Oxygen

General advice:

• Oxygen is a treatment for hypoxemia not breathlessness

• Must be prescribed on drug chart according to target saturations

• Target sats 88-92% initially, if history of moderate or severe COPD, hypercapnia or previous NIV

• Nasal prongs give following approximate inspired 02 concentrations 1L/min = 24%; 2L/min = 28% but use should be considered in type 2 respiratory failure where there is a need for controlled oxygen.

• Perform ABG if oxygen required to achieve sats >88%

Type I respiratory failure (Pa02 low, PaCO2 normal/low)

• Target sats 94-98%

• Use high concentration oxygen i.e. 40% or higher (prescribe on drug chart)

• Measure arterial blood gases after 30 minutes & alter 02% according to results

• Aim to raise Pa02 > 8kPa

Type II respiratory failure (Pa02 low, PaCO2 high)

• Target sats 88-92%

• Start with low concentration 02 i.e. 24 – 28% by Venturi mask

• Nebulisers should be air driven and any necessary oxygen administered simultaneously via nasal cannulae for duration of nebuliser

• Measure arterial blood gases 30 minutes after any change in 02 concentration

Consider NIV if acidosis persists after initial standard medical therapy or in extremis. Consider ceiling of treatment early.

Antibiotics

1. Indicated if sputum more purulent or CXR suggestive of pneumonia
2. Obtain appropriate cultures first - i.e. blood cultures
3. Do not delay antibiotic therapy because awaiting results or sputum sample. Refer to antibiotic policy on intranet for empirical treatment Antimicrobial prescribing policy microguide.global
4. Sputum cultures should be performed if purulent sputum present

Other agents

• Nebulised beta agonists - Salbutamol 2.5 - 5 mg

• Continue inhaled triple therapy where possibleSteroids prednisolone 30mg od for 5-7 days

• VTE prophylaxis as per trust guidelines

If not settling, consider

If not settling – consider:

• IV aminophylline: (see full Aminophylline guideline for further information)

  • 200-500mg (5mg/kg based on ideal body weight) in 100ml normal saline over 30 minutes (loading dose) with cardiac monitoring

  • No loading dose if on oral theophylline / aminophylline (check level on admission).

  • Then 500micrograms/kg/hr by continuous IV infusion over 24 hrs. (reduced to 300micrograms/kg/hr in patients over 70 years). Dilute 1g aminophylline in 1000ml 0.9% normal saline (1mg/ml) and run infusion at flow rate according to table from Aminophylline guideline. Withhold oral theophylline

  • Check levels if infusion continues 6-18 hours after start of infusion, repeat daily (mark urgent)

  • Should be delivered in Resus, MADU, AMU (FPH) only

• Diuretics if evidence of Cor pulmonale with visceral venous congestion and peripheral oedema

• Give advice and offer assistance (nicotine replacement therapy / inpatient referral to smoking cessation nurse) to all current smokers

Non-Invasive Ventilation

1. NIV may be considered for patients with acidotic (pH<7.35) type 2 respiratory failure, after an initial 1 hour trial of optimal medical therapy (controlled oxygen, nebulised bronchodilators, steroids, +/- antibiotics or aminophylline)
2. It is most commonly used in exacerbations of COPD, but is also useful in neuromuscular disease, chest wall deformity, obesity hypoventilation and decompensated obstructive sleep apnoea.
3. NIV can be delivered n FPH in ED, MADU or ICU. At WPH AMU, MADU, Respiratory Ward and ICU.
4. If used NIV before, what were their previous settings that worked for patient

Before starting NIV, consider

1. Review the CXR – exclude a pneumothorax or other reversible cause (NIV must not be given to patients with undrained pneumothoraces)
2. Optimise their medical therapy to treat the underlying cause
3. Is oxygen level appropriate (target paO2 of 8kPa, sats 88-92%)
4. Is NIV appropriate?
5. Does the patient want to try NIV?
6. Is this a reversible illness?
7. If pH < 7.25 or severe pneumonia – would intubation + ventilation of ICU be more appropriate?
8. Escalation plans - If the patient does not improve on NIV – are they a candidate for ICU? Consider usual functional status, BMI, requirement for oxygen when stable, comorbidities, previous admissions to intensive care, age and FEV1, collateral
9. At the same time consider their resuscitation and NEWS status
10. Consider arterial line for ABG monitoring
11. Discuss with respiratory Consultant or respiratory / medical SpR (contact as above)
12. Involve outreach team out of hours if transfer required to appropriate care setting
13. Update NOK – this patient has a significant risk of further deterioration and family should be involved in discussions around care

Once NIV commenced Review at 1 hour with ABG and review of Tidal Volume, targeting a TV of 6-8ml/kg

NIV | British Thoracic Society | Better lung health for all

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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