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NEW guidelines to help minimise the hazards of oxygen administration in acute care have been welcomed by experts.
Dr Simon Joosten, respiratory specialist and fellow of the Royal Australasian College of Physicians, told MJA InSight said the guidelines, from the Thoracic Society of Australia and New Zealand (TSANZ), addressed the problem of oxygen being given too easily in hospitals, “often without a thought to the potential risks, and at a much greater rate than is necessary”.
However, he emphasised that much more must happen before oxygen could be formalised as a drug. “It’s all good and well to have guidelines, but making people aware of them and then changing practice is the real issue.”
Dr Joosten was commenting on an MJA editorial which highlighted the importance of regularly monitoring oxygen use to maintain saturation levels within the prescribed range. (1)
The editorial authors, Professor Haydn Walters from the University of Tasmania, and Associate Professor Greg King, of the University of Sydney, wrote that a core and firm principle of the TSANZ guidelines was to formalise the use of oxygen as a drug “that is rationally and precisely prescribed”.
They said that meant it should have a specified mode of delivery, with nasal cannulae their preferred option, a flow rate (or FiO2) and rational target range of oxygen saturation.
While oxygen therapy was a common clinical approach, existing evidence for its use was at best anecdotal, and mainly cultural, they wrote. The guidelines for oxygen use in the acute medical setting, to be published soon in Respirology, would help provide evidence-based interpretation in this currently confusing area.
The guidelines had already been endorsed by the TSANZ board and a wide range of other professional medical, nursing and allied health bodies.
The saturation range recommended allowed “both deterioration and improvement in the patient’s condition to be detected easily and in a timely way, rather than being masked by overoxygenation”, the authors wrote.
They said the emphasis of the guidelines was “on heeding changes in the levels of oxygen saturation, not for their own sake, but as a reflection of the underlying condition”.
The guidelines support initial arterial blood gas measurements to define the true oxygen and carbon dioxide status of the patients. They also include sufficient safety margins to account for the variability of pulse oximeters in monitoring oxygenation levels.
Professor Ian Yang, director of thoracic medicine at The Prince Charles Hospital and head of the University of Queensland Northside Clinical School, said the guidelines reflected the move towards a more systematised approach to complex prescriptions in Australia.
“For example, anticoagulation charts for [intravenous] heparin and commencing oral warfarin, and insulin charts, have proven to be practical and safe”, he told MJA InSight. “The same could be done for oxygen prescription in the acute setting — to give the multidisciplinary health care team a practical guide for individualising safe oxygen therapy for inpatients under their care.”
Professor Richard Beasley, a respiratory physician and spokesperson for TSANZ, told MJA InSight that the guidelines had been developed to be used by “all health professionals responsible for the administration and/or monitoring of oxygen therapy”.
“This includes the community and hospital settings, but excludes perioperative and intensive care patients”, he said.
Professor Beasley said that once published, the TSANZ guidelines should form part of the ongoing training of physicians in oxygen therapy best-practice.
However, Dr Joosten said the implementation of guidelines were always a “hard sell” to hospital nurses and doctors, who are often overburdened with paperwork, policies and procedures.
“The TSANZ guidelines are essentially — and quite rightly, in my opinion — making it more difficult to prescribe oxygen and potentially increasing the documentation required to do so.
“I cannot see the TSANZ being able to implement this sort of change on their own, perhaps [they will need] the help of regulatory bodies such as the Therapeutic Goods Administration or some other overarching body that can influence hospital policy”, Dr Joosten said.
I think Sue Ieraci misses the point. I would be interested to see what the evidence is that may or may not back up Sue’s assertions above. In the out-of-hospital and pre-ambulance attendance scenarios Sue’s argument might be the case, but I intuitively suspect that where there is medical intervention available (because oxygen is now so ubiquitous) …any ‘hypoxic’ mortality or morbidity is less likely to be due to insufficient provision of oxygen and much more likely to be due consequences of inappropriate use of supplemental oxygen, which is the message of the original article. I wonder what role the now wide-spread use of the “venous blood gas” (which is absolutely bereft of any credible scientific or clinical data) has had in the increasingly poor understanding of the risks of supplemental O2?
Hypoxia remains a far more common cause of morbidity and mortality than oxygen therapy. In calling for yet more guidelines, it’s important not to create more harms than we prevent.
I don’t see what paperwork has to do with it. The guidelines are simply common sense. We shouldn’t be providing ANY type of treatment without thought about the potential benefit or harm (nor without specifying the required “dose”). Oxygen is no different. Within the hospital system the easiest means to initiate this change is modification to the standard statewide inpatient observation charts. Policy and procedure documents may well follow but won’t affect practice (with the likelihood of any person reading them being inversely proportional to the number of pages).
The major issue to prevent and detect is MAJOR ventilatory failure/sedation which leads to hypoxic damage/death. Routine oxygen only reduces the initial prevalence of mild hypoxia. (I’m not arguing against the use of oxygen, but blanket oxygen for even people with normal/ high oxygen saturation.) Routine oxygen removes or inhibits one early sign in the detection of ventilatory failure/sedation. The treatment for worsening ventilatory failure/sedation is not the application of more facial oxygen as cornoial cases have demonstrated. When catastrophic ventilatory failure occurs, it occurs quickly, despite recent normal sats on facial oxygen. When routine oxygen is used and mild hypoxia occurs, it occurs at a stage of deeper ventilatory depression, higher hypercarbia and deeper sedation. That is, the detection of ventilatory failure may occur at a more dangerous and critical stage. Oxygen administration has also been shown to increase opiod induced ventilatory depression. In addition the data for adverse effects of hyperoxia is increasing.
Over the past two decades, I have experienced a disproportional increase in regulatory burden usually resulting in more paperwork and time wasted on administrative tasks.
When I compare my productivity a decade ago to now, it has about halved. When I look at time actually spent with a patient, be it physical examination, explaining the problem and management, and ensuring the patient has understood – it has more than halved. When I look at actual outcome achieved in terms of working hours per day – my hunch is it has deteriorated too. You cannot expect to improve outcome merely by increasing the paperwork burden and micro-managing professionals.
Hence, I won’t hold my breath in expectation of more regulations and paperwork for oxygen administration improving outcome. I would expect far more improvement in outcome (at a fraction of the cost) if quality unbiased and affordable education were provided to doctors.
Western Australia has enforced oxygen prescription via leadership from its then Chief Medical Officer following a Coronial Inquest into the death of a patient from asphyxia. Subsequently, there has been an Operational Directive from the Director General of Health some years ago. This has been reaffirmed in recent weeks, after further review. Oxygen prescription is mandated in all public and private hospitals in WA.