Reference to topic 1 Treatment summary for oxygen


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Treatment summary
for oxygen from the National Institute of Health and Care Excellence (NICE).
It is aimed at medical and healthcare professionals and gives an overview of
medicinal oxygen and oxygen therapy.

It is an
unreferenced webpage which presumably draws upon information provided by the
British National Formulary (BNF) and from NICE guidance. Whilst it covers the
basics of oxygen therapy the detail is fairly limited.

It has been
referenced as it highlights that medicinal oxygen should be considered as a
drug and that is very commonly prescribed, although it provides no data or
evidence to demonstrate this claim.


Guidelines for oxygen use
in healthcare produced by the British Thoracic Society (BTS). It is aimed at
healthcare and medical professionals and contains evidence-based guidance for
the use of oxygen in adults.

Produced by the BTS which
is composed of experts in the field of respiratory medicine. Guidance within
is extensively referenced and exhaustively covers all aspects of oxygen
administration. These guidelines are generally held as the gold standard and
are the source of recommendations in other guidelines such as JRCALC.

It has been referenced
multiple times in the text relating to oxygen’s legal status, as a current
guideline and as support material in theories behind oxygen-induced


UK ambulance service
clinical guidelines produced by  Joint
Royal Colleges Ambulance Liaison Committee (JRCALC) to support current
paramedic practice.

Supposedly evidence-based
guidelines, but some content has a questionable evidence base. Most UK
ambulance services have developed their own guidelines that are less
restrictive but JRCALC is still the basis for many of these. The information
on oxygen is heavily based upon BTS guidance and therefore can be presumed to
be fairly robust.

Referenced to illustrate
recommendations relating to oxygen in current guidelines.


Evidence-based document
published by the Global Initiave for Chronic Obstructive Lung Disease (GOLD)
that details strategies relating to diagnosis, management and prevention of

GOLD is a US-based
organisation with links to the World Health Organisation. It claims that the
guidelines are evidenced based and based on expert opinion from multiple
countries. Similar to the BTS guidelines it contains extensive evidence base
to support any reccommendations.

Referenced to illustrate
recommendations relating to oxygen in current guidelines.


Guidelines from the BTS
regarding management of hypercapnic respiratory failure in adults. Mostly
aimed at medical professionals in an HDU/ICU setting.

Similarly to other guidance
from the BTS is extensively referenced and has well-presented guidance.
Papers referenced were critically appraised by two reviewers. Although
primarily aimed at in-hospital care, there are features that are relevant to
current and possible future paramedic practice.

Referenced in relation to
the risk of hypercapnic respiratory failure






This cohort study by
Robinson, et al. (2000) examined
mechanisms that result in oxygen-induced hypercapnia in patients during acute
exacerbation of COPD. Results were produced from objective physiological
measures. The study classified participants as either CO2
retainers or non-retainers and found that while both groups had increased
shunt, retainers had decreased minute ventilation and increased dead space ventilation
when compared to the non-retainer group. Low initial PaO2
correlated strongly with retaining CO2.

This study is similar in
aim as Aubier et al. (1980) but
seems to refute those findings. It uses objective measures and innovative
methods to study ventilation-perfusion ratios. This study is not very recent
and the cohort is fairly small so may not be generalizable to larger
populations. The division of participents into retainer/non-retainer is based
an PaCO2. Compared to Aubier et
al. (1980) the non-retainer group had realitvely high PaO2,
possibly higher than that when hypoxic pulomnary vasconstriction (HPV) and
the Haldane effect have a physiologic role. Although hypoventialtion may have
been a component in the retainers, they also had increased dead space
ventiatlion presumably due to release of HPV which supports Aubier et al. findings.

Referced multiple times to
support theories behined oxygen-induced hypercapnia.


A figure showing the torso








Published in a US emergency
medicine journal this is a prospective cohort study of COPD patients at a
Turkish ED. Pre and Post-Treatment ETCO2 readings were correlated
with arterial blood values. Those patients that were discharged generally had
a lower pre-treatment ETCO2 level compared to those admitted and
corresponding blood gas values.

This study is useful in
that it shows a correlation between ETCO2 and PaCO2 and
the possibility of using ETCO2 as a predicater of severity of COPD
excererabation, but it also states that it is of limited use in an ED setting
due to the avialablity of blood gas analysis.
The authers aknowldge the
limitiatins of a small smaple siize taken at a single centre. Also the method
of monitoring involved breathing into a separate capnometer which could have
anomalous results from those patients unable to breathe through the
capnometer tube.

Referenced to illustrate
the limited evidence for the usefulness of ETCO2 in monitoring
COPD patients.


Published in a peer-reviewd
open access journal aimed at ICU clinicans. A prospective pilot study aiming
to assess if ETCO2 measured with a nasal-buccal sensor during
noninvasive ventilation (NIV) could predict PaCO2 variation and
absolute values. The results showed that in this study ETCO2 was a
poor predictor of PaCO2 levels during NIV.

This study demonstrates a
lack of evidence for correlating ETCO2 with PaCO2 in a
hospital setting. It uses good objective measurments and acknowledges
previous studies that have shown a correlation.
Limitations include that it
a single centre study with a very small cohort. Due to the high airflow and
possibility of leaks the sample gas could have been diluted. Participants had
variable presenting conditions and variations in respiratory and haemodynamic
status could have affected the results.

Referenced to illustrate
the limited evidence for the usefulness of ETCO2 in monitoring COPD patients.


Clinical guidelines from
South Western Ambulance Service describing usage of ETCO2
monitoring. Covers the basics of theory behind ETCO2, indications
for use and descriptions of equipment currently available in the local trust.
Aimed clinicians currently working in the service to guide their practice.

These guidelines provide a
concise summary of the basics behind using ETCO2. They have been
reviewed within the past 2 years and seemingly reflect current accepted
practice around this area. The guidelines are basic and unreferenced but are
presumably based on other evidence or guidelines.
They are referenced due to
the points regarding monitoring patient deterioration using ETCO2,
but the same caveats of no supporting evidence apply.
Although they support the
point made in the text better evidence could be found.



This retrospective cohort
study was published in a journal aimed at emergency medical clinicians. It
set out to assess if prehospital ETCO2 can be used to
differentiate between cardiac or obstructive causes of dyspnoea. The study
concluded that lower ETCO2 were associated with dyspnoea related
to congestive heart failure rather than obstructive causes.

This study provided an
interesting possible use for prehospital ETCO2 to determine
between two common presentations that are difficult to differentiate between.

As with all retrospective
cohort studies it is using data not designed for the study so therefore
reliant on the medical records being accurately noted. The authors
acknowledge that the study is subject to selection bias and also that there
was a relatively small sample size from a single ambulance service and
receiving hospital.



































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