate and patient’s minute volume and inspiratory flow and pattern of breathing. • • • 12/05/2017 Comfortable and easily tolerated No re-breathing Patient can eat and drink Preferred by patients (Vs simple mask) Low cost product

Venturi or fixed performance masks (V) • Aims to deliver constant oxygen concentration within and between breaths. • The minimum oxygen flow is displayed. With TACHYPNOEA (RR >30/min) the oxygen flow should be increased by 50% - see next slide • Increasing flow does not increase oxygen concentration, it is a fixed dose device • Good device for patients with raised C 02 (patients with a target of 88 -92%) 12/05/2017

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 12/05/2017

Simple face mask (SM) (Medium concentration, variable performance) • Used for patients with type I respiratory failure • Delivers variable O 2 concentration between 35% & 60% • Low cost product • Flow 5 -10 L/min Flow must be at least 5 L/min to avoid CO 2 build up and resistance to breathing 12/05/2017

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 ( H 24, H 28, H 35 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. 12/05/2017

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 12/05/2017

High flow 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 12/05/2017

Oxygen flow meter The centre of the ball indicates the correct flow rate. The ball must be centred on the line. 12/05/2017 This diagram illustrates the correct setting of the flow meter to deliver a flow of 2 litres per minute.

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 when not in use 12/05/2017 Oxygen outlet (Usually white) Air outlet (usually black)

Oxygen prescribing Summary • Oxygen is a life saving drug • Oxygen must be prescribed (in emergencies, give immediately, record later) • Doctors will prescribe a target saturation range for all patients • Prescription will be written in oxygen section of drug chart or EPR • Nurses will choose device and flow rate to achieve target saturation • Nurses can titrate oxygen up & down & record on obs chart (Medical review is required after up-titration of oxygen) • Nurses can wean stable patients off oxygen • Oxygen must be monitored minimum four hourly • Nurses must sign drug chart for oxygen at every drug round 12/05/2017

Check your knowledge 1 What monitoring is needed when starting oxygen therapy? 2 What should you do if the patient’s saturation is lower than the target range prescribed in the 94 -98% group? 3 What should you do if the patient’s saturation is lower than the target range prescribed in the 88 -92% group? 4 What should you do if the patient’s Sp 02 is higher than the target saturation range prescribed in both groups? 5 When do you consider stopping oxygen therapy? 6 How do you stop oxygen therapy? 7 What scenario do you use high flow oxygen therapy and seek immediate medical review? 12/05/2017 Answers at end of presentation

Answer to question 1 What monitoring is needed when starting 02 therapy ? Record Sp 02 before starting 02 therapy where possible If target range is 94 -98% • Choose mask and flow rate to meet target range • No blood gases needed If target range is 88 -92% • Start with 1 -2 litres nasal oxygen or 28% Venturi mask then titrate up to meet target range • Check blood gases after 30 -60 mins Monitor Sp 02 for first 5 mins and then monitor Sp 02 on chart minimum 4 hourly 12/05/2017

Answer to question 2 What to do if oxygen level (Sp. O 2) is lower than prescribed target range of 94 -98% ? • If Sp 02 less than 90% urgent medical review required • Step up oxygen therapy immediately • Monitor Sp 02 for 5 mins after each change up & record on chart • Inform doctor that patient is unstable & monitor according to clinical condition 12/05/2017

Answer to question 3 What to do if saturation is lower than prescribed target range of 88 -92% ? • Seek immediate medical review • Step up oxygen immediately as per oxygen escalator slide • Monitor Sp 02 for 5 minutes & record on obs chart • Blood gases must be taken within 1 hour of increase in oxygen therapy to check for C 02 increase (Doctor to review blood gases) 12/05/2017

Answer to question 4 What to do if Saturation is higher than the target range in both groups? • Wean oxygen down using oxygen escalator by: 1. 2. Reducing oxygen flow and/or Change delivery device • Monitor Sp 02 for 5 mins & record on chart • If stable remain on lower oxygen • Document in notes and obs chart 12/05/2017

Answer to question 5 When do you consider stopping oxygen therapy? • When the patient is clinically stable and has maintained target Sp. O 2 on low dose 02 therapy for 2 sets of observations 12/05/2017

Answer to question 6 How do you stop oxygen ? • Stop oxygen (as per previous slide) and monitor Sp. O 2 for 5 minutes • If stable at 5 mins, document this and monitor Sp. O 2 for one hour on air • If saturation remains within prescribed target range on air stop 02 • If Target Sp. O 2 not maintained, resume original 02 therapy and consider stopping 02 at a later stage • Document changes in bedside observation charts or electronic records 12/05/2017

Answer to question 7 When do you use high amounts of oxygen and seek urgent medical review ? • Cardiac arrest and other critical illness • If a patient with target range of 94 -98% deteriorates <85% • See unit Track & Trigger / Early Warning System / NEWS rules • Get urgent medical review whilst giving high amounts of oxygen (Reservoir mask should be used) 12/05/2017

These slides are provided for use on a local basis – permission is not required 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 i 1 -i 89 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 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.