Intended for healthcare professionals

Practice Rapid Recommendations

Oxygen therapy for acutely ill medical patients: a clinical practice guideline

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4169 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4169

Overview of recommendations

Applies to:Patients withacute stroke or myocardialinfarction 100 99 98 97 96 95 94 93 92 91 90 89 88 87 Recommendation 1 Stop oxygen therapy no higherthan 96% saturation Recommendation 3 Do not start oxygen therapy at or above 93% saturation Recommendation 2 We suggest not starting oxygen therapy between 90-92% saturation Applies to:Acutely ill adult medical patients (with exceptions) STRONG WEAK STRONG Peripheral capillary oxygen saturation (SpO2)

Recommendation 1 - upper limit

or ≥97% target ≤96% target An upper limit of oxygen saturation target 97% or higher An upper limit of oxygen saturation target of no more than 96% Applies to: Does not apply to patients with: Including: Acutely ill adult medical patients already receiving oxygen therapy ≥97% target ≤96% target Carbon monoxide poisoning Critically ill surgical patients Sickle cell crisis Pneumothorax Cluster headaches

We recommend that oxygen saturation be maintained no higher than 96% Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms

Favours ≥97% target Favours ≤96% target Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

51 11 fewer Mortality Moderate More 62

Risk of Bias No serious concerns Imprecision Borderline Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Liberal oxygen therapy probably increases mortality Note: There is a dose-response gradient with larger increases in oxygen saturation being associated with greater mortality risk

No important difference Hospital acquired infection High More 132 127

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Liberal oxygen therapy has little or no impact on hospital acquired infection
Mean number of days

No important difference Length of hospitalisation Moderate More 10.3 10.5

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns Liberal oxygen therapy probably has little or no impact on length of stay in hospital
See all outcomes
When upper limits for oxygen saturation are lowered, nursing demands will increase The ideal upper limit for those receiving oxygen therapy is probably lower than 96%, for example 94% Ideal levels Almost all patients will place a high value on avoiding even a small increased risk of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

Recommendation 2 - lower limit (90-92%)

or Oxygen therapy No oxygen therapy Oxygen therapy No oxygen therapy Provision of supplemental oxygen No provision of supplemental oxygen Applies to people with: or + Acute stroke Acute myocardialinfarction Oxygen saturation of 90-92% on ambient air

We suggest not providing oxygen therapy More details Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms - patients with stroke

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

Mortality Low More 87 69 18 fewer

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may not decrease mortality
3-6 months

No important difference Functionally dependent Low More 560 549

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on becoming functionally dependent Functional dependancy is defined as a modified Rankin score greater than 2

No important difference Severe disability Low More 270 270

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on severe disability Severe disability is defined as a modified Rankin score greater than 4
See all outcomes

Comparison of benefits and harms - patients with myocardial infarction

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

No important difference Mortality Low More 55 49

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may not decrease mortality

No important difference Chest pain requiring antianginal Low More 215 211

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may have little or no impact on chest pain
6 months

Coronary revascularisation Low More 106 34 fewer 72

Risk of Bias No serious concerns Imprecision Serious Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy may increase coronary revascularisation procedures
6 months to 1 year

Recurrent myocardial infarction Moderate More 62 11 fewer 51

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not reduce the risk of recurrent myocardial infarction
See all outcomes
The ideal oxygen saturation at which to start oxygen therapy is uncertain, but is probably 90% or lower Ideal levels Wearing a mask or nasal prongs can be uncomfortable. However, aside from terminally ill patients, almost all patients are likely to accept this discomfort for even a small reduction in chance of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

Recommendation 3 - lower limit (>92%)

or Oxygen therapy No oxygen therapy Provision of supplemental oxygen No provision of supplemental oxygen Applies to people with: or + Acute stroke Acute myocardialinfarction Oxygen saturation of greater than 92% on ambient air Oxygen therapy No oxygen therapy

We recommend not providing oxygen therapy Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms - patients with stroke

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

Mortality Moderate More 87 69 18 fewer

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not decrease mortality
3-6 months

No important difference Functionally dependent Moderate More 560 549

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on becoming functionally dependent Functional dependancy is defined as a modified Rankin score greater than 2

No important difference Severe disability Moderate More 270 270

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on severe disability Severe disability is defined as a modified Rankin score greater than 4
See all outcomes

Comparison of benefits and harms - patients with myocardial infarction

Favours oxygen therapy Favours no oxygen therapy Evidence quality Events per 1000 people In hospital No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm

No important difference Mortality Moderate More 55 49

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably does not decrease mortality

No important difference Chest pain requiring antianginal Moderate More 215 211

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably has little or no impact on chest pain
6 months

Coronary revascularisation Moderate More 106 34 fewer 72

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy probably increases coronary revascularisation procedures
6 months to 1 year

Recurrent myocardial infarction High More 62 11 fewer 51

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Oxygen therapy does not reduce the risk of recurrent myocardial infarction
See all outcomes
The ideal oxygen saturation at which to start oxygen therapy is uncertain, but is likely below 93% Ideal levels Wearing a mask or nasal prongs can be uncomfortable. However, aside from terminally ill patients, almost all patients are likely to accept this discomfort for even a small reduction in chance of death Values and preferences Key practical issues Sometimes causes one or more of: claustrophobia, nasal or throat dryness, hoarseness, irritation Oxygen delivery devices may hinder patients’ freedom of movement, eating, drinking, and communication Oxygen therapy No practical issues No oxygen therapy

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