Over-oxygenation ‘frequent’ in hospitalised patients with COPD: study

The misconception that oxygen is a benign ‘cure-all’ for COPD patients in acute care settings must be dispelled, warn experts amid new data suggesting low adherence to guideline recommendations.

An audit of acute oxygen use in patients with COPD admitted to Monash Health Services between April and June 2018 reveals a number of practice gaps leading to the over-oxygenation of hospitalised patients – and those most at risk of complications from the therapy.

The study involved a single site retrospective chart review of 457 patients predominately admitted for respiratory or cardiac conditions with clinical suspicion of COPD.

According to respiratory physician Dr Paul Leong and colleagues who examined the records, Australian and international guidelines identify patients with COPD as being at-risk of liberal oxygen-associated complications including worsening ventilation-perfusion mismatch, reduced ventilatory drive, the Haldane effect and increased atelectasis. 

But despite specific guideline recommendations designed to reduce risk – including documenting written oxygen therapy prescriptions and treating with lower saturation aims – Dr Leong said oxygen prescription and oxygen administration were suboptimal.

Only 31.2% of ED episodes  and 79% of ward episodes had a prescription documented.

And even when a prescription was documented one third of patients did not receive guideline concordant oxygen therapy.

Writing in Internal Medicine Journal the study investigators said that potential oxygen-related adverse events were frequent across both settings, occurring in approximately 8% of episodes, all of whom received more oxygen than recommended in guidelines.

While the retrospective nature of the study meant investigators could not definitively attribute the complications to over-oxygenation, they labelled the data ‘concerning’ and ‘implying suboptimal care coordination between medical and nursing staff’.

In a linked editorial respiratory physician Associate Professor Natasha Smallwood and physiotherapist Professor Ann Holland from The Alfred Hospital in Melbourne said the findings regarding suboptimal oxygen management – replicated in other studies both in Australia and internationally – came despite decades of evidence supporting the need for change. They also came off the back of the recently developed guidelines that recommend specific practices to safeguard patients from oxygen associated harms.

Calling for a cultural shift to dispel the myth that oxygen therapy is a benign treatment, they said more needed to be done to implement guideline recommended care.

“The fundamental message remains that acute oxygen therapy is still not well managed in hospitals … this issue affects multiple acute care settings, patients with many different acute illnesses and many different healthcare professionals. What we need now is a deeper understanding of why this implementation failure persists, and targeted strategies to address it,” they wrote.

Among several recommendations A/Professor Smallwood and Professor Holland said education on safe acute oxygen therapy should be priority.

The education should be individualised to suit health professionals working across different hospital environments – and senior medical staff aren’t exempt, they added.

Along with ‘oxygen champions’- health professionals who would drive change and coordinate senior medical support when guideline discordant care occurs – the COPD specialists also endorsed a more ‘high-tech’ approach to oxygen therapy.

Wearable continuous oximetry monitoring and closed-loop automated oxygen delivery systems would be more ‘sophisticated, effective options’ for delivering individualised oxygen therapy. 

Meanwhile, electronic medical records and electronic prescribing already offered opportunities to prompt healthcare professionals to flag patients at risk of oxygen-associated complications, they noted.

“[Such prompts would] mandate documentation of complete oxygen prescriptions including dose, device, flow and target saturations for all patients receiving acute oxygen therapy, and prompt healthcare staff to take action if oxygen saturations are outside the prescribed range, including prompting nurses to cease oxygen therapy in patients who are over-oxygenated, they said.

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