Emergency oxygen use
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6856 (Published 18 October 2012) Cite this as: BMJ 2012;345:e6856
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Dear Sir,
O’Driscolls’ otherwise helpful, thoughtful and comprehensive review of emergency oxygen administration makes no mention of High Flow Nasal Oxygen delivery devices [1]. These devices deliver humidified oxygen at between 40 -70 l/min, and the achieved FiO2 (around 0.9) is substantially more than traditional ‘high flow’ methods such as non-rebreathing (‘trauma’) masks, at around 0.7 [2]. They may also provide a small amount of continuous positive airway pressure.
This method of oxygen administration is very well tolerated. In patients with severe hypoxaemia, who are not hypercapnic or exhausted, these devices may avoid the need for mechanical ventilation.
Yours sincerely,
Pamela Dean, Martin Hughes and Prof. John Kinsella.
1. O’Driscoll R. Emergency oxygen use. BMJ 2012;345:e6856
2. Sim MA, Dean P, Kinsella J, Black R, Carter R, Hughes M. Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated. Anaesthesia 2008;63(9):938-40.
Competing interests: No competing interests
Dear Sir,
An excellent article by Dr O'Driscoll giving a respiratory medicine point of view of emergency oxygen use. Unfortunately only one clinical example was used and this was the typical respiratory medicine case who has severe respiratory disease and is sensitive to oxygen.
Far more patients are treated with oxygen in other areas of the hospital, and sensitivity to oxygen is unusual in these departments. With respiratory medicine specialists constantly referring to oxygen as a dangerous drug, junior doctors and nurses are terrified of giving it and the numbers of patients in urgent need of oxygen (who far outnumber those sensitive to it - usually even within the respiratory ward) get too little as their inspired oxygen is slowly and timidly increased over many hours - hours during which they are hypoxic.
We need to encourage juniors and nurses to give high flow oxygen as a first response to all acutely unwell patients and then teach them how to titrate that down if severe COPD and oxygen sensitivity are reasonably suspected. Please don't scare health workers away from giving the drug that has probably saved more lives than any other.
yours sincerely
Competing interests: No competing interests
Re: Emergency oxygen use
We thank O’Driscoll for his review of emergency oxygen usage and would like to elaborate further on oxygen prescribing(1). The BTS guidelines on oxygen administration emphasise the importance of oxygen prescribing and adjusting treatment to achieve target saturations(2). Oxygen should be considered a drug, with side effects – particularly oxygen toxicity and hypercapnia. Oxygen audits often address and highlight substandard prescribing practice; however whether this correlates with administration is not always acknowledged.
We conducted an audit of oxygen prescription and administration within a 58 bed respiratory department at large teaching hospital. 50 patients (86%) had been administered oxygen at some stage. Predictably, the prescription of oxygen was poor (3 patients; 1%). However, the correct application of oxygen occurred in 46 cases (92%) despite this. New drug charts were issued with dedicated sections for oxygen prescribing with target oxygen saturations. A re-audit showed oxygen prescribing had improved to 59%.
Whilst we agree that the prescription of oxygen is important; an improvements in this facet may not equate to improved administration or decreased complications. Redesigning drug charts, electronic prescribing, and prompts can improve oxygen prescribing(3,4); however forced prescribing may lead to increased paperwork (albeit sometimes electronic) without improved patient outcomes.
The ubiquity of oxygen usage within hospitals makes the issue of safe and correct oxygen administration complex. Oxygen prescription may not equate to administration and therefore efforts to improve patient outcomes may be more complex than improving prescribing practice, requiring a multitude of approaches. We should be wary of using oxygen prescribing as a surrogate marker of oxygen administration.
References
1) O’Driscoll BR. Emergency oxygen usage. BMJ 2012;345:39-43
2) O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax 2008; 63(6):vi1-vi68.
3) Dodd ME, Kellet F, Davis A, Simpson JCG, Webb AK, Haworth CS, Niven RMcL. Audit of oxygen prescribing before and after the introduction of a prescription chart. BMJ 2000;321:864-5.
4) Wijesinghe M, Shirtcliffe P, Perrin K, Healy B, James K. An audit of the effect of oxygen prescription charts on clinical practice. Postgraduate Medical Journal 2010;86(1012):89‐93.
Competing interests: No competing interests