Kelly and Lynes. Int J Crit Care Emerg Med 2015, 1:1 ISSN: 2474-3674 International Journal of Critical Care and Emergency Medicine Review Article: Open Access To Give or Not To Give – Is that the Question?: The Changing Face of Emergency Oxygen Therapy Carol Ann Kelly1* and Dave Lynes2 1Postgraduate Medical Institute, Faculty of Health and Social Care, Edge Hill University, UK 2Faculty of Health & Social Care, Edge Hill University, UK *Corresponding author: Carol Ann Kelly, Postgraduate Medical Institute, Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, Lancashire, L39 4QP, UK, Tel: 0044-1695-657090, E-mail: [email protected] Abstract Historical Context and Contemporary Issues Oxygen’s image, together with its reputation, is changing. No longer It is interesting to note that caution regarding the use of oxygen is it regarded as a benign panacea for all clinical presentations; therapy isn’t new; indeed it has been surrounded by contradiction indeed it is now increasingly evident that oxygen has the potential and controversy since its discovery in the late 18th century. The first to contribute to clinical deterioration and mortality. reference to the potential detrimental effects of too much oxygen was There is an emerging recognition that oxygen is a drug when made by Joseph Priestly himself in 1774 [2], who warned that in the administered as a therapeutic intervention and should be used presence of oxygen that: with caution. Contemporary guidelines offer criteria and directives for administration and prescription of oxygen, dependant on the “as a candle burns out much faster in [oxygen] than in common patient’s condition, acuity and care setting, yet clinical audit and air, so we might, as may be said, live out too fast ... the air which nature gathering evidence repeatedly demonstrates that poor practice has provided for us is as good as we deserve”. persists. There is a need to raise awareness of the importance of maintaining In this citation Priestley seems to be referring to the potential normal oxygen levels and be aware of the detrimental effects of toxicity of oxygen dependant on its concentration, and the fact that both over and under oxygenation. Clearly more research is needed the oxygen level provided in atmospheric air is sufficient for health but in the meantime titration to normal or near normal levels seems and sustaining life. a pragmatic solution. In 1849 Lorrain Smith [3] next recognised oxygen’s potentially Keywords noxious qualities. Smith reported in animal studies that high oxygen Oxygen therapy, Emergency care, Clinical guidelines tensions act as an irritant, inflaming lung tissue. Advances in physiological understanding were furthered by John Scott Haldane in 1917 [4], when he identified the regulation of the respiratory drive Introduction by carbon dioxide and its effects on blood pH and outlined the need Oxygen is a colourless, odourless and tasteless chemical element for rational use of oxygen. Haldane’s cautious advice was to give (O). As a therapeutic intervention it is the diatomic molecule, only as much oxygen as would ‘suffice to relieve anoxaemia’ [4]. dioxygen (O ), that is commonly referred to as oxygen the name itself This recognition of judicious employment of oxygen remains a key 2 ; message in today’s guidelines [1]. a misnomer. O2 is present as 20.8% of the volume of air, it is essential for cell metabolism in all humans and most forms of life. Experimental work by Meakins in 1920 outlined methods for Oxygen’s image, together with its reputation, is changing. No calculating percentage of oxygen saturation of haemoglobin and its longer is it regarded as a benign panacea for all clinical presentations; relationship to the patient’s condition [5]. setting the scene for the th indeed it is now increasingly evident that oxygen has the potential clinical application of the physiological discoveries of the early 20 to contribute to clinical deterioration and mortality. But it’s not all century. bad press; in a patient with hypoxaemia or sudden collapse oxygen is Juxtaposition to these warnings regarding cautious still one of the principle treatments, without which emergency care administration of oxygen was the widespread introduction of the would be primitive. Yet misinformation, misunderstanding, and use of 100% oxygen therapy for most acute clinical presentations. misplaced beliefs regarding oxygen therapy in clinical practice appear The ability to administer high flow oxygen economically, efficiently to flourish [1]. This non-systematic review has attempted to highlight and comfortably was widely endorsed [6] and although claims were the historical context of oxygen, contemporary issues related to its cautioned by those aware of oxygen toxicity, current practice suggests use, and some of the emerging evidence base that has contributed to this caveat was seldom heeded and the practice of administrating a paradigm shift in the use of emergency oxygen therapy. Citation: Kelly CA, Lynes D (2015) To Give or Not To Give – Is that the Question?: The Changing Face of Emergency Oxygen Therapy. Int J Crit Care Emerg Med 1:005 ClinMed Received: July 07, 2015: Accepted: September 12, 2015: Published: September 14, 2015 International Library Copyright: © 2015 Kelly CA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. high flow oxygen to treat most clinical presentations was established Cytotoxic levels of ROS caused by hyperoxygenation are thought and persists today [7,8]. to be detrimental to metabolism and cause damage at cellular level [23]. When an excess of ROS or a depletion of antioxidants occurs Given the frequency of its use in clinical interventions, there oxidative stress results, causing damage and cell injury. These is widespread potential for the misuse of oxygen therapy. For free radicals in excess are known to cause mutations and cancers example one UK audit of oxygen use in ambulances recorded use through damage to DNA and protein, and lipid damage causes in 34% of patients [7]. For patients with conditions such as COPD loss of functionality and an excess of toxic by-products in the cells. (Chronic Obstructive Pulmonary Disease), this prevalence rises to They are implicated in inflammation; carcinogenesis; ischeamia- 82% in the emergency department [9]. A further audit found that reperfusion injury; atherosclerosis; aging and death [24]. Seemingly 88.7% of oxygen administered to patients presenting with an acute the evolutionary irony of oxygen is that in addition to sustaining life exacerbation of COPD in the pre-hospital setting was ‘inappropriate’ it is also what limits lifespan and ultimately kills. [10]. This seems unsurprising given that the most common reason cited for the administration of emergency oxygen in the acute clinical The Danger of Oxygen during Emergency Therapy setting is not hypoxemia but shortness of breath [9]. For several decades now it has been recognised that oxygen There is an emerging cognisance that oxygen should be used administration can cause significant increases in CO2 levels that can with caution, and oxygen is regarded as a drug when administered be detrimental to some patients, particularly those with hypercapnic as a therapeutic intervention [11]. Contemporary guidelines offer respiratory failure [25]. Advice was proffered by Campbell in 1960 criteria and directives for administration and prescription of oxygen, who advocated small increments of oxygen to correct hypoxaemia in dependant on the patient’s condition, acuity and care setting [1,12- order to avoid the risk of worsening hypercapnia [26], referring to 14]. Guidelines generally suggest that oxygen should be prescribed the need for ‘care and precision’ rather than ‘haphazard and imprecise for hypoxaemia, as either an acute or chronic therapy; the condition dosage’. being treated normally determining the concentration and duration of oxygen administered. Yet despite these widely accepted guidelines In 1962 the detrimental effects of withdrawing oxygen abruptly it is evident that poor practice persists [1,15-17]. The reasons why this from patients with hypercapnic respiratory failure was highlighted, may be the case remains elusive, but conjecture implies an ingrained cautioning that such practice could worsen hypoxia and hypercapnia culture of ‘more is better’ [15] and a belief that oxygen alleviates and further lower pH. This finding further supported a growing breathlessness [1]. consensus that continuous administration of low flow oxygen with graded increases avoids deterioration of respiratory failure whilst Can Oxygen Therapy Harm? maintaining acceptable oxygen tensions [27]. This philosophy still underpins contemporary emergency oxygen guidelines [1]. It has long been established that oxygen can be toxic to the body; evolutionary processes have resulted in the development of Further evidence advocating judicious use of oxygen therapy was protective measures to defend against hyperoxic damage. The ability published in 1964 [28], suggesting that an arterial oxygen tension of to harness oxygen as a fuel was developed through the acquisition 50 mmHg (7kPa) would prevent death from hypoxia in patients with of mitochondria, which are the inherited legacy from photosynthetic respiratory failure. The use of arterial blood gases was promoted to ancestors [18]. The