1/21/19. The History of Oxygen Therapy Fun Facts!

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1 The Evolution of Oxygen Therapy; Where Are We At Now? Patti DeJuilio, MS, RRT-ACCS, RRT-NPS Disclosures Southmedic is sponsoring this lecture The Evolution of Oxygen Therapy; Where Are We At Now? Objectives Learner will Describe the history of oxygen therapy. Describe the data defining the possible dangers of liberal oxygen therapy. Understand the recommended saturation ranges; how and why they are important. Describe devices available today that may help to achieve timely titration of oxygen. 1

2 The History of Oxygen Therapy Fun Facts! Oxygen: Comprises 65% of the mass of the human body Third most abundant element in the universe (H+ and He are more abundant) Vital to aerobic respiration May be harmful as reactive oxygen molecules can degrade biological tissue. The History of Oxygen Therapy Discovery Karl Scheele, 1771 Joseph Priestly, 1777 Both performed experiments with mercuric oxide and potassium nitrate. Found that oxygen was potentially valuable resource for patients with respiratory conditions. The History of Oxygen Therapy Thomas Beddoes The Father of Respiratory Therapy (worked with James Watt) Generated oxygen and other gases. Watt opened a Pneumatic Institute, Bristol England, 1798 Used oxygen and nitrous oxide to treat asthma, CHF, and more! 2

3 History of Oxygen Therapy George Holtzapple 1885 Used oxygen to manage a young patient with pneumonia. Oxygen has a role in acute care History of Oxygen Therapy Arbuthnot Lane 1907; Haldane, J.S. Devised rubber tubing that served as a nasal catheter to deliver oxygen. Haldane became hypoxic during a trip up Pikes Peak and created the first oxygen masks. Are We Overusing Oxygen? Too Much of a Good Thing 3

4 Oxygen Toxicity What is it? Development of reactive oxygen species (ROS) - Superoxide anion (O2) - Hydrogen Peroxide (H2O2) - Lipid Peroxide (LOOH) - Peroxyl radicals (RO) - Nitric Oxide (NO) - Hydroxyl radical (OH) OH packs a punch! Potent oxidant in biological fluids; may damage tissues as it reacts with lipids, proteins, DNA, amino acids, and more! NICU Supplemental Oxygen STOP-ROP and BOOST Trials Resuscitations start at 40% oxygen (NRP Guidelines) Infants <27 weeks (or < 1500g) 88% - 94% (target 90 92%) weeks 90 95% (target 91-94%) Term Infants (with the exception of PPHN who benefit from higher oxygen levels) 90 96%. Excessive Oxygen, wide swings of oxygen, and too little oxygen can all be potentially harmful. Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis Approximately 34% of patients receive oxygen in ambulances 25% receive oxygen in Emergency Departments 15% of patients in the hospital receive oxygen 50-84% of these patients are exposed to excess oxygen and hyperoxemia as a result of efforts to treat hypoxemia. Many healthcare providers consider oxygen therapy to be harmless, possibly beneficial therapy, even without hypoxemia present. 4

5 Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis Deleterious Effects of Excessive Oxygen Therapy: - Absorption atelectasis - Acute lung injury - Inflammatory cytokine production - Central nervous system toxicity - Reduced cardiac output - Cerebral and coronary vasoconstriction Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis The use of supplemental oxygen for acute illness in adults is not consistent and may be contradictory. No high quality evidence exists. Outcome Measures: Mortality (in-hospital, at 30 days, and at longest follow up) Morbidity (disability measured by modified Rankin scale at longest follow up, risk of HAP, risk of HAI, and hospital LOS) Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis OUTCOMES 1150 unique records of research screened. 67 full texts were assessed for eligibility 25 RCT reported in 26 publications >16,000 patients with critical illness, trauma, sepsis, stroke, MI, cardiac arrest, or emergency surgery. 5

6 Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis Liberal oxygen supplementation = median FiO2 of 0.52 (range ) for a median duration of 8 hours; baseline SpO2 96.4% (range %) Conservative oxygen supplementation = median FiO2 0.21, range 0.21 to 0.50); baseline SpO2 96.7% (range %) Room air or oxygen delivered by nasal prongs in 4 trials Facemask in 13 trials Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis OUTCOMES Liberal oxygen therapy increases mortality. - without improving patient-important outcomes This effect decreases over time after exposure. For every 1% increase in SpO2, the relative risk of in-hospital mortality is associated with a 25% increase. For every 1% increase in SpO2, the relative risk of mortality at longest follow-up is associated with a 17% increase. Overall, these results are consistent with a sensitivity analysis using patientlevel survival (time-to-event) data: 1 year mortality HR 1 11 (95% CI ). Liberal oxygen therapy does not reduce the risk of worsening disability after acute stroke. Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis 6

7 Mortality and morbidity in acutely ill adults treated with liberal vs conservative oxygen therapy Chu D, Kim L, Young P, et al; Lancet April 2018; systematic review and meta-analysis OUTCOMES Assuming a baseline risk of trials included, the mean number needed to harm resulting in one death using a liberal approach is approximately 71 (95% CI ). Liberal oxygen therapy does not reduce the risk of worsening disability after acute stroke THIS META-ANALYSIS PROVIDES HIGH QUALITY EVIDENCE THAT LIBERAL SUPPLEMENTAL OXYGEN IS HARMFUL! PATIENTS TREATED LIBERALLY WITH OXYGEN HAD A DOSE-DEPENDENT INCREASED RISK OF MORTALITY (SHORT AND LONG TERM) Those treated liberally had no significant difference in complications such as disability, HAP, HAI, or LOS. Supplemental oxygen may become unfavorable above SpO2 range of 94-96%. Too Much of a good thing? Yes! Animal and human studies have shown that excessive oxygen can promote vasoconstriction, inflammation, and oxidative stress on pulmonary, cardiovascular, and neurological systems. RCTs have suggested increased risk of respiratory failure, new shock episodes, recurrent MI, arrhythmia, other cardiac adverse events as potential harm caused by liberal oxygen therapy. Hyperoxia is life threatening! Too Much of a Good Thing? Reducing Harm form Respiratory Depression in Non-ICU Patients; Guidelines of Care Tool Kit, Hospital Quality Institute, Nov, 2017 Obstructive Sleep Apnea (Sleep Disordered Breathing) Protocols recognize that liberal oxygen use may decrease vigilance and delay recognition of patients in pending respiratory failure because of falsely reassuring SpO2 levels. There may be false confidence of the level of risk! In normal circumstances, SpO2 is sensitive to hypoventilation As PaCO2 rises, PaO2 decreases Normal PaCO2 is 40 and normal max for PaO2 is 100 = 100% Sat With supplemental oxygen, PaO2 may be higher than 100 When PaO2 drops due to increase in FiO2, saturation stays at higher level longer which misleads clinicians. This is how respiratory depression may be missed until a code is being called! 7

8 Too Much of a Good Thing? Reducing Harm form Respiratory Depression in Non-ICU Patients; Guidelines of Care Tool Kit, Hospital Quality Institute, Nov, 2017 Perform continuous monitoring of oxygenation and ventilation for those patients at high risk of hypoventilation and/or apnea and receiving supplemental oxygen and not adherent with NIV. Ventilation can be measured with the use of EtCO2, transcutaneous CO2 and RVM. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: Swimming between the flags * Beasley R, Chien J, Douglas J, et al; Respirology Nov, 20(8) Concepts Oxygen should be prescribed and administered for specific indications, with documented targeted O2sat range and with regular monitoring. Oxygen treats hypoxia, not breathlessness. There are risks with both hypoxemia and hyperoxemia - Use oxygen only when required - Target oxygen saturation range Too Much of a Good Thing? 2015 Thoracic Society of Australia and New Zealand recommendations and Chu D et al How much supplemental oxygen is enough? Maximum of 96% SpO2 (range 92%-96%) for titration protocols Thoughtfully consider oxygen therapy administration and the titration of oxygen therapy with each and every patient. 8

9 Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury Johnson, Nicholas J. MD; Carlbom, David J. MD; Gaieski, David F. MD, CHEST 2018 Jun 153(6): Biological rationale for oxygen management after cardiac arrest attempts to strike a balance between sufficient oxygen delivery to meet the metabolic needs of the cells while avoiding hyperoxia and the potential injury from excess oxygen present during ischemia and reperfusion. Hypoxemia produces ongoing ischemia, irreversible cellular injury, and organ dysfunction Hyperoxemia may increase oxidative stress, amplify free radical production, and worsen organ function. Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury Johnson, Nicholas J. MD; Carlbom, David J. MD; Gaieski, David F. MD, CHEST 2018 Jun 153(6): A number of preclinical studies demonstrated improved outcome and decreased neuronal injury when animals received lower FiO2 post-arrest. Kilgannon et al used the Project Impact database, a repository of data from admissions to 120 ICUs in the United States, to examine relationship between PaO2 on initial blood gas after ICU admission and outcomes in 6,326 patients. They found significantly higher mortality in the hyperoxemia (PaO2 > 300 mm Hg) group (63%) than in the normoxemia (PaO mm Hg [45%]) and hypoxemia (PaO2 < 60 mm Hg [57%]) groups. More specifically, they found that each 100 mm Hg increase in PaO2 was associated with a 24% increase in risk of death. Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury Johnson, Nicholas J. MD; Carlbom, David J. MD; Gaieski, David F. MD, CHEST 2018 Jun 153(6): The Oxygen-ICU Randomized Clinical Trial was a single-center trial enrolling patients admitted to ICU in Italy between March 2010 and October Patients received - conservative oxygen therapy (oxygen to maintain a PaO2 70 to 100 mm Hg or an SpO2 of 94% to 98%, or - conventional oxygen therapy (oxygen to maintain a PaO2 < 150 mm Hg or an SpO2 of 97% to 100%). A total of 434 patients were randomized; patients in the conventional control group had higher daily median PaO2 values than patients in the conservative oxygen therapy group (102 vs 87 mm Hg) and higher mortality (20% vs 12%). In addition, the patients in the conservative oxygen therapy group had fewer episodes of shock, liver failure, and bacteremia. 9

10 Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury Johnson, Nicholas J. MD; Carlbom, David J. MD; Gaieski, David F. MD, CHEST 2018 Jun 153(6): Given the preceding data, we recommend titration of FiO2 to maintain SpO2 between 92% and 97%, approximately PaO2 of 0 to 100 mm Hg, immediately on ROSC. Current guidelines recommend titration of FiO2 to maintain an SpO2 >= 94%. Whether hyperoxemia and hypoxemia are biologically harmful or simply markers of underlying illness is not clear in the post-arrest population. Rapid Recommendations; October, 2018 Siemieniuk, Reed, et al; Oxygen therapy for acutely ill medical patients: a clinical practice guideline; BMJ 2018;363:k4169 doi: /bmj.k4169 The panel strongly recommends SpO2 no greater than 96%. Target of 90-94% is reasonable for most patients % for patients at risk of hypercapnic respiratory failure. Patients with MI or acute stroke should not receive oxygen if saturation is > 93% (strong recommendation). Use the minimum amount of oxygen necessary! Rapid Recommendations; October, 2018 Siemieniuk, Reed, et al; Oxygen therapy for acutely ill medical patients: a clinical practice guideline; BMJ 2018;363:k4169 doi: /bmj.k

11 Northwestern Medicine Central DuPage Hospital About Us 400 bed acute-care designated Magnet facility Full service tertiary hospital - Certified stroke center - Open heart and cancer programs - Thoracic surgery center Partner with Lurie Children s Hospital - Level III NICU - PICU/Pediatrics - Pediatric ED Extensive physician network NM Oxygen Therapy Protocol Where we are at INDICATIONS FOR USE A. Documented hypoxemia (PaO2 < 60 torr or SpO2 < 90% while breathing room air, are considered hypoxemia unless there is a special clinical situation. Pregnant women should be considered hypoxemic with Sp02 < 94%. B. Acute situations which may include respiratory distress or significantly abnormal vital signs, changes in level of consciousness, severe trauma, acute MI or severe chest pain, short term therapy in relation to surgery or procedure. C. Maintain SpO2 88%-92% for COPD and conditions associated with chronic respiratory failure/patients at risk for hypercapnia. NM Oxygen Therapy Protocol Exclusions 1. Patients receiving home oxygen therapy that do not require additional oxygen during hospital stay. 2. Patients with a history of Bleomycin treatment. 3. Patients with a history of Paraquat poisoning. 11

12 NM Oxygen Therapy Protocol 1. Start 2 LPM by nasal cannula or open design oxygen mask and increase or decrease flow based on assessment. 2. Patients whose respiratory rate > 30 initially place on open design oxygen mask. If SpO2 is <90% (94% for pregnant women; 88% COPD) liter flow will be increased until a SpO2 of 90% (or 94% / 88%) or greater is achieved. Adjustments are in 1 liter increments. 3. After oxygen titration, repeat a SpO2 within 15 minutes to allow for stabilization. May continue to titrate up if saturation remains below 90% (94% / 88%). NOTE: Women in active labor may be placed immediately on open design oxygen mask at 12LPM. Do not titrate. NM Oxygen Therapy Protocol F. If oxygen requirement > 5 LPM nasal cannula, replace oxygen delivery device to open design oxygen mask and place on continuous pulse oximetry. G. If SpO2 >95% oxygen, weaning is indicated. If SpO2 is >90% (94% / 88%) and patient has normal respiratory pattern, patient may be weaned. NM Oxygen Therapy Protocol H. Decrease open design oxygen mask or nasal cannula by 1 LPM decrements. Repeat SpO2 within 15 minutes to allow for stabilization. May continue to titrate down if saturation remains 90% (94%; 88%) or greater. I. If patient not tolerating weaning process (SpO2 < 90% (94% /88%), HR increase by 20 beats per minute, RR greater than 30 breaths per minute or level of consciousness changes) return to previous oxygen settings, reassess patient and maintain saturation 90% or greater but less than 95%. Attempts at weaning should be done at least daily. K. All oxygen changes are to be performed by RN/RCP. 12

13 Evolution of Devices Oxygen Devices Where we were Oxygen Devices Where we have been for many years 13

14 Oxygen Devices Where we are Headed Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital Patricia A DeJuilio MSc RRT RRT-ACCS RRT-NPS, Maya B Jenkins MSc RRT, and Jeffrey P Huml MD; Respiratory Care. April 2018 vol 63 No 4 Safety Reports of traditional oxygen masks found set at inappropriately low flows. Cost/Efficiency Open design oxygen mask may lead to more timely titration of flow which would lead to less gas consumption. There would be far less waste with one oxygen mask meeting all patient requirements. Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital Patricia A DeJuilio MSc RRT RRT-ACCS RRT-NPS, Maya B Jenkins MSc RRT, and Jeffrey P Huml MD; Respiratory Care. April 2018 vol 63 No 4 METHODS: We conducted a retrospective analysis, 12 months before and 12 months after implementation of the open-design oxygen mask. Unusual occurrence reports related to supplemental oxygen delivery were reviewed. Oxygen device use and bulk oxygen consumption were recorded. The total number of patient days was obtained from the electronic medical record 14

15 Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital Patricia A DeJuilio MSc RRT RRT-ACCS RRT-NPS, Maya B Jenkins MSc RRT, and Jeffrey P Huml MD; Respiratory Care. April 2018 vol 63 No 4 RESULTS No unusual occurrence reports or concerns involving an oxygen device in those areas that converted to the open-design oxygen mask. Reduction in oxygen consumption was $3,670 despite the increase in patient days. FY14, 3,848 oxygen devices cost of $3,411, and in FY16, 5,512 devices cost of $12,963. Net savings from open-design oxygen mask conversion was $23,487 annual and corrected for increased patient population. Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital Patricia A DeJuilio MSc RRT RRT-ACCS RRT-NPS, Maya B Jenkins MSc RRT, and Jeffrey P Huml MD; Respiratory Care. April 2018 vol 63 No 4 July 2013-June 2014 June 2015-July 2016 Difference July June 2014 Percent Change Patient Days 74,734 99,428 24, % Bulk Oxygen 13,036,686 12,072, , % Oxygen Cost $ 85, , , % O2 Cost/patient $ 1.14 $ 0.82 $ (0.32) -28.1% Oxygen Masks Total units 3,848 5,512 1, % Mask cost $ 3, , , % Mask cost/patient $ 0.05 $ 0.13 $ % Total cost/patient $ 1.19 $ 0.95 $ (0.24) -19.9% Evaluation of Safety and Cost of an Open-Design Oxygen Mask in a Large Community Hospital Patricia A DeJuilio MSc RRT RRT-ACCS RRT-NPS, Maya B Jenkins MSc RRT, and Jeffrey P Huml MD; Respiratory Care. April 2018 vol 63 No 4 $2,000 Box and Whisker Plot for Dollars per 1000 Patient Days $ per 1000 Patient Days $1,800 $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 Ju l Ju n Ju l Ju n

16 Make the right thing to do the easiest thing to do! Evaluation of an Open Design Oxygen Mask CONCLUSIONS: Oxygen consumption and supply cost per patient day resulted in $1.19 per patient day pre-implementation and $0.95 after implementation of the open-design oxygen mask (P.003). The open-design oxygen mask may be a safe and less costly alternative to traditional oxygen delivery devices. The open-design oxygen mask led to less oxygen use which may indicate more timely titration of oxygen. Thank You Use Oxygen judiciously! Titrate appropriately and in a timely manner! Use the right devices: make the right thing to do the easiest thing to do! Questions? 16