Policy Name: Oxygen Protocol Department: Respiratory Care Author: Teri Allen, RRT BA To Replace: Policy Identification Number:

RC.2601 Policy Name: Oxygen Therapy Purpose: To provide protocol driven oxygen therapy for the administration of oxygen at concentrations greater than ambient air with the intent of treating or preventing the symptoms and/or manifestations of hypoxia. Policy: The Oxygen Protocol will be initiated upon every patient admitted to the hospital or by a written order from the physician for any type of oxygen therapy. Scope: A Respiratory Care Practitioner (RCP), Licensed Practical Nurse (LPN) or Registered Nurse (RN) may initiate and/or discontinue oxygen per this protocol. The RCP, RN or LPN will notify the physician of any acute changes in the patients condition. In addition, oxygen may be ordered in forms other than specified by this protocol by the physician writing an order that specifies the type of oxygen delivery device, liter flow or FiO2 or a SpO2 level or range of levels to be maintained. Indications: The following conditions are accepted indications for oxygen therapy Peri and post cardiac or respiratory arrest Hypoxia - diminished blood oxygen levels (oxygen saturation levels of <92%) Acute and chronic hypoxemia (PaO2 < 65mmHg, SaO2 < 92%) Signs and symptoms of shock Low cardiac output and metabolic acidosis (HCO3 < 18mmol/l) Equipment: Oxygen flow meter Pulse oximeter Humidifier (optional) Device for oxygen delivery such as: Nasal cannula Simple mask Venturi mask Mask with reservoir bag Procedure: 1. Upon patient admission to the hospital a qualified RCP, LPN or RN will: a. Assemble the equipment needed and proceed to the patients room

b. Ensure that procedure is performed with the correct patient as follows: i. Check the name on the patients wristband ii. Ask the patient his or her name and date of birth c. Inform the patient of the procedure as follows: i. Introduce yourself by name and department ii. Inform the patient what procedure is to be performed iii. Explain the procedure by describing: 1. Why it is to be performed 2. How it will be performed 3. What the patient is expected to do 4. What you will be doing 5. How frequently it will be performed d. Evaluate the patients need for oxygen using pulse oximetry i. If unable to evaluate pulse oximetry in RA the physician will be notified. An ABG may be considered. e. Place the patient on oxygen depending upon the examination criteria i. Modalities of oxygen are as follows: 1. Nasal Cannula a. Delivers low to moderate FiO2 b. Used with oxygen flows of 1-6 liters per minute (LPM) c. At flows > 4 LPM, a humidifier may be added to the system for patient comfort 2. Simple Mask a. Delivers higher FiO2 b. Used with oxygen flows of 6-10 LPM (use of this device at lower than 6 LPM flow may result in CO2 retention and adverse patient outcomes. 3. Mask with reservoir bag a. Delivers maximum FiO2 (up to 100%) b. Used with oxygen flows of 10-15 LPM. Reservoir bag must remain inflated or CO2 retention and adverse patient outcome may occur. 4. Venturi Mask a. Delivers a precise FiO2 up to 50% b. Used with varying oxygen flows. Refer to packaging for details. f. Titrate the oxygen flow rate and/or FiO2 to keep the SpO2 > 92% or within the physician specified criteria g. Notify the physician if the patient cannot maintain a SpO2 of > 92% on 4 lpm nasal cannula or if the patient is requiring a FiO2 > 60% or if the patient is demonstrating a steady increase in O2 requirement.

2. If the physician desires to order oxygen outside the Oxygen Protocol, the physician will write: a. An order for a specified oxygen delivery device b. A liter flow/FiO2 and/or an SpO2 level or range of levels to be maintained c. A statement that the Oxygen Protocol is not to be initiated The RCP, RN or LPN will: 1. Evaluate the patient 2. Contact the physician for any modification in the treatment regimen 3. All patients on oxygen will be re-evaluated every 4 hours and/or as frequently as the patient's clinical condition indicates and/or upon the specific order of a physician and titrated to maintain an SpO2 of > 92% 4. Patients with cardiac issues a. Patients with cardiac issues are exempt from the protocol unless the physician has specifically requested the protocol. Patients with cardiac issues may be placed on 2 lpm via nasal cannula and made PRN for shortness of breath, chest pain, and/or cardiac arrhythmias despite adequate SaO2 levels. 5. Pulmonary Considerations: a. Oxygen therapy should never be limited to a patient in respiratory failure for fear of CO2 retention or of blunting a patients respiratory drive. 6. Documentation: a. Complete the computerized charting, including documentation of qualifying SpO2 and/or PaO2, date, time, liter flow at which oxygen was started and SpO2 achieved on said liter flow. b. Additional spot checks will be recorded in the computerized charting fields every 4 hours, and/or as frequently as the patient's clinical condition indicates and/or upon the specific order of a physician until the patient has been on room air for 48 hours. 7. Outcome Evaluation: a. Patient outcome is determined by clinical and physiologic assessment to establish adequacy of patient response to therapy 8. Clinical goals for oxygen therapy to treat hypoxemia: a. PaO2 > 65 in room air b. SpO2 > 92% or within physicians specified limits c. Decrease in work of breathing (respiratory rate < 25) d. Decrease myocardial workload 9. Re-evaluation a. After the patient has been discontinued from oxygen, the patient will be re-evaluated every 4 hours and/or as frequently as the patient's clinical condition indicates and/or upon the specific order of a physician to assure that an acute change has not occurred in their condition 10. Justification of discontinuation of oxygen

a. Patients will be discontinued from oxygen when the room air SpO2 is > 92% or within physician specified limits. 11. Hazards of oxygen therapy: a. Oxygen administered at a FiO2 of > 60% can have harmful effects especially for patients receiving oxygen therapy over an extended period of time. The potential hazards of oxygen therapy include: b. Oxygen-induced hypoventilation, especially in patients with chronic obstructive lung disease c. Absorption atelectasis caused by an increased partial pressure of oxygen accompanied by a decreased partial pressure of oxygen in the lungs d. Oxygen toxicity caused by inspiring a high concentration of oxygen over an extended period of time e. Neonatal retrolental fibroplasia caused by high partial pressures of oxygen in the arterial blood of premature neonates f. Fire hazard as oxygen supports combustion g. Drying of respiratory mucosa from improper humidification References: Oxygen Protocol Sky Lakes Medical Center Respiratory Care Department AARC Clinical Practice Guidelines: Oxygen Therapy for Adults in the Acute Care Facility: Respir Care. June 2002. Vol. 47 No 6 717-720.