Reprinted from the June 2002 issue of RESPIRATORY CARE [Respir Care 2002;47(6):717–720]
AARC Clinical Practice Guideline
Oxygen Therapy for Adults in the Acute Care Facility — 2002 Revision & Update
OT-AC 1.0 PROCEDURE:
The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers.
OT-AC 2.0 DEFINITION/DESCRIPTION:
Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.(1)
OT-AC 3.0 SETTING:
This Guideline is confined to oxygen administration in the acute care facility.
OT-AC 4.0 INDICATIONS:
- 4.1 Documented hypoxemia. Defined as a decreased PaO2 in the blood below normal range.(2) PaO2 of < 60 torr or SaO2 of < 90% in subjects breathing room air or with PaO2 and/or SaO2 below desirable range for specific clinical situation.(1)
- 4.2 An acute care situation in which hypoxemia is suspected(1,3-6) substantiation of hypoxemia is required within an appropriate period of time following initiation of therapy.
- 4.3 Severe trauma(5,6)
- 4.4 Acute myocardial infarction(1,7)
- 4.5 Short-term therapy or surgical intervention (eg, post-anesthesia recovery(5,8), hip surgery(9,10))
OT-AC 5.0 CONTRAINDICATIONS:
No specific contraindications to oxygen therapy exist when indications are judged to be present.
OT-AC 6.0 PRECAUTIONS AND/OR POSSIBLE COMPLICATIONS:
- 6.1 With PaO2 > or = 60 torr, ventilatory depression may occur in spontaneously breathing patients with elevated PaCO2.(6,11-14)
- 6.2 With FIO2 > or = 0.5, absorption atelectasis, oxygen toxicity, and/or depression of ciliary and/or leukocytic function may occur.(12,15,16)
- 6.3 Supplemental oxygen should be administered with caution to patients suffering from paraquat poisoning(17) and to patients receiving bleomycin.(18)
- 6.4 During laser bronchoscopy, minimal levels of supplemental oxygen should be used to avoid intratracheal ignition.(19)
- 6.5 Fire hazard is increased in the presence of increased oxygen concentrations.
- 6.6 Bacterial contamination associated with certain nebulization and humidification systems is a possible hazard.(20-22)
OT-AC 7.0 LIMITATIONS OF PROCEDURE:
Oxygen therapy has only limited benefit for the treatment of hypoxia due to anemia, and benefit may be limited with circulatory disturbances. Oxygen therapy should not be used in lieu of but in addition to mechanical ventilation when ventilatory support is indicated.
OT-AC 8.0 ASSESSMENT OF NEED:
Need is determined by measurement of inadequate oxygen tensions and/or saturations, by invasive or noninvasive methods, and/or the presence of clinical indicators as previously described.
OT-AC 9.0 ASSESSMENT OF OUTCOME:
Outcome is determined by clinical and physiologic assessment to establish adequacy of patient response to therapy.
OT-AC 10.0 RESOURCES:
For other types of oxygen delivery devices used outside of the acute care facility, reference the AARC Clinical Practice Guideline: Oxygen Therapy in the Home or Extended Care Facility for further description. Respir Care 1992;37(8):918-922.
- 10.1 Equipment
- 10.1.1 Low-flow systems deliver 100% (ie, FDO2 = 1.0) oxygen at flows that are less than the patient's inspiratory flowrate (ie, the delivered oxygen is diluted with room air) and, thus, the oxygen concentration inhaled (FIO2) may be low or high, depending on the specific device and the patient's inspiratory flowrate.(23,24)
- 10.1.1.1 Nasal cannulas can provide 24-40% oxygen with flowrates up to 6 L/min in adults (depending on ventilatory pattern).(1) Oxygen supplied via nasal cannula at flowrates < or = 4 L/min need not be humidified.(25,26) Care must be taken when assigning an estimated FIO2 to patients as this low-flow system can have great fluctuations.(27)
- 10.1.1.2 Simple oxygen masks can provide 35-50% FIO2, depending on fit, at flowrates from 5-10 L/min. Flowrates should be maintained at 5 L/min or more in order to avoid rebreathing exhaled CO2 that can be retained in the mask.(1,20,28) Caution should be taken when using a simple mask where accurate delivery of low concentrations of oxygen is required.(29) Long-term use of simple mask can lead to skin irritation and pressure sores.(30)
- 10.1.1.3 Partial rebreathing mask is a simple mask with a reservoir bag. Oxygen flow should always be supplied to maintain the reservior bag at least one third to one half full on inspiration. At a flow of 6-10 L/min the system can provide 40-70% oxygen. It is considered a low-flow system. The non-rebreathing mask is similar to the partial rebreathing mask except it has a series of one-way valves. One valve is placed between the bag and the mask to prevent exhaled air from returning to the bag. There should be a minimum flow of 10 L/min. The delivered FIO2 of this system is 60-80%.
- 10.1.1.4 Patients who have been receiving transtracheal oxygen at home may continue to receive oxygen by this method in the acute care facility setting provided no problems present. If difficulties related to the transtracheal route of administration appear, oxygenation should be assured by other means.
- 10.1.2 High-flow systems deliver a prescribed gas mixture -- either high or low FDO2 at flowrates that exceed patient demand.(23,24,31)
- 10.1.2.1 Currently available air-entrainment masks can accurately deliver predetermined oxygen concentration to the trachea up to 40%. Jet-mixing masks rated at 35% or higher usually do not deliver flowrates adequate to meet the inspiratory flowrates of adults in respiratory distress.(7,24,31,32)
- 10.1.2.2 Aerosol masks, tracheostomy collars, T-tube adapters, and face tents can be used with high-flow supplemental oxygen systems. A continuous aerosol generator or large-volume reservoir humidifier can humidify the gas flow. Some aerosol generators cannot provide adequate flows at high oxygen concentrations.(1)
- 10.2 Personnel
- 10.2.1 Level I personnel -- ie, any person who has adequately demonstrated the ability to perform the task -- may check and document that a device is being used appropriately and the flow is as prescribed.
- 10.2.2 Level II personnel -- licensed or credentialed respiratory care practitioners or persons with equivalent training and documented ability to perform the tasks -- may assess patients, initiate and monitor oxygen delivery systems, and recommend changes in therapy.
OT-AC 11.0 MONITORING:
- 11.1 Patient
- 11.1.1 clinical assessment including but not limited to cardiac, pulmonary, and neurologic status
- 11.1.2 assessment of physiologic parameters: measurement of PaO2s or saturation in any patient treated with oxygen. An appropriate oxygen therapy utilization protocol is suggested as a method to decrease waste and to realize increased cost savings.(33) Consider need/indication to adjust FDO2 for increased levels of activity and exercise.
- 18.104.22.168 in conjunction with the initiation of therapy; or
- 22.214.171.124 within 12 hours of initiation with FIO2 < 0.40
- 126.96.36.199 within 8 hours, with FIO2 > or = 0.40 (including postanesthesia recovery)
- 188.8.131.52 within 72 hours in acute myocardial infarction7
- 184.108.40.206 within 2 hours for any patient with the principal diagnosis of COPD
- 11.2 Equipment
- 11.2.1 All oxygen delivery systems should be checked at least once per day.
- 11.2.2 More frequent checks by calibrated analyzer are necessary in systems
- 220.127.116.11 susceptible to variation in oxygen concentration (eg, high-flow blending systems)
- 18.104.22.168 applied to patients with artificial airways
- 22.214.171.124 delivering a heated gas mixture
- 126.96.36.199 applied to patients who are clinically unstable or who require an FIO2 of 0.50 or higher.
- 11.2.3 Care should be taken to avoid interruption of oxygen therapy in situations including ambulation or transport for procedures.
OT-AC 12.0 FREQUENCY:
Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations (eg, exercise and sleep).
OT-AC 13.0 INFECTION CONTROL:
Under normal circumstances, low-flow oxygen systems (including cannulas and simple masks) do not present clinically important risk of infection and need not be routinely replaced.1 High-flow systems that employ heated humidifiers and aerosol generators, particularly when applied to patients with artificial airways, can pose important risk of infection. In the absence of definitive studies to support change-out intervals, results of institution-specific and patient-specific surveillance measures should dictate the frequency with which such equipment is replaced.
Revised by Thomas J Kallstrom RRT FAARC, Fairview Hospital, Cleveland, OH, and approved by the 2002 CPG Steering Committee.
Original publication: Respir Care 1991;36(12):1410-1413.
- Fulmer JD, Snider GL. ACCP-NHLBI National Conference on Oxygen Therapy. Chest 1984;86(2):234-247. Concurrent publication in Respir Care 1984;29(9):922-935.
- Pierson DJ. Pathophysiology and clinical effects of chronic hypoxia. Respir Care 2000;45(1):39-51; discussion 51-53.
- Winter PM, Miller JN. Carbon monoxide poisoning. JAMA 1976;236(13):1502-1504.
- Office of Professional Standards Review Organization, Health Care Financing Administration. Technical assistance document: approaches to the review of respiratory therapy services. Respir Care 1981;26(5):459-478.
- Blue Cross and Blue Shield Association. Medical necessity guidelines for respiratory care (inpatient). Chicago: Blue Cross/Blue Shield, 1982.
- Snider GL, Rinaldo JE. Oxygen therapy in medical patients hospitalized outside of the intensive care unit. Am Rev Respir Dis 1980;122(5 Pt 2):29-36.
- Maroko PR, Radvany P, Braunwell E, Hale SL. Reduction of infarct size by oxygen inhalation following acute coronary occlusion. Circulation 1975;52(3):360-368.
- Fairley HB. Oxygen therapy for surgical patients. Am Rev Respir Dis 1980;122(5 rt 2):37-44.
- Fugere F, Owen H, Ilsley AH, Plummer JL, Hawkins DJ. Changes in oxygen saturation in the 72 hours after hip surgery: the effect of oxygen therapy. Anaesth Intensive Care 1994;22(6):724-728.
- Clayer M, Bruckner J. Occult hypoxia after femoral neck fracture and elective hip surgery. Clin Orthop 2000 Jan;(370):265-271.
- Mithoefer JC, Karetsky MS, Mead GD. Oxygen therapy in respiratory failure. N Engl J Med 1967;277(18):947-949.
- Fisher AB. Oxygen therapy: side effects and toxicity. Am Rev Respir Dis 1980;122(5 Pt 2):61-69.
- Hanson CW 3rd, Marshall BE, Frasch HF, Marshall C. Causes of hypercarbia with oxygen therapy in patients with chronic obstructive pulmonary disease. Crit Care Med 1996;24(1):23-28.
- Chien JW, Ciufo R, Novak R, Skowronski M, Nelson J, Coreno A, McFadden ER Jr. Uncontrolled oxygen administration and respiratory failure in acute asthma. Chest 2000;117(3):728-733.
- Frank L, Massaro D. Oxygen toxicity. Am J Med 1980;69(1):117-126.
- Lodato RF. Oxygen toxicity. Crit Care Clin 1990;6(3):749-765.
- Fairshter RD, Rosen SM, Smith WR, Glauser FL, McRae DM, Wilson AF. Paraquat poisoning: new aspects of therapy. Q J Med 1976;45(180):551-565.
- Ingrassia TS 3rd, Ryu JH, Trastek VF, Rosenow EC 3rd. Oxygen-exacerbated bleomycin pulmonary toxicity. Mayo Clin Proc 1991;66(2):173-178.
- Schramm VL Jr, Mattox DE, Stool SE. Acute management of laser-ignited intratracheal explosion. Laryngscope 1981;91(9 Pt 1):1417-1426.
- Reinarz JA, Pierce AK, Mays BB, Sanford JP. The potential role of inhalation therapy equipment in nosocomial pulmonary infections. J Clin Invest 1965; 44:831-839.
- Pierce AK, Sanford JP, Thomas GD, Leonard JS. Long-term evaluation of decontamination of inhalation-therapy equipment and the occurrence of necrotizing pneumonia. N Engl J Med 1970;282(10):528-531.
- U.S. Department of Health and Human Services, Public Health Services, Centers for Disease Control. Guideline for prevention of nosocomial pneumonia and guideline ranking scheme. Atlanta: CDC; 1982.
- Redding JS, McAffee DD, Gross CW. Oxygen concentrations received from commonly used delivery systems. South Med J 1978;71(2):169-172.
- Goldstein RS, Young J, Rebuck AS. Effect of breathing pattern on oxygen concentration received from standard face masks. Lancet 1982;2(8309):1188-1190.
- Estey W. Subjective effects of dry versus humidified low-flow oxygen. Respir Care 1980;25(11):1143-1144.
- Campbell EJ, Baker MD, Crites-Silver P. Subjective effects of humidification of oxygen for delivery by nasal cannula: a prospective study. Chest 1988;93(2):289-293.
- Bazuaye EA, Stone TN, Corris PA, Gibson GJ. Variability of inspired oxygen concentration with nasal cannulas. Thorax 1992;47(8):609-611.
- Jensen AG, Johnson A, Sandstedt S. Rebreathing during oxygen treatment with face mask: the effect of oxygen flow rates on ventilation. Acta Anaesthesiol Scand 1991;35(4):289-292.
- Jeffrey AA, Warren PM. Should we judge a mask by its cover? Thorax 1992;47(7):543-546.
- Kacmarek RM. Methods of oxygen delivery in the hospital. Prob Respir Care 1990;3:563-574.
- Friedman SA, Weber B, Brisco WA, Smith JP, King TKC. Oxygen therapy: evaluation of various air-entraining masks. JAMA 1974;228(4):474-478.
- Branson R. Respiratory care equipment. New York: Lippincott Williams & Wilkins; 1999:77.
- Konschak MR, Binder A, Binder RE. Oxygen therapy utilization in a community hospital: use of a protocol to improve oxygen administration and preserve resources. Respir Care 1999;44(5):506-511.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the June 2002 issue of RESPIRATORY CARE [Respir Care 2002;47(6):717–720]