Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease

Background: The Norfolk and Norwich University Hospital (NNUH) is situated in rural Norfolk, and ambulance journey times are often > 30 min. Longer ambulance journeys could lead to a greater risk of hypercapnia, if inappropriately high concentrations of oxygen are given during an exacerbation of COPD. Aim: To investigate the effect of high concentration oxygen (HCO, FiO(2) > 0.28) on COPD patients, and the outcome of instituting a simple protocol to reduce such exposure. Design: Retrospective audit. Method: An audit was conducted of all patients admitted with an exacerbation of COPD to the NNUH during the 2 months from 1 December 2001 to 31 January 2002 (n = 108). Results were shared with paramedics, and guidelines agreed for the initial provision of lower concentrations of oxygen (LCO, FiO(2) <= 0.28). A second audit was conducted a year later between 1 December 2002 and 31 January 2003 (n = 103). Results: HCO caused significant (p < 0.01) acidosis and inappropriately high PaO2 and PaCO2, compared to initial LCO therapy. There was a significantly increased complication rate during admission (p < 0.01) in those COPD patients receiving HCO compared to LCO, particularly when ambulance journeys exceeded 30 min. The second audit demonstrated a significant (p < 0.001) reduction in the number of patients initially receiving HCO, but the complication rate was unaltered. Discussion: A simple intervention, such as providing paramedics with 28% Venturi masks, can reduce the number of COPD patients exposed to HCO. A randomized controlled trial is long overdue to establish whether HCO or LCO as initial management is associated with the most favourable prognosis in different hospital settings.