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International first aid, resuscitation, and education guidelines 2020.https://www.globalfirstaidcentre.org/ Oxygen administration | 1

Oxygen administration

Until emergency medical care is available, give supplementary oxygen incircumstances defined below, if specifically trained to do so.

Giving oxygen to a person with a severe illness or injury is generally acceptedpractice, although there is no evidence for its overall effectiveness. Providingsupplementary oxygen is not a routine first aid step, as many emergencies do notdeprive the person of oxygen. Additionally, administering oxygen may cause thebody (and therefore the blood) to take in too much oxygen and this may harm theperson. However, under specific circumstances, oxygen administration may bebeneficial 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 asuspected stroke. *

Good practice points

The administration of supplementary oxygen should be limited to first aidproviders 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 ofsupplementary 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 keepSpO2 at 94% (at sea level) if the first aid responder has been trained intranscutaneous pulse oximetry and has a proper tool for measurement.

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A first aid provider should not routinely give supplementary oxygen to anadult with a suspected heart attack unless they recognise the person ishypoxic.

Guideline classifications explained

Education considerations

Context considerations

Local laws, regulations and processes, including liability protection, maydictate whether a first aid provider can give supplementary oxygen to an ill orinjured person.Programme designers may need to adapt how they implement this topicaccording to the educational opportunities, such as the equipment available intheir area.

Learner considerations

Oxygen administration is not regarded as a routine first aid element but insome circumstances, it may be suitable for some learners to learn about it.Oxygen administration may not be feasible for some learners, depending ontheir line of work or activities in which they participate. For example, a remoterescue team may not be able to carry bulky equipment to providesupplementary oxygen and, therefore, may be less likely to use this topic.

Facilitation tips and tools

Emphasise the importance of understanding the logistical aspects of theequipment, including how to maintain and store it, as well as how to care forthe compressed gas cylinders. Learners should also be aware of and follow anylocal regulatory testing and inspections.Emphasise that it is critical that learners take extra precautions when usingoxygen administration equipment as it can be a fire hazard. Learners mustcomplete the necessary training on how to use the equipment if it is relevant

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to them.The SpO2 reading from a pulse oximetry reading often determines the use ofoxygen. Therefore, learners may have to complete additional training on theiruse.Provide time for learners to practise using the different devices associatedwith administering oxygen such as nasal prongs, simple masks or partialrebreather masks.Develop scenarios that assess learners’ ability to determine when to useoxygen administration, the potential benefits and how to do it safely, as well ashow to store the equipment properly.

Scientific foundation

Systematic review

The International Liaison Committee on Resuscitation (ILCOR) conducted asystematic review about the use of supplementary oxygen for acute stroke(Singletary, 2020), and identified eight randomised controlled trials and oneretrospective observational study.

For the outcome of survival at 1 week, 3 months, 6 months and 1 year, no benefitcould be shown of giving supplementary oxygen (moderate-certainty evidence fromthree randomised controlled trials). Also, for neurological outcomes at 1 week, 3months or 6 months, no benefit could be shown in six randomised controlled trialsand an observational study (moderate- to very low-certainty evidence). However,one of these randomised controlled trials showed a higher chance of improvementfor one of its outcomes (“improvement of NIH stroke scale score of more than 4 at1 week”) (moderate-certainty evidence), and a separate randomised controlled trialalso showed benefit at seven months (low-certainty evidence).

For the outcome of quality of life, no benefit of supplementary oxygen was shown intwo randomised controlled trials, and one randomised controlled trial even showeda lower quality of life (low-certainty evidence). One observational study also lookedat complications and could not show an association between supplementary oxygenand pneumonia at hospital discharge, and pulmonary oedema nor the use of non-

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invasive positive-pressure ventilation. However, it showed a lower rate of hospital-acquired pneumonia, and a higher rate of tracheal intubation and of respiratorycomplications (very low-certainty evidence).

ILCOR (Singletary et al., 2015) found very low-certainty evidence for the criticaloutcomes 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 ofchronic obstructive pulmonary disease. With regards to the outcome shortness ofbreath, very low-certainty evidence was identified from one randomised controlledtrial in terminal cancer patients with dyspnoea and hypoxemia. It showed a benefitof supplementary oxygen administration. For the outcome of oxygen saturation,moderate-certainty evidence was identified from three randomised controlled trialsshowing benefit with supplementary oxygen. For shortness of breath, low-certaintyevidence was identified from one meta-analysis and four randomised controlledtrials showing no benefit for supplementary oxygen for advanced cancer patientswith dyspnoea without hypoxemia. Very low-certainty evidence was identified fromone observational study showing a benefit of using supplemental oxygen when providingfirst aid to patients with a decompression injury.

A Cochrane systematic review on oxygen use in people with a heart attackidentified evidence from five randomised controlled trials that compared peoplewho had a suspected or proven heart attack and were given inhaled oxygen to asimilar 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. Deathrates 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 norwhen 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 foroxygen 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 useof inhaled oxygen in people with a heart attack, and we cannot rule out a harmfuleffect.

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

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post-acute myocardial infarction (heart attack) settings and 3,860 people who didnot. 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 oxygentherapy in people with acute myocardial infarction.

Another Cochrane systematic review by Barbateskovic et al. (2019) included tenrandomised controlled trials with 1458 participants that received oxygen therapy inthe hospital’s intensive care unit (ICU). Seven of the trials (making a total of 1,285participants) reported relevant outcomes for this review. A meta-analysis indicatedtwo key results:

concerning the risk of death at about three months after oxygen therapy in theICU: it may be higher for high amounts of inspired oxygen compared to loweramounts of oxygenation (4 trials; 1135 participants; very low-certaintyevidence).concerning the occurrence of serious adverse events at about three monthsafter oxygen therapy in the ICU: it may be higher for higher amounts ofinspired oxygen compared to lower amounts of oxygenation (6 trials; 1234participants; very low-certainty evidence).

In addition, there was no evidence of a difference in lung injuries with the use ofhigher supplemental oxygen compared with lower supplemental oxygen (5 trials;1167 participants; very low-certainty evidence). Overall, the review found noevidence for a beneficial effect of higher compared with lower supplemental oxygenlevels for adults admitted to the ICU.

A recent Cochrane systematic review (Kopsaftis, 2020) identified one study forinclusion, with two awaiting classification, out of a total of 824 citations. This studyinvolved 214 adults with acute exacerbations of chronic obstructive pulmonarydisease, who received treatment by paramedics en route to the hospital. The studyobserved a reduction in pre- and in-hospital mortality when people received titratedoxygen via nasal prongs. This method achieved an arterial saturation of 88 to 92per cent. There were only two deaths in the titrated oxygen group compared to 11deaths in the high-flow (oxygen delivered via mask; 8-10 L/min) controlled group.

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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 numberof deaths that occurred, confidence in the size of the difference between the twotreatments is limited. Evidence is of low certainty.

Non-systematic review

An ILCOR scoping review by Bierens et al. (2020) found insufficient specificevidence to guide the prehospital use of oxygen therapy in drowning. Work in otherdomains of resuscitation science has identified adverse outcomes associated withboth sustained hypoxia and hyperoxia . Pulse oximetry can be unreliable,particularly following cold water immersion, but where feasible it can supportcontinuous titration of FIO2 following the restoration of spontaneous circulation. Inthe absence of specific research in drowning, the existing ILCOR TreatmentRecommendation for Oxygenation after ROSC applies. A systematic review onoxygen and carbon dioxide targets in adult patients with return of spontaneouscirculation after cardiac arrest recommends avoiding hypoxaemia and hyperoxia(Berg, 2020). The review’s guidance is to use 100 per cent inspired oxygen untilarterial oxygen saturation or the partial pressure of arterial oxygen can bemeasured.

Carbon monoxide

Public Health England and the Canadian Centre for Occupational Health and Safetyrecommend that oxygen should be administered to someone with carbon monoxideintoxication (PHE, 2019; CCOHS, 2017).

References

Systematic reviews

Abuzaid, A, Fabrizio C, … Felpel, K. (2018). Oxygen therapy in patients with acutemyocardial infarction: A systemic review and meta-analysis. The American Journalof Medicine, 131(6).

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Barbateskovic, M., Schjørring, O. L., … Russo Krauss, S. (2019). Higher versuslower fraction of inspired oxygen or targets of arterial oxygenation for adultsadmitted 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). Oxygentherapy 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 chronicobstructive 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 TreatmentRecommendations. Circulation, 142 (suppl 1):S284–S334. DOI10.1161/CIR.0000000000000897Full 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 ScienceCollaborators. (2020). 2020 International Consensus on First Aid Science withTreatment Recommendations. Resuscitation, Nov;156:A240-A282. DOI10.1016/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 onfirst aid science with treatment recommendations. Circulation, 132(16_suppl_1),S269-S311.

Non-systematic reviewsBerg K.M., Holmberg M., Nicholson T., Nolan J., Reynolds J., Schexnayder S.,Nation K., Soar J., on behalf of the International Liaison Committee on

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Resuscitation Advanced Life Support Task Force., (2020). Oxygenation andVentilation Targets in Adults with Return of Spontaneous Circulation after CardiacArrest, 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 inDrowning. Review and Task Force Insights [Internet] Brussels, Belgium:International Liaison Committee on Resuscitation (ILCOR) Basic Life Support TaskForce. 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 fromhttps://www.ccohs.ca/oshanswers/chemicals/chem_profiles/carbon_monoxide.html

Public Health England, (2019). Carbon monoxide. Incident Management. August2019. Retrieved fromhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/825202/Carbon_monoxide_incident_management_PHE.pdf

Related topicsStrokeDecompression illnessChest pain

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