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British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings
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The full Guideline for oxygen use in adults in healthcare and emergency settings, published in Thorax1 provides an update to the 2008 BTS Emergency oxygen guideline.2 The following is a summary of the recommendations and good practice points. The sections noted to within this summary refer to the full guideline sections. Executive summaryPhilosophy of the guideline
Table 1 Critical illnesses requiring high levels of supplemental oxygen (section 8.10) Table 2 Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic (section 8.11) Table 3 Conditions for which patients should be monitored closely but oxygen therapy is not required unless the patient is hypoxaemic (section 8.13) Table 4 COPD and other conditions requiring controlled or low-dose oxygen therapy (section 8.12) Table 5 Abbreviations for oxygen devices for use on bedside charts
Figure 1 Oxygen prescription guidance for acutely hypoxaemic patients in hospital. COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; NIV, non-invasive ventilation; PO2, oxygen tension; PCO2, arterial or arteriolised carbon dioxide tension; SpO2, arterial oxygen saturation measured by pulse oximetry.
Figure 2 Flow chart for oxygen administration on general wards in hospitals. COPD, chronic obstructive pulmonary disease. EPR, electronic patient record; EWS, early warning score; NEWS, National Early Warning Score; SpO2, arterial oxygen saturation measured by pulse oximetry. Key changes since the first edition of this guideline published in 2008MethodologyThe evidence review methodology has changed from NICE methodology to the BTS NICE accredited guideline production process which is based on the Scottish Intercollegiate Guideline Network (SIGN) methodology and adheres to AGREE methodology (see section 1). Evidence levels and grade of recommendationThese are now in SIGN format (see section 1 and tables 6 and 7). Table 6 SIGN evidence levels Table 7 SIGN grades of recommendation Evidence baseThe evidence base for the guideline has been updated to August 2013 (and extended to mid-2016 for key references). None of the 2008 recommendations have been challenged by new evidence, but many of the existing recommendations are supported by new information. There have been many observational studies but few randomised trials directly relevant to the guideline since 2008. The remit of the guideline has been extendedThe new guideline covers not just emergency oxygen use but most oxygen use in healthcare settings. It also covers short-term oxygen use by healthcare workers outside of healthcare settings, but domiciliary oxygen use by patients is covered by the BTS Guideline for home oxygen use in adults.1–3 The scope of the guideline has been widenedThe present guideline includes the following new topics and settings which have been requested by guideline users:
The structure and format of the guideline has been changed since 2008The 2008 Guideline was published as a self-contained document in Thorax.1 Additional educational materials and other resources including audit tools were made available on the British Thoracic Society website. The new guideline exists in two complementary formats.
IntroductionAim of the guidelineThe key aim of this guideline is to make oxygen use in emergency and healthcare settings safer, simpler and more effective. Oxygen is probably the commonest drug used in the care of patients who present with medical emergencies. Prior to the publication of the first British Thoracic Society Guideline for Emergency Oxygen Use in Adult Patients in 2008,1 ambulance teams and emergency department teams were likely to give oxygen to virtually all breathless or seriously ill patients and also to a large number of non-hypoxaemic patients with conditions such as ischaemic heart disease or stroke based on custom and practice. About 34% of UK ambulance journeys in 2007 involved oxygen use.4 This translated to about two million instances of emergency oxygen use per annum by all UK ambulance services, with further use in patients' homes, GP surgeries and in hospitals. Audits of oxygen use and oxygen prescription have shown consistently poor performance in many countries, and most clinicians who deal with medical emergencies have encountered adverse incidents and occasional deaths due to underuse and overuse of oxygen.5–11 Historically, oxygen has been administered for three main indications of which only one is evidence-based. First, oxygen is given to correct hypoxaemia because severe hypoxaemia is clearly harmful to the human body. Second, oxygen has been administered to ill patients in case they might become hypoxaemic. Recent evidence suggests that, if impaired gas exchange does actually develop, this practice may actually place patients at increased risk (see full Guideline section 6.3). Third, a very high proportion of medical oxygen was administered because most clinicians believed, prior to 2008, that oxygen can alleviate breathlessness in most circumstances. However, there is no good evidence that oxygen relieves breathlessness in non-hypoxaemic patients. There is evidence of lack of effectiveness or minimal effectiveness in mildly hypoxaemic breathless patients with chronic obstructive pulmonary disease (COPD) and advanced cancer (see full Guideline sections 6 and 8.11.4). Against this background, the Standards of Care Committee of the British Thoracic Society (BTS) established a working party in association with 21 other societies to produce an evidence-based guideline for emergency oxygen use in the UK. This led to the production of the 2008 BTS Guideline for emergency oxygen use in adult patients which was the world's first guideline for emergency oxygen therapy.1 This guideline has been implemented throughout the UK and in many other countries leading to over 500 citations in the medical literature up to the end of 2016. The purpose of the update to the 2008 guideline is to strengthen the evidence base of the previous guideline based on revised methodology (which meets criteria contained in the AGREE II Instrument) and to extend the evidence base to the end of 2013.12 Additionally, the remit of the 2008 Guideline has been broadened to cover several new aspects of oxygen use and a broader range of locations where oxygen might be used.
Intended users of the guideline and target patient populationsThis guideline is mainly intended for use by all healthcare professionals who may be involved in emergency oxygen use. This will include ambulance staff, first responders, paramedics, doctors, nurses, midwives, physiotherapists, pharmacists and all other healthcare professionals who may deal with ill or breathless patients. Advice is also provided for first responders belonging to voluntary organisations or other non-NHS bodies. Information based on this guideline is available on the BTS website for use in the following situations:
These abbreviated versions of the guideline contain the key recommendations and tables and charts that are relevant to the particular situation. Areas covered by this guidelineThe guideline addresses the use of oxygen in three main categories of adult patients in the prehospital and hospital setting and in other settings such as palliative care:
Areas not covered by this guideline
Limitations of the guidelineThis guideline is based on the best available evidence concerning oxygen therapy. However, a guideline can never be a substitute for clinical judgement in individual cases. There may be cases where it is appropriate for clinicians to act outwith the advice contained in this guideline because of the needs of individual patients, especially those with complex or interacting disease states. Furthermore, the responsibility for the care of individual patients rests with the clinician in charge of the patient's care and the advice offered in this guideline must, of necessity, be of a general nature and should not be relied on as the only source of advice in the treatment of individual patients. In particular, this guideline gives very little advice about the management of the many medical conditions that may cause hypoxaemia (apart from the specific issue of managing the patients' hypoxaemia). Readers are referred to other guidelines for advice on the management of specific conditions such as COPD, pneumonia, heart failure etc. Some of these disease-specific guidelines may suggest slightly different approaches to emergency oxygen therapy whereas the present guideline aims to provide simple all-embracing advice about oxygen therapy. Definitions of terms used in the guideline (and normal values)Terms such as hypoxaemia and normal values for oxygen and carbon dioxide in blood gases are provided in the full Guideline (sections 3–6). Planned review and updating of the guidelineThe 2017 guideline will be reviewed by BTS within 5 years from publication. Declarations of interestAll members of the Guideline Group made declarations of interest in line with the BTS Policy, and further details can be obtained on request from BTS. Summary of guideline recommendations and good practice pointsA. Achieving desirable oxygen saturation ranges in acute illness (see figures 1–2 and full Guideline sections 6 and 8)
B. Clinical and laboratory assessment of hypoxaemia and hypercapnia (see full Guideline section 7)
Good practice points for clinical assessment of patients with suspected hypoxaemia
C. Arterial and capillary blood gases (see full Guideline sections 7.1.3 and 8.4 and 8.5)
Good practice point: patients requiring increased concentration of oxygen
D. Initial oxygen therapy; initial choice of equipment for patients who do not have critical illness (see figures 1–2 and table 2 and full Guideline sections 8.9 and 10)i Initial oxygen therapy in critical illness is covered in the next section.
Good practice point
E. Oxygen therapy in critical illness (see table 1 and full Guideline section 8.10)
F. Oxygen therapy for specific conditions that frequently require oxygen therapy (see tables 2 and 3 and full Guideline sections 8.11 and 8.13) Respiratory conditions with low risk of hypercapnic respiratory failure:
Non-respiratory conditions:
Good practice point
Good practice point regarding sickle cell crisis
Good practice points regarding stroke management
Suspected hyperventilation: Good practice points regarding patients with suspected hyperventilation
G. Patients at risk of hypercapnic respiratory failure (see table 4 and full Guideline section 8.12)
Good practice points for COPD and other conditions that may cause hypercapnic respiratory failure Diagnosis of COPD or suspected exacerbation of COPD:
Immediate management of patients with known or suspected COPD:
Initial hospital management of patients with exacerbation of COPD:
Good practice point Management of hypercapnia or respiratory acidosis due to excessive oxygen therapy (avoidance of life-threatening rebound hypoxaemia):
Good practice point regarding patients with neurological disorders ✓ Patients with respiratory failure due to neurological disorders or muscle disease are at high risk of dying and require urgent assessment to determine if they are likely to require non-invasive or invasive ventilator support rather than oxygen therapy. Monitor these patients with blood gases and regular spirometry (forced vital capacity). Patients’ wishes regarding this form of treatment should established as early as possible in the course of the illness, ideally before an acute episode has developed.
H. Oxygen use during pregnancy (see full Guideline section 8.14)
J. Oxygen use in perioperative care and during procedures requiring conscious sedation (see full Guideline sections 8.15–8.16 and 10.11)
Good practice points related to oxygen use in perioperative care
K. Oxygen use in palliative care (see full Guideline section 8.17)
Good practice points related to oxygen use in palliative care Oxygen therapy for the symptomatic relief of breathlessness in palliative care patients is more complex than the simple correction of hypoxaemia. Consider the following issues:
L. Mixtures of oxygen with other gases (Heliox and Entonox) Use of helium–oxygen mixtures (Heliox) (see full Guideline section 8.18):
M. Use of nitrous oxide/oxygen mixtures (Entonox) for analgesia (see full Guideline section 9.11)
N. CPAP and humidified high-flow nasal oxygen Use of CPAP in the perioperative period and for pulmonary oedema (see online section 8.19):
Good practice point, high-flow humidified nasal oxygen via nasal cannulae
P. Patients with tracheostomy or laryngectomy (see section 10.3)
Q. Humidification of oxygen (see section 10.2)
Good practice points related to humidified oxygen therapy
R. Driving gas for nebulised treatments (see section 10.4)
Good practice points Do not allow hypoxaemia to occur while administering nebulised treatments.
Driving gas for nebulised treatment in ambulances:
S. Prescribing oxygen therapy (see full Guideline section 11)
Good practice points related to prescribing and administering oxygen therapy to patients
T. Monitoring and adjusting oxygen therapy (see full Guideline sections 9–11)
Good practice points related to administration of oxygen therapy
U. Weaning and discontinuation of oxygen therapy
V. Practical aspects of oxygen use in prehospital and hospital care and use of oxygen alert cards (see full Guideline sections 9–11)
Good practice points related to practical aspects of oxygen therapy Assessment and immediate oxygen therapy:
Oxygen alert cards for patients with hypercapnic respiratory failure:
W. Practical aspects of oxygen dispensing, documentation and monitoring
X. Training in oxygen prescribing and use
Supplemental materialOnline appendices—available at http://www.brit-thoracic.org.uk
References
Read the full text or download the PDF:Log in using your username and passwordWhich assessment finding would indicate the patient needs airway suctioning?A pressure change on the ventilator, specifically peak inspiratory pressure (PIP), is a classic indicator that your patient may need suctioning.
Which immediate action does the nurse take when discovering that a patient's chest tube is disconnected from the chest drainage unit?A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately clamp the tube and place the end of chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. Bleeding may occur after insertion of the chest tube.
Which instruction does the nurse give to a patient when removing the patient's chest tube?Instruct the patient to perform the Valsalva maneuver as the practitioner quickly removes the tube at maximum inspiration. Immediately after tube removal, apply an occlusive dressing to the site and secure it with tape.
What should the nurse conclude if constant bubbling is noted in the water seal chamber of a closed chest drainage system?Bubbling in the Water Seal Chamber May Mean an Air Leak
If the water seal is continuously bubbling, you should suspect an air leak. Think of the lungs as wrapped in plastic. An air leak occurs when there is a hole in the plastic wrap allowing air to escape from the lung tissue into to the pleural cavity.
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