Understanding Clinicians' Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults.

Background: Supplemental oxygen is commonly administered to patients in acute care. It may cause harm when used inappropriately. Guidelines recommend prescription of acute oxygen, yet adherence is poor. We aimed to identify barriers and facilitators to practicing in accordance with the evidence-based Thoracic Society of Australia and New Zealand (TSANZ) oxygen guideline, and to determine the beliefs and attitudes relating to acute oxygen therapy. Methods: A national cross-sectional survey was conducted. The survey consisted of 3 sections: (1) introduction and participant characteristics; (2) opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and (3) barriers and facilitators to use of the TSANZ guideline. Convenience sampling was employed. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to John Hunter Hospital's clinical staff. Results: Responses were received from 133 clinicians: 52.6% nurses, 30.1% doctors, and 17.3% other clinicians. Over a third (37.7%) were unaware/unsure of the oxygen guideline's existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated they only administered it based on clinical need. For four hypothetical cases, there was only one where the majority of participants identified the optimal oxygen saturation. A number of barriers and facilitators were identified when asked about practicing in accordance with the TSANZ guideline. Lack of oxygen equipment, getting doctors to prescribe oxygen and oxygen being treated differently to other drugs were seen as barriers. The guideline itself and multiple clinician characteristics were considered facilitators. Conclusion: There is discordance between clinicians' beliefs and actions regarding the administration of oxygen therapy and knowledge gaps about optimal oxygen therapy in acute care. Identified barriers and facilitators should be considered when developing evidence-based guidelines to improve dissemination and knowledge exchange.

Attitudes of Dutch intensive care unit clinicians towards oxygen therapy.

BACKGROUND: Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands. METHODS: In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios. RESULTS: In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg). CONCLUSION: A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.

Prolonged treatment of COVID-19 pneumonia with high-flow nasal oxygen: A story of oxygen and resilience.

The COVID-19 pandemic has placed significant strain on the oxygen delivery infrastructure of health facilities in resource-constrained health systems. In this case report, we describe a patient with severe COVID-19 pneumonia who was managed with high-flow nasal oxygen for 40 days, with an eventual successful outcome. We discuss the oxygen delivery infrastructure needed to offer this intervention, as well as the psychosocial impact on those undergoing treatment.

Characteristics at the time of oxygen initiation associated with its adherence: Findings from the COPD Long-term Oxygen Treatment Trial.

RATIONALE: Characteristics associated with adherence to long-term oxygen therapy (LTOT) in COPD remain unclear. OBJECTIVES: To identify patient characteristics at the time of oxygen initiation associated with its adherence. METHODS: We conducted a secondary analysis of data from 359 COPD participants assigned to oxygen in the Long-term Oxygen Treatment Trial. Participants were prescribed continuous (n = 214) or intermittent (n = 145) oxygen based on desaturation patterns at study entry. At the time of initial prescription, participants rated their perceived readiness, confidence, and importance to use oxygen on a 0-10 scale (0 = not at all, 10 = very much). During follow-up, they self-reported average hours per day of use (adherence). Adherence was averaged over short-term (0-30 days), medium-term (months 9-12), and long-term (month 13 to last follow-up) intervals. Multivariable logistic regression models explored characteristics associated with high adherence (≥16 h/day [continuous] or ≥8 h/day [intermittent]) during each time interval. RESULTS: Participant readiness, confidence, and importance at the time of oxygen initiation were associated with high short- and medium-term adherence. For each unit increase in baseline readiness, the odds of high short-term adherence increased by 21% (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.05-1.40) and 94% (OR 1.94, 95% CI 1.45-2.59) in the continuous and intermittent groups, respectively. In both groups, high adherence in the medium-term was associated with high adherence in the long-term (continuous, OR 12.49, 95% CI 4.90-31.79; intermittent, OR 38.08, 95% CI 6.96-208.20). CONCLUSIONS: Readiness, confidence, and importance to use LTOT at initiation, and early high adherence, are significantly associated with long-term oxygen adherence.

Ensuring Breathing Comfort at the End of Life: The Integral Role of the Critical Care Nurse.

This article describes the author's program of clinical research focused on assessment and treatment of respiratory distress among critically ill patients at the end of life. Dyspnea is a subjective experience of breathing discomfort that occurs in the presence of cardiopulmonary and neuromuscular diseases. Dyspnea is one of the most common and most distressing symptoms experienced by critically ill patients. Many critically ill patients, particularly those not expected to survive, become cognitively impaired or unconscious and lose the ability to report symptoms, although dyspnea can be known only from a patient's report. When self-reporting ability is lost, the critical care nurse must rely on signs indicative of a patient's respiratory distress. The critically ill patient unable to self-report is vulnerable to under-recognition of symptom distress and subsequent over-treatment or undertreatment. When the patient is dying, there is only 1 chance to optimize the assessment and treatment of symptoms.

Perspectives From COPD Subjects on Portable Long-Term Oxygen Therapy Devices.

BACKGROUND: Oxygen therapy for patients with COPD and severe hypoxemia requires the use of oxygen delivery devices that allow mobility as needed. However, the characteristics of some devices may limit the freedom of individuals to be as physically active as they desire. Limited mobility may negatively affect the perceived quality of life of individuals with COPD. The aim of this study was to understand perceived limitations that patients with COPD experience in using long-term oxygen therapy (LTOT) devices. METHODS: We performed a qualitative analysis of 311 responses to an open-ended question from a previously deployed electronic survey designed to investigate how LTOT devices affect oxygen-dependent patients with COPD. Our thematic analysis was facilitated by NVivo, a qualitative data analysis software package. This involved identifying patterns and themes within the robust, text-rich data from the open-ended survey question regarding the survey subjects' experiences with their LTOT devices. Cluster analysis was also performed to highlight relationships between various concepts. RESULTS: Themes generated revealed that subjects experienced decreased mobility, which resulted in feelings of decreased autonomy and isolation. We also found that subjects perceived a decrease in quality of life due to their described experience of portable oxygen cylinders being heavy and cumbersome. Subjects described feelings of fear and anxiety due to insufficient support for breathing provided by pulse-dose portable oxygen concentrators, as well as portable oxygen cylinders that run out before they are able to complete errands and other activities of daily living. Some subjects also reported that they willingly pay for liquid oxygen systems out-of-pocket because of the mobility it affords, which in their perception improves their quality of life. CONCULSIONS: Oxygen-dependent individuals with COPD may be at risk of adverse outcomes associated with decreased mobility encouraged by unsatisfactory physical and technical characteristics of portable oxygen cylinders and concentrators.

Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula.

BACKGROUND: The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort. METHODS: A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%. RESULTS: Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p < 0.0001). Higher flow, however, was not associated with poorer comfort. In the subgroup of patients with clinical FiO2 ≥ 45%, both lower temperature (31 °C) and higher HFNC flow (60 l/min) led to higher comfort (p < 0.01). CONCLUSIONS: HFNC temperature seems to significantly impact the comfort of AHRF patients: for equal flow, lower temperature could be more comfortable. Higher flow does not decrease patient comfort; at variance, it improves comfort in the more severely hypoxemic patient.

A wolf in sheep's clothing? Patients' and healthcare professionals' perceptions of oxygen therapy: An interpretative phenomenological analysis.

BACKGROUND: Despite emerging evidence and guidelines, poor prescribing and administration of oxygen therapy persists. This study aimed to explore healthcare professionals' (HCPs) and patients' perceptions of oxygen. DESIGN: Semi-structured interviews with 28 patients and 34 HCPs. FINDINGS: Three master themes uncovered: oxygen as a panacea, the burden of oxygen and antecedents to beliefs. Patients used oxygen for breathlessness and as an enabler; they were grateful to oxygen and accepted it as part of the disease. HCPs used oxygen because it helps patients; it works; and it makes HCPs feel better. But oxygen is not benign and a burden is evident with potential antecedents to beliefs revealed. SUMMARY: The findings suggest that a set of fixed beliefs regarding oxygen exist, influenced by several impacting factors. The perception that oxygen is a universal remedy presides, but is, at times, contradictory. These findings will raise awareness of entrenched cultures, influence future educational and research strategies, and inform policy.

Perceived Satisfaction With Long-Term Oxygen Delivery Devices Affects Perceived Mobility and Quality of Life of Oxygen-Dependent Individuals With COPD.

BACKGROUND: Although routine physical activity for individuals with COPD is recommended, there are inherent limitations of available oxygen delivery devices that may result in hypoxemia during activity. Changes in Medicare laws have resulted in an increased use of oxygen cylinders and a reduction in the use of liquid oxygen devices. The aim of this survey was to assess the impact of perceived satisfaction with various oxygen delivery devices on perceived mobility and quality of life (QOL) of oxygen-dependent subjects with COPD. METHODS: A survey was developed to measure perceived satisfaction with current portable oxygen delivery devices, perceived mobility, and perceived QOL. The survey was deployed via a link posted on the COPD Foundation's COPD360SOCIAL social media site for 5 weeks, which resulted in the recruitment of 529 participants, of which 417 were included in the data analysis. RESULTS: Quantile regression analysis revealed that the median perceived device satisfaction score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder and portable oxygen concentrator (POC) groups. The median perceived mobility score was significantly higher in the liquid oxygen device group (P < .001) compared with the portable oxygen cylinder group, but not the POC group. The median QOL score was significantly higher in the liquid oxygen device group (P < .001) compared with the POC and portable oxygen cylinder groups. Moreover, partial least-squares structural equation modeling regression analysis showed that perceived mobility is significantly affected by perceived satisfaction with the long-term oxygen therapy (LTOT) device (adjusted R2 = 0.15, P < .001), and perceived QOL is significantly affected by both perceived satisfaction with the LTOT device and perceived mobility (adjusted R2 = 0.45, P < .001). CONCLUSIONS: For individuals with COPD requiring LTOT, perceived satisfaction with a portable LTOT device significantly and positively affects perceived mobility and QOL.

[In Exchange with COPD Patients: Towards a Patient-Oriented Communication]. / Im Gespräch mit COPD-Patienten: patientenzentriert kommunizieren.

The quality of life can be severely impaired in patients with COPD. In addition to physical restraints, they often suffer from psychological comorbidities (e. g. anxiety, depression). Psychological comorbidities are often associated with dysfunctional beliefs about the illness and its treatment. Such dysfunctional beliefs, in turn, are likely to negatively affect patients' quality of life as well as their communication with physicians and their illness behavior in general. It is therefore important for physicians to adapt their communication to account for patients' dysfunctional beliefs. This paper will review the role of dysfunctional beliefs and psychological comorbidities in COPD. It will also elaborate on potential ways to adjust communication between physicians and patients accordingly.

Informal caregivers experience of supplemental oxygen in pulmonary fibrosis.

BACKGROUND: Patients prescribed supplemental oxygen (O2) therapy face challenges as they adjust to being constantly "tethered" to an oxygen delivery device. Informal caregivers (ICs) of patients with pulmonary fibrosis (PF) face their own, often overlooked hardships when O2 is brought into their home and added to their lives. Our aim was to understand the multiple effects of supplemental oxygen therapy on ICs of patients with PF. METHODS: We conducted single, semi-structured telephone interviews with twenty ICs of patients with PF who were using O2 for at least 8 months. We performed a qualitative, content analysis based in grounded theory to examine data across subjects. RESULTS: ICs initially reacted to O2 with trepidation and sadness as they came to recognize the changes it would cause in the lives of their patient-loved one (PLO). ICs recognized both beneficial and negative effects of O2 on their PLOs. ICs also realized that O2 created significant changes in their own lives, including introducing new roles and responsibilities for them, altering their home environments and significantly impacting their relationships with their PLOs. Although O2 was a tangible and constant reminder of disease progression, over time ICs were able to adapt and accept their new lives with O2. CONCLUSION: ICs of patients with PF experience many life changes when their PLO is prescribed O2. Having O2 prescribers anticipate and recognize these challenges provides an opportunity to give support and guidance to ICs of PF patients who require O2 in the hopes of limiting the negative impact of O2 on their lives. TRIAL REGISTRATION: Clinicaltrials.gov , registration number NCT01961362 . Registered 9 October 2013.

Emergency Department-initiated Home Oxygen for Bronchiolitis: A Prospective Study of Community Follow-up, Caregiver Satisfaction, and Outcomes.

OBJECTIVE: Retrospective studies have shown home oxygen to be a safe alternative to hospitalization for some patients with bronchiolitis living at high altitudes. We aimed to prospectively describe adverse events, follow-up, duration of home oxygen, factors associated with failure, and caregiver preferences. METHODS: This was a prospective observational study of hypoxemic bronchiolitis patients ages 3 to 18 months who were discharged from a tertiary care pediatric emergency department on home oxygen over three winters (2011-2014). Caregivers were contacted on postdischarge days ~3, 7, 14, and 28 while on oxygen. Caregivers not reached by phone were sent a survey and their primary care physicians were contacted. Records of admitted subjects were reviewed. Outcome measures included hospital readmission, positive pressure ventilation (noninvasive or intubation), outpatient follow-up, duration of home oxygen therapy, and caregiver satisfaction. RESULTS: A total of 274 patients were enrolled. Forty-eight (17.5%) were admitted and 225 (82.1%) were discharged on oxygen. The median age was 8 months. Eighteen subjects were lost to follow-up. A total of 196 (87.1%) were successfully treated with outpatient oxygen, and 11 (4.9%) failed outpatient therapy and were hospitalized. Only one hospitalized patient required invasive ventilation. The median duration of home oxygen was 7 days. Child noncompliance was the most common problem (reported by 14%). The median caregiver comfort level with home oxygen was 9 of 10. Eighty-eight percent of caregivers would again choose home oxygen over admission. CONCLUSIONS: This study confirms that outpatient oxygen therapy can reduce hospitalizations due to bronchiolitis in a relatively high-altitude setting, with low failure and complication rates. Caregivers are comfortable with home oxygen and prefer it to hospitalization.

The experience of couples being given an oxygen concentrator to use at home: A longitudinal interpretative phenomenological analysis.

This longitudinal study explores the lived experience of four couples where one person from each couple is prescribed an oxygen concentrator to use at home. Transcripts were analysed using interpretative phenomenological analysis. The findings reported here focus on two super-ordinate themes: 'the journey of acceptance' and 'negotiating changing relationships'. Participants described a gradual process of accepting the device into their lives, the impact on couple's relationships and the role that expectations have in mediating that process. These themes suggest that patient education that considers the psychological and social issues may prove useful in facilitating the acceptance process.

The practicalities of living with oxygen: a perspective from a person living with COPD.

Although I welcomed oxygen into my life, it required a degree of adjustment and perseverance. The concentrator told all visitors that this was the home of a 'patient', and using ambulatory oxygen in public takes a lot of getting used to. Safe use of oxygen entailed some changes in routine activities, and travel needs to be planned ahead to ensure that I don't run out of oxygen. Despite its drawbacks, oxygen has enabled me to have a full and active life once again.

Patient Involvement in the Design of a Patient-Centered Clinical Trial to Promote Adherence to Supplemental Oxygen Therapy in COPD.

BACKGROUND: Patients are increasingly viewed as key stakeholders who can contribute in meaningful ways to clinical research and are emphasized in research funded by the Patient-Centered Outcomes Research Institute (PCORI). We are not aware of other peer-reviewed publications that report methods and outcomes of patient engagement to refine study design for a PCORI-sponsored clinical effectiveness trial. OBJECTIVE: The aim of this report was to describe the process and outcomes of involving patients in the design of a clinical trial to promote adherence to supplemental oxygen therapy among patients with chronic obstructive pulmonary disease. METHODS: In-person focus groups and individual discussions via telephone and email were used to elicit feedback to refine the intervention and clarify outcomes of highest importance to patients. RESULTS: A total of 25 patients and five caregivers provided feedback. Their feedback has informed decisions regarding the length of intervention sessions (20 min and in some cases longer was acceptable), the importance of including caregivers, and discussion topics (e.g., social discomfort about using oxygen in public, identifying personally relevant reasons to use oxygen, pulmonary rehabilitation). Multiple outcomes were rated as highly important to patients (physical function, fatigue, sleep, anxiety, depression, and ability to participate in social roles and activities), and the outcome that was ranked as most important varied by individual. Therefore, multiple patient-reported outcomes will be used as endpoints for the clinical trial. CONCLUSIONS: Patient involvement led to refinements of the intervention and clinical trial endpoints to better address the expressed needs and concerns of patients and caregivers.

Defining Patient and Caregivers' Experience of Home Oxygen Therapy.

INTRODUCTION: Home oxygen therapy has a great impact on the lives of patients and their families. The aim of this study is to define the opinions, perceptions and attitudes of patients and their caregivers regarding home oxygen. METHOD: Qualitative, phenomenological study of a sample of 57 subjects, consisting of 18 family members and/or caregivers and 39 patients receiving home oxygen in urban centers. Five focus groups were formed between March and July 2014 in hospitals in Barcelona, Madrid and Alicante. Prior informed consent was obtained from patients and families. The study material consisted of audio recordings of all focus group interviews, transcription of selected materials and field notes. Data analysis was performed using constant comparison method, establishing 2 levels of analysis. RESULTS: Data from the focus groups were analyzed on 2 levels. A first level of analysis gave 21 categories. In a second level of analysis, these were integrated into 6 meta-categories: care provided by health professionals, psychological impact, care provided by commercial companies, impact on daily life, problems and satisfaction. CONCLUSIONS: Home oxygen has a major psychological impact on the daily lives of both patients and their families, and can cause social isolation. Although the results show that healthcare professionals are highly appreciated, better coordination is needed between different levels of care and companies supplying oxygen in order to provide patients and families with consistent information and useful strategies.

Fear of oxygen therapy for children in Malawi.

BACKGROUND: Although pneumonia is a common cause of death in children in Malawi, healthcare staff frequently encounter patients or carers who refuse oxygen therapy. This qualitative study documents factors that influence acceptance or refusal of oxygen therapy for children in Malawi. METHODS: Nine group interviews involving 86 participants were held in community and hospital settings in rural and urban Malawi. Eleven in-depth interviews of healthcare staff providing oxygen were held in a central hospital. Thematic analysis of transcripts of the audio recordings was carried out to identify recurring themes. RESULTS: Similar ideas were identified in the group interviews and in-depth staff interviews. Past experiences of oxygen use (direct and indirect, positive and negative) had a strong influence on views of oxygen. A recurrent theme was fear of oxygen, often due to a perceived association between death and recent oxygen use. Fears were intensified by a lack of familiarity with equipment used to deliver oxygen, distrust of medical staff and concerns about cost of oxygen. CONCLUSIONS: This study identifies reasons for refusal of oxygen therapy for children in a low-income country. Findings from the study suggest that training of healthcare staff to address fears of parents, and information, education and communication (IEC) approaches that improve public understanding of oxygen and provide positive examples of its use are likely to be helpful in improving uptake of oxygen therapy in Malawi.

How do respiratory patients perceive oxygen therapy? A critical interpretative synthesis of the literature.

Oxygen therapy is a common intervention in health care worldwide; yet, despite universal use, it is evident through poor practice that oxygen is often prescribed and administered injudiciously. It is proposed that possibly an influencing culture presides, whereby oxygen is often poorly understood and uncertainty regarding its use exists. It is unclear where the origins of this culture lie but exploring perceptions may enlighten the problem. A review of the literature was undertaken to establish what is already known about this elusive phenomenon. The paucity of any direct evidence regarding perceptions of oxygen directed the review to utilize a critical interpretative synthesis (CIS). The aim of this study was to explore how respiratory patients perceive oxygen therapy. A systematic search in Medline, Cinahl, Embase, British Nursing Index and PsychInfo yielded 1514 studies of which 42 were selected to consider the review question. The CIS allowed evidence from across studies to synthesize existing and new interpretations of data related to patients' perceptions of oxygen therapy. Synthetic constructs then informed the synthesizing arguments, namely positive - feeling safe, enabler and comforter; negative - fear, oxygen versus self, restriction and embarrassment; and impartiality - mixed blessings. The findings are divergent, and at times contradictory. There appears uncertainty among patients regarding the purpose and benefits of oxygen therapy, though an underlying faith in health-care professionals is apparent. This faith seems to foster acceptance of a life-changing therapy, despite the impact, burden and incomplete understanding. There is a clear need for further research regarding these elusive perceptions in order to improve clinical practice in respect of oxygen.