Can oxygen saturation goals be safely liberalized to greater than 90% on room air in very elderly patients, such as those over 100 years old, with emphysema appearance on Chest X-ray (CXR) and requiring supplemental oxygen via nasal prongs (0.5 liters) to maintain oxygen saturation greater than 92%?

From the Guidelines

Oxygen goals can be safely liberalized in very elderly patients (100 years old) to >90% on room air, rather than the traditional >92%. For the patient with emphysema appearance on CXR but no smoking history or known lung disease, it would be reasonable to accept oxygen saturations of 90-92% without supplemental oxygen. If the patient is comfortable and not showing signs of hypoxemia (confusion, tachycardia, dyspnea), maintaining saturations above 90% is generally adequate, as stated in the BTS guideline for oxygen use in adults in healthcare and emergency settings 1.

The physiological basis for this approach is that normal aging causes changes in lung mechanics, including decreased elastic recoil and increased air trapping, which can mimic emphysema on imaging. Additionally, elderly patients often have altered ventilation-perfusion matching that affects oxygen saturation. Supplemental oxygen should be reserved for when saturations consistently fall below 90% or if the patient is symptomatic. When oxygen is needed, start with low-flow nasal cannula at 0.5-1 L/min and titrate as needed, following the guidelines for initial hospital management of patients with exacerbation of COPD 1.

Regular reassessment is important, as oxygen requirements may change with position, activity, or during sleep. The BTS guideline also recommends careful monitoring for hypercapnic respiratory failure with respiratory acidosis, which may develop in the course of a hospital admission even if the initial blood gases were satisfactory 1. It is essential to avoid excessive oxygen use in patients with COPD, as the risk of respiratory acidosis in patients with hypercapnic respiratory failure is increased if the PaO2 is above 10.0 kPa due to previous excessive oxygen use 1.

Key points to consider:

• Target oxygen saturation range for very elderly patients with emphysema appearance on CXR: 90-92%
• Supplemental oxygen should be reserved for when saturations consistently fall below 90% or if the patient is symptomatic
• Start with low-flow nasal cannula at 0.5-1 L/min and titrate as needed
• Regular reassessment is important, as oxygen requirements may change with position, activity, or during sleep
• Avoid excessive oxygen use in patients with COPD, as it can increase the risk of respiratory acidosis.

From the Research

Oxygen Saturation Goals for Very Elderly Patients

• The target oxygen saturation for most patients, including those with respiratory failure, is generally considered to be between 92% and 96% 2, 3, 4.
• For patients with chronic obstructive pulmonary disease (COPD), a target oxygen saturation of 88-92% is recommended to avoid hypercapnia 5, 4.
• In the case of very elderly patients, such as those over 100 years old, with emphysema appearance on Chest X-ray (CXR) and requiring supplemental oxygen via nasal prongs, the goal should be to maintain an oxygen saturation greater than 92% 2.
• Liberalizing oxygen saturation goals to greater than 90% on room air may be safe for these patients, as long as they are closely monitored and their oxygen therapy is titrated to avoid hyperoxia 6, 2, 3.

Considerations for Supplemental Oxygen Therapy

• Supplemental oxygen should be administered according to the monitoring of SpO2, with the aim of maintaining SpO2 above 92% and below 98% 3.
• High-flow nasal cannula oxygen (HFNC) may be considered for patients requiring more than 6 L/min of oxygen or with a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress 3.
• The use of supplemental oxygen should be individualized based on the patient's condition and response to therapy, and should be guided by evidence-based practices to provide maximum benefit and avoid harm 5.