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Thoracic Society of australia and new Zealand

oxyGen GuidelineS for acuTe oxyGen uSe in adulTS

“Swimming between the ags"

clinical Practice Guideline Published as Clinical Practice Guideline Original Article Beasley, R., Chien, J., Douglas, J., Eastlake, L., Farah, C., King, G., Moore, R., Pilcher, J., Richards, M., Smith, S. and Walters, H. (2015) , Thoracic

Fisher and Paykel Healthcare.

(Associate Editor: Chi Chiu Leung)

October 2015

ii

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS

Richard Beasley

Jimmy Chien

Australia

James Douglas

Claude Farah

Gregory King

Australia

Rosemary Moore

Janine Pilcher

Medical Research Institute of New Zealand, Wellington, New Zealand

Sheree Smith

Haydn Walters

iii

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS

GloSSary

ABG:

Arterial blood gas

BTS:

British Thoracic Society

MDI:

Metered dose inhaler

SaO2: Arterial oxygen saturation (measured by arterial blood gas) SIGN:

Scottish Intercollegiate Guidelines Network

TSANZ:

Thoracic Society of Australia and New Zealand

1

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS

Purpose:

org.au/).

Systematic review:

Grading:

Grade of recommendationDescription

A B C D

Guideline development Group:

guidelines. inTroducTion 2

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS

Peer review:

and New Zealand College of Anaethetists, the Australian College of Nursi ng Ltd, the Cardiac Society of Aus Authorities Inc, and the Internal Medicine Society of Australia and New

Zealand.

dissemination plan:

New Zealand.

implementation: expiry date: 2019 conict of interest statements: declare. 3

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS K ey r eco MM endaTionS 1. Pulse oximetry should be available in all clinical situations in which o xygen is used. [GRADE C] 2. Arterial blood gas measurements should be considered in the following si tuations: [GRADE C] 2 2 3. Oxygen saturation measured by pulse oximetry should be considered a ‘vital sign" and documented with other vital signs in patient assessment and management. [GRADE D] 4. An oxygen prescription should be documented in the patient records and drug chart. [GRADE D] 5.

In COPD [GRADE B] and other conditions [GRADE C] associated with chronic respiratory failure, oxygen should be administered if the SpO

2 is less than 88%, and titrated to a target SpO 2 range of 88% to 92%. 6. In other acute medical conditions, oxygen should be administered if the SpO 2 is less than 92%, and titrated to a target SpO 2 range of 92% to 96%. [GRADE C] 7.

Patients who need an:

FiO 2 2 FiO 2 2 8.

In COPD and other conditions associated with chronic respiratory failure the preferred method of bronchodilator administration is an air-driven nebuliser or metered dose inhaler +/- a spacer. [GRADE B]

9. For most patients standard nasal cannulae are the preferred method of oxygen delivery, with ȵ 10. In patients with hypercapnic respiratory failure (arterial pH <7.35 and PaCO 2 >45 mmHg), NIV or invasive ventilation should be considered. [GRADE A] COPD patients with a pH <7.26 managed with NIV require intensive monitoring with a low threshold for intubatio n. [GRADE A] 11.

It is recommended that patients receiving ventilatory support are located in an area, such as an HDU, ICU, a close observation unit or monitored bed unit, where there are adequate numbers ΍titration of therapy. [GRADE D]

4

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS

Figure 1: Treatment algorithm for oxygen therapy

grading. 2 : Oxygen, PaCO 2 PaO 2 2 SpO 2 <88% SpO 2 <88% 2 admission O 2 to maintain 2 rangeO 2 as needed to 2

Titrate O

2 to target 2

TitrateO

2 to 2 PaCO 2 or PaO 2 2 PaCO 2 and PaO 2

ȲSpO

2 <92% SpO 2 >88%SpO 2 <85%SpO 2

85-91%SpO

2 >92%

Start O

2 nasal cannulae or mask

Titrate O

2 to 2 bronchodilator (if or MDI 2

Continue monitoring

2 nasal cannulae, mask, 15L/

HFNC (Fi O

2 clinical situation

Titrate O

2 to 2

Titrate O

2 to 2 2 not routinely

Continue monitoring O

2 saturation NO 5

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS concePTS 1. 2. 5. 2 8. 2 2 6

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline - a cu T e o xy G en uS e in a dulTS reco MM endaTionS assessment: [Grade C] Practice point: There is variable accuracy of pulse oximetry to predict SaO 2 in acutely ill patients, with SpO 2 measurements both over and under estimating SaO 2 , with wide limits of agreement. 4-9

The accuracy of SpO

2 may worsen with progressive hypoxaemia. 8, 9 Clinicians need to be aware of the variable accuracy of SpO 2 in the utilisation of pulse oximetry in clinical practice. (Footnote 5) An SpO 2 of >92% is a practical lower threshold to rule out hypoxaemia, 2 <90%7 or an arterial partial pressure of oxygen (PaO 2 ) <60mmHg (8 kPa). 5

2. Arterial blood gas (ABG) measurement should be considered in the f

ollowing situations: [Grade C] 2 2 of PaCO 2 or PaO 2 10 10 (Footnote 2 2 measurements.

11, 12

PCO 2 2

Practice point: Hypoxaemia requires investigation and treatment of the underlying cause, and consideration of the

contribution of hypoventilation, including measurement of arterial partial pressure of carbon dioxide (PaCO

2 ) and pH.

Prescription:

[Grade D]

Practice point:

The main requirement for an oxygen prescription is documentation of the target SpO 2 range.

In its most detailed form, the prescription could include the delivery system and interface, the target oxygen saturation

2 and FiO 2 at which clinical review should be sought. Considerable space on the prescription form is needed to provide such detail. 7

Thoracic Socie

T y of a u ST ralia and n ew Zealand c linical Prac T ice Guideline -quotesdbs_dbs50.pdfusesText_50

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