Below is the UKRC response to the BTS guidelines - this statement can be found on their website
British Thoracic Society Guideline for emergency oxygen use in adult patients
The British Thoracic Society (BTS) has recently published guidelines for emergency oxygen use in adult patients. It has been suggested that the advice given by the BTS on the use of oxygen in patients with acute coronary syndromes conflicts with recommendations made in the ALS Course manual. This statement is intended to clarify these issues.
In October 2008, the British Thoracic Society (BTS) published the “BTS guideline for emergency oxygen use in adult patients” (
www.brit-thoracic.org.uk/emergencyoxygen ). Along with several other organisations, the Resuscitation Council (UK) was approached by the BTS for endorsement of the first draft of this guideline. As a result of the feedback received on this document, significant amendments were made before the collaborating organisations endorsed this final guideline.
The majority of the recommendations in this guideline are consistent with the contents of the Advanced Life Support (ALS) course and manual and other RC(UK) guidelines and publications. Key is that the BTS guideline states “for critically ill patients, high concentrations of oxygen should be administered immediately”. Furthermore, in the critically ill patient or peri-arrest situation, treatment should commence with oxygen at 15 L min-1 via a reservoir mask or bag-mask, and during cardiac arrest the aim should be for maximal oxygen saturation until the patient is stable. Once these patients are stable, the oxygen dose should be reduced with the aim of achieving an oxygen saturation in the range of 94-98%. In those situations where pulse oximetry is not available to monitor critically ill patients, oxygen should continue to be given via a reservoir mask until definitive treatment is available. For those patients with serious illness causing acute hypoxaemia (initial SpO2 <85%), oxygen should also be given via a reservoir mask at a flow of 10-15 L min-1. As before, once stable, the target is an oxygen saturation of 94-98%. The guideline recommends that arterial blood gas values should be checked in all of these patients. Although the guideline emphasises the need to avoid giving excessive concentrations of oxygen to patients with chronic obstructive pulmonary disease (COPD) or other risk factors for hypercapnic (Type II) respiratory failure, when critically ill, these patients should initially be given oxygen at high flow, but arterial blood gas analysis should be undertaken promptly to guide further management.
It is highly likely that future resuscitation guidelines will emphasise the need to target the oxygen saturation in all patients once a reliable pulse oximetry reading and arterial blood gas analysis can be obtained.
One recommendation in the BTS document that apparently conflicts with RC(UK) ALS guidelines is the recommendation to withhold oxygen from a patient with an acute coronary syndrome, including myocardial infarction, unless the patient is hypoxaemic: “in myocardial infarction and acute coronary syndromes, aim at an oxygen saturation of 94-98% or 88-92% if the patient is at risk of hypercapnic respiratory failure.” However, this is in the context of those patients who are not critically or seriously ill with these conditions. The ALS course focuses on the resuscitation and treatment of those patients who are critically ill (including those with acute coronary syndromes) and as described above, high concentrations of oxygen are appropriate for these patients until a reliable measure of their oxygen saturation can be obtained that confirms that they are not hypoxaemic. At this point, oxygen therapy can be targeted or stopped completely as indicated in the BTS guideline.
Although there is some low-level evidence that high oxygen concentrations may be harmful in the presence of myocardial ischaemia (and stroke), this has yet to be confirmed in prospective controlled trials. This topic will be addressed in the 2010 International Consensus on Cardiopulmonary Resuscitation Science Conference and revised RC(UK) guidelines will be based on the recommendations that emerge from this meeting as well as those made in the BTS guideline.
Finally, the guideline contains a lot of excellent information on the physiology of oxygen, carbon dioxide and blood gases, oxygen delivery devices and pulse oximetry. If you don’t want to read all 81 pages of the main guideline, there is an executive summary.
March 2009
