Running head: Oxygen Therapy
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Oxygen Therapy and its Relation to Increased Cardiac Perfusion During Acute Coronary
Syndrome
Miranda Lindsey
Ferris State University
OXYGEN THERAPY
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Oxygen Therapy and its Relation to Increased Cardiac Perfusion During Acute Coronary
Syndrome
In order to care for our patients optimally, nursing research must be performed
frequently. “Nurses interpret research findings and use evidence-based research to support
nursing decisions” (Ursuy, 2014, p. 11). The interpretation and implementation of research
findings is otherwise known as evidence-based nursing practice (EBNP) and is an important part
of health care and nursing practice today (Nieswiadomy, 2012, p. 5). “The purpose of this
assignment is to reflect how nursing knowledge is disseminated for use in personal and
professional practice” (2014, p. 11).
Clinical Question
When it comes to the care of patients that are in acute coronary syndrome (ACS), oxygen
therapy has always been a standard of care. Recently, there has been question about whether or
not the use of oxygen therapy is necessary for a patient in ACS that has a normal oxygen
saturation level. According to the American Heart Association 2010 Advance Cardiac Life
Support (ACLS) standards, “supplementary oxygen is not needed for patients without evidence
of respiratory distress if the oxyhemoglobin saturation is ≥ 94%” (American Heart Association,
2010). The question that then arises relates to whether or not this additional oxygen is hindering
or helping the patient in ACS.
The PICOT format of research is helpful in assisting to obtain research and questions
about a particular subject (Riva, J. J., Malik, K., Burnie, S. J., Endicott, A. R., & Busse, J. W.,
2012). The “P” in PICOT refers to the population being studied. “I” stands for interventions
that will take place for the particular population in the study. “C” refers to the comparison group
that will be studied. “O” refers to the outcome or result of the interventions that the study is
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planning on measuring. “T” speaks of the time frame of the data collection (2012). An
accurately written out PICOT question includes at least “PICO” with “T” being optional (2012).
In relation to oxygen therapy for patients in ACS, a PICOT question can be derived. This
question is as follows: Does oxygen therapy increase cardiac perfusion compared to no oxygen
therapy in patients with ACS with room air oxygen saturation levels greater than or equal to 94%
without evidence of respiratory distress? It is imperative that patients suffering from ACS
receive the safest and most effective care possible, whether it be oxygen therapy or no oxygen
therapy based on a normal oxygen saturation level without outward signs of respiratory distress.
Methodology
“Evidence-based nursing practice requires that nurses write clinical questions”
(Nieswiadomy, 2012, p. 282). In order to write these questions, nurses must perform research of
meta-analytic studies. Meta-analytic studies combine statistics into research and are often used
by nurses and there is a suggested hierarchy of six levels of evidence relating to meta-analytic
studies (p. 284).
The first level of evidence provides evidence from multiple studies. The second level is
made up of single experimental studies. Quasi-experimental studies, cohort studies, and timeseries studies make up the third level of evidence. Non-experimental studies, comparative and
correlation studies complete the fourth level. The fifth level consists of program evaluation
research and quality improvement projects. The sixth and final level includes the opinions of
authorities or experts (Nieswiadomy, 2012, p. 282).
In order for evidence-based nursing practice to occur, research must be based on a variety
of resources. For the most accurate evidence based practice relating to nursing, only nursing
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research must be used. Nurses must be knowledgeable in practice guidelines specific to his or
her own practice (Nieswiadomy, 2012, p. 282).
Discussion of Literature
Does oxygen therapy increase cardiac perfusion compared to no oxygen therapy in
patients with ACS with room air oxygen saturation levels greater than or equal to 94% without
evidence of respiratory distress? This is the PICO question we will explore with the reference
and critique of three articles. All articles are meta-analytic studies and provide varying degrees
of nursing research applicable to the PICO question.
Article I
The first article observed titled Pre-hospital Oxygen Administration for Chest Pain
Patients Decreases Significantly Following Implementation of the 2010 AHA Guidelines (2014),
can be described as quantitative, experimental, and a level 3 article of nursing research (Carhart,
E. & Salzman, J. G.). The article describes the experiment as involving 10,552 patient
encounters by 2,447 paramedic students from 195 different paramedic programs in 49 states
across the United States of America (2014).
The purpose of the study was to “examine trends in oxygen administration following the
2010 American Heart Association guidelines recommendation to withhold oxygen therapy for
patients with uncomplicated presentations of ACS whose SpO2 is 94% or higher” (2014). The
study found that “the pre-hospital administration of supplemental O2 decreased significantly
following release of the 2010 updated guidelines; however, our data revealed that 50% of
patients not meeting criteria for administration still received supplemental O2” (2014). This
article shows that there is confusion to health care providers on whether or not to provide
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supplemental oxygen in the presence of ACS, following the 2010 guidelines by the American
Heart Association (AHA).
Article II
The second article examined titled Revisiting the Role of Oxygen Therapy in Cardiac
Patients (2010), is an example of a quantitative, experimental, level 1 meta-analytic article
(Moradkhan, R. & Sinoway, L. I.). In this article, several studies are explored and revisited in
relation to applying oxygen to patients being faced with ACS. According to the article, there
have been multiple studies completed which have studied the effects of oxygen therapy in
cardiac patients presenting with oxygen saturation levels greater than or equal to 94% without
the presence of respiratory distress (2010).
After reviewing many different studies, the article states that an overuse of oxygen could
lead to detrimental effects on patients. Once such study included seven healthy subjects. A
second study included three post-cardiac transplant patients who had received a transplant five to
fourteen months prior to the experiment. A third study included stable patients with coronary
artery disease (CAD). All studies monitored the changes of coronary vascular resistance (CVR)
and coronary blood velocity (CBV) of the left anterior descending coronary artery with the
administration of 100% oxygen for five minutes in patients with normal oxygen saturation levels.
“Hyperoxia decreased CBV by 15 ± 3% (p < 0.01) and raised CVR by 20 ± 4% (p < 0.01)” in the
healthy patients (2014). “CBV decreased by 16 ± 2% [p < 0.01] and CVR increased by 23 ± 3%
[p < 0.01]” in post-cardiac transplant patients. “hyperoxia decreased CBF by 29% and raised
CVR by 41%” in stable patients with coronary artery disease (2010). Ultimately, the article
concludes blood flow velocity is significantly decreased with the use of oxygen therapy for all of
the patients included in the study, stating “we hypothesize that excessive use of supplemental
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oxygen in normoxic cardiac patients could potentially lead to worse outcomes in a number of
patients” (2010).
Article III
The third article included in my research is titled Reduction of infarct size by oxygen
inhalation following acute coronary occlusion (Maroko, P. R., Radvany, P., Braunwald, E. &
Hale, S. L., 1975). This article is an example of a level 2, quantitative, and experimental study.
The experiment performed in 1975 was performed to determine the effects of the inspiration of
oxygen enriched air on the size of myocardial infarction.
The 15 anesthetized dogs included in this study underwent intermittent occlusion of the
left anterior descending coronary artery or one of its major branches (1975). During the
experiment “epicardial electrograms were recorded from ten to fourteen sites on the anterior
surface of the left ventricle before and after intermittent occlusion” of the artery or one of the
other major branches (1975). Ultimately, the study found that “0.4 FiO2 following an
experimental coronary artery occlusion decreases acute ischemic injury and reduces the eventual
development of necrosis, as evaluated by enzymatic and histological techniques” (1975).
Significance to Nursing
After reviewing these articles, it is clear that there is conflict in research outcomes on
whether or not it is appropriate to provide supplemental oxygen therapy to patients suffering
from ACS, in the presence of oxygen saturation levels greater than or equal to 94%. The
American Heart Association states in the 2010 Advanced Cardiac Life Support guidelines that
oxygen does not need to be applied to patients that have oxygen saturation levels greater than
94% without the presence of respiratory distress (American Heart Association, 2010).
According to several research studies that have been reported, unnecessary oxygen
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administration can be more harmful than helpful in the presence of normal oxygen saturation
levels (Moradkhan, R. & Sinoway, L. I., 2010).
As nurses, we must be responsible for our own actions and care for our patients in order
to provide the safest and most effective care possible. Though there may be conflicting
information between facility policy standards and the AHA guidelines, our patients are our
number one concern. This is where the nursing process comes in place. Through proper
assessment, diagnosis, outcomes identification, planning, implementation, and outcomes
evaluation, safe effective care can be achieved.
According to the American Nurses Association (ANA), “quality improvement efforts are
challenged in resourced-constrained environments. However, as quality efforts within health
care continue to question how care is delivered, resource utilization must be a part of the
equation” (White, K.M. & O'Sullivan, A., 2012). There must be a delicate balance between safe,
quality care, while following implemented policy standards. Nursing is and will continue to be
dynamic professional role. It must continue to meet the needs of the ever changing community
with regards to evidence based practice and continual research while upholding elevated
standards of patient care.
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References
American Heart Association. (2010). 2010 American heart association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care. Retrieved from
http://www.heart.org/idc/groups/heartpublic/@wcm/@ecc/documents/downloadable/ucm_318152.pdf
Carhart, E. & Salzman, J. G. (2014, May 30). Prehospital oxygen administration for chest pain
patients decreases significantly following implementation of the 2010 AHA guidelines.
Prehospital Emergency Care. Retrieved from
www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/24878268
Maroko, P. R., Radvany, P., Braunwald, E. & Hale, S. L. (1975). Reduction of infarct size by
oxygen inhalation following acute coronary occlusion. Circulation.
doi:10.1161/01.CIR.52.3.360
Moradkhan, R. & Sinoway, L. I. (2010, Sept 21). Revisiting the role of oxygen therapy in
cardiac patients. Journal of the American College of Cardiology, 56(13), 1013-1016.
doi:10.1016/j.jacc.2010.04.052
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.
Riva, J. J., Malik, K., Burnie, S. J., Endicott, A. R., & Busse, J. W. (2012, Sept). What is your
research question? An introduction to the PICOT format for clinicians. The Journal of the
Canadian Chiropractic Association, 3(56), 167-171.
Ursuy, P. (2014). NURS 350 Ferris State University Summer 2014 Syllabus. Retrieved from
https://fsulearn.ferris.edu/bbcswebdav/pid-567001-dt-content-rid3690195_1/courses/50170.201405/NURS350%20syllabus%20summer2014.PAU.pdf
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White, K.M. & O'Sullivan, A. (2012). The essential guide to nursing practice. Washington, D.C.:
Nursesbooks.org.