Learning objective: Know definitions of the clinical states of hypoxia, hypoxaemia, hypercapnia and breathlessness.

Activity: Outline definitions of the four clinical states above.

Begin your response here.

Learning objective: Understand how to prescribe oxygen therapy and how to audit implementation of the new BTS guidance.

Activity: a) Your patient requires oxygen therapy as they have become hypoxaemic - what actions should be taken?

b) How and what should your ward, clinic, PCT or hospital audit to check they are in line with implementation of this new BTS guideline?

Begin your response here.

Learning objective: Know how to manage acute exacerbations of asthma in hypoxaemic patients.

Activity: A hospitalised patient with an acute exacerbation of asthma needs nebulised salbutamol and is hypoxaemic. What action do you need to take in order to administer therapy and how will you monitor effectiveness?

Begin your response here.

Learning objective: Understand how to manage hypoxaemic patients with COPD.

Activity: You are working in a primary care practice and your hypoxaemic patient with COPD needs to be transferred to hospital. They also need to have single doses of nebulised saline to improve mucous clearance. How do you deliver this medication?

Begin your response here.

British Thoracic Society Standards of Care Committee (2004) Management of exacerbations of COPD. Thorax; 59: Suppl I, i131-i56.

Cretikos, M.A. et al (2008) Respiratory rate: the neglected vital sign. Medical Journal of Australia; 188: 11, 657-9.

Hairon, N. (2008) First guidance on emergency oxygen sets new standards. Nursing Times; 104: 41, 23-24.

Khan, S.Y., O'Driscoll, B.R. (2004) Is nebulized saline a placebo in COPD? BMC Pulmonary Medicine; 4: 9.

NICE (2004) Chronic Obstructive Pulmonary Disease. Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. London: NICE. www.nice.org.uk/Guidance/CG12

O'Driscoll, B.R. et al (2008) BTS Guideline for Emergency Oxygen Use in Adult Patients. Thorax; 63: Suppl VI, vi1-vi68.

Poole, P.J. et al (1998) The effects of nebulised isotonic saline and terbutaline on breathlessness in severe chronic obstructive pulmonary disease (COPD). Australian and New Zealand Journal of Medicine; 28: 322-6.

Plant, P.K. et al (2000) One-year period prevalence study of respiratory acidosis in acute exacerbations of COPD: implications for the provision of non-invasive ventilation and oxygen administration. Thorax; 55: 7, 550–554.

Scottish Intercollegiate Guidelines Network, British Thoracic Society (2008) British Guideline on the Management of Asthma - A National Clinical Guideline. Thorax; 63: Suppl IV, iv1-iv121.

tinyurl.com/signguidance

Wedzicha, J.A., Donaldson, G.C. (2003) Exacerbations of chronic obstructive pulmonary disease. Respiratory Care; 48: 12, 1204-13.

Zhao, I., Yates, P. (2008) Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliative Care; 22: 6, 693-701.

Answer 1

Hypoxia – lack of oxygen in a particular compartment (alveolar or tissue). There are several types of hypoxia described in the guideline.

Hypoxaemia – low oxygen tension or partial pressure in the blood (PaO₂). This can be measured in millimetres of mercury (mmHg) or kilopascals (kPa).

Hypercapnia – increased carbon dioxide in the blood and is reported as PaCO₂.

Breathlessness – can be described as being short of breath and therefore having an increased respiration rate (tachypnoea), rapid shallow breathing or a difficulty in breathing (dyspnoea), with or without any physiological change.

Answer 2a

Oxygen therapy should be prescribed and the prescription should also have the desired oxygen saturation range to be achieved and maintained. 

Selecting the most appropriate delivery device (mask/nasal cannulae) is extremely important, along with ensuring the accurate flow rate is delivered.

Patient monitoring should incorporate the accurate recording of their respiration status (rate, depth, effort), saturations and signing for the prescribed oxygen therapy at each drug round (delivery device, flow rate, oxygen saturation level and oxygen percentage prescribed).

Answer 2b

Does the trust have an oxygen prescribing policy based on the guideline?

Is this policy known to all staff and available at all times on the trust intranet?

Was oxygen prescribed for every patient at the time of the audit?

Did every patient have a target oxygen saturation specified (and was the target appropriate) in their chart?

Was oxygen given in accordance with the current BTS guideline?

Answer 3

The patient would require their nebulised medication to be given via wall oxygen and not by compressed air as this would compromise their respiratory status. Close regular monitoring of oxygen saturations and/or arterial blood gases are required, including carbon dioxide (PaCO₂ ), as this may indicate the patient is entering type 2 respiratory failure.

Answer 4

The BTS guidance provides some information on this. The nebulised saline can be given using a disposable or re-usable nebuliser chamber and using oxygen cylinders capable of delivering a flow of > 6L per minute. Ideally they should have an integral valve/regulator.

11