Improving the safety of oxygen therapy in hospitals: summary of a safety report from the National Patient Safety Agency
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c187 (Published 26 January 2010) Cite this as: BMJ 2010;340:c187All rapid responses
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I was very pleased to note that the BMJ and NPSA have felt the need
to reinforce the intended message of the recently published guidelines on
oxygen prescribing by the British Thoracic Society. I read with interest
the observation of improved oxygen prescribing since the publication of
the British Thoracic society (BTS) National guideline on emergency oxygen
prescribing in October 2008. It is regrettable that my current
experience is not in keeping with theirs. We have carried out a
prospective audit of 47 consecutive hospital admissions with community
acquired pneumonia over a one month period between November and December
2009 at a central London teaching hospital. It is an alarming finding of
this study that only 3 of 47 patients had target oxygen saturations
documented in the medical notes or prescription chart.
In COPD, the highest PaCO2 levels occur following oxygen therapy(1)
and oxygen partial pressures over 10 KPa predispose to hypercapnic failure
with acidosis(2), a situation commonly seen during my working practice as
a medical registrar on call and respiratory specialist trainee when
arterial blood gases have not been acted on appropriately, leading to over
-oxygenation and the subsequent need for non-invasive ventilation.
It seems that although the BTS guideline has a relatively high
profile and uptake by respiratory specialists, it has not been
sufficiently communicated to doctors from other medical backgrounds
involved in acute medical admissions. Oxygen use is prosaic and incorrect
usage of oxygen is therefore a major cause for concern. Further strategies
are required to ensure that current recommended national guidelines are
appropriately disseminated in the interest of safe and effective patient
care.
1.Murphy R, Driscoll P, O’Driscoll R. Emergency oxygen therapy for
the COPD patient. Emerg Med J 2001;18:333–9.
2.Plant PK, Owen JL, Elliott MW. One year period prevalence study of
respiratory
acidosis in acute exacerbations of COPD: implications for the provision of
non-invasive ventilation and oxygen administration. Thorax 2000;55:550–4.
Competing interests:
None declared
Competing interests: No competing interests
NPSA report for oxygen use - Neglects focus on ACS
We applaud the NPSA for bringing attention to the oft overlooked area
of the emergency use of oxygen therapy in adults. However, we note that
once again the spotlight remains on the dangerous use of oxygen in chronic
obstructive airways disease (COAD) patients with type two respiratory
failure. We wish to draw attenton on another common indication of oxygen
therapy; in that for acute coronary syndromes (ACS) and mycoardial
infarction (MI).
ACS and MI are the commonest cardiovascular emergencies in which
oxygen therapy is used. This has been imprinted on the memory of every
medical student and junior doctor with the well known mnemonic MONA,
standing for morphine, oxygen, nitro-glycerine, and aspirin that are the
staple initial treatments for ACS and MI. However, the use of oxygen in
these patients is based more on historical precedent and MONA-related
anecdotes than on evidence. Recent research into cardiac vascular
physiology indicates that such blanket administration of oxygen therapy
may actually do more harm than good. The MONA–ACS marriage may be on the
rocks.
A systematic review of six studies conducted by Farquhar et al (2009)
published in the American Heart Journal has shown that high concentration
oxygen can in fact reduce coronary blood flow and myocardial oxygen
consumption. In the lone study on healthy subjects, a mean reduction of
17.1% reduction was seen in coronary blood flow with a 25% increase in
coronary vasculature resistance. In those with coronary heart disease
five studies showed a mean coronary blood flow reduction of 7.9% to 28.9%,
a phenomenon that may in fact potentiate myocardial ischemia. This is
consistent with the previous research by Wijesinghe et al (2009) showing
that oxygen therapy in uncomplicated MI can lead to a greater infarct size
and may possibly increase mortality.
The potentially harmful effects of hyperoxia in acute medical
ailments such as COAD is de rigueur in the Emergency Room and well known
amongst acute medical staff. To reflect similar concerns the British
Thoracic Society (BTS) national guideline on the use of emergency oxygen
therapy in 2008 recommended that oxygen only be used in uncomplicated ACS
or MI when there is confirmed hypoxaemia. However, the notion of
restricting oxygen use in a patient with ACS or MI will more than raise a
few eyebrows in the Accident & Emergency (A&E) department. As
confirmed by the NPSA report, the medical community has responded with not
unexpected inertia, there being a lack of acknowledgement of the new
guidance in many A&E departments. That said change is coming.
Thus to inaugurate this change in the oxygen therapy paradigm we
propose that a new mnemonic be invoked when faced with ACS/MI. We feel
that the traditional MONA therapy be replaced with “MAN” therapy or
morphine, aspirin, and nitroglycerin. This lexicographic gender change
from MONA to MAN may help shift ingrained beliefs, smoke out oxygen
zealots and finally redress the ever increasing feminisation of the
medical profession. This is one small victory for MAN!
References
1. Farquhar H et al (2009). Systematic review of studies of the
effect of hyperoxia on coronary blood flow. American Heart Journal 158(3):
371-377
2. O’Driscoll BR, Howard LS, Davison AG (2008). Guideline for
emergency oxygen use in adult patients. Thorax 63 (Suppl VI)
3. Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M,
Beasley R (2009). Routine use of oxygen in the treatment of myocardial
infarction: systematic review. Heart 95:198-202
Competing interests:
None declared
Competing interests: No competing interests