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AARC GUIDELINE: FOR ADULTS IN THE ACUTE CARE FACILITY

AARC Clinical Practice Guideline

Oxygen Therapy for Adults in the Acute Care Facility — 2002 Revision & Update

OT-AC 1.0 PROCEDURE: 6.2 With FIO2 ≥ 0.5, absorption atelectasis, oxy- The procedure addressed is the administration of gen toxicity, and/or depression of ciliary and/or oxygen therapy in the acute care facility other than leukocytic function may occur.12,15,16 with mechanical ventilators and hyperbaric cham- 6.3 Supplemental oxygen should be adminis- bers. tered with caution to patients suffering from poisoning17 and to patients receiving OT-AC 2.0 DEFINITION/DESCRIPTION: .18 Oxygen therapy is the administration of oxygen at 6.4 During laser , minimal levels greater than that in ambient air with of supplemental oxygen should be used to the intent of treating or preventing the symptoms avoid intratracheal ignition.19 and manifestations of .1 6.5 Fire is increased in the presence of increased oxygen concentrations. OT-AC 3.0 SETTING: 6.6 Bacterial contamination associated with This Guideline is confined to oxygen administra- certain nebulization and humidification sys- tion in the acute care facility. tems is a possible hazard.20-22

OT-AC 4.0 INDICATIONS: OT-AC 7.0 LIMITATIONS OF PROCEDURE: 4.1 Documented . Defined as a de- Oxygen therapy has only limited benefit for the 2 creased PaO2 in the blood below normal range. treatment of hypoxia due to anemia, and benefit PaO2 of < 60 torr or SaO2 of < 90% in subjects may be limited with circulatory disturbances. Oxy- room air or with PaO2 and/or SaO2 gen therapy should not be used in lieu of but in ad- below desirable range for specific clinical situ- dition to when ventilatory ation.1 support is indicated. 4.2 An acute care situation in which hypoxemia is suspected1,3-6 substantiation of hypoxemia is OT-AC 8.0 ASSESSMENT OF NEED: required within an appropriate period of time fol- Need is determined by measurement of inadequate lowing initiation of therapy. oxygen tensions and/or saturations, by invasive or 4.3 Severe trauma5,6 noninvasive methods, and/or the presence of clini- 4.4 Acute myocardial infarction1,7 cal indicators as previously described. 4.5 Short-term therapy or surgical intervention (eg, post- recovery5,8, hip surgery9,10) OT-AC 9.0 ASSESSMENT OF OUTCOME: Outcome is determined by clinical and physiologic OT-AC 5.0 CONTRAINDICATIONS: assessment to establish adequacy of patient re- No specific contraindications to oxygen therapy sponse to therapy. exist when indications are judged to be present. OT-AC 10.0 RESOURCES: OT-AC 6.0 PRECAUTIONS AND/OR POSSI- For other types of oxygen delivery devices used BLE COMPLICATIONS: outside of the acute care facility, reference the 6.1 With PaO2 ≥ 60 torr, ventilatory depression AARC Clinical Practice Guideline: Oxygen Thera- may occur in spontaneously breathing patients py in the Home or Extended Care Facility for fur- 6,11-14 with elevated PaCO2. ther description. Respir Care 1992;37(8):918-922.

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10.1 Equipment provided no problems present. If diffi- 10.1.1 Low-flow systems deliver 100% culties related to the transtracheal route (ie, FDO2 = 1.0) oxygen at flows that are of administration appear, oxygenation less than the patient’s inspiratory flowrate should be assured by other means. (ie, the delivered oxygen is diluted with 10.1.2 High-flow systems deliver a pre- room air) and, thus, the oxygen concentra- scribed gas mixture—either high or low tion inhaled (FIO2) may be low or high, FDO2 at flowrates that exceed patient de- depending on the specific device and the mand.23,24,31 patient’s inspiratory flowrate.23,24 10.1.2.1 Currently available air-en- 10.1.1.1 Nasal cannulas can provide trainment masks can accurately deliver 24-40% oxygen with flowrates up to 6 predetermined oxygen to L/min in adults (depending on ventila- the up to 40%. Jet-mixing tory pattern).1 Oxygen supplied via masks rated at 35% or higher usually nasal cannula at flowrates ≤ 4 L/min do not deliver flowrates adequate to need not be humidified.25,26 Care must meet the inspiratory flowrates of adults be taken when assigning an estimated in respiratory distress.7,24,31,32 FIO2 to patients as this low-flow system 10.1.2.2 Aerosol masks, tracheostomy can have great fluctuations.27 collars, T-tube adapters, and face tents 10.1.1.2 Simple oxygen masks can pro- can be used with high-flow supplemen- vide 35-50% FIO2, depending on fit, at tal oxygen systems. A continuous flowrates from 5-10 L/min. Flowrates aerosol generator or large-volume should be maintained at 5 L/min or reservoir humidifier can humidify the more in order to avoid rebreathing ex- gas flow. Some aerosol generators can- haled CO2 that can be retained in the not provide adequate flows at high mask.1,20,28 Caution should be taken oxygen concentrations.1 when using a simple mask where accu- 10.2 Personnel rate delivery of low concentrations of 10.2.1 Level I personnel—ie, any person oxygen is required.29 Long-term use of who has adequately demonstrated the simple mask can lead to skin irritation ability to perform the task—may check and sores.30 and document that a device is being used 10.1.1.3 Partial rebreathing mask is a appropriately and the flow is as pre- simple mask with a reservoir bag. Oxy- scribed. gen flow should always be supplied to 10.2.2 Level II personnel—licensed or maintain the reservior bag at least one credentialed respiratory care practitioners third to one half full on inspiration. At or persons with equivalent training and a flow of 6-10 L/min the system can documented ability to perform the tasks— provide 40-70% oxygen. It is consid- may assess patients, initiate and monitor ered a low-flow system. The non-re- oxygen delivery systems, and recommend breathing mask is similar to the partial changes in therapy. rebreathing mask except it has a series of one-way valves. One valve is placed OT-AC 11.0 MONITORING: between the bag and the mask to pre- 11.1 Patient vent exhaled air from returning to the 11.1.1 clinical assessment including but bag. There should be a minimum flow not limited to cardiac, pulmonary, and of 10 L/min. The delivered FIO2 of this neurologic status system is 60-80%. 11.1.2 assessment of physiologic parame- 10.1.1.4 Patients who have been re- ters: measurement of PaO2s or saturation ceiving transtracheal oxygen at home in any patient treated with oxygen. An ap- may continue to receive oxygen by this propriate oxygen therapy utilization pro- method in the acute care facility setting tocol is suggested as a method to decrease

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waste and to realize increased cost sav- change-out intervals, results of institution-specific ings.33 Consider need/indication to adjust and patient-specific surveillance measures should FDO2 for increased levels of activity and dictate the frequency with which such equipment is exercise. replaced. 11.1.2.1 in conjunction with the initia- tion of therapy; or Revised by Thomas J Kallstrom RRT FAARC, 11.1.2.2 within 12 hours of initiation Fairview Hospital, Cleveland, OH, and approved with FIO2 < 0.40 by the 2002 CPG Steering Committee. 11.1.2.3 within 8 hours, with FIO2 ≥ 0.40 (including postanesthesia recov- Original publication: Respir Care 1991;36(12):1410-1413. ery) 11.1.2.4 within 72 hours in acute my- REFERENCES 7 ocardial infarction 1. Fulmer JD, Snider GL. ACCP-NHLBI National Confer- 11.1.2.5 within 2 hours for any patient ence on Oxygen Therapy. Chest 1984;86(2):234-247. Con- with the principal diagnosis of COPD publication in Respir Care 1984;29(9):922-935. 11.2 Equipment 2. Pierson DJ. Pathophysiology and clinical effects of chronic 11.2.1 All oxygen delivery systems hypoxia. Respir Care 2000;45(1):39-51; discussion 51-53. should be checked at least once per day. 3. Winter PM, Miller JN. Carbon monoxide poisoning. JAMA 1976;236(13):1502-1504. 11.2.2 More frequent checks by calibrated 4. Office of Professional Standards Review Organization, analyzer are necessary in systems Health Care Financing Administration. Technical assis- 11.2.2.1 susceptible to variation in oxy- tance document: approaches to the review of respiratory gen concentration (eg, high-flow therapy services. Respir Care 1981;26(5):459-478. blending systems) 5. Blue Cross and Blue Shield Association. Medical necessi- ty guidelines for respiratory care (inpatient). Chicago: 11.2.2.2 applied to patients with artifi- Blue Cross/Blue Shield, 1982. cial airways 6. Snider GL, Rinaldo JE. Oxygen therapy in medical pa- 11.2.2.3 delivering a heated gas mix- tients hospitalized outside of the intensive care unit. Am ture Rev Respir Dis 1980;122(5 Pt 2):29-36. 11.2.2.4 applied to patients who are 7. Maroko PR, Radvany P, Braunwell E, Hale SL. Reduction clinically unstable or who require an of infarct size by oxygen inhalation following acute coro- nary occlusion. Circulation 1975;52(3):360-368. FIO2 of 0.50 or higher. 8. Fairley HB. Oxygen therapy for surgical patients. Am Rev 11.2.3 Care should be taken to avoid inter- Respir Dis 1980;122(5 rt 2):37-44. ruption of oxygen therapy in situations in- 9. Fugere F, Owen H, Ilsley AH, Plummer JL, Hawkins DJ. cluding ambulation or transport for proce- Changes in in the 72 hours after hip dures. : the effect of oxygen therapy. Anaesth Intensive Care 1994;22(6):724-728. 10. Clayer M, Bruckner J. Occult hypoxia after femoral neck OT-AC 12.0 FREQUENCY: fracture and elective hip surgery. Clin Orthop 2000 Oxygen therapy should be administered continu- Jan;(370):265-271. ously unless the need has been shown to be associ- 11. Mithoefer JC, Karetsky MS, Mead GD. Oxygen therapy in ated only with specific situations (eg, exercise and . N Engl J Med 1967;277(18):947-949. sleep). 12. Fisher AB. Oxygen therapy: side effects and toxicity. Am Rev Respir Dis 1980;122(5 Pt 2):61-69. 13. Hanson CW 3rd, Marshall BE, Frasch HF, Marshall C. OT-AC 13.0 INFECTION CONTROL: Causes of hypercarbia with oxygen therapy in patients Under normal circumstances, low-flow oxygen sys- with chronic obstructive pulmonary disease. Crit Care tems (including cannulas and simple masks) do not Med 1996;24(1):23-28. present clinically important risk of infection and 14. Chien JW, Ciufo R, Novak R, Skowronski M, Nelson J, 1 Coreno A, McFadden ER Jr. Uncontrolled oxygen admin- need not be routinely replaced. High-flow systems istration and respiratory failure in acute asthma. Chest that employ heated humidifiers and aerosol genera- 2000;117(3):728-733. tors, particularly when applied to patients with arti- 15. Frank L, Massaro D. . Am J Med ficial airways, can pose important risk of infection. 1980;69(1):117-126. In the absence of definitive studies to support 16. Lodato RF. Oxygen toxicity. Crit Care Clin

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1990;6(3):749-765. face masks. Lancet 1982;2(8309):1188-1190. 17. Fairshter RD, Rosen SM, Smith WR, Glauser FL, McRae 25. Estey W. Subjective effects of dry versus humidified low- DM, Wilson AF. Paraquat poisoning: new aspects of ther- flow oxygen. Respir Care 1980;25(11):1143-1144. apy. Q J Med 1976;45(180):551-565. 26. Campbell EJ, Baker MD, Crites-Silver P. Subjective ef- 18. Ingrassia TS 3rd, Ryu JH, Trastek VF, Rosenow EC 3rd. fects of humidification of oxygen for delivery by nasal Oxygen-exacerbated bleomycin pulmonary toxicity. cannula: a prospective study. Chest 1988;93(2):289-293. Mayo Clin Proc 1991;66(2):173-178. 27. Bazuaye EA, Stone TN, Corris PA, Gibson GJ. Variabili- 19. Schramm VL Jr, Mattox DE, Stool SE. Acute manage- ty of inspired oxygen concentration with nasal cannulas. ment of laser-ignited intratracheal explosion. Laryn- Thorax 1992;47(8):609-611. gscope 1981;91(9 Pt 1):1417-1426. 28. Jensen AG, Johnson A, Sandstedt S. Rebreathing during 20. Reinarz JA, Pierce AK, Mays BB, Sanford JP. The poten- oxygen treatment with face mask: the effect of oxygen tial role of inhalation therapy equipment in nosocomial flow rates on ventilation. Acta Anaesthesiol Scand pulmonary infections. J Clin Invest 1965; 44:831-839. 1991;35(4):289-292. 21. Pierce AK, Sanford JP, Thomas GD, Leonard JS. Long- 29. Jeffrey AA, Warren PM. Should we judge a mask by its term evaluation of decontamination of inhalation-therapy cover? Thorax 1992;47(7):543-546. equipment and the occurrence of necrotizing . 30. Kacmarek RM. Methods of oxygen delivery in the hospi- N Engl J Med 1970;282(10):528-531. tal. Prob Respir Care 1990;3:563-574. 22. U.S. Department of Health and Human Services, Public 31. Friedman SA, Weber B, Brisco WA, Smith JP, King Health Services, Centers for Disease Control. Guideline TKC. Oxygen therapy: evaluation of various air-entrain- for prevention of nosocomial pneumonia and guideline ing masks. JAMA 1974;228(4):474-478. ranking scheme. Atlanta: CDC; 1982. 32. Branson R. Respiratory care equipment. New York: Lip- 23. Redding JS, McAffee DD, Gross CW. Oxygen concentra- pincott Williams & Wilkins; 1999:77. tions received from commonly used delivery systems. 33. Konschak MR, Binder A, Binder RE. Oxygen therapy uti- South Med J 1978;71(2):169-172. lization in a community hospital: use of a protocol to im- 24. Goldstein RS, Young J, Rebuck AS. Effect of breathing prove oxygen administration and preserve resources. pattern on oxygen concentration received from standard Respir Care 1999;44(5):506-511.

Interested persons may photocopy these Guidelines for noncommercial purposes of scientific or educational advancement. All of the AARC CPGs may be downloaded at no charge from http://www.rcjournal.com/online_resources/cpgs/cpg_index.htm/. Please credit AARC and RESPIRATORY CARE Journal.

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