Post‐procedural considerations

Immediate care

The patient should be educated regarding the necessity of keeping the oxygen cannula or mask on to prevent periods of hypoxaemia. This includes during periods of mobilization. Reassurance should be given and the patient should be allowed opportunities to ask questions and express any concerns or discomfort.
Document the device, flow rate and concentration of oxygen administered, in addition to the patient's observations, within 5 minutes of commencing oxygen therapy (O'Driscoll et al. [209]). Monitor for changes in consciousness level, especially if the patient is at risk of hypercapnic respiratory failure, and escalate any concerns immediately.
All patients should be assessed and monitored using the National Early Warning Score (NEWS) (RCP [230]). The device, flow and/or concentration delivered should also be documented on the patient's observation chart (see Table 12.7 for the approved abbreviations for recording oxygen delivery on the observation chart).
Table 12.7  Abbreviations for recording oxygen delivery on an observation chart
AbbreviationMeaning
AAir (not requiring oxygen)
CPCPAP system
H28Humidified oxygen 28% (also H35, H40 and H60 for humidified oxygen at 35%, 40% and 60% respectively)
HFNHigh‐flow oxygen via nasal cannula
NNasal cannula
NIVNon‐invasive ventilation system
RMReservoir mask/non‐rebreathing mask
SMSimple mask
TMTracheostomy mask
V24Venturi 24%
V28Venturi 28%
V35Venturi 35%
V40Venturi 40%
V60Venturi 60%
Source: Adapted from O'Driscoll et al. ([209]) with permission of BMJ Publishing Group, Ltd.
Patients who are hypoxaemic must be assessed by an experienced clinician to determine the cause of their hypoxaemia so the underlying cause can be treated (O'Driscoll et al. [209]). The clinician should also determine what the target saturations for the patient are and document this on the observation chart, on the drug chart, and in the nursing and medical records (Brill and Wedzicha [31], O'Driscoll et al. [209]).
Arterial blood gas (ABG) analysis should be undertaken as soon as possible in all critically ill patients and situations involving hypoxaemic patients. It also forms part of the essential assessment in patients who are at risk of hypercapnic respiratory failure (GOLD [91]). Interpretation of the results must take into account the amount of supplementary oxygen being administered at the time of ABG sampling. ABG sampling should be repeated after 30 minutes in accordance with the patient's clinical response to treatment, and in all cases where the patient is found to be both hypercapnic and acidotic (GOLD [91], O'Driscoll et al. [209]).

Ongoing care

Recheck the patient's condition, observations and NEWS 1 hour after starting oxygen therapy and then a minimum of every 4 hours thereafter (O'Driscoll et al. [209]). Patients with a NEWS of 5 or more will require more frequent observations (RCP [230]). This will allow for early identification and escalation of patients at risk of clinical deterioration.
For patients requiring high‐flow oxygen therapy for more than 24 hours, or when a patient reports discomfort due to dryness, humidification should be commenced to protect airway defences and optimize patient comfort.
Encouraging patients to sit out in a chair and mobilize frequently will help to prevent atelectasis (incomplete lung inflation) and aid removal of secretions. Ensuring that post‐operative patients have effective pain relief will allow them to carry out deep breathing exercises and aid early ambulation, reducing the risk of post‐operative atelectasis.

Weaning and discontinuing oxygen therapy

Reduce oxygen flow/concentration or stop oxygen therapy if the patient is clinically stable and their peripheral oxygen saturations have been within the target range for two consecutive observations (O'Driscoll et al. [209]). Observe the patient 5 minutes after stopping or lowering the dose of oxygen therapy and document the observations. Repeat observations again after 1 hour; if saturations remain within the desired target range, oxygen therapy has been successfully weaned or stopped (O'Driscoll et al. [209]).
Patients should be observed for signs and symptoms of hypercapnia. These include anxiety, mild dyspnoea, headache, hypersomnolence, delirium, confusion, facial flushing, bounding pulse, tachycardia, warm peripheries, drowsiness and flapping tremor (Feller‐Kopman and Schwartzstein [78], Patel and Majmundar [215]). If hypercapnia is suspected, reduce the oxygen concentration down slowly. Do not stop oxygen completely as this may cause rebound hypoxia (Feller‐Kopman and Schwartzstein [78]).

Documentation

Accurate documentation of patient observations and the oxygen device, flow and concentration administered will assist healthcare professionals in determining whether a patient is clinically improving or deteriorating, and help to guide future treatments. Clear documentation of the events that led up to a patient requiring oxygen therapy, in addition to any other relevant information, must be available for all healthcare professionals to review if required, as this will improve communication and reduce patient risk (NMC [198]).

Domiciliary oxygen and patient education

Long‐term oxygen therapy at home may be required if the patient is chronically hypoxaemic and requires oxygen for more than 15 hours per day (Hardinge et al. [99]). Relevant conditions include COPD, cystic fibrosis, interstitial lung disease, neuromuscular and skeletal disorders, pulmonary hypertension, obstructive sleep apnoea and heart failure. Palliative oxygen therapy may also be required for patients with intractable breathlessness caused by their underlying lung disease (O'Driscoll et al. [209]). A full clinical assessment should be performed before a referral is made to the home oxygen assessment team.
The patient and their family should be formally educated and provided with written information on the hazards of oxygen use at home. Healthcare providers must be sure that the patient and their family members understand the dangers of smoking (including e‐cigarettes) in an oxygen‐enriched environment. An increased amount of oxygen in the environment increases the speed at which things burn once a fire starts. Oxygen can saturate clothing, fabric, hair and beards. Even flame‐retardant clothing can burn when oxygen content increases. It is important to keep all naked flames and heat sources away from oxygen systems. Patients should be advised never to smoke or light a match while using oxygen, or allow others in the same room to do so. The local fire brigade should be informed of any home with an oxygen system (Hardinge et al. [99]) and every home should have at least one working smoke detector on every level and near all bedrooms. When transported in a car, oxygen cylinders should be adequately secured, a warning triangle should be displayed and the car insurance company should be informed.
The oxygen supplier in the community has a responsibility to carry out a detailed risk assessment of the patient's home and ensure the environment is safe, as well as educate the patient and provide written information on the use of oxygen equipment. The patient should also be followed up by a specialist home oxygen assessment team at least 4 weeks after hospital discharge to ensure safe use and compliance with oxygen therapy (Hardinge et al. [99]). Oxygen may be supplied in cylinders or in an oxygen concentrator, which is more economical for patients requiring long‐term oxygen therapy. For more guidance see the British Thoracic Society's guidelines for home oxygen use in adults (Hardinge et al. [99]).