Oxygen including HFNO and NIV

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Oxygen

All patients must have a target oxygen saturation range prescribed on the drug chart on admission.

The appropriate range depends on the patient’s risk of hypercapnoea*

  • Patient at risk of chronic hypercapnoea:  Rx Target SpO2 85-90%
  • Patient NOT at risk of hypercapnoea: Rx target SpO2 92-96% 

Start Oxygen if SpO2 is below required range or RR >24bpm

(elevated RR suggests patient is working hard to maintain SpO2 in required range)

  • Patients at risk of hypercapnoea start with 24% (BLUE) Venturi mask
  • Patients not at risk of hypercapnoea start with 2-4L via nasal prongs

If SpO2 is greater than the UPPER limit of the prescribed Sp02 range – reduce the oxygen

If unable to maintain SpO2 >=92% (90% if at risk of hypercapnoea) with RR <25bpm on 60% FiO2:

  • Request urgent ST3+ medical review
  • Critical care referral if appropriate
  • Consider proning 

Notes

* Chronic/ intermittent hypercapnoea may occur in severe COPD, obesity, hypoventilation and significant neuromuscular/musculoskeletal disorders.  Review pre-existing respiratory diagnoses/previous episodes of hypercapnoea/chronically elevated bicarbonate

CPAP, HFNO, and NIV

Continuous Positive Airway Pressure, High Flow Nasal Oxygen and Non-Invasive Ventilation are considered Aerosol Generating Procedures (AGP).

All patients must be discussed with the respiratory registrar on call via switchboard BEFORE starting NIV, even for patients on home NIV, and have a documented ceiling of care decision.

All patients on CPAP/NIV/HFNO must be managed in the correct environment usually a side room with full AGP PPE - including face fit tested FFP3 respirator 

See COVID-19 IPC PPE intranet page

  • Patients NOT usually on CPAP or NIV at home
    • In Lothian, CPAP and HFNO should only be given in the context of critical care.
    • NIV (BiPAP) may be given on the ward for patients with T2RF due to underlying respiratory disease (COPD, OSA, respiratory muscle dysfunction).
    • All patients must be discussed with the respiratory registrar on call via switchboard BEFORE starting NIV, and have a documented ceiling of care decision.
  • Patients with Home CPAP or NIV
    • Careful assessment should be undertaken to assess the whether CPAP/NIV is required in the acute situation.
    • If unsure – contact the respiratory registrar on call via switchboard.

More information is available here.

Secretions

Consider referral to physiotherapy for chest clearance assistance if significant secretions or difficulty expectorating.

Airway suctioning is an AGP - Patient must be managed in a side room with full AGP PPE – including face fit tested FFP3 respirator - COVID-19 PPE IPC intranet page