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Document derivation /
evidence base:
Review Date
Lead Executive
Author/Lead Manager
March 2018
Director of Nursing
Bob Browne, Charge Nurse, Critical Care
Outreach Team
Further Guidance/Information Critical Care Outreach Team
Distribution:
Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.
This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.
Page1
Table of Contents
Introduction;
Assessing the need for oxygen therapy
Pulse oximetry
Indications for oxygen therapy
Principles of care
Guidelines for the selection of equipment
Procedure for applying correct oxygen delivery device
Equipment;
1. Variable performance devices;
Nasal cannulae/catheters
Hudson masks without a Venturi barrel; Tracheostomy masks
2. Fixed performance devices
Venturi masks & adaptors, Cold water humidification
Non-rebreathing oxygen masks
High flow oxygen therapy
Indications for high flow oxygen therapy
Procedure for applying high flow oxygen therapy via a mask
Equipment (for high flow)
Procedure for applying Optiflow nasal high flow oxygen
therapy
Equipment
Humidification
Hazards:
1. Patient safety:
Loss of hypoxic drive
Oxygen toxicity and Alveolar damage, Coronary and Cerebral
vasoconstriction, Poisons, Inter and Intra trust transfer
2. Health & safety
References
Further reading
Appendix 1: Normal blood gas values
Appendix 2: Definition of terms
Appendix 3: Equipment for high flow Oxygen therapy
Appendix 3: Equipment for Optiflow Humidified High Flow
Via nasal Cannulae
Equality and diversity statement;
Equality impact assessment
Authors
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Introduction
Oxygen should be regarded as a drug. It is prescribed to
prevent/treat hypoxaemia, but not hypercapnia or breathlessness.
The concentration of oxygen prescribed aims to bring oxygen
saturation (SpO2) to normal or near normal oxygen saturation.
However, this depends on the condition being treated; an
inappropriate concentration may have serious or even lethal
effects (British Thoracic Society Guideline 2008). It must therefore
be administered by prescription to achieve target saturations only.
In an emergency situation, a Patient Group Direction
(Administration of high percentage Oxygen to adults in an
emergency) allows staff to commence oxygen therapy without a
prescription.
In an emergency situation i.e. cardiorespiratory arrest, plus
peri-arrest situations and critical illness such as sepsis,
oxygen at high percentage (i.e. non rebreathe mask) may be
commenced before a written prescription has been made.
This would include those patients with risk factors for
hypercapnia, on whom arterial blood gas (ABG) analysis must
be performed within 60 minutes. Written documentation of
percentage, device and duration must be made.
Pulse Oximetry
This will be the default method of initiating and adjusting the
direction of therapy. Clinical staff need to be aware of the
limitations of this monitoring (Valdez-Lowe et al 2009):
Peripheral vasoconstriction (hypothermia, cardiac failure,
fluid loss)
Bright ambient light
Patient motion, fitting
Sickle cell disease when in vaso-active crisis
False nails, nail varnish
Carbon monoxide poisoning, patients returning from smoking
tobacco have misleadingly normal SpO2
Some dyes, such as methylene blue
NOT affected by jaundice, anaemia: can be slightly altered
with dark skin
Pulse oximetry will NOT identify patients with Type II (high
CO2) respiratory failure
An acceptable SpO2 will only inform of hypoxaemia (low
oxygen tension in blood), not hypoxia (delivery of oxygen to
tissues)
Best Practice
The waveform and/or signal strength must be optimal before a
reading can be accepted.
A blood pressure cuff on the arm of probe will lead to a false SpO2
reading.
Normal oxygen saturations at rest;
Pre-term (36 weeks or less) neonates; 88-92%
Term (>36 weeks) neonates and children; greater than 94%
Adults less than 70 years of age; 96% - 98%.
Aged 70 and above; greater than 94%.
Patients of all ages may have transient dips of saturation to
84% during sleep.
Note that fingers, then earlobes, are more accurate than toes as
measurement points
Nursing Guidelines Oxygen updated Jan 2013
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Nursing Practice Guidelines Group
Best Practice
Ensure that the probe is repositioned periodically onto different
fingers to prevent tissue necrosis
is
given
to
treat/prevent
hypoxia
and
Principles of care
It is the registered clinicians responsibility to ensure the required
dose of oxygen is delivered to the patient correctly: the patients
condition should be regularly monitored. The clinician must allow
5 minutes after any change to oxygen percentage or device before
assessing response. The device, percentage or litres per minute
and respiratory rate MUST be documented on the patients
observation chart. Document oxygen delivery in percentage
terms unless nasal cannulae, or non-rebreathe trauma mask is in
use. (Adult observation and EWS policy CLCGP 068)
Best Practice
Oxygen cannot travel easily through wet secretions, so optimize
their removal by:
Sitting the patient up, or out in a chair
Ensuring mouth is kept moist
Providing tissues and/or a sputum pot
Regularly assessing if a patient can take a deep breath and
cough, ensuring analgesia is sufficient to achieve this
Action
1.
Rationale
2.
3.
6.
7.
8.
To detect changes in
patients condition
9.
To clear bronchial
secretions and to maximise
the effect of the oxygen
therapy.
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Minimise
dryness
and
soreness
to
mouth.
Discomfort and sputum
tenacity are minimised
(Ashurst, 1995).
To
enable
the
correct
treatment and adherence to
wound management policy.
Selection of equipment
There are 2 basic types of oxygen delivery devices: either
variable performance devices or fixed performance devices.
Variable performance devices such as a face/tracheostomy mask
(without a Venturi device), nasal cannulae, cannot deliver a fixed
percentage (fractional inspired concentration, FiO2) of oxygen as
this is dependent on respiratory rate and tidal volume. There is a
risk of rebreathing carbon dioxide with facemasks (Jensen et al
1991). In patients with known COPD oxygen MUST be delivered
via fixed performance device. Fixed performance devices attempt
to deliver a known percentage of oxygen irrespective of the
patients respiratory rate or tidal volume (e.g. Venturi, nonrebreathe). Any mask will only work if positioned correctly on the
patients mouth and nose.
Equipment
1. Variable Performance Devices
These devices deliver oxygen in litres and cannot deliver a fixed
percentage of oxygen. The amount of oxygen delivered is
dependent on the patients rate and depth of breathing. Devices
which deliver a variable flow are:
Nasal cannulae/Catheters
Hudson masks without a Venturi barrel
Tracheostomy masks
Nasal Cannulae/Catheters
They are available as single or double cannulae: the latter is most
commonly used in the Trust. The concentration of oxygen is
dependent on the flow rate (1 4 litres per minute). Patients
should be assessed whether they require/prefer nasal cannulae or
mask: cannulae can give equivalent oxygen saturations to Venturi
masks at 1 to 4 litres per minute (Waldau et al 1998), and mouth
breathers are not necessarily disadvantaged by these (Wettstein
et al 2005).
Advantages
Simple to use, high degree of safety. Nasal cannulae prevent rebreathing of exhaled CO2, and can be comfortable for long
periods.
Patients are also able to hold a conversation,
expectorate and eat without removing them. (Bateman and
Leach, 1998).
They have low cost. Effective for delivering low concentrations of
oxygen approx between 24% & 35% (2 to 4 litres per minute).
Best Practice
Use nasal cannulae in conjunction with air driven nebulizers to
deliver oxygen in patients who require both nebulised drugs and
oxygen therapy (e.g. Asthmatics requiring back to back therapy).
Disadvantages
Occasionally there may be local irritation or dermatitis if high flow
rates are used.
Should not be used for those needing over 40% ( 4 litres/min).
Not suitable for patients with nasal obstruction i.e. polyps, mucosal
oedema.
May cause headaches or dry mucous membranes if flow exceeds
4 Litres per minute.
Inspired oxygen concentrations are variables dependent on flow
settings and patient respiratory pattern e.g. such as those with
dyspnoea (Ashurst 1995). For accurate concentrations a Venturi
mask is preferable.
Recommendation for Use
Can be used on patients with type I and type II respiratory failure.
Best Practice
Some patients may have difficulty tolerating oxygen masks: the oxygen
demand can be increased if a disturbed patient is constantly struggling to
remove it. In such cases, nasal cannulae/catheters may be a better
alternative (Porter-Jones, 2002).
Best Practice
For patients who have a tracheostomy or laryngectomy, an
appropriate mask must be used that is designed to fit around the
stoma. A face mask is not effective.
doctor may ask for a higher flow than the Venturi mask
recommendation, as this will increase flow rate without effecting
oxygen concentration.
Advantages
Venturi barrels can be changed to vary oxygen concentrations.
Reduced re-breathing of exhaled air.
Is independent of oxygen flow and patient breathing factors
(Ashurst, 1995).
Disadvantages
May be noisy, claustrophobic / interferes with eating and
drinking.
Oxygen cannot be humidified, although the entrained air contains
some humidification.
Recommendation for Use
Can be used for Type II Respiratory failure. See definition of
terms (appendix 2).
Best Practice
For general administration of oxygen in non-specialised areas, a
standard aerosol mask with a Venturi device should be used. This
will ensure that oxygen can be controlled to give inspired levels of
24-60%" (Bateman and Leach, 1998).
Advantages
For high percentage of oxygen 60% - 90% when the patient is
not at risk of retaining CO2 or losing their hypoxic drive: if
emplaced in an emergency, these patients will need an ABG
assessment. Should only be used for short-term treatment.
Disadvantages
Risk of oxygen toxicity and reabsorbtion atelectasis (failure of the
alveoli to expand).
Requires tight seal around the mouth. High oxygen flow rates are
required to ensure bag is inflated during inspiration.
2. Ensure patient is in a
comfortable position,
encourage an upright
position, maybe supported
with pillows
Rationale
Oxygen readily supports
combustion therefore fire
regulations should be adhered
to
To aid chest expansion and
ensure patient is comfortable
Best practice
Ensure humidifier is switched on to the correct temperature setting
(automatically set by the humidifier when selecting invasive vs,
non-invasive mode) when a patient with a tracheostomy airway
remain moistened, easier expectoration of secretions are facilitated
(Woodrow, 2000)
Rationale
Maintain consistent
humidification Prevent nuisance
alarms
Enables correct delivery of
oxygen
Humidification
Oxygen therapy can dry the mucous membrane of the upper
respiratory tract causing soreness and reducing the efficacy of
the mucociliary escalator.
It can also cause pulmonary
secretions to become stickier making them more difficult to
expectorate (Porter-Jones, 2002).
Therefore consideration
should be given to humidification of oxygen. Please refer to the
Trust Clinical Guidelines for the Humidification of Oxygen for Self
ventilating Patients.
Hazards
1. Patient safety
Loss of Hypoxic Drive.
Elevated arterial carbon dioxide (PaCO2) and reduced blood pH
are both strong stimulants to respiration. However, patients with
chronic lung disease who have experienced carbon dioxide
retention for some time become sensitive to high levels of carbon
dioxide and rely on reduced levels of oxygen in the blood to
stimulate their respiratory drive. This is Type II respiratory failure.
Administration of an inspired oxygen concentration above 24% in
this type of patient may abolish the hypoxic drive and lead to
further carbon dioxide retention and respiratory arrest. However,
Nursing Guidelines Oxygen updated Jan 2013
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Nursing Practice Guidelines Group
not all patients with chronic lung disease fall into this category, and
the only way to determine this is to measure arterial blood gases
(Udwadia 2005 pp 253). In an emergency situation, when a
patient is hypoxic, administration of oxygen is the priority as
hypoxia will kill whereas apnoea caused by loss of hypoxic drive
can be managed by mechanical ventilation. The clinician must
remain with the patient, observing vital signs and conscious level,
after increasing oxygen.
Best practice
Do not drive nebulizers with oxygen on patients who are at risk of
loss of hypoxic drive: use the mechanical air driven nebulizers
References
Acute Illness management (AIMS) Course Manual (2007), North
West Strategic Health Authority.
Ashurst S (1995). Oxygen Therapy British Journal Nursing Vol.
l4 No. 9 ,pp. 508 515
Bateman NT, Leach RM (1998) ABC of Oxygen Acute Oxygen
Therapy British Medical Journal Vol.317 No. 19 September pp.
798 - 801
Black, J.M., Cuddigan, J.E. and Walko, M.A. (2010) Medical
device related pressure ulcers in hospitalised patients.
International Wound Journal. 7(5): pp. 358-65.
Further reading
Bourke S (1998) Blood gases and respiratory failure Lecture
Notes on Respiratory Medicine 5th edition Oxford: Blackwell
Science
Viney C (ed) (1996) Nursing the Critically Ill London: Bailliere
Tindall
Appendix 1
NORMAL ARTERIAL BLOOD GAS VALUES
Oxygen saturation (SpO2) normal range 95% to 100%. Falls with age and in
chronic respiratory disease
pH 7.35-7.45
PaO2 12-15 kPa (slightly less in older people)
PaCO2 4.50-6.10kPa
HCO3 22-26 mmol/l
Base excess 2 +2
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Appendix 2
DEFINITION OF TERMS
ABG
Atelectasis
CPAP
CCOT
FiO2
HCO3
Hypercarbia
Hypoxaemia
Hypoxia
PaCO2
PaO2
SpO2
Type I
Respiratory
failure
Type II
Respiratory
failure
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02 Analyser
Calibrate
ON/OFF
Oxygen
Mask
9
02
Regulator
3
Hea ted
Wire 0 2
Tubing
10
Litre
Regulator
always on
Max
4
Wate r Bath
11
Particle
Filter
Controls.
ON/OFF Alarm
Trouble Shoot
Default
Intubated non
Intubated
12
6 Heater
Wires
KH/CCSC/2004
13
T Piece & 02
Analyser
White Tubing
Appendix 3
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Flowmeter
for total
gas flow
Water tube
to bag
Knobs to
adjust total
gas flow
and oxygen
Filter for air
inlet
Humidifier
Flow to
patient
(nasal
prongs not
shown)
Appendix 4
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NPGG Link:
For Review:
Stuart Thompson-Mchale
2018
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