Emergency oxygen therapy in the dental practice: administration and managementP. Jevon1

Prescribing:failuretoorwronglyprescribed

Monitoring:patientsnotmonitored,abnormaloxygensaturationlevelsnotactedupon

Administration:confusionofoxygenwithmedicalcompressedair,incorrectflowrates,inadvertentdisconnectionofsupply

Equipment:emptycylinders,faultyandmissingequipment.2

Dental practitioners must thereforeunderstand when and how to safelyand effectively administer oxygen. Anunderstanding of the hazards associatedwiththeuseandstorageofoxygenisalsoimportant.3

INDICATIONS FOR OXYGEN THERAPY IN THE DENTAL PRACTICEOxygenisprescribedtotreathypoxaemia.4Oxygen therapy is therefore aimed atsupplementing the inspired oxygen

INTRODUCTIONDental practices should have facilities toadministerhighflowoxygen toapatientwhoiscriticallyill.1Althoughoxygencansavelivesbypreventingseverehypoxaemia,if it isnt administered and managedappropriately,thereisapotentialforseriousharmandevendeath.2

The aim of this article is to providean overview to the administration andmanagementofemergencyoxygen in thedentalpractice.

RELATED ANATOMY AND PHYSIOLOGYOxygenisacolourless,odourlessgasthatformsabout21%oftheearthsatmosphereand isessential forplantandhuman life.Tissue oxygenation is dependent uponinspired oxygen, the concentration ofhaemoglobinanditsabilitytosaturatewithoxygen,aswellasthecirculationofblood.

EVIDENCE OF HARM ASSOCIATED WITH OXYGEN THERAPYUptoJune2009,theNationalPatientSafetyAgency(NPSA)hadreceived281reportsofserious incidents relating to inappropriateadministrationandmanagementofoxygen;oftheseincidents,pooroxygenmanagementappearstohavecausedninepatientdeathsandmayhavecontributedtoafurther35deaths.2Commonthemesidentifiedfromthereviewofthese incidents, local investigationsandothersourcesare:

Dental practitioners should understand when and how to safely and effectively administer emergency oxygen therapy. This article provides an overview on its administration and management, as well as reviewing the hazards associated with its use and storage.

concentrationtopreventtissuehypoxiaandresultantcellulardysfunctionthatcanoccurintheacutelyillpatient.5

Indications for administration ofemergencyoxygen in the dental practiceinclude:SyncopeAcuteasthmaattackAnaphylaxisDuringanepilepticfitCardiopulmonaryresuscitation.1

Itisnolongerrecommendedtoroutinelyadminister oxygen to a patient withchest painwho is suspected of having amyocardial infarction.Highflowoxygenmaybeadministered(15litresperminute)ifthepatientiscyanosed(bluelips)orifthelevelofconsciousnessdeteriorates.1

OXYGEN THERAPY EQUIPMENTTheResuscitationCouncil(UK)1recommendsthat, asaminimum, eachdentalpracticeshouldhave:

1Resuscitation Officer/Clinical Skills Lead, Manor Hospital, Walsall Correspondence to: Phil Jevon Email: phil.jevon@walsallhealthcare.nhs.uk

Refereed Paper Accepted 25 September 2013 DOI: 10.1038/sj.bdj.2014.49 British Dental Journal 2014; 216: 113-115

Stresses responsibilities of dentists regarding storage and inspection of oxygen in the dental practice.

Highlights indications for oxygen therapy in the dental practice.

Discusses principles of safe oxygen therapy.

I N B R I E F

PRA

CTICE

Fig.1 Oxygen face mask with reservoir bag and tubing

Fig.2 Portable oxygen cylinder, reproduced with kind permission of BOC Lifeline

BRITISH DENTAL JOURNAL VOLUME 216 NO. 3 FEB 7 2014 113

2014 Macmillan Publishers Limited. All rights reserved

PRACTICE

Anoxygenfacemaskwithoxygenreservoirandtubing(Fig.1)

Aportableoxygencylinder(Fig.2)ofsufficientsizetoenablethedeliveryofadequateflowrates,forexample,15litresperminute,untilthearrivalofanambulanceorthepatientfullyrecovers.AfullDsizecylindercontains340litresofoxygenandwillallowaflowrateof10litresperminuteforupto30minutes.Itmaybenecessarytohavetwosuchcylindersinthedentalpracticetoensurethesupplyofoxygendoesnotrunoutduringamedicalemergency

Anoxygencylinderkey(ifappropriate).Someoxygencylindersrequireaspecialkeytounlockthecylinderitismostimportantthatthekeyiskeptwiththecylinder

Ideally,thepatentsoxygensaturationlevelsshouldbemonitoredbefore,duringandfollowingoxygentherapy.Ifapulseoximeterisavailable,itshouldbeused.2However,usuallyonlydentalpracticesthatadministersedationwillhaveapulseoximeter.

OXYGEN FACE MASK WITH OXYGEN RESERVOIRAnoxygenfacemaskwithoxygenreservoir(sometimescalledanoxygennon-rebreathemask) (Fig. 1) has a one-wayvalve thatdivertstheoxygenflowintothereservoirbagduringexpiration;thecontentsofthereservoirbag togetherwith thehighflowoxygen (15 litres perminute), results inminimalentrainmentofairandaninspiredoxygen concentration of approximately90%.1Thevalvealsopreventsthepatientsexhaledgases fromentering thereservoirbag.Theuseof theoxygenreservoirbaghelps to increase the inspired oxygenconcentrationbypreventingoxygen lossduringinspiration.Toensurethemaskisfunctioningcorrectly

and iseffectivelyused, it is important tofollowthemanufacturersrecommendationsforsimplebasicchecksbeforeuse.6

PORTABLE OXYGEN CYLINDERPortableoxygen cylinders areblackwithwhiteshoulders.7Therearemanydifferenttypes of portable cylinders available. AcommonlyusedoneisfeaturedinFigure2.Thiscylinderhas:Aregulatorintegratedwiththecylindervalve

Agaugethatshowslivecontentsatalltimes,evenwhenthecylinderisturnedoff

Simpleon-offhandwheel(notoolsneeded)

Click-stopflowcontrolknobshowingflowinlitres/min,rangingfrom1to15litresperminute

Sufficientcapacitytolastapproximately30minutesathighestflowrateof15litres/min.8

Always follow the manufacturersrecommendationswhenusing anoxygencylinder.Beforeusingtheoxygencylinder,asdisplayedinFigure2: Ifnecessary,removetheprotectivecapAttachtheoxygentubingandmasktothefirtreeoutlet(theoxygenoutlet)ofthecylinder

Ensuretheflowcontrolknobonthetopofthecylinderissetat0

Openthevalveslowlybyturningthegreyorblackhandwheelanti-clockwisetworevolutions

Turntheflowcontrolknobclockwisetoselecttherequiredflowrate.Ateachfullclickadifferentflowratesettingwillberevealedinthewindowoftheknob.Thecorrectflowratesettingmustbefullyvisibleinthewindow

SelectflowrateaspertrainingreceivedCheckforaflowofgasthroughthemaskbeforeuse.8

After using the oxygen cylinder, asdisplayedinFigure2: Turnoffcylinderusingthegreyorblackhandwheelbyturningitclockwise

Removetubingandmaskfromthefirtreeoutletandallowresidualoxygenintheregulatortovent

Turnflowcontrolknobto0Checkthecylindercontentsgaugetoensureadequatesupplyfornextadministration.8

GUIDELINES ON THE ADMINISTRATION OF OXYGENThe British Thoracic Society (BTS)9 hasissued detailed guidance on emergencyoxygen therapy in adults. The guidancerelating to the use of highflow oxygenhas caused some concern and confusionregarding its safety. It is emphaticallyclear that inanycritically illpatient theinitialadministrationofhighflowoxygen(15litresperminute)isthecorrectcourseofaction.Whenoxygensaturation levelscan be accurately measured using apulse oximeter, the amount of oxygenadministeredcanbetitratedaccordingly.

PROCEDURE FOR ADMINISTRATION OF OXYGEN USING A NON-REBREATHE MASKAssessandtreatthepatientfollowingtheABCDE(Airway,Breathing,

Circulation,DisabilityandExposure)approach;callforhelpfromcolleagues.Itmaybenecessarytocall999foranambulance

Explaintheproceduretothepatient Ifavailable,attachpulseoximetry(usuallyonlydentalpracticesthatadministersedationwillhaveapulseoximeter)toguideoxygentherapy

Ensurethepatientisinanappropriatepositionforexample,ifbreathless,thepatientwillusuallyprefertobeinanuprightposition

Preparetheoxygencylinderandattachtheoxygentubing(seeabove)

Selectanoxygenflowrateof15litres/min

Occludethevalvebetweenthemaskandtheoxygenreservoirbagandcheckthatthereservoirbagisfillingup.Removethefinger

Squeezetheoxygenreservoirbagtocheckthepatencyofthevalvebetweenthemaskandthereservoirbag.Ifthevalveisworkingcorrectlyitwillbepossibletoemptythereservoirbag(ifthereservoirbagdoesntemptydiscarditandselectanothermask)

Againoccludethevalvebetweenthemaskandtheoxygenreservoirbag,allowingthereservoirbagtofillup

Placethemaskwithafilledoxygenreservoirbagonthepatientsface,ensuringatightfit

ReassurethepatientCloselymonitorthepatentsvitalsigns.Inparticular,assessthepatientsresponsetotheoxygentherapyforexample,respiratoryrate,mechanicsofbreathing,colour,oxygensaturationlevels(ifpulseoximetryavailable),levelofconsciousness.

Discontinue/reducetheinspiredoxygenconcentrationasappropriatefollowingadvicefromasuitablyqualifieddentalpractitioner

Awaitthearrivaloftheambulance.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTSAlthoughoxygen shouldbeadministeredwith extreme caution in patients withCOPD,8incriticalillnesshighflowoxygenasdescribedaboveshouldbeadministered.1

CARE, HANDLING AND STORAGE OF OXYGEN CYLINDERSThe Medicines and Healthcare productsRegulatory Agency (MHRA)10 has issuedguidance on the care and handling ofoxygen cylinders and their regulators. Itrecommendsthathealthcarestaffshould:

114 BRITISH DENTAL JOURNAL VOLUME 216 NO. 3 FEB 7 2014

2014 Macmillan Publishers Limited. All rights reserved

PRACTICE

Befullytrainedintheuseofoxygencylinders

Beawareofalltherelatedriskssuchasfireandmanualhandling

Carryoutfullchecksonoxygencylindersandtheirregulatorsbeforeeachuse,ensuringthattheycontainenoughoxygenfortherequiredtherapy

Checkthelabelontheoxygencylinderensuringitisnotout-of-date

Ensuretheirhandsarecleanbeforehandlinganoxygencylinder;thereisariskofcombustionfromoilsandgrease.Itisalsoimportanttoensuretheirhandsareadequatelydriedaftertheuseofalcoholgel

Ensurethattheoxygencylinderoutletandoxygenregulatorinletarecleanbeforeattachingaregulator

Alwaysopenthecylinderslowlyandcheckforleaks.Closecylindervalveswhennotinuse

Handleoxygencylinderswithcare.Ifthecylinderisdroppedorknockedinuseitmustbecheckedbeforefurtheruse;cylinderswithintegralvalvesshouldbereturnedtothesupplier;separateregulatorsshouldbesenttotheservicedepartmentforinspection.

The MHRA10 recommends that oxygencylindersshouldbestoredinasecureareathatiswellventilated,cleananddry,aswellasbeingfreefromanysourcesofignitionsuchaspatients/staffsmokingormachinery.BOCMedical9advisesthatitisimportant

to:Keeptheoxygencylinderawayfromnakedflamesandsourcesofheat.Oxygenisanon-flammablegas,butitdoesstronglysupportcombustion

Ensuretheoxygencylindersarestoredinasafeandsecureareawheretheycannotfalloverandcauseinjury

Ensuretheoxygencylinderisstoredinawell-ventilatedarea

Neveruseexcessiveforcewhenopeningorclosingthecylinderusingthegreyorblackhandwheel

Notpaintthecylindersasalllabelsandmarkingsmustremainclearlyvisible

Refrainfromusingoilorgrease(oranyoil-basedproducts,whichincludeshandcreams)inthevicinityoftheoxygencylinder.Highvelocityoxygenandoil/greasecouldcausespontaneouscombustion.9

Defective oxygen cylinders should bereportedtotheDefectiveMedicinesReportingCentre (DMRC) and defective detachableregulators to theAdverse Incident Centre(AIC),bothattheMHRA(www.mhra.gov.uk).

CONCLUSION Critically illpatients should receivehighflowoxygen.Dentalpractitioners shouldunderstand when and how to safelyand effectively administer oxygen. Anoverview of the hazards associatedwiththeuse and storageof oxygenhasbeenprovided togetherwith theprocedure foradministeringit.

GLOSSARYDyspnoea:difficultorlabouredbreathing(derivedfromLatinandGreekwords:dusbadordifficult,pnoebreathing)

Cyanosis:bluediscolourationoftheskinduetopoorcirculationorinadequateoxygenationoftheblood(derivedfrom

theGreekwordkuanosisblueness)Haemoglobin:aredproteincontainingiron,responsiblefortransportingoxygenintheblood;thenormalhaemoglobin(HB)countinmenis13-18gper100mlandinwomenis12-16g/100ml

Anaemia:conditioncharacterisedbyinadequateredbloodcellsand/orhaemoglobinintheblood;inmen

Reproduced with permission of the copyright owner. Further reproduction prohibited withoutpermission.