Adult Oxygen Therapy Guidelines

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 Document derivation / evidence base: Review Date Lead Executive Author/Lead Manager Clinical Practitioners administrating oxygen 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.
Page1
Nottingham University Hospitals NHS Trust CLINICAL GUIDELINES GUIDELINES FOR THE ADMINISTRATION OF OXYGEN IN ADULTS
Page No 3 4 5 6 7 11
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
13 13 14 15 16 16 17
18
19 20 21 23 24 25 26 27 28
Nursing Guidelines Oxygen updated Jan 2013 Page2 Nursing Practice Guidelines Group
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
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
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.
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
Procedure for applying correct oxygen delivery device
Action 1. Assess patients need for mask or nasal cannulae. Explain to the patient what the treatment is for and familiarise the patient with the oxygen delivery device.
Rationale To ensure effective delivery of oxygen. 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). 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.
Oxygen is safely delivered as prescribed.
Oxygen must be documented as a percentage for mask and Venturi barrel, or flow rate if using Non-rebreathing mask / nasal cannulae. 4 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. 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.
6.
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. Inform medical staff and / or Critical Care Outreach Team.
To detect changes in patients condition
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. Liaise with the physiotherapist if the patient is having difficulty in expectorating.
To clear bronchial secretions and to maximise the effect of the oxygen therapy.
10
Collection of water in the tubing can partially or completely occlude the flow of oxygen.
Routinely check tubing for water collection and empty as necessary.
11
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. 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. To enable the correct treatment and adherence to wound management policy.
12
Observe for elastic strap causing tissue damage around the ears & bridge of nose, using a strip of hydrocolloid, or an Aderma strip if necessary.
If pressure damage is found, record and treat and monitor as with any other pressure ulceration. 13
When discontinuing oxygen To prevent the possibility of rebound hypoxemia therapy, do this gradually
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).
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
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.
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).
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 Rationale Oxygen readily supports combustion therefore fire regulations should be adhered to To aid chest expansion and ensure patient is comfortable
2. Ensure patient is in a comfortable position, encourage an upright position, maybe supported with pillows 3. Monitor and record patients respiratory rate and oxygen saturations, wherever possible use arterial blood analysis (Porter-Jones 2002) 4. Observe patients breathing pattern and any use of accessory muscles
To obtain baseline values and observe for vital changes to direct oxygen therapy (Lowton 1999)
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
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
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,
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
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.
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
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
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
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.
Nursing Guidelines Oxygen updated August 2011 Nursing Practice Guidelines Group
24
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.
25
EQUIPMENT FOR HIGH FLOW OXYGEN THERAPY 7

Sterile Water for Inhalation
02 Analyser Calibrate
2
Oxygen Mask
8
ON/OFF
9
02 Regulator
3
Hea ted Wire 0 2 Tubing
10
Litre Regulator always on Max
4
Wate r Bath
5
Fishe r & Paykel Controls. ON/OFF Alarm Trouble Shoot Default Intubated non Intubated
11
Particle Filter
12 6 Heater Wires 13
White Tubing T Piece & 02 Analyser
KH/CCSC/2004
Appendix 3
26
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
27
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 Stuart Thompson-Mchale 2018
28
NPGG Link: For Review:
29

Adult Oxygen Therapy Guidelines

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Adult Oxygen Therapy Guidelines

Uploaded by

Copyright:

Available Formats

CLINICAL GUIDELINES Guideline for Administration of Oxygen in Adults 2012 Reference Date approved Feb 2013 Approving Body

Assessing the need for oxygen therapy

Indications for oxygen therapy

Procedure for applying correct oxygen delivery device

Oxygen is safely delivered as prescribed.

Assess and record pulse rate.

To detect changes in patients condition

Routinely check tubing for water collection and empty as necessary.

If lips or nose become dry or sore a water-based cream can be used.

Non Re-Breathing Oxygen Mask (trauma mask).

High flow oxygen therapy

To ensure the analyser is accurate when being used in the circuit

See Appendix 4 (Picture of a completed high flow circuit)

To maintain patient comfort and accuracy of delivery

Use a loop of tubing below the nose

Oxygen should be read from the display

Updated January 2012 Review date: 2018

SpO2 Type I Respiratory failure Type II Respiratory failure

EQUIPMENT FOR HIGH FLOW OXYGEN THERAPY 7

EQUIPMENT FOR OPTIFLOW HUMIDIFIED HIGH FLOW VIA NASAL CANNULAE

Water tube to bag

Humidifier Flow to patient (nasal prongs not shown)

Equality and Diversity Statement

Equality Impact Assessment Statement

NPGG Link: For Review:

You might also like