Giving oxygen to a person with a severe illness or injury is generally accepted practice, although there is no evidence for its overall effectiveness. Providing supplementary oxygen is not a routine first aid step, as many emergencies do not deprive the person of oxygen. Additionally, administering oxygen may cause the body (and therefore the blood) to take in too much oxygen and this may harm the person. However, under specific circumstances, oxygen administration may be beneficial but should be provided by a specifically trained first aid provider.
Guidelines
- A first aid provider should not give supplementary oxygen to an adult with a suspected stroke. *
Good practice points
- The administration of supplementary oxygen should be limited to first aid providers with specific training in oxygen administration.
- Supplementary oxygen should only be administered to a person with normal, spontaneous breathing.
- Until emergency medical care is available, the administration of supplementary oxygen is reasonable for a person:
> after exposure to carbon monoxide
> experiencing decompression illness (e.g. a scuba diver)
> experiencing breathing difficulties
> experiencing hypoxia (SpO2 at 94% or less). - When oxygen is given, it is ideal to taper oxygen supplementation to keep SpO2 at 94% (at sea level) if the first aid responder has been trained in transcutaneous pulse oximetry and has a proper tool for measurement.
- A first aid provider should not routinely give supplementary oxygen to an adult with a suspected heart attack unless they recognise the person is hypoxic.
Education considerations
Context considerations
- Local laws, regulations and processes, including liability protection, may dictate whether a first aid provider can give supplementary oxygen to an ill or injured person.
- Programme designers may need to adapt how they implement this topic according to the educational opportunities, such as the equipment available in their area.
Learner considerations
- Oxygen administration is not regarded as a routine first aid element but in some circumstances, it may be suitable for some learners to learn about it.
- Oxygen administration may not be feasible for some learners, depending on their line of work or activities in which they participate. For example, a remote rescue team may not be able to carry bulky equipment to provide supplementary oxygen and, therefore, may be less likely to use this topic.
Facilitation tips and tools
- Emphasise the importance of understanding the logistical aspects of the equipment, including how to maintain and store it, as well as how to care for the compressed gas cylinders. Learners should also be aware of and follow any local regulatory testing and inspections.
- Emphasise that it is critical that learners take extra precautions when using oxygen administration equipment as it can be a fire hazard. Learners must complete the necessary training on how to use the equipment if it is relevant to them.
- The SpO2 reading from a pulse oximetry reading often determines the use of oxygen. Therefore, learners may have to complete additional training on their use.
- Provide time for learners to practise using the different devices associated with administering oxygen such as nasal prongs, simple masks or partial rebreather masks.
- Develop scenarios that assess learners’ ability to determine when to use oxygen administration, the potential benefits and how to do it safely, as well as how to store the equipment properly.
Scientific foundation
Systematic review
The International Liaison Committee on Resuscitation (ILCOR) conducted a systematic review about the use of supplementary oxygen for acute stroke (Singletary, 2020), and identified eight randomised controlled trials and one retrospective observational study.
For the outcome of survival at 1 week, 3 months, 6 months and 1 year, no benefit could be shown of giving supplementary oxygen (moderate-certainty evidence from three randomised controlled trials). Also, for neurological outcomes at 1 week, 3 months or 6 months, no benefit could be shown in six randomised controlled trials and an observational study (moderate- to very low-certainty evidence). However, one of these randomised controlled trials showed a higher chance of improvement for one of its outcomes (“improvement of NIH stroke scale score of more than 4 at 1 week”) (moderate-certainty evidence), and a separate randomised controlled trial also showed benefit at seven months (low-certainty evidence).
For the outcome of quality of life, no benefit of supplementary oxygen was shown in two randomised controlled trials, and one randomised controlled trial even showed a lower quality of life (low-certainty evidence). One observational study also looked at complications and could not show an association between supplementary oxygen and pneumonia at hospital discharge, and pulmonary oedema nor the use of non-invasive positive-pressure ventilation. However, it showed a lower rate of hospital-acquired pneumonia, and a higher rate of tracheal intubation and of respiratory complications (very low-certainty evidence).
ILCOR (Singletary et al., 2015) found very low-certainty evidence for the critical outcomes of survival and therapeutic endpoints (a composite measure of death, need for assisted ventilation, and respiratory failure) from one observational study. It showed no benefit of using supplemental oxygen for acute exacerbation of chronic obstructive pulmonary disease. With regards to the outcome shortness of breath, very low-certainty evidence was identified from one randomised controlled trial in terminal cancer patients with dyspnoea and hypoxemia. It showed a benefit of supplementary oxygen administration. For the outcome of oxygen saturation, moderate-certainty evidence was identified from three randomised controlled trials showing benefit with supplementary oxygen. For shortness of breath, low-certainty evidence was identified from one meta-analysis and four randomised controlled trials showing no benefit for supplementary oxygen for advanced cancer patients with dyspnoea without hypoxemia. Very low-certainty evidence was identified from one observational study showing a benefit of using supplemental oxygen when providing first aid to patients with a decompression injury.
A Cochrane systematic review on oxygen use in people with a heart attack identified evidence from five randomised controlled trials that compared people who had a suspected or proven heart attack and were given inhaled oxygen to a similar group of people given air (evidence is current to June 2016) (Cabello et al., 2016). These trials involved a total of 1,173 participants, 32 of whom died. Death rates were similar in both groups (very low-certainty evidence). Regarding pain, there was no effect for oxygen on pain relief when pain was directly measured nor when trials measured opiate use as a surrogate for pain (low-certainty evidence). With regard to complications following a heart attack, there was no clear effect for oxygen on a range of complications in the oxygen group compared to the air group (low-certainty evidence). Together, there is no evidence to support the routine use of inhaled oxygen in people with a heart attack, and we cannot rule out a harmful effect.
A more recent systematic review and meta-analysis by Abuzaid et al. (2018) included a total of seven studies with 3,842 people who received oxygen therapy in post-acute myocardial infarction (heart attack) settings and 3,860 people who did not. High-certainty evidence was identified showing that, compared to no oxygen, oxygen therapy did not decrease the risk of all-cause mortality, recurrent ischemia or myocardial infarction, heart failure, and the occurrence of heart arrhythmias. These findings confirmed that there is no substantial benefit to routine oxygen therapy in people with acute myocardial infarction.
Another Cochrane systematic review by Barbateskovic et al. (2019) included ten randomised controlled trials with 1458 participants that received oxygen therapy in the hospital’s intensive care unit (ICU). Seven of the trials (making a total of 1,285 participants) reported relevant outcomes for this review. A meta-analysis indicated two key results:
- concerning the risk of death at about three months after oxygen therapy in the ICU: it may be higher for high amounts of inspired oxygen compared to lower amounts of oxygenation (4 trials; 1135 participants; very low-certainty evidence).
- concerning the occurrence of serious adverse events at about three months after oxygen therapy in the ICU: it may be higher for higher amounts of inspired oxygen compared to lower amounts of oxygenation (6 trials; 1234 participants; very low-certainty evidence).
In addition, there was no evidence of a difference in lung injuries with the use of higher supplemental oxygen compared with lower supplemental oxygen (5 trials; 1167 participants; very low-certainty evidence). Overall, the review found no evidence for a beneficial effect of higher compared with lower supplemental oxygen levels for adults admitted to the ICU.
A recent Cochrane systematic review (Kopsaftis, 2020) identified one study for inclusion, with two awaiting classification, out of a total of 824 citations. This study involved 214 adults with acute exacerbations of chronic obstructive pulmonary disease, who received treatment by paramedics en route to the hospital. The study observed a reduction in pre- and in-hospital mortality when people received titrated oxygen via nasal prongs. This method achieved an arterial saturation of 88 to 92 per cent. There were only two deaths in the titrated oxygen group compared to 11 deaths in the high-flow (oxygen delivered via mask; 8-10 L/min) controlled group. Other than mortality, no other adverse events were reported in the included study. Still, because the review only included one study, in addition to the small number of deaths that occurred, confidence in the size of the difference between the two treatments is limited. Evidence is of low certainty.
Non-systematic review
An ILCOR scoping review by Bierens et al. (2020) found insufficient specific evidence to guide the prehospital use of oxygen therapy in drowning. Work in other domains of resuscitation science has identified adverse outcomes associated with both sustained hypoxia and hyperoxia . Pulse oximetry can be unreliable, particularly following cold water immersion, but where feasible it can support continuous titration of FIO2 following the restoration of spontaneous circulation. In the absence of specific research in drowning, the existing ILCOR Treatment Recommendation for Oxygenation after ROSC applies. A systematic review on oxygen and carbon dioxide targets in adult patients with return of spontaneous circulation after cardiac arrest recommends avoiding hypoxaemia and hyperoxia (Berg, 2020). The review’s guidance is to use 100 per cent inspired oxygen until arterial oxygen saturation or the partial pressure of arterial oxygen can be measured.
Carbon monoxide
Public Health England and the Canadian Centre for Occupational Health and Safety recommend that oxygen should be administered to someone with carbon monoxide intoxication (PHE, 2019; CCOHS, 2017).
References
Systematic reviews
Abuzaid, A, Fabrizio C, … Felpel, K. (2018). Oxygen therapy in patients with acute myocardial infarction: A systemic review and meta-analysis. The American Journal of Medicine, 131(6).
Barbateskovic, M., Schjørring, O. L., … Russo Krauss, S. (2019). Higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database of Systematic Reviews, Issue 11. Art. No.: CD012631.
Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016). Oxygen therapy for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12). DOI 10.1002/14651858.CD007160.pub4
Kopsaftis, Z., Carson-Chahhoud, K. V., Austin, M. A., Wood-Baker, R. (2020). Oxygen therapy in the prehospital setting for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD005534.
DOI 10.1002/14651858.CD005534.pub3
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., … Woodin, J.A.; on behalf of the First Aid Science Collaborators. (2020). 2020 International Consensus on First Aid Science with Treatment Recommendations. Circulation, 142 (suppl 1):S284–S334. DOI 10.1161/CIR.0000000000000897
Full text article
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., … Lee, C.C.; First Aid Science Collaborators; First Aid Science Collaborators. (2020). 2020 International Consensus on First Aid Science with Treatment Recommendations. Resuscitation, Nov;156:A240-A282. DOI 10.1016/j.resuscitation.2020.09.016
Singletary, E. M., Zideman, D. A., De Buck, E. D., Chang, W. T., Jensen, J. L., Swain, J. M., … & Hood, N. A. (2015). Part 9: first aid: 2015 international consensus on first aid science with treatment recommendations. Circulation, 132(16_suppl_1), S269-S311.
Non-systematic reviews
Berg K.M., Holmberg M., Nicholson T., Nolan J., Reynolds J., Schexnayder S., Nation K., Soar J., on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force., (2020). Oxygenation and Ventilation Targets in Adults with Return of Spontaneous Circulation after Cardiac Arrest, Consensus on Science with Treatment Recommendations; 4 January 2020, Retrieved from http://ilcor.org
Bierens, J., Barcala, Furelos R., Beerman, S., et al., (2020). Prehospital Oxygen in Drowning. Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force. Available from: http://ilcor.org
International Federation of Red Cross and Red Crescent Societies, (2016). International first aid and resuscitation guidelines 2016, 8, 68-69.
Canadian Centre for Occupational Health and Safety, (2017). Carbon Monoxide. OSH Answer Fact Sheets, January 4, 2017. Retrieved from https://www.ccohs.ca/oshanswers/chemicals/chem_profiles/carbon_monoxide.html
Public Health England, (2019). Carbon monoxide. Incident Management. August 2019. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/825202/Carbon_monoxide_incident_management_PHE.pdf
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