Hypoxaemia: Difference between revisions

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Type 1 respiratory failure is related to respiratory distress, with increased work of breathing and deranged gas exchange.<ref name=":1">Harden B, Cross J, Broad MA. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2009.</ref> It may occur with or without the presence of excessive pulmonary secretions and/or sputum retention, and is not necessarily related to a primary respiratory problem, e.g. neurological problems may be related to respiratory depression, hypoventilation, reduced level of consciousness and inability to protect the airway<ref name=":1" />. Cough depression and risk of aspiration are a serious concern.
Type 1 respiratory failure is related to respiratory distress, with increased work of breathing and deranged gas exchange.<ref name=":1">Harden B, Cross J, Broad MA. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2009.</ref> It may occur with or without the presence of excessive pulmonary secretions and/or sputum retention, and is not necessarily related to a primary respiratory problem, e.g. neurological problems may be related to respiratory depression, hypoventilation, reduced level of consciousness and inability to protect the airway<ref name=":1" />. Cough depression and risk of aspiration are a serious concern.
== Clinical Signs ==
A patient with acute hypoxaemia will display some or all of the following symptoms<ref name=":1" /><ref>Colledge NR, Walker BR, Ralston SH, eds. (2010). ''Davidson's principles and practice of medicine'' (21st ed.). Edinburgh: Churchill Livingstone/Elsevier.</ref>;
{{#ev:youtube|v=Qj3xxNfWsH8}}<ref>marcophage. Signs and symptoms of hypoxemia. Available from: https://www.youtube.com/watch?v=Qj3xxNfWsH8 [last accessed 15/04/2017]</ref>
{| class="wikitable"
!Sign
!Clinical feature
!Observation
|-
|Central cyanosis
|Blue-ish palor, blue lips
|Hypothermic <36.5 degrees C
|-
|Peripheral shut down
|Cool to touch, clammy
|Hypothermic <36.5 degrees C
|-
|Tachypnoea
|Increased respiratory rate
|>20 breaths per min, appears in distress with breathing
|-
|Low O2
|Low O2 saturations
|<90%
|-
|Accessory muscle use
|Tracheal tug, flared nostrils, bracing through upper limbs
|
|-
|Reduced mental state
|Confused, agitated
|
|}
Chronic hypoxaemia can occur from chronic lung conditions such as [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]] [[Sleep Apnea|or seep apnoea]], but it can also be caused by environmental factors such as frequent flying or living at high altitudes. which can be compensated or uncompensated<ref name=":4" />. The compensation may result in the symptoms to be overlooked initially, however, further disease progression or mild illness such as a chest infection may increase oxygen demand and unmask the existing hypoxaemia. <ref>Adde FV, Alvarez AE, Barbisan BN, Guimarães BR. [https://www.sciencedirect.com/science/article/pii/S0021755713000041 Recommendations for long-term home oxygen therapy in children and adolescents]. Jornal de pediatria. 2013 Feb;89(1):06-17. </ref>
== Classification of Hypoxaemia  ==
== Classification of Hypoxaemia  ==
There are many causes of hypoxaemia, often due to respiratory disorders:<ref name=":2" />
There are many causes of hypoxaemia, often due to respiratory disorders:<ref name=":2" />
Line 62: Line 98:
<ref name=":0" /><ref name=":1" /><ref name=":3" />
<ref name=":0" /><ref name=":1" /><ref name=":3" />


== Causes of Hypoxemia ==
== Causes of Hypoxaemia ==
Bronchopneumonia
Some of the respiratory causes of hypoxaemia are:
 
# [[Pneumonia]]: is caused by an infection which can start off as a lower respiratory tract infection, which when untreated can cause consolidation and significant sputum retention.<ref>Blaisdell FW. Pathophysiology of the respiratory distress syndrome. Arch Surg. 1974 Jan 1;108(1):44-9.
Bronchopneumonia is a form of pneumonia, sometimes referred to as lobar pneumonia, that also causes inflammation in the bronchi. <ref>Blaisdell FW. Pathophysiology of the respiratory distress syndrome. Arch Surg. 1974 Jan 1;108(1):44-9.
</ref> Due to the lobe consolidation, the lungs are not adequately ventilated.
</ref> A patient presenting with bronchopneumonia will present with troubled breathing due to airway constriction. Due to inflammation, their lungs are not adequately ventilated. Symptoms can range from mild to severe. Physiotherapy treatment can include;
# [[Pulmonary Embolism|Pulmonary embolus]] (PE): is a blockage of an artery in the lungs by a clot that has moved from elsewhere in the body through the bloodstream (embolism).<ref>Dalen JE, Alpert JS. Natural history of pulmonary embolism. Progress in cardiovascular diseases. 1975 Jan 1;17(4):259-70.</ref> Symptoms of a PE may include shortness of breath and chest pain particularly on inspiration.
* Ensure medication is optimised (oxygen, analgesia, bronchodilators, antibiotics, etc.)
# [[Pulmonary Fibrosis|Pulmonary fibrosis]]: describes a collection of diseases which lead to interstitial lung damage and ultimately fibrosis and loss of the elasticity of the lungs. It is a chronic condition characterised by shortness of breath.<ref>Gribbin J, Hubbard RB, Le Jeune I, Smith CJ, West J, Tata LJ. [https://www.ncbi.nlm.nih.gov/pubmed/16844727 Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK]. Thorax. 2006 Nov 1;61(11):980-5.</ref> The lung tissue becomes thickened, stiff and scarred over a period of time. The development of scar tissue is called fibrosis. As the lung tissue becomes scarred and thicker, the lungs start to lose their ability to transfer oxygen into the bloodstream.
* Positioning to decrease work of breathing
# Pulmonary oedema: occurs when fluid accumulates in the alveoli of the lungs causing an increased work of breathing. This fluid accumulation interferes with gas exchange and can cause respiratory failure.<ref>Masip J, Betbesé AJ, Páez J, Vecilla F, Cañizares R, Padró J, Paz MA, de Otero J, Ballús J. [https://www.ncbi.nlm.nih.gov/pubmed/11191538 Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial.] The Lancet. 2000 Dec 23;356(9248):2126-32.</ref>
* Airway clearance techniques
# Chronic respiratory conditions: such as [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]] or [[Cystic Fibrosis|CF]]
* Humidification<ref name=":1" />
# Distended abdomen, e.g. pancreatitis, ascites. This prevents the diaphragm from descending which reduces the surface area for gas exchange.
 
==== Acute lobar pneumonia ====
Lobar [[pneumonia]] is an acute exudative inflammation of an entire pulmonary lobe, produced in 95% of cases by Streptococcus pneumoniae (pneumococci). If not treated lobar pneumonia progresses in 4 stages; namely consolidation, red hepatization, grey hepatization and resolution.<ref>Pneumonia. (2018, January 9). ''Physiopedia,'' . Retrieved 11:29, March 31, 2018 from https://www.physio-pedia.com/index.php?title=Pneumonia&oldid=182184.</ref>  Treatment is dependent on the severity of symptoms and may include some of the following techniques;
* During the unproductive phase advice on positioning may reduce WOB
* CPAP is useful for hypoxaemia
* Sputum clearance s only indicated if the patient becomes productive
 
==== Pulmonary embolus ====
Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism).<ref>Dalen JE, Alpert JS. Natural history of pulmonary embolism. Progress in cardiovascular diseases. 1975 Jan 1;17(4):259-70.</ref> Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. Physiotherapy is not indicated. CPAP may help with severe hypoxaemia.  


==== Pulmonary fibrosis ====
== Medical Treatment of Hypoxaemia ==
Pulmonary fibrosis describes a collection of diseases which lead to interstitial lung damage and ultimately fibrosis and loss of the elasticity of the lungs. It is a chronic condition characterised by shortness of breath.<ref>Gribbin J, Hubbard RB, Le Jeune I, Smith CJ, West J, Tata LJ. Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK. Thorax. 2006 Nov 1;61(11):980-5.</ref> The lung tissue becomes thickened, stiff and scarred over a period of time. The development of scar tissue is called fibrosis. As the lung tissue becomes scarred and thicker, the lungs start to lose their ability to transfer oxygen into the bloodstream. Treatment of pulmonary fibrosis may involve;
The primary treatment for hypoxaemia is controlled oxygen therapy, alongside the identification and treatment of the underlying cause.   
* Present with profound hypoxaemia. Humidified CPAP is effective
* Ensure sufficient oxygen is available when CPAP removed
 
==== Pulmonary oedema ====
Pulmonary oedema occurs when fluid accumulates in the alveoli of the lungs causing an increased work of breathing. This fluid accumulation interferes with gas exchange and can cause respiratory failure.<ref>Masip J, Betbesé AJ, Páez J, Vecilla F, Cañizares R, Padró J, Paz MA, de Otero J, Ballús J. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. The Lancet. 2000 Dec 23;356(9248):2126-32.</ref> Treating a patient with pulmonary oedema may include;
* CPAP is effective in the treatment of pulmonary oedema
* If hypotensive, check that BP does not drop with increased intrathoracic pressure.
* NIV (pressure support with EPAP) may be useful in the patient tiring on CPAP<ref name=":1" />
 
==== CO2 retention ====
Uncontrolled oxygen therapy, or receiving too much oxygen, can make people who usually have higher CO2 levels retain more until it reaches dangerous levels.
* Acute CO2 retention is not a reason to reduce FiO2 unless patients have evidence of acute-on-chronic CO2 retention secondary to chronic respiratory disease
* This can be diagnosed by interpretation of recent [[Arterial Blood Gases|blood gas]] results, assessing pH, in relation to PaCO2, standard bicarbonate and base excess. Only this group of patients require judicious oxygen administration )24-28%), which should be prescribed accordingly
 
==== Fatigue ====
* Hypoxaemic patients may start to fatigue. This is seen by a rising PaCO2 - type II respiratory failure failure. An important clinical sign requiring immediate attention
 
==== Chronic chest patients ====
* Patients who have longstanding chest diseases may have a regular chest clearing routine they adhere to e.g. Bronchiectatic, CF patient
* It is important to discuss this and mould your treatment plan so that it fits within their existing regimen and their current physiotherapy problems<ref name=":1" />
 
==== Renal failure ====
* Patient in renal failure may present with an increased work of breathing
* [[Arterial Blood Gases|ABGs]] will show metabolic acidosis, generally with some form of respiratory ompensation e.g. Decreased CO2
* Pulmonary oedema and pleural effusion may also be present<ref name=":1" />
 
==== Distended abdomen, e.g. pancreatitis, ascites ====
* Positioning in alternate side-lying or well supported high side-lying is useful
* Standing where possible<ref name=":1" />
 
== Clinical Signs ==
A patient with acute hypoxemia will display some or all of the following symptoms<ref name=":1" /><ref>Colledge NR, Walker BR, Ralston SH, eds. (2010). ''Davidson's principles and practice of medicine'' (21st ed.). Edinburgh: Churchill Livingstone/Elsevier.</ref>;
{{#ev:youtube|v=Qj3xxNfWsH8}}<ref>marcophage. Signs and symptoms of hypoxemia. Available from: https://www.youtube.com/watch?v=Qj3xxNfWsH8 [last accessed 15/04/2017]</ref>
 
{| class="wikitable"
!Sign
!Clinical feature
!Observation
|-
|Central cyanosis
|Blue-ish palor, blue lips
|Hypothermic <36.5 degrees C
|-
|Peripheral shut down
|Cool to touch, clammy
|Hypothermic <36.5 degrees C
|-
|Tachypnoea
|Increased respiratory rate
|>20 breaths per min, appears in distress with breathing
|-
|Low O2
|Low O2 saturations
|<90%
|-
|Accessory muscle use
|Tracheal tug, flared nostrils, bracing through upper limbs
|
|-
|Reduced mental state
|Confused, agitated
|
|}
 
Chronic hypoxemia can occur from chronic lung conditions such as [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]] [[Sleep Apnea|or seep apnoea]], but it can also be caused by environmental factors such as frequent flying or living at high altitudes. which can be compensated or uncompensated<ref name=":4" />. The compensation may result in the symptoms to be overlooked initially, however, further disease progression or mild illness such as a chest infection may increase oxygen demand and unmask the existing hypoxemia. <ref>Adde FV, Alvarez AE, Barbisan BN, Guimarães BR. [https://www.sciencedirect.com/science/article/pii/S0021755713000041 Recommendations for long-term home oxygen therapy in children and adolescents]. Jornal de pediatria. 2013 Feb;89(1):06-17. </ref>
 
== Medical Treatment of Hypoxemia ==
The primary treatment for hypoxemia is controlled oxygen therapy, alongside the identification and treatment of the underlying cause.   


=== [[Oxygen Therapy|Controlled Oxygen Therapy]] ===
=== [[Oxygen Therapy|Controlled Oxygen Therapy]] ===
Line 172: Line 131:
* Cough assist or IPPB
* Cough assist or IPPB


== Complications with Hypoxemia ==
== Complications with Hypoxaemia ==


If left untreated hypoxemia can lead to type 1 respiratory failure. This may result is further symptoms which can be life threatening:
If left untreated hypoxaemia can lead to type 1 respiratory failure. This may result is further symptoms which can be life threatening:
* Respiratory acidosis
* Respiratory acidosis
* Cardiac arrhythmia
* Cardiac arrhythmia
Line 180: Line 139:
* Altered mental state including coma
* Altered mental state including coma
* Cardiorespiratory arrest <ref name=":1" />
* Cardiorespiratory arrest <ref name=":1" />
== Resources ==
[[Respiratory Failure|Respiratory failure]]
[[Respiratory System|Respiratory system]]
[[Arterial Blood Gases|Arterial blood gases]]


== References  ==
== References  ==

Revision as of 11:03, 7 April 2020

Original Editor - Adam Vallely Farrell


Top Contributors - Adam Vallely Farrell, Lucinda hampton, Abbey Wright, Kim Jackson, Rishika Babburu and Chelsea Mclene  

Introduction[edit | edit source]

Hypoxaemia is an abnormally low amount of oxygen in the blood, specifically arterial blood[1][2]. Hypoxaemia is defined as the inability to maintain the PaO2 above 8kPa (see ABGs for more details).[3]

An oxygenated red blood cell

It can cause hypoxia (low oxygen) in body tissues if unresolved, which can in turn lead to cell death of the peripheral then central tissues. Hypoxia is also known as type 1 respiratory failure.

Type 1 Respiratory Failure[edit | edit source]

Respiratory failure is characterised by a reduction in the function of the lungs due to lung disease, skeletal or neuromuscular disorder.

It occurs when gas exchange in the lungs is significantly impaired causing a drop in the levels of oxygen in the blood: hypoxaemia or type 1 respiratory failure.[4]

When there is a drop in oxygen and a rise in carbon dioxide levels this is known as: hypercapnia or type 2 respiratory failure.

Respiratory failure is demonstrated in arterial blood gas (ABG). Type I respiratory failure is defined as PaO2 <8.0kPa with a normal or lowered PaCO2.[1]

Type 1 respiratory failure is related to respiratory distress, with increased work of breathing and deranged gas exchange.[5] It may occur with or without the presence of excessive pulmonary secretions and/or sputum retention, and is not necessarily related to a primary respiratory problem, e.g. neurological problems may be related to respiratory depression, hypoventilation, reduced level of consciousness and inability to protect the airway[5]. Cough depression and risk of aspiration are a serious concern.

Clinical Signs[edit | edit source]

A patient with acute hypoxaemia will display some or all of the following symptoms[5][6];

[7]

Sign Clinical feature Observation
Central cyanosis Blue-ish palor, blue lips Hypothermic <36.5 degrees C
Peripheral shut down Cool to touch, clammy Hypothermic <36.5 degrees C
Tachypnoea Increased respiratory rate >20 breaths per min, appears in distress with breathing
Low O2 Low O2 saturations <90%
Accessory muscle use Tracheal tug, flared nostrils, bracing through upper limbs
Reduced mental state Confused, agitated

Chronic hypoxaemia can occur from chronic lung conditions such as COPD or seep apnoea, but it can also be caused by environmental factors such as frequent flying or living at high altitudes. which can be compensated or uncompensated[8]. The compensation may result in the symptoms to be overlooked initially, however, further disease progression or mild illness such as a chest infection may increase oxygen demand and unmask the existing hypoxaemia. [9]

Classification of Hypoxaemia[edit | edit source]

There are many causes of hypoxaemia, often due to respiratory disorders:[3]

Definition Cause
Hypoxic hypoxemia
  • Occurs where blood flows through parts of the lung which are un-ventilated
  • Inability to transfer oxygen across the pulmonary membrane (gas diffusion limitation)
  • Acute bronchoconstriction: insufficient gas flow in and out of the lung
  • Insufficient inspired oxygen therapy (including faulty oxygen delivery equipment)
  • Primary respiratory disease: COPD, pulmonary fibrosis, asthma, CF, pneumonia, sputum retention, decreased gas transfer across thickened (fibrotic/ oedematous) membrane
  • Primary cardiac disease: heart failure, congestive cardiac failure, pulmonary oedema (causing a diffusion limitation across the respiratory membrane)
Ischaemic hypoxemia
  • Usually due to inadequate blood flow through the lung
Anaemic hypoxemia
  • Reduction in the oxygen carrying capacity of the blood
  • Shock (significant blood loss with a reduced Hb)
  • Primary haematological diseases, e.g. sickle cell crisis, anaemia
Toxic hypoxemia
  • Difficulty in the utilisation of oxygen
  • It is common in patients admitted with inhalation burns/ smoke inhalation injuries
  • E.g. carbon monoxide poisoning, cyanide poisoning

[1][5][2]

Causes of Hypoxaemia[edit | edit source]

Some of the respiratory causes of hypoxaemia are:

  1. Pneumonia: is caused by an infection which can start off as a lower respiratory tract infection, which when untreated can cause consolidation and significant sputum retention.[10] Due to the lobe consolidation, the lungs are not adequately ventilated.
  2. Pulmonary embolus (PE): is a blockage of an artery in the lungs by a clot that has moved from elsewhere in the body through the bloodstream (embolism).[11] Symptoms of a PE may include shortness of breath and chest pain particularly on inspiration.
  3. Pulmonary fibrosis: describes a collection of diseases which lead to interstitial lung damage and ultimately fibrosis and loss of the elasticity of the lungs. It is a chronic condition characterised by shortness of breath.[12] The lung tissue becomes thickened, stiff and scarred over a period of time. The development of scar tissue is called fibrosis. As the lung tissue becomes scarred and thicker, the lungs start to lose their ability to transfer oxygen into the bloodstream.
  4. Pulmonary oedema: occurs when fluid accumulates in the alveoli of the lungs causing an increased work of breathing. This fluid accumulation interferes with gas exchange and can cause respiratory failure.[13]
  5. Chronic respiratory conditions: such as COPD or CF
  6. Distended abdomen, e.g. pancreatitis, ascites. This prevents the diaphragm from descending which reduces the surface area for gas exchange.

Medical Treatment of Hypoxaemia[edit | edit source]

The primary treatment for hypoxaemia is controlled oxygen therapy, alongside the identification and treatment of the underlying cause.

Controlled Oxygen Therapy[edit | edit source]

Patients who are unable to maintain a SaO2 >90% with a face mask may require additional respiratory support. This might include either continuous positive airway pressure (CPAP), non-invasive ventilation or intubation with mechanical ventilation[14].

Controlled oxygen therapy is prescribed for hypoxaemic patients to increase alveolar oxygen tension and decrease work of breathing.[15] It is important to remember that oxygen is a drug and should always be prescribed with the required percentage and/or flow rate.[8]

Humidification[edit | edit source]

Oxygen therapy is known to dry out the airways. Humidifying oxygen is often used in an attempt to help prevent the drying of the upper respiratory tract. In patients who are requiring high flow oxygen or oxygen for longer periods consider cold or heated humidification.[16] Heated humidification is believed to be better for tenacious secretions or severe bronchospasm. [5]

Treat the cause, e.g. bronchospasm, sputum retention, volume loss[edit | edit source]

Whilst the delivery of oxygen therapy is the primary treatment for hypoxaemia it is essential to treat the cause. There may be an acute primary respiratory problem, however, the respiratory failure could be due to compensation for another condition such as cardiac or renal. Multi-disciplinary team (MDT) working is vital in managing this.[5]

Physiotherapy[edit | edit source]

The overall aim of physiotherapy is to identify and treat the cause of the hypoxaemia, thus aiming to increase PaO2 >8kPa while administering appropriate oxygen therapy. [5] The cause of hypoxaemia may be sputum retention in which case various physiotherapy techniques can be used[17]:

Complications with Hypoxaemia[edit | edit source]

If left untreated hypoxaemia can lead to type 1 respiratory failure. This may result is further symptoms which can be life threatening:

  • Respiratory acidosis
  • Cardiac arrhythmia
  • Cerebral hypoxaemia
  • Altered mental state including coma
  • Cardiorespiratory arrest [5]

Resources[edit | edit source]

Respiratory failure

Respiratory system

Arterial blood gases

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Pollak, Charles P.; Thorpy, Michael J.; Yager, Jan (2010). The encyclopedia of sleep and sleep disorders (3rd ed.). New York, NY. p. 104.
  2. ↑ 2.0 2.1 Eckman, Margaret (2010). Professional guide to pathophysiology (3rd ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 208. 
  3. ↑ 3.0 3.1 Martin, Lawrence (1999). All you really need to know to interpret arterial blood gases (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
  4. ↑ Tulaimat A, Patel A, Wisniewski M, Gueret R. The validity and reliability of the clinical assessment of increased work of breathing in acutely ill patients. Journal of critical care. 2016 Aug 1;34:111-5.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Harden B, Cross J, Broad MA. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2009.
  6. ↑ Colledge NR, Walker BR, Ralston SH, eds. (2010). Davidson's principles and practice of medicine (21st ed.). Edinburgh: Churchill Livingstone/Elsevier.
  7. ↑ marcophage. Signs and symptoms of hypoxemia. Available from: https://www.youtube.com/watch?v=Qj3xxNfWsH8 [last accessed 15/04/2017]
  8. ↑ 8.0 8.1 Bonsignore MR, Baiamonte P, Mazzuca E, Castrogiovanni A, Marrone O. Obstructive sleep apnea and comorbidities: a dangerous liaison. Multidisciplinary respiratory medicine. 2019 Dec;14(1):8.
  9. ↑ Adde FV, Alvarez AE, Barbisan BN, Guimarães BR. Recommendations for long-term home oxygen therapy in children and adolescents. Jornal de pediatria. 2013 Feb;89(1):06-17. 
  10. ↑ Blaisdell FW. Pathophysiology of the respiratory distress syndrome. Arch Surg. 1974 Jan 1;108(1):44-9.
  11. ↑ Dalen JE, Alpert JS. Natural history of pulmonary embolism. Progress in cardiovascular diseases. 1975 Jan 1;17(4):259-70.
  12. ↑ Gribbin J, Hubbard RB, Le Jeune I, Smith CJ, West J, Tata LJ. Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK. Thorax. 2006 Nov 1;61(11):980-5.
  13. ↑ Masip J, Betbesé AJ, Páez J, Vecilla F, Cañizares R, Padró J, Paz MA, de Otero J, Ballús J. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. The Lancet. 2000 Dec 23;356(9248):2126-32.
  14. ↑ Simon M, Braune S, Frings D, Wiontzek AK, Klose H, Kluge S. High-flow nasal cannula oxygen versus non-invasive ventilation in patients with acute hypoxaemic respiratory failure undergoing flexible bronchoscopy-a prospective randomised trial. Critical Care. 2014 Dec 1;18(6):712.
  15. ↑ Hardinge M, Annandale J, Bourne S, Cooper B, Evans A, Freeman D, Green A, Hippolyte S, Knowles V, MacNee W, McDonnell L. British Thoracic Society guidelines for home oxygen use in adults: accredited by NICE. Thorax. 2015 Jun 1;70(Suppl 1):i1-43.
  16. ↑ O'driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun 1;72(Suppl 1):ii1-90.
  17. ↑ Derakhtanjani AS, Jaberi AA, Haydari S, Bonabi TN. Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery: A Randomized Clinical Trial. Anesthesiology and Pain Medicine. 2019 Oct;9(5).
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