From the Guidelines
To increase oxygenation in the Emergency Department, start with a nasal cannula at 1-6 L/min and titrate up to higher concentrations and flow rates as needed, with the goal of maintaining an oxygen saturation of 94-98% in most adults. The steps to increase oxygenation include:
- Starting with nasal cannula at 1-6 L/min, as it is comfortable and allows speaking, and adjusting the flow rate to achieve the desired target saturation 1
- Progressing to simple face mask at 5-10 L/min if needed, although nasal cannulae are preferred by patients for medium-concentration oxygen therapy due to comfort and cost-saving 1
- Escalating to non-rebreather mask at 10-15 L/min if required, with the high-concentration reservoir mask at 15 L/min being the preferred means for delivering high-concentration oxygen to critically ill patients until reliable pulse oximetry monitoring has been established 1
- Considering high-flow nasal cannula (HFNC) at 30-60 L/min with FiO2 up to 100% for patients who require higher oxygen concentrations and flow rates
- Moving to non-invasive ventilation (NIV) like CPAP or BiPAP if still inadequate, which supports breathing with positive pressure
- Proceeding to intubation and mechanical ventilation for severe cases of respiratory failure or exhaustion It is essential to monitor oxygen saturation (SpO2) and aim for 94-98% in most adults (88-92% in COPD patients), and to assess work of breathing and clinical status alongside SpO2 1. The British Thoracic Society (BTS) guideline for oxygen use in adults in healthcare and emergency settings recommends that oxygen therapy should be titrated to achieve a target saturation, and that the inspired oxygen concentration should be recorded on the observation chart with the oximetry result 1. Always reassess the patient's response to oxygen therapy and be prepared to escalate or de-escalate as needed, considering underlying causes of hypoxemia and treating accordingly 1.
From the Research
Steps to Increase Oxygenation in the Emergency Department (ED)
- Assess the patient's oxygen saturation levels using pulse oximetry and initiate supplemental oxygen if necessary 2
- Use high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure, as it has been shown to improve oxygenation and reduce breathlessness compared to standard oxygen therapy 3
- Titrate supplemental oxygen to achieve an oxygen saturation level of 92% or above, as recommended by current guidelines 2
- Consider using supplemental nasal cannula oxygen in addition to bag-valve-mask or nonrebreather face mask preoxygenation, especially in scenarios with a mask leak, as it has been shown to improve preoxygenation efficacy 4
- Monitor patients closely for signs of respiratory depression, such as hypoxia or increased end-tidal CO2 levels, and adjust oxygen therapy accordingly 5
Key Considerations
- Oxygen therapy should be tailored to the individual patient's needs, taking into account their underlying medical condition and oxygen saturation levels 6
- Hyperoxia should be avoided, as it may increase morbidity and mortality in certain patient populations, such as those with acute exacerbation of chronic obstructive lung disease or myocardial infarction 6
- Normoxic oxygenation strategies should be employed to avoid both hypoxemia and hyperoxia 6