CLINICAL GUIDELINES

Guideline for Administration of Oxygen in Adults 2012

Reference
Date approved Feb 2013
Approving Body Matrons Forum
Supporting Policy/ Working in No
New Ways (WINW) Package
Implementation date March 2013
Supersedes Guidelines for Administration of Oxygen
(2005)
Consultation undertaken Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons, Medical Gas Committee.

Target audience Clinical Practitioners administrating oxygen

Document derivation / CLMM032 In-patient Oxygen Therapy

evidence base:
Review Date March 2018
Lead Executive Director of Nursing
Author/Lead Manager Bob Browne, Charge Nurse, Critical Care
Outreach Team
Further Guidance/Information Critical Care Outreach Team
Distribution: Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.

This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.

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 Nottingham University Hospitals NHS Trust

CLINICAL GUIDELINES

GUIDELINES FOR THE ADMINISTRATION OF OXYGEN

IN ADULTS

Page No Table of Contents

3 Introduction;
Assessing the need for oxygen therapy
4 Pulse oximetry
5 Indications for oxygen therapy
6 Principles of care
Guidelines for the selection of equipment
7 Procedure for applying correct oxygen delivery device
11 Equipment;
1. Variable performance devices;
Nasal cannulae/catheters
13 Hudson masks without a Venturi barrel; Tracheostomy masks
13 2. Fixed performance devices
Venturi masks & adaptors, Cold water humidification
14 Non-rebreathing oxygen masks
15 High flow oxygen therapy
Indications for high flow oxygen therapy
16 Procedure for applying high flow oxygen therapy via a mask
16 Equipment (for high flow)
17 Procedure for applying Optiflow nasal high flow oxygen
therapy
Equipment
18 Humidification
Hazards:
1. Patient safety:
Loss of hypoxic drive
19 Oxygen toxicity and Alveolar damage, Coronary and Cerebral
vasoconstriction, Poisons, Inter and Intra trust transfer
20 2. Health & safety
21 References
23 Further reading
24 Appendix 1: Normal blood gas values
25 Appendix 2: Definition of terms
26 Appendix 3: Equipment for high flow Oxygen therapy
27 Appendix 3: Equipment for Optiflow Humidified High Flow
Via nasal Cannulae
28 Equality and diversity statement;
Equality impact assessment
Authors

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 Nottingham University Hospitals NHS Trust

CLINICAL GUIDELINES

GUIDELINES FOR THE ADMINISTRATION OF OXYGEN

IN ADULTS

Introduction

Oxygen should be regarded as a drug. It is prescribed to

prevent/treat hypoxaemia, but not hypercapnia or breathlessness.
The concentration of oxygen prescribed aims to bring oxygen
saturation (SpO2) to normal or near normal oxygen saturation.
However, this depends on the condition being treated; an
inappropriate concentration may have serious or even lethal
effects (British Thoracic Society Guideline 2008). It must therefore
be administered by prescription to achieve target saturations only.
In an emergency situation, a Patient Group Direction
(Administration of high percentage Oxygen to adults in an
emergency) allows staff to commence oxygen therapy without a
prescription.

In an emergency situation i.e. cardiorespiratory arrest, plus

peri-arrest situations and critical illness such as sepsis,
oxygen at high percentage (i.e. non rebreathe mask) may be
commenced before a written prescription has been made.
This would include those patients with risk factors for
hypercapnia, on whom arterial blood gas (ABG) analysis must
be performed within 60 minutes. Written documentation of
percentage, device and duration must be made.

Assessing the need for oxygen therapy

In acutely ill patients oxygen delivery to the lungs relies on a

patent airway. Airway patency should always be checked prior to
delivering oxygen therapy (Greater Manchester Acute Illness
management (AIM) 2007).

The concentration of oxygen will be titrated to a target saturation,

not a set percentage amount. This will be between 94-98% for
most acutely unwell patients or 88-92% for those with possible
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hypercapnic (Type II) respiratory failure. Therefore, oxygen
should be increased or reduced to maintain these saturations, as
very high levels will not offer any clinical advantage in most
conditions. Note this major change to the previous oxygen
prescribing policy.

Pulse Oximetry

This will be the default method of initiating and adjusting the

direction of therapy. Clinical staff need to be aware of the
limitations of this monitoring (Valdez-Lowe et al 2009):
Peripheral vasoconstriction (hypothermia, cardiac failure,
fluid loss)
Bright ambient light
Patient motion, fitting
Sickle cell disease when in vaso-active crisis
False nails, nail varnish
Carbon monoxide poisoning, patients returning from smoking
tobacco have misleadingly normal SpO2
Some dyes, such as methylene blue
NOT affected by jaundice, anaemia: can be slightly altered
with dark skin
Pulse oximetry will NOT identify patients with Type II (high
CO2) respiratory failure
An acceptable SpO2 will only inform of hypoxaemia (low
oxygen tension in blood), not hypoxia (delivery of oxygen to
tissues)

Best Practice
The waveform and/or signal strength must be optimal before a
reading can be accepted.
A blood pressure cuff on the arm of probe will lead to a false SpO2
reading.

Normal oxygen saturations at rest;

Pre-term (36 weeks or less) neonates; 88-92%
Term (>36 weeks) neonates and children; greater than 94%
Adults less than 70 years of age; 96% - 98%.
Aged 70 and above; greater than 94%.
Patients of all ages may have transient dips of saturation to
84% during sleep.
Note that fingers, then earlobes, are more accurate than toes as
measurement points

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 Best Practice
Ensure that the probe is repositioned periodically onto different
fingers to prevent tissue necrosis

Indications for oxygen therapy

The principal clinical indicator for initiating, monitoring and

adjusting oxygen therapy is peripheral oxygen saturation (SpO2).
Patient colour and respiratory rate and work of breathing MUST
also be observed. Arterial oxygenation (PaO2) and arterial
saturation (SpO2) are assessed by arterial blood gas analysis,
which will have priority in the direction of oxygen therapies.

Oxygen therapy is given to treat/prevent hypoxia and

hypoxaemia.

Acute hypoxaemia (for example pneumonia, shock, asthma,

heart failure, pulmonary embolus)
Ischaemia (for example myocardial infarction, but only if
associated with hypoxaemia (abnormally high levels may be
harmful to patients with ischaemic heart disease and stroke).
Abnormalities in quantity, quality or type of haemoglobin (for
example acute gastrointestinal blood loss or carbon monoxide
poisoning). Carbon monoxide poisoning is the only condition to
aim for a SpO2 over 98%.

Other indications include:

Pneumothorax Oxygen may increase the

rate of resolution of pneumothorax. (British Thoracic Society
Guideline 2010)
Postoperative state (general anaesthesia can lead to a
decrease in functional residual capacity with in the lungs
(especially following thoracic or abdominal surgery) resulting in
hypoxaemia. There is some evidence to suggest a decreased
incidence of post operative wound infections with short-term
oxygen therapy following bowel surgery. (Kabin & Karz 2006) If
oxygen is used for this purpose, please ask the
surgeon/anaesthetist to document this, and ensure this
information is handed over.

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 Reduced Oxygen Concentration
Atmospheric air at sea level has a normal oxygen
concentration of 21%. However, at altitude, this concentration
is markedly reduced. If patients are to be sent on commercial
aircraft to another hospital, expert help must be sought.
(British Thoracic Society Guideline 2011)

Principles of care

It is the registered clinicians responsibility to ensure the required

dose of oxygen is delivered to the patient correctly: the patients
condition should be regularly monitored. The clinician must allow
5 minutes after any change to oxygen percentage or device before
assessing response. The device, percentage or litres per minute
and respiratory rate MUST be documented on the patients
observation chart. Document oxygen delivery in percentage
terms unless nasal cannulae, or non-rebreathe trauma mask is in
use. (Adult observation and EWS policy CLCGP 068)

Best Practice
Oxygen cannot travel easily through wet secretions, so optimize
their removal by:
Sitting the patient up, or out in a chair
Ensuring mouth is kept moist
Providing tissues and/or a sputum pot
Regularly assessing if a patient can take a deep breath and
cough, ensuring analgesia is sufficient to achieve this

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 Procedure for applying correct oxygen delivery device

Action Rationale

1. Assess patients need for To ensure effective delivery of

mask or nasal cannulae. oxygen.
Explain to the patient what
the treatment is for and To promote patient comfort,
familiarise the patient with the compliance and
oxygen delivery device. understanding.

2. Attach humidification device if To reduce the risk of side

required. This is indicated by a effects associated with dry
flow rate of 5 or more litres for gas administration. To
more than 30 minutes via a promote patient comfort.
face mask or 35% or more
oxygen unless in pulmonary
oedema (Sheppard & Wright
2006).

3. Complete the administration Oxygen is safely delivered as

system by attaching tubing prescribed.
either small bore or wide bore
corrugated (elephant tubing)
as appropriate (no more than
11 small sections or 5 large
sections).

Connect to oxygen flow meter

and turn on to the required
flow rate: ensure the ball is in
the middle of the line within
the flow meter. It is the
nurses responsibility to
maintain the correct flow rate,
to deliver the required
concentration.

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 Oxygen must be documented
as a percentage for mask and
Venturi barrel, or flow rate if
using Non-rebreathing mask /
nasal cannulae.

4 Adjust oxygen delivery to To prevent the problems

optimize saturation levels to
94-98% 0r 88-92% in those at
risk of hypercapnic
respiratory failure
5 Assess and record all vital
signs observations (NICE
2007) including respiratory
rate and pulse oximetry.
Observe for signs of
respiratory distress e.g.
increasing respiratory rate,
wheezing, panting and use of
accessory muscles (see NUH
Guideline for Performing and
Recording Physiological
Observations in the Adult
Patient (2011) and Adult
Observation and EWS Policy
(2011).
Observe patients colour,
6. looking at nail beds and lips
to detect worsening or
improving cyanosis or as the
patients condition dictates.
Monitor patient's oxygen
saturation levels. If it drops
below 90% or 10% below
baseline check position of
probe and inform medical
staff and / or Critical Care
Outreach Team.
associated to both
hypoxemia and
hyperoxemina
To obtain baseline (initial)
values and observe for
changes in a patients
condition.
An increased respiratory
rate is a primary indication
that a patient is becoming
acutely ill.
Slow and shallow respirations
may indicate respiratory
depression.
As a patient becomes more
hypoxic their saturation will
fall, their colour will
deteriorate. Central cyanosis
indicates an arterial oxygen
tension below 8 kPa.

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7. Assess and record pulse rate. To obtain a baseline value
and observe for any change
in heart rate.
Patients in respiratory
distress often become
tachycardic.

8. Observe for clinical signs of To detect changes in

deterioration i.e. conscious patients condition
level decreases, patients often
become restless, confused or
drowsy and there may be a
drop in saturation.

Inform medical staff and / or

Critical Care Outreach Team.

9. Patients who require oxygen or To clear bronchial

are in respiratory failure should secretions and to maximise
be encouraged to take regular the effect of the oxygen
deep breaths in a high sitting therapy.
or full-side lying position.

Liaise with the physiotherapist

if the patient is having difficulty
in expectorating.

10 Collection of water in the

tubing can partially or Routinely check tubing for
completely occlude the flow of water collection and empty as
oxygen. necessary.

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11 Offer mouth care. Oral
hygiene and an adequate fluid
intake should be encouraged.
If mask becomes grossly
contaminated with secretions it
should be cleaned/replaced.
If lips or nose become dry or
sore a water-based cream can
be used.
12 Observe for elastic strap
causing tissue damage around
the ears & bridge of nose,
using a strip of hydrocolloid, or
an Aderma strip if necessary.
If pressure damage is found,
record and treat and monitor
as with any other pressure
ulceration.
13 When discontinuing oxygen To prevent the possibility of
therapy, do this gradually rebound hypoxemia
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Minimise dryness and
soreness to mouth.
Discomfort and sputum
tenacity are minimised
(Ashurst, 1995).
Only water-based products,
(such as aqueous cream)
should be used for dry lips
because of the potential
inflammatory properties of
petroleum jelly. Do
examine products bought in
by visitors.
Oxygen masks, tubing and
ventilation masks are made of
plastic, rubber or silicone,
which can cause rubbing or
create pressure on the soft
tissues (Jaul, 2010). In
addition, adhesive tapes used
to secure the device may
irritate susceptible skin (Black
et al. 2010). To avoid
pressure ulcers from occurring
in any location of the body, it
is important to inspect all
external tubing and devices
regularly, adjust pads if
necessary.
To enable the correct
treatment and adherence to
wound management policy.
Selection of equipment

There are 2 basic types of oxygen delivery devices: either

variable performance devices or fixed performance devices.
Variable performance devices such as a face/tracheostomy mask
(without a Venturi device), nasal cannulae, cannot deliver a fixed
percentage (fractional inspired concentration, FiO2) of oxygen as
this is dependent on respiratory rate and tidal volume. There is a
risk of rebreathing carbon dioxide with facemasks (Jensen et al
1991). In patients with known COPD oxygen MUST be delivered
via fixed performance device. Fixed performance devices attempt
to deliver a known percentage of oxygen irrespective of the
patients respiratory rate or tidal volume (e.g. Venturi, non-
rebreathe). Any mask will only work if positioned correctly on the
patients mouth and nose.

Equipment

1. Variable Performance Devices

These devices deliver oxygen in litres and cannot deliver a fixed

percentage of oxygen. The amount of oxygen delivered is
dependent on the patients rate and depth of breathing. Devices
which deliver a variable flow are:

Nasal cannulae/Catheters
Hudson masks without a Venturi barrel
Tracheostomy masks

Nasal Cannulae/Catheters

They are available as single or double cannulae: the latter is most

commonly used in the Trust. The concentration of oxygen is
dependent on the flow rate (1 4 litres per minute). Patients
should be assessed whether they require/prefer nasal cannulae or
mask: cannulae can give equivalent oxygen saturations to Venturi
masks at 1 to 4 litres per minute (Waldau et al 1998), and mouth
breathers are not necessarily disadvantaged by these (Wettstein
et al 2005).

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 Advantages
Simple to use, high degree of safety. Nasal cannulae prevent re-
breathing of exhaled CO2, and can be comfortable for long
periods. Patients are also able to hold a conversation,
expectorate and eat without removing them. (Bateman and
Leach, 1998).

They have low cost. Effective for delivering low concentrations of

oxygen approx between 24% & 35% (2 to 4 litres per minute).

Best Practice
Use nasal cannulae in conjunction with air driven nebulizers to
deliver oxygen in patients who require both nebulised drugs and
oxygen therapy (e.g. Asthmatics requiring back to back therapy).

Disadvantages
Occasionally there may be local irritation or dermatitis if high flow
rates are used.

Should not be used for those needing over 40% ( 4 litres/min).

Not suitable for patients with nasal obstruction i.e. polyps, mucosal
oedema.

May cause headaches or dry mucous membranes if flow exceeds

4 Litres per minute.

Inspired oxygen concentrations are variables dependent on flow

settings and patient respiratory pattern e.g. such as those with
dyspnoea (Ashurst 1995). For accurate concentrations a Venturi
mask is preferable.

Recommendation for Use

Can be used on patients with type I and type II respiratory failure.

Best Practice
Some patients may have difficulty tolerating oxygen masks: the oxygen
demand can be increased if a disturbed patient is constantly struggling to
remove it. In such cases, nasal cannulae/catheters may be a better
alternative (Porter-Jones, 2002).

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Hudson masks without a Venturi barrel; Tracheostomy masks
(with small oxygen port)

These devices are rarely used within the trust, although some
specific areas may still use these devices for short term, specific
use. It is recommended to change to another device if the patient
is transferred outside these areas.

2. Fixed performance devices:

These devices deliver a known percentage of oxygen by mixing

oxygen and air via a Venturi device. Devices which use this
system are:

Venturi masks and adapters; Cold Water Humidification Devices

Non-rebreathing (trauma) masks
High Flow/ Optiflow

Best Practice
For patients who have a tracheostomy or laryngectomy, an
appropriate mask must be used that is designed to fit around the
stoma. A face mask is not effective.

Venturi masks and adapters, Cold water humidification devices

The Venturi mask contains a differing size holes situated at the

base of the mask and uses the Venturi effect. A similar
adjustable aperture is present on most cold water humidification
devices. When oxygen passes through the narrow orifice it
produces a high velocity stream which becomes a low pressure
system that draws a constant proportion (up to 40 litres) of room
air through the holes within the mask. Air entrainment depends
on the velocity of the jet, size of the holes and oxygen flow rate.
Each diameter of Venturi gives a different final oxygen
concentration and are available to give oxygen concentration of
24 60%. Note that each concentration will need a different
oxygen flow setting: document the percentage of oxygen
delivered, not the flow rate.
However, if the respiratory rate is over 30 breaths per minute, a
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doctor may ask for a higher flow than the Venturi mask
recommendation, as this will increase flow rate without effecting
oxygen concentration.

Advantages
Venturi barrels can be changed to vary oxygen concentrations.
Reduced re-breathing of exhaled air.
Is independent of oxygen flow and patient breathing factors
(Ashurst, 1995).

Disadvantages
May be noisy, claustrophobic / interferes with eating and
drinking.
Oxygen cannot be humidified, although the entrained air contains
some humidification.

Recommendation for Use

Can be used for Type II Respiratory failure. See definition of
terms (appendix 2).

Best Practice
For general administration of oxygen in non-specialised areas, a
standard aerosol mask with a Venturi device should be used. This
will ensure that oxygen can be controlled to give inspired levels of
24-60%" (Bateman and Leach, 1998).

Non Re-Breathing Oxygen Mask (trauma mask).

Advantages
For high percentage of oxygen 60% - 90% when the patient is
not at risk of retaining CO2 or losing their hypoxic drive: if
emplaced in an emergency, these patients will need an ABG
assessment. Should only be used for short-term treatment.

Disadvantages
Risk of oxygen toxicity and reabsorbtion atelectasis (failure of the
alveoli to expand).
Requires tight seal around the mouth. High oxygen flow rates are
required to ensure bag is inflated during inspiration.

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Recommendation for Use
They should NOT be used routinely for patients with COPD/ Type
II respiratory failure. Suitable for trauma patients, on a short term
basis only. The patient should be regularly assessed to see if this
device is still appropriate. Used in an emergency situation (for
example hypoxia, loss of cardiac output or low perfusion).

Best Practice

When in use, the flow rate must be sufficient to keep the reservoir
bag at least a third to half full at all times (Jevon, 2000).

High flow oxygen therapy

High flow oxygen is defined as a device that can deliver over 40

litres of air plus oxygen per minute. This is not to be confused
with high percentage devices although it is common to give both
high flow and a high percentage of oxygen. Between 35% and
100% oxygen can be given. Air is entrained through a Venturi
valve and is humidified before reaching the patient.

Indications for high flow oxygen therapy

Patients who are unable to maintain adequate arterial saturation of

oxygen despite current low flow oxygen therapy and are at risk of
further deterioration would require high flow oxygen. Those who
have respiratory rates over 30 breaths per minute would be
possible candidates for this type of therapy.

The Nasal High Flow device (Optiflow) can deliver oxygen with
better compliance of therapy, with ability to eat, expectorate and
talk, with possible reductions in respiratory rate and complications
(Lowery 2011)

A patient on a specific high flow oxygen must receive oxygen via a

humidified circuit, as piped oxygen is both cold and dry (Viney
1996).

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Procedure for applying high flow oxygen therapy via mask

Equipment

Oxygen supply from a piped supply

Fisher & Paykel humidifier & humidifier set
Corrugated tubing
Water for inhalation
Green T piece
Flow meter
Oxygen analyser
Hudson Mask

Action
1. Ensure all staff and patients
are aware of fire precautions
2. Ensure patient is in a
comfortable position,
encourage an upright
position, maybe supported
with pillows
Rationale
Oxygen readily supports
combustion therefore fire
regulations should be adhered
to
To aid chest expansion and
ensure patient is comfortable

3. Monitor and record patients To obtain baseline values and

respiratory rate and oxygen observe for vital changes to
saturations, wherever direct oxygen therapy (Lowton
possible use arterial blood 1999)
analysis (Porter-Jones 2002)

4. Observe patients breathing Respiratory rate is a primary

pattern and any use of indication that a patient is
accessory muscles becoming acutely ill (Jevon &
Ewenns 2001)

5. Observe patients colour with A patient with falling saturations

special attention to nail beds may have a deterioration in
and lips to check for cyanosis colour

6. Calibrate the oxygen To ensure the analyser is

analyser to air before setting accurate when being used in the
up the circuit circuit

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 7. Set up high flow circuit - See Appendix 4 (Picture of a
firstly attach the humidifier completed high flow circuit)
set to the humidifier and
attach to water for inhalation
bag. Connect oxygen
analyser to the T piece and
insert into the circuit, ensure
the flow meter is connected
to the piped oxygen supply in
the wall, switch oxygen on
8. Position the mask on the To maintain patient comfort and
patients face, adjust the accuracy of delivery
straps for desired fit

Best practice
Ensure humidifier is switched on to the correct temperature setting
(automatically set by the humidifier when selecting invasive vs,
non-invasive mode) when a patient with a tracheostomy airway
remain moistened, easier expectoration of secretions are facilitated
(Woodrow, 2000)

Procedure for applying Optiflow nasal high flow oxygen therapy

Equipment

The equipment for this device is not to be stored on the clinical

area when not in use, and will only to be set up by those
competent in the use of this equipment. As these patients are the
most oxygen dependant patients, the Critical Care Outreach Team
(CCOT) will be reviewing these patients frequently. The equipment
is outlined in the picture in Appendix 5. The responsibility of the
ward clinician is limited to the following:

Principle Rationale
1 Ensure water for inhalation is Maintain consistent
constantly present: the humidifier will humidification Prevent nuisance
self fill, but there must always be a alarms
bag with content available
2 Ensure nasal prongs are seated in Enables correct delivery of
each nostril, particularly following oxygen
repositioning
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3 Use a loop of tubing below the nose
4 Oxygen should be read from the
display
5 Only those taught directly and
competency assessed by CCOT
should adjust oxygen
6 Check with CCOT prior to disposing
of equipment
To catch any rain out water
before in is delivered to the
patient
This direct measurement is
accurate; and a sudden change
can indicate tube blockage:
CCOT should be informed if this
occurs
The volume flowmeter is often
confused with the oxygen
flowmeter on this device
The wires are expensive, and
their loss denies another patient
of this device

Humidification

Oxygen therapy can dry the mucous membrane of the upper

respiratory tract causing soreness and reducing the efficacy of
the mucociliary escalator. It can also cause pulmonary
secretions to become stickier making them more difficult to
expectorate (Porter-Jones, 2002). Therefore consideration
should be given to humidification of oxygen. Please refer to the
Trust Clinical Guidelines for the Humidification of Oxygen for Self
ventilating Patients.

Hazards
1. Patient safety

Loss of Hypoxic Drive.

Elevated arterial carbon dioxide (PaCO2) and reduced blood pH

are both strong stimulants to respiration. However, patients with
chronic lung disease who have experienced carbon dioxide
retention for some time become sensitive to high levels of carbon
dioxide and rely on reduced levels of oxygen in the blood to
stimulate their respiratory drive. This is Type II respiratory failure.

Administration of an inspired oxygen concentration above 24% in

this type of patient may abolish the hypoxic drive and lead to
further carbon dioxide retention and respiratory arrest. However,
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 not all patients with chronic lung disease fall into this category, and
the only way to determine this is to measure arterial blood gases
(Udwadia 2005 pp 253). In an emergency situation, when a
patient is hypoxic, administration of oxygen is the priority as
hypoxia will kill whereas apnoea caused by loss of hypoxic drive
can be managed by mechanical ventilation. The clinician must
remain with the patient, observing vital signs and conscious level,
after increasing oxygen.

Best practice
Do not drive nebulizers with oxygen on patients who are at risk of
loss of hypoxic drive: use the mechanical air driven nebulizers

Oxygen Toxicity and Alveolar Damage.

Oxygen may be toxic, especially in high concentrations. When

greater than 60% may damage the alveolar membrane through
the formation of reactive oxygen species when inhaled for more
than 48 hours (Udwadia 2005 pp253), or result in absorption
atelectasis.

Coronary and cerebral vasoconstriction.

There has been a strong line of research dating back to the

1970s in patients with myocardial infarction and strokes, which
suggests the automatic administration of oxygen may be
associated with greater mortality (Thompson et al 2002). Current
advice is to carefully monitor and give oxygen to achieve, but not
exceed prescribed targets outlined earlier.

Poisons.

Oxygen should be given with caution in those patients with

Paraquat ingestion or Bleomycin lung injury.

Inter and Intra Trust patient transfer.

If the patient is requiring high concentrations of oxygen, then this

could signpost a very sick patient who may not be suitable for
transfer. An assessment must be performed utilizing the Adult
Patient Transfer Assessment Matrix, found within the Internal
Transfer of the Adult Patient Throughout NUH Policy (CLCGP067).
The Critical Care Outreach Team is available for advice regarding
transfer. The amount of oxygen required for any transfer can be
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quickly estimated using the cylinder depletion values on posters
situated near the main oxygen storage on each ward, or Appendix
3 within the Oxygen policy.

2. Health & Safety

All staff should be aware that oxygen supports combustion

(Ashurst, 1995) and patients and visitors be advised of the risks.

Oxygen does not, in itself, explode or burn, but it does enhance

the flammable properties of other materials such as grease and
oils. (Porter-Jones, 2002) It is therefore important to turn off gas
flow to unused devices as soon as possible. Patients cannot leave
the ward for a cigarette with portable oxygen; moreover, if their
condition requires oxygen, they will be probably too ill to do so.
All nurses should know the location of the central oxygen turn off
point for the piped supply in the area they are working, and the
course of action required in the event of fire.

There is also a small risk of fire if dirt, oil, grease contaminate

connections between medical devices and gas cylinders
(Medicines and Healthcare products Regulatory Agency, 2008).
This includes hand creams and alcohol gels, which should be
washed off hands first.

Oxygen cylinders must be stored in a designated dry room, their

numbers should be kept to a minimum, and they must be
secured in a suitable cylinder holder, away from electrical
appliances Appropriate signs should be displayed when a
compressed gas cylinder is in use on the ward or where cylinders
are stored. (Signs can be obtained from Estates Dept). Advice
on transportation of oxygen cylinders can be obtained from
Estates Dept.

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References

Acute Illness management (AIMS) Course Manual (2007), North

West Strategic Health Authority.

Ashurst S (1995). Oxygen Therapy British Journal Nursing Vol.

l4 No. 9 ,pp. 508 515

Bateman NT, Leach RM (1998) ABC of Oxygen Acute Oxygen

Therapy British Medical Journal Vol.317 No. 19 September pp.
798 - 801

Black, J.M., Cuddigan, J.E. and Walko, M.A. (2010) Medical

device related pressure ulcers in hospitalised patients.
International Wound Journal. 7(5): pp. 358-65.

British Thoracic Society Guidelines (2011) Managing passengers

with stable respiratory disease planning air travel: British Thoracic
Society recommendations, British Thoracic Society Air Travel
Working Group Thorax Vol 66 Supplement 1

British Thoracic Society Guidelines (2010) Management of

spontaneous pneumothorax within Pleural Disease Guideline:
British Thoracic Society recommendations, MacDuff, A; Aronld,A;
Harvey, J. Thorax Vol 65 Supplement 2

British Thoracic Society Guidelines (2008) Guideline for

emergency oxygen use in adult patients: British Thoracic Society
recommendations, ODriscoll BR, Howard LS, Davison AG Thorax
Vol 63 Supplement 4

Jaul, E (2011) A prospective pilot study of atypical pressure ulcer

presentation in a skilled geriatric unit. Ostomy Wound
Management. 57(2): pp. 49-54.

Jensen, AG; Johnson, A; Sandtedt, S (1991) Rebreathing during

oxygen treatment with face mask; The effects of oxygen flow rates
on ventilation. Acta anaesthesiol Scand Vol 35 pp289-292

Jevon P, Ewenns B (2001) Assessment of a breathless patient

Nursing Standard Vol. 15 No. 16 pp. 48-53
Nursing Guidelines Oxygen updated Jan 2013
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Kabin, B; Karz, AB; (2006) Optimal perioperative oxygen
administration. Current opinion in Anaesthesiology Vol 19(1) pp11-
18

Lowery, F (2011) High Flow Oxygen cuts need for intubation in

Acute Respiratory Syndrome. Society of Critical Care Medicine.
Congress: Abstract 381

Lowton, K . (1999) Pulse Oximeters for the detection of

hypoxaemia. Professional Nurse 14 (5) pp. 343-350

Porter-Jones, G. (2002) Short Term oxygen therapy

Nursing Times 98 (40) p.53-56

Patient Group Direction (NMPAS) Administration of high

percentage oxygen to adults in an emergency Nottingham
University Hospitals NHS Trusts, Nottingham 2011.

The Medicines and Healthcare products regulatory Agency (2008)

Oxygen Cylinders and their regulators: Top tips for care and
handling London: MHRA available at www.mrha.gov.uk

Nottingham Nursing Practice Development Group (NNPDG) Mouth

Care Nottingham University Hospitals NHS Trusts, Nottingham
2009. pdf 1287

Nottingham Nursing Practice Development Group (NNPDG)

Physiological Observations Guidelines for Performing. Nottingham
University Hospitals NHS Trusts, Nottingham 2011. pdf 1843

Sheppard M & Wright M (2005) Principles and Practice of High

Dependency Nursing. Bailliere Tindall, London.

Udwadia F (2005) 2nd Edition. Principles of Critical Care. Oxford university

press, Oxford.

Valdez-Lowe, MS; Artinan, NT; Ghareeb, SA (2009) Pulse Oximitry in Adults.

American Journal of Nursing Vol 109 No 6

Waldau, T; Larson, VH; Bonde, J (1998) Evaluation of five oxygen

delivery devices in spontaneously breathing subjects by
oxygraphy. Anaesthesia Vol 53 pp256-263

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Wettstein, RB; Shelledy, DC; Peters, JL (2005) Delivered oxygen
concentrations using low-flow and high flow nasal cannulas. Respir
care Vol 50 pp604-609

Woodrow, P. (2000) Intensive care nursingA framework for

practice. Routledge. London.

Further reading

Bourke S (1998) Blood gases and respiratory failure Lecture

Notes on Respiratory Medicine 5th edition Oxford: Blackwell
Science

Viney C (ed) (1996) Nursing the Critically Ill London: Bailliere

Tindall

Updated January 2012

Review date: 2018

Nursing Guidelines Oxygen updated Jan 2013

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Appendix 1

NORMAL ARTERIAL BLOOD GAS VALUES

Oxygen saturation (SpO2) normal range 95% to 100%. Falls with age and in
chronic respiratory disease

pH 7.35-7.45
PaO2 12-15 kPa (slightly less in older people)
PaCO2 4.50-6.10kPa
HCO3 22-26 mmol/l
Base excess 2 +2

Deviation from these values should be reported immediately to the medical

staff so that appropriate action can be taken.

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Appendix 2

DEFINITION OF TERMS

ABG Arterial blood gas.

Atelectasis Failure of part of the lung to expand/collapse of lung
segments.
CPAP Continuous positive airway pressure.
CCOT Critical Care Outreach team
FiO2 The % of oxygen the patient is breathing in expressed as a
decimal.
HCO3 Bicarbonate.
Hypercarbia High PaCO2.
Hypoxaemia Deficiency of oxygen in the blood - PaO2 less than 8kPa.
Hypoxia Deficiency of oxygen within the tissues.
PaCO2 Partial pressure of carbon dioxide in arterial blood.
PaO2 Partial pressure of oxygen. Daltons law indicates each gas
exerts a partial pressure relative to the concentration in the
mixture. A P before the gas symbol denotes partial
pressure, the a denotes arterial.
SpO2 Oxygen saturation as measured by pulse oximeter
Type I The PaO2 is low the PaCO2 is normal or low (Field 1997)
Respiratory e.g. asthma, pulmonary oedema, pulmonary embolism, lung
failure fibrosis.
Type II The PaO2 may be normal or low and the PaCO2 is high
Respiratory (Field 1997) e.g.; in some chronic obstructive pulmonary
failure disease (COPD), lack of neuromuscular control of ventilation
e.g. overdose of respiratory depressive drugs i.e. opioids,
myopathy. Type I respiratory failure may progress to Type II
when the patient becomes exhausted.

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 1
EQUIPMENT FOR HIGH FLOW OXYGEN THERAPY
7
02 Analyser Sterile Water
Calibrate for Inhalation

2 8
ON/OFF
Oxygen
Mask
9
02
3 Regulator

Hea ted
Wire 0 2 10
Tubing
Litre
4 Regulator
always on
Wate r Bath Max

5 11
Fishe r & Paykel Particle
Controls. Filter
ON/OFF Alarm
Trouble Shoot
12
Default
Intubated non T Piece & 02
Intubated Analyser
6 Heater 13
KH/CCSC/2004
Wires White Tubing

Appendix 3

Nursing Guidelines Oxygen updated August 2011 26

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 EQUIPMENT FOR OPTIFLOW HUMIDIFIED HIGH FLOW VIA
NASAL CANNULAE

Oxygen
display Flowmeter
for total
gas flow

Water tube
to bag Knobs to
adjust total
gas flow
and oxygen
Filter for air
inlet

Humidifier
Flow to
patient
(nasal
prongs not
shown)

Appendix 4

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Equality and Diversity Statement

All patients, employees and members of the public should be treated fairly and
with respect, regardless of age, disability, gender, marital status, membership or
non-membership of a trade union, race, religion, domestic circumstances,
sexual orientation, ethnic or national origin, social & employment status, HIV
status, or gender re-assignment.

All trust polices and trust wide procedures must comply with the relevant
legislation (non exhaustive list) where applicable:

Equal Pay Act (1970 and amended 1983)

Sex Discrimination Act (1975 amended 1986)
Race Relations (Amendment) Act 2000
Disability Discrimination Act (1995)
Employment Relations Act (1999)
Rehabilitation of Offenders Act (1974)
Human Rights Act (1998)
Trade Union and Labour Relations (Consolidation) Act 1999
Code of Practice on Age Diversity in Employment (1999)
Part Time Workers - Prevention of Less Favourable Treatment Regulations
(2000)
Civil Partnership Act 2004
Fixed Term Employees - Prevention of Less Favourable Treatment Regulations
(2001)
Employment Equality (Sexual Orientation) Regulations 2003
Employment Equality (Religion or Belief) Regulations 2003
Employment Equality (Age) Regulations 2006
Equality Act (Sexual Orientation) Regulations 2007

Equality Impact Assessment Statement

NUH is committed to ensuring that none of its policies, procedures, services,

projects or functions discriminate unlawfully. In order to ensure this
commitment all policies, procedures, services, projects or functions will undergo
an Equality Impact Assessment.

Reviews of Equality Impact Assessments will be conducted inline with the

review of the policy, procedure, service, project or function

Authors: Bob Browne, Cheryl Crocker

NPGG Link: Stuart Thompson-Mchale

For Review: 2018

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Nursing Guidelines Oxygen updated August 2011 29
Nursing Practice Guidelines Group