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CLINICAL GUIDELINES

Guideline for Administration of Oxygen in Adults 2012


Reference
Date approved
Feb 2013
Approving Body
Matrons Forum
Supporting Policy/ Working in No
New Ways (WINW) Package
Implementation date
March 2013
Supersedes
Guidelines for Administration of Oxygen
(2005)
Consultation undertaken
Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons, Medical Gas Committee.
Target audience

Clinical Practitioners administrating oxygen

Document derivation /
evidence base:
Review Date
Lead Executive
Author/Lead Manager

CLMM032 In-patient Oxygen Therapy

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.

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Nottingham University Hospitals NHS Trust


CLINICAL GUIDELINES
GUIDELINES FOR THE ADMINISTRATION OF OXYGEN
IN ADULTS
Page No

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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Nottingham University Hospitals NHS Trust


CLINICAL GUIDELINES
GUIDELINES FOR THE ADMINISTRATION OF OXYGEN
IN ADULTS

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.

Assessing the need for oxygen therapy


In acutely ill patients oxygen delivery to the lungs relies on a
patent airway. Airway patency should always be checked prior to
delivering oxygen therapy (Greater Manchester Acute Illness
management (AIM) 2007).
The concentration of oxygen will be titrated to a target saturation,
not a set percentage amount. This will be between 94-98% for
most acutely unwell patients or 88-92% for those with possible
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hypercapnic (Type II) respiratory failure. Therefore, oxygen


should be increased or reduced to maintain these saturations, as
very high levels will not offer any clinical advantage in most
conditions. Note this major change to the previous oxygen
prescribing policy.

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
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Best Practice
Ensure that the probe is repositioned periodically onto different
fingers to prevent tissue necrosis

Indications for oxygen therapy


The principal clinical indicator for initiating, monitoring and
adjusting oxygen therapy is peripheral oxygen saturation (SpO2).
Patient colour and respiratory rate and work of breathing MUST
also be observed. Arterial oxygenation (PaO2) and arterial
saturation (SpO2) are assessed by arterial blood gas analysis,
which will have priority in the direction of oxygen therapies.
Oxygen therapy
hypoxaemia.

is

given

to

treat/prevent

hypoxia

and

Acute hypoxaemia (for example pneumonia, shock, asthma,


heart failure, pulmonary embolus)
Ischaemia (for example myocardial infarction, but only if
associated with hypoxaemia (abnormally high levels may be
harmful to patients with ischaemic heart disease and stroke).
Abnormalities in quantity, quality or type of haemoglobin (for
example acute gastrointestinal blood loss or carbon monoxide
poisoning). Carbon monoxide poisoning is the only condition to
aim for a SpO2 over 98%.
Other indications include:
Pneumothorax Oxygen may increase the
rate of resolution of pneumothorax. (British Thoracic Society
Guideline 2010)
Postoperative state (general anaesthesia can lead to a
decrease in functional residual capacity with in the lungs
(especially following thoracic or abdominal surgery) resulting in
hypoxaemia. There is some evidence to suggest a decreased
incidence of post operative wound infections with short-term
oxygen therapy following bowel surgery. (Kabin & Karz 2006) If
oxygen is used for this purpose, please ask the
surgeon/anaesthetist to document this, and ensure this
information is handed over.

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Reduced Oxygen Concentration


Atmospheric air at sea level has a normal oxygen
concentration of 21%. However, at altitude, this concentration
is markedly reduced. If patients are to be sent on commercial
aircraft to another hospital, expert help must be sought.
(British Thoracic Society Guideline 2011)

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

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Procedure for applying correct oxygen delivery device

Action
1.

Rationale

Assess patients need for


mask or nasal cannulae.

To ensure effective delivery of


oxygen.

Explain to the patient what


the treatment is for and
familiarise the patient with the
oxygen delivery device.

To promote patient comfort,


compliance and
understanding.

2.

Attach humidification device if


required. This is indicated by a
flow rate of 5 or more litres for
more than 30 minutes via a
face mask or 35% or more
oxygen unless in pulmonary
oedema (Sheppard & Wright
2006).

To reduce the risk of side


effects associated with dry
gas administration. To
promote patient comfort.

3.

Complete the administration


system by attaching tubing
either small bore or wide bore
corrugated (elephant tubing)
as appropriate (no more than
11 small sections or 5 large
sections).

Oxygen is safely delivered as


prescribed.

Connect to oxygen flow meter


and turn on to the required
flow rate: ensure the ball is in
the middle of the line within
the flow meter. It is the
nurses responsibility to
maintain the correct flow rate,
to deliver the required
concentration.
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Oxygen must be documented


as a percentage for mask and
Venturi barrel, or flow rate if
using Non-rebreathing mask /
nasal cannulae.
4

6.

Adjust oxygen delivery to


optimize saturation levels to
94-98% 0r 88-92% in those at
risk
of
hypercapnic
respiratory failure
Assess and record all vital
signs observations (NICE
2007) including respiratory
rate and pulse oximetry.
Observe
for
signs
of
respiratory
distress
e.g.
increasing respiratory rate,
wheezing, panting and use of
accessory muscles (see NUH
Guideline for Performing and
Recording
Physiological
Observations in the Adult
Patient (2011) and Adult
Observation and EWS Policy
(2011).
Observe patients colour,
looking at nail beds and lips
to detect worsening or
improving cyanosis or as the
patients condition dictates.
Monitor
patient's
oxygen
saturation levels. If it drops
below 90% or 10% below
baseline check position of
probe and inform medical
staff and / or Critical Care
Outreach Team.

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To prevent the problems


associated to both
hypoxemia and
hyperoxemina
To obtain baseline (initial)
values and observe for
changes in a patients
condition.
An increased respiratory
rate is a primary indication
that a patient is becoming
acutely ill.
Slow and shallow respirations
may indicate respiratory
depression.

As a patient becomes more


hypoxic their saturation will
fall, their colour will
deteriorate. Central cyanosis
indicates an arterial oxygen
tension below 8 kPa.

7.

Assess and record pulse rate.

To obtain a baseline value


and observe for any change
in heart rate.
Patients in respiratory
distress often become
tachycardic.

8.

Observe for clinical signs of


deterioration i.e. conscious
level decreases, patients often
become restless, confused or
drowsy and there may be a
drop in saturation.

To detect changes in
patients condition

Inform medical staff and / or


Critical Care Outreach Team.

9.

Patients who require oxygen or


are in respiratory failure should
be encouraged to take regular
deep breaths in a high sitting
or full-side lying position.

To clear bronchial
secretions and to maximise
the effect of the oxygen
therapy.

Liaise with the physiotherapist


if the patient is having difficulty
in expectorating.
10

Collection of water in the


tubing can partially or
completely occlude the flow of
oxygen.

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Routinely check tubing for


water collection and empty as
necessary.

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Offer mouth care. Oral


hygiene and an adequate fluid
intake should be encouraged.
If mask becomes grossly
contaminated with secretions it
should be cleaned/replaced.

Minimise
dryness
and
soreness
to
mouth.
Discomfort and sputum
tenacity are minimised
(Ashurst, 1995).

If lips or nose become dry or


sore a water-based cream can
be used.

Only water-based products,


(such as aqueous cream)
should be used for dry lips
because of the potential
inflammatory properties of
petroleum
jelly.
Do
examine products bought in
by visitors.

Observe for elastic strap


causing tissue damage around
the ears & bridge of nose,
using a strip of hydrocolloid, or
an Aderma strip if necessary.

Oxygen masks, tubing and


ventilation masks are made of
plastic, rubber or silicone,
which can cause rubbing or
create pressure on the soft
tissues (Jaul, 2010).
In
addition, adhesive tapes used
to secure the device may
irritate susceptible skin (Black
et al. 2010).
To avoid
pressure ulcers from occurring
in any location of the body, it
is important to inspect all
external tubing and devices
regularly, adjust pads if
necessary.

If pressure damage is found,


record and treat and monitor
as with any other pressure
ulceration.

To
enable
the
correct
treatment and adherence to
wound management policy.

When discontinuing oxygen To prevent the possibility of


rebound hypoxemia
therapy, do this gradually

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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).

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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).

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Hudson masks without a Venturi barrel; Tracheostomy masks


(with small oxygen port)
These devices are rarely used within the trust, although some
specific areas may still use these devices for short term, specific
use. It is recommended to change to another device if the patient
is transferred outside these areas.

2. Fixed performance devices:


These devices deliver a known percentage of oxygen by mixing
oxygen and air via a Venturi device. Devices which use this
system are:
Venturi masks and adapters; Cold Water Humidification Devices
Non-rebreathing (trauma) masks
High Flow/ Optiflow

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.

Venturi masks and adapters, Cold water humidification devices


The Venturi mask contains a differing size holes situated at the
base of the mask and uses the Venturi effect. A similar
adjustable aperture is present on most cold water humidification
devices. When oxygen passes through the narrow orifice it
produces a high velocity stream which becomes a low pressure
system that draws a constant proportion (up to 40 litres) of room
air through the holes within the mask. Air entrainment depends
on the velocity of the jet, size of the holes and oxygen flow rate.
Each diameter of Venturi gives a different final oxygen
concentration and are available to give oxygen concentration of
24 60%. Note that each concentration will need a different
oxygen flow setting: document the percentage of oxygen
delivered, not the flow rate.
However, if the respiratory rate is over 30 breaths per minute, a
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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).

Non Re-Breathing Oxygen Mask (trauma mask).

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.

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Recommendation for Use


They should NOT be used routinely for patients with COPD/ Type
II respiratory failure. Suitable for trauma patients, on a short term
basis only. The patient should be regularly assessed to see if this
device is still appropriate. Used in an emergency situation (for
example hypoxia, loss of cardiac output or low perfusion).
Best Practice
When in use, the flow rate must be sufficient to keep the reservoir
bag at least a third to half full at all times (Jevon, 2000).

High flow oxygen therapy


High flow oxygen is defined as a device that can deliver over 40
litres of air plus oxygen per minute. This is not to be confused
with high percentage devices although it is common to give both
high flow and a high percentage of oxygen. Between 35% and
100% oxygen can be given. Air is entrained through a Venturi
valve and is humidified before reaching the patient.
Indications for high flow oxygen therapy
Patients who are unable to maintain adequate arterial saturation of
oxygen despite current low flow oxygen therapy and are at risk of
further deterioration would require high flow oxygen. Those who
have respiratory rates over 30 breaths per minute would be
possible candidates for this type of therapy.
The Nasal High Flow device (Optiflow) can deliver oxygen with
better compliance of therapy, with ability to eat, expectorate and
talk, with possible reductions in respiratory rate and complications
(Lowery 2011)
A patient on a specific high flow oxygen must receive oxygen via a
humidified circuit, as piped oxygen is both cold and dry (Viney
1996).

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Procedure for applying high flow oxygen therapy via mask


Equipment
Oxygen supply from a piped supply
Fisher & Paykel humidifier & humidifier set
Corrugated tubing
Water for inhalation
Green T piece
Flow meter
Oxygen analyser
Hudson Mask
Action
1. Ensure all staff and patients
are aware of fire precautions

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

3. Monitor and record patients


respiratory rate and oxygen
saturations, wherever
possible use arterial blood
analysis (Porter-Jones 2002)

To obtain baseline values and


observe for vital changes to
direct oxygen therapy (Lowton
1999)

4. Observe patients breathing


pattern and any use of
accessory muscles

Respiratory rate is a primary


indication that a patient is
becoming acutely ill (Jevon &
Ewenns 2001)

5. Observe patients colour with A patient with falling saturations


special attention to nail beds may have a deterioration in
and lips to check for cyanosis colour
6. Calibrate the oxygen
analyser to air before setting
up the circuit
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To ensure the analyser is


accurate when being used in the
circuit

7. Set up high flow circuit firstly attach the humidifier


set to the humidifier and
attach to water for inhalation
bag. Connect oxygen
analyser to the T piece and
insert into the circuit, ensure
the flow meter is connected
to the piped oxygen supply in
the wall, switch oxygen on
8. Position the mask on the
patients face, adjust the
straps for desired fit

See Appendix 4 (Picture of a


completed high flow circuit)

To maintain patient comfort and


accuracy of delivery

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)

Procedure for applying Optiflow nasal high flow oxygen therapy


Equipment
The equipment for this device is not to be stored on the clinical
area when not in use, and will only to be set up by those
competent in the use of this equipment. As these patients are the
most oxygen dependant patients, the Critical Care Outreach Team
(CCOT) will be reviewing these patients frequently. The equipment
is outlined in the picture in Appendix 5. The responsibility of the
ward clinician is limited to the following:
Principle
1

Ensure water for inhalation is


constantly present: the humidifier will
self fill, but there must always be a
bag with content available
Ensure nasal prongs are seated in
each nostril, particularly following
repositioning
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Rationale
Maintain consistent
humidification Prevent nuisance
alarms
Enables correct delivery of
oxygen

Use a loop of tubing below the nose

Oxygen should be read from the


display

Only those taught directly and


competency assessed by CCOT
should adjust oxygen
Check with CCOT prior to disposing
of equipment

To catch any rain out water


before in is delivered to the
patient
This direct measurement is
accurate; and a sudden change
can indicate tube blockage:
CCOT should be informed if this
occurs
The volume flowmeter is often
confused with the oxygen
flowmeter on this device
The wires are expensive, and
their loss denies another patient
of this device

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,
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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

Oxygen Toxicity and Alveolar Damage.


Oxygen may be toxic, especially in high concentrations. When
greater than 60% may damage the alveolar membrane through
the formation of reactive oxygen species when inhaled for more
than 48 hours (Udwadia 2005 pp253), or result in absorption
atelectasis.
Coronary and cerebral vasoconstriction.
There has been a strong line of research dating back to the
1970s in patients with myocardial infarction and strokes, which
suggests the automatic administration of oxygen may be
associated with greater mortality (Thompson et al 2002). Current
advice is to carefully monitor and give oxygen to achieve, but not
exceed prescribed targets outlined earlier.
Poisons.
Oxygen should be given with caution in those patients with
Paraquat ingestion or Bleomycin lung injury.
Inter and Intra Trust patient transfer.
If the patient is requiring high concentrations of oxygen, then this
could signpost a very sick patient who may not be suitable for
transfer. An assessment must be performed utilizing the Adult
Patient Transfer Assessment Matrix, found within the Internal
Transfer of the Adult Patient Throughout NUH Policy (CLCGP067).
The Critical Care Outreach Team is available for advice regarding
transfer. The amount of oxygen required for any transfer can be
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quickly estimated using the cylinder depletion values on posters


situated near the main oxygen storage on each ward, or Appendix
3 within the Oxygen policy.

2. Health & Safety


All staff should be aware that oxygen supports combustion
(Ashurst, 1995) and patients and visitors be advised of the risks.
Oxygen does not, in itself, explode or burn, but it does enhance
the flammable properties of other materials such as grease and
oils. (Porter-Jones, 2002) It is therefore important to turn off gas
flow to unused devices as soon as possible. Patients cannot leave
the ward for a cigarette with portable oxygen; moreover, if their
condition requires oxygen, they will be probably too ill to do so.
All nurses should know the location of the central oxygen turn off
point for the piped supply in the area they are working, and the
course of action required in the event of fire.

There is also a small risk of fire if dirt, oil, grease contaminate


connections between medical devices and gas cylinders
(Medicines and Healthcare products Regulatory Agency, 2008).
This includes hand creams and alcohol gels, which should be
washed off hands first.
Oxygen cylinders must be stored in a designated dry room, their
numbers should be kept to a minimum, and they must be
secured in a suitable cylinder holder, away from electrical
appliances Appropriate signs should be displayed when a
compressed gas cylinder is in use on the ward or where cylinders
are stored. (Signs can be obtained from Estates Dept). Advice
on transportation of oxygen cylinders can be obtained from
Estates Dept.

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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.

British Thoracic Society Guidelines (2011) Managing passengers


with stable respiratory disease planning air travel: British Thoracic
Society recommendations, British Thoracic Society Air Travel
Working Group Thorax Vol 66 Supplement 1
British Thoracic Society Guidelines (2010) Management of
spontaneous pneumothorax within Pleural Disease Guideline:
British Thoracic Society recommendations, MacDuff, A; Aronld,A;
Harvey, J. Thorax Vol 65 Supplement 2

British Thoracic Society Guidelines (2008) Guideline for


emergency oxygen use in adult patients: British Thoracic Society
recommendations, ODriscoll BR, Howard LS, Davison AG Thorax
Vol 63 Supplement 4
Jaul, E (2011) A prospective pilot study of atypical pressure ulcer
presentation in a skilled geriatric unit. Ostomy Wound
Management. 57(2): pp. 49-54.

Jensen, AG; Johnson, A; Sandtedt, S (1991) Rebreathing during


oxygen treatment with face mask; The effects of oxygen flow rates
on ventilation. Acta anaesthesiol Scand Vol 35 pp289-292
Jevon P, Ewenns B (2001) Assessment of a breathless patient
Nursing Standard Vol. 15 No. 16 pp. 48-53
Nursing Guidelines Oxygen updated Jan 2013
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Kabin, B; Karz, AB; (2006) Optimal perioperative oxygen


administration. Current opinion in Anaesthesiology Vol 19(1) pp1118
Lowery, F (2011) High Flow Oxygen cuts need for intubation in
Acute Respiratory Syndrome. Society of Critical Care Medicine.
Congress: Abstract 381
Lowton, K . (1999) Pulse Oximeters for the detection of
hypoxaemia. Professional Nurse 14 (5) pp. 343-350
Porter-Jones, G. (2002) Short Term oxygen therapy
Nursing Times 98 (40) p.53-56
Patient Group Direction (NMPAS) Administration of high
percentage oxygen to adults in an emergency Nottingham
University Hospitals NHS Trusts, Nottingham 2011.
The Medicines and Healthcare products regulatory Agency (2008)
Oxygen Cylinders and their regulators: Top tips for care and
handling London: MHRA available at www.mrha.gov.uk
Nottingham Nursing Practice Development Group (NNPDG) Mouth
Care Nottingham University Hospitals NHS Trusts, Nottingham
2009. pdf 1287
Nottingham Nursing Practice Development Group (NNPDG)
Physiological Observations Guidelines for Performing. Nottingham
University Hospitals NHS Trusts, Nottingham 2011. pdf 1843
Sheppard M & Wright M (2005) Principles and Practice of High
Dependency Nursing. Bailliere Tindall, London.
Udwadia F (2005) 2nd Edition. Principles of Critical Care. Oxford university
press, Oxford.
Valdez-Lowe, MS; Artinan, NT; Ghareeb, SA (2009) Pulse Oximitry in Adults.
American Journal of Nursing Vol 109 No 6
Waldau, T; Larson, VH; Bonde, J (1998) Evaluation of five oxygen
delivery devices in spontaneously breathing subjects by
oxygraphy. Anaesthesia Vol 53 pp256-263

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Wettstein, RB; Shelledy, DC; Peters, JL (2005) Delivered oxygen


concentrations using low-flow and high flow nasal cannulas. Respir
care Vol 50 pp604-609
Woodrow, P. (2000) Intensive care nursingA framework for
practice. Routledge. London.

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

Updated January 2012


Review date: 2018

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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

Deviation from these values should be reported immediately to the medical


staff so that appropriate action can be taken.

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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

Arterial blood gas.


Failure of part of the lung to expand/collapse of lung
segments.
Continuous positive airway pressure.
Critical Care Outreach team
The % of oxygen the patient is breathing in expressed as a
decimal.
Bicarbonate.
High PaCO2.
Deficiency of oxygen in the blood - PaO2 less than 8kPa.
Deficiency of oxygen within the tissues.
Partial pressure of carbon dioxide in arterial blood.
Partial pressure of oxygen. Daltons law indicates each gas
exerts a partial pressure relative to the concentration in the
mixture. A P before the gas symbol denotes partial
pressure, the a denotes arterial.
Oxygen saturation as measured by pulse oximeter
The PaO2 is low the PaCO2 is normal or low (Field 1997)
e.g. asthma, pulmonary oedema, pulmonary embolism, lung
fibrosis.
The PaO2 may be normal or low and the PaCO2 is high
(Field 1997) e.g.; in some chronic obstructive pulmonary
disease (COPD), lack of neuromuscular control of ventilation
e.g. overdose of respiratory depressive drugs i.e. opioids,
myopathy. Type I respiratory failure may progress to Type II
when the patient becomes exhausted.

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EQUIPMENT FOR HIGH FLOW OXYGEN THERAPY


7
Sterile Water
for Inhalation

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

Fishe r & Paykel

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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EQUIPMENT FOR OPTIFLOW HUMIDIFIED HIGH FLOW VIA


NASAL CANNULAE
Oxygen
display

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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Equality and Diversity Statement


All patients, employees and members of the public should be treated fairly and
with respect, regardless of age, disability, gender, marital status, membership or
non-membership of a trade union, race, religion, domestic circumstances,
sexual orientation, ethnic or national origin, social & employment status, HIV
status, or gender re-assignment.
All trust polices and trust wide procedures must comply with the relevant
legislation (non exhaustive list) where applicable:
Equal Pay Act (1970 and amended 1983)
Sex Discrimination Act (1975 amended 1986)
Race Relations (Amendment) Act 2000
Disability Discrimination Act (1995)
Employment Relations Act (1999)
Rehabilitation of Offenders Act (1974)
Human Rights Act (1998)
Trade Union and Labour Relations (Consolidation) Act 1999
Code of Practice on Age Diversity in Employment (1999)
Part Time Workers - Prevention of Less Favourable Treatment Regulations
(2000)
Civil Partnership Act 2004
Fixed Term Employees - Prevention of Less Favourable Treatment Regulations
(2001)
Employment Equality (Sexual Orientation) Regulations 2003
Employment Equality (Religion or Belief) Regulations 2003
Employment Equality (Age) Regulations 2006
Equality Act (Sexual Orientation) Regulations 2007

Equality Impact Assessment Statement


NUH is committed to ensuring that none of its policies, procedures, services,
projects or functions discriminate unlawfully. In order to ensure this
commitment all policies, procedures, services, projects or functions will undergo
an Equality Impact Assessment.
Reviews of Equality Impact Assessments will be conducted inline with the
review of the policy, procedure, service, project or function
Authors:

Bob Browne, Cheryl Crocker

NPGG Link:
For Review:

Stuart Thompson-Mchale
2018

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