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

Can guidelines rein in oxygen use? A retrospective cross-sectional study using routinely collected data

Oxygen is one of the most commonly used emergency therapies. Like other therapies, oxygen can cause harm if used inappropriately. During the COVID-19 pandemic, guidelines were released to optimize oxygen and medication use. In the current study, we examine whether oxygen and medication use during the first wave of the COVID-19 pandemic was in concordance with new guidelines. A retrospective cross-sectional study was conducted using routinely collected data from University of Birmingham NHS Foundation Trust in England. Patients were admitted between April 2020 and September 2020, were over the age of 18 years, and had a confirmed diagnosis of COVID-19. To assess adherence to the oxygen guidelines (i.e. SpO2 adherence), the percentage of times oxygen therapy was administered within, over, and under guideline specifications were calculated for patients overall, and then for patients with and without chronic obstructive pulmonary disease (COPD)/pulmonary disease separately. Next, two multinomial regression analyses were conducted to assess whether clinical processes, pre-admission diagnoses, and other demographic factors were related to oxygen use. Analysis 1 included patients not diagnosed with COPD/pulmonary disease. Analysis 2 included patients diagnosed with COPD/pulmonary disease. Results are reported as tallies, percentages, and odds ratios with 95% confidence intervals. To assess adherence to a new medication guideline, the percentage of patients administered oxygen and dexamethasone was calculated for those admitted after 25 June 2020. The overall number of patients included in our SpO2 adherence analyses was 8751 (female = 4168). Oxygen was used within guideline specifications less than half the time, i.e. 41.6% (n = 3638/8751); non-adherence involving under-administering (3.5%, n = 304/8751) was markedly lower than over-administering (55.0%, n = 4809/8751). Adherence was higher for patients without COPD (43.7%, n = 3383/7741) than with COPD (25.2%, n = 255/1010). Under-administering was low across groups (non-COPD 3.5%, n = 274/7741 and COPD 2.9%, n = 30/1010). Over-administering was markedly lower for non-COPD (52.3%, n = 4084/7741) than COPD (71.8%, n = 725/1010) patients. Diagnoses associated with over-administering varied across the groups. Regarding the dexamethasone guidelines, of the 6397 patients admitted after the 24th of June, only 12.6% (n = 805) received dexamethasone. Suboptimal use of oxygen and medication were common during the first wave of the COVID-19 pandemic. As found in previous studies, over-administering was more common than under-administering. The new guidelines issued during the COVID-19 pandemic were not by themselves sufficient to optimize oxygen use. Behavioural strategies are explored which may help policymakers optimize oxygen use.

Effects of long-term oxygen therapy on the mental state of patients with chronic obstructive pulmonary disease: A systematic review

OBJECTIVES

This systematic review aimed to examine the effects of long-term oxygen therapy on the mental state of patients with chronic obstructive pulmonary disease.

METHODS

Web of Science, Medline, CINAHL, EMBASE, ProQuest, and Cochrane Library were selected to search for relevant studies. We followed the Cochrane Handbook for Systematic Reviews of Interventions, adopted the Cochrane risk-of-bias tool and Risk Of Bias In Non-randomized Studies of Interventions tool, and synthesized the outcomes narratively with Grading of Recommendations, Assessment, Development and Evaluations evidence profile.

RESULTS

Six studies were included. Moderate quality of evidence supported no effects of long-term oxygen therapy on the mental state in patients with severe resting hypoxemia and moderate resting hypoxemia (or exertional desaturation) at follow-up of 6 to 12 months; however, adverse effects on mental state among patients with moderate resting or exertional desaturation were reported at the follow-up of 36 to 48 months.

DISCUSSION

Nurses should focus on the mental state of patients treated with long-term oxygen therapy, especially those who use it for a prolonged time. Due to ethical constraints in this study, a quasi-experimental study with faithful consideration of internal validity can be commenced in the future.

Oxygen Supplementation and Hyperoxia in Critically Ill Cardiac Patients: From Pathophysiology to Clinical Practice

Oxygen supplementation has been a mainstay in the management of patients with acute cardiac disease. While hypoxia is known to be detrimental, the adverse effects of artificially high oxygen levels (hyperoxia) have only recently been recognized. Hyperoxia may induce harmful hemodynamic effects, including peripheral and coronary vasoconstriction, and direct cellular toxicity through the production of reactive oxygen species. In addition, emerging evidence has shown that hyperoxia is associated with adverse clinical outcomes. Thus, it is essential for the cardiac intensive care unit (CICU) clinician to understand the available evidence and titrate oxygen therapies to specific goals. This review summarizes the pathophysiology of oxygen within the cardiovascular system and the association between supplemental oxygen and hyperoxia in patients with common CICU diagnoses, including acute myocardial infarction, heart failure, shock, cardiac arrest, pulmonary hypertension, and respiratory failure. Finally, we highlight lessons learned from available trials, gaps in knowledge, and future directions.

Association between long-term oxygen therapy provided outside the guidelines and mortality in patients with COPD

INTRODUCTION

Hypoxaemia is a frequent complication of chronic obstructive pulmonary disease (COPD). To prevent its consequences, supplemental oxygen therapy is recommended by international respiratory societies. However, despite clear recommendations, some patients receive long-term oxygen therapy (LTOT), while they do not meet prescription criteria. While evidence suggests that acute oxygen supply at high oxygenation targets increases COPD mortality, its chronic effects on COPD mortality remain unclear. Thus, the study will aim to evaluate through a systematic review and individual patient data meta-analysis (IPD-MA), the association of LTOT prescription outside the guidelines on survival over time in COPD.

METHODS

Systematic review and IPD-MA will be conducted according to Preferred Reporting Items for a Systematic Review and Meta-Analyses IPD guidelines. Electronic databases (PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, OpenGrey and BioRxiv/MedRxix) will be scanned to identify relevant studies (cohort of stable COPD with arterial oxygen tension data available, with indication of LTOT filled out at the moment of the study and with a survival follow-up). The anticipated search dates are January-February 2022. The main outcome will be the association between LTOT and time to all-cause mortality according to hypoxaemia severity, after controlling for potential covariates and all available clinical characteristics. Quantitative data at the level of the individual patient will be used in a one-step approach to develop and validate a prognostic model with a Cox regression analysis. The one-step IPD-MA will be conducted to study the association and the moderators of association between supplemental oxygen therapy and mortality. Multilevel survival analyses using Cox-mixed effects models will be performed.

ETHICS AND DISSEMINATION

As a protocol for a systematic review, a formal ethics committee review is not required. Only studies with institutional approval from an ethics committee and anonymised IPD will be included. Results will be disseminated through peer-reviewed publications and presentations in conferences.

PROSPERO REGISTRATION NUMBER

CRD42020209823.

Perceptions of Hyperoxemia and Conservative Oxygen Therapy in the Management of Acute Respiratory Failure

Rationale: Mechanically ventilated patients in the intensive care unit (ICU) are often managed to maximize oxygenation, yet hyperoxemia may be deleterious to some. Little is known about how ICU providers weigh tradeoffs between hypoxemia and hyperoxemia when managing acute respiratory failure. Objectives: To define ICU providers' mental models for managing oxygenation for patients with acute respiratory failure and identify barriers and facilitators to conservative oxygen therapy. Methods: In two large U.S. tertiary care hospitals, we performed semistructured interviews with a purposive sample of ICU nurses, respiratory therapists, and physicians. We assessed perceptions of oxygenation management, hyperoxemia, and conservative oxygen therapies through interviews, which we audio recorded and transcribed verbatim. We analyzed transcripts for representative themes using an iterative thematic-analysis approach. Results: We interviewed 10 nurses, 10 respiratory therapists, 4 fellows, and 5 attending physicians before reaching thematic saturation. Major themes included perceptions of hyperoxemia, attitudes toward conservative oxygen therapy, and aspects of titrated-oxygen-therapy implementation. Many providers did not recognize the term "hyperoxemia," whereas others described a poor understanding; several stated they never encounter hyperoxemia clinically. Concerns about hyperoxemia varied: some providers believed that typical ventilation strategies emphasizing progressive lowering of the fraction of inspired oxygen mitigated worries about excess oxygen administration, whereas others maintained that hyperoxemia is harmful only to patients with chronic lung disease. Almost all interviewees expressed familiarity with lower oxygen saturations in chronic obstructive pulmonary disease. Cited barriers to conservative oxygen therapy included concerns about hypoxemia, particularly among nurses and respiratory therapists; perceptions that hyperoxemia is not harmful; and a lack of clear evidence supporting conservative oxygen therapy. Interviewees suggested that interprofessional education and convincing clinical trial evidence could facilitate uptake of conservative oxygenation. Conclusions: This study describes attitudes toward hyperoxemia and conservative oxygen therapy. These preferences and uncertain benefits and risks of conservative oxygen therapy should be considered during future implementation efforts. Successful oxygen therapy implementation most likely will require 1) improving awareness of hyperoxemia's effects, 2) normalizing lower saturations in patients without chronic lung disease, 3) addressing ingrained beliefs regarding oxygen management and oxygen's safety, and 4) using interprofessional education to obtain buy-in across providers and inform the ICU team.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

Audit of oxygen administration to achieve a target oxygen saturation range in acutely unwell medical patients

PURPOSE OF THE STUDY

To evaluate documentation of a target oxygen saturation (SpO₂) range and ability to achieve this range in acutely unwell inpatients.

STUDY DESIGN

In this single-centre audit, patients with discharge diagnoses of pneumonia, heart failure and exacerbation of asthma or COPD admitted to Wellington Regional Hospital, New Zealand between 1 June 2019 and 31 August 2019 who received oxygen were identified. In those with a documented target SpO₂ range, the proportion of SpO₂ measurements in the observation chart which were within, above and below range were determined as well as the maximum and minimum SpO₂. Regression analysis was performed to determine whether these outcomes were influenced by the prescribed range, high-dependency care or the number of adjustments to oxygen administration.

RESULTS

268 admissions were screened. Of the 100 eligible admissions who received oxygen, a target SpO₂ range was documented in 62. The mean (SD) proportion of SpO₂ measurements within range was 56.2 (30.6)%. A hypercapnic target SpO₂ range was associated with a higher probability of an SpO₂ above range; multivariate OR 5.34 (95% CI 1.65 to 17.3, p=0.006) and a lower probability of an SpO₂ below range; multivariate OR 0.25 (95% CI 0.08 to 0.80) p=0.02. The mean (SD) maximum SpO₂ was similar in those with a target range of 92%-96% versus a hypercapnic range; 96.2 (3.0)% and 95.2 (3.4)%, respectively.

CONCLUSIONS

Oxygen prescription and delivery in this clinical setting was suboptimal. SpO₂ values above the designated range are common, particularly in patients with a hypercapnic target range.

Impact of Using a Non-Rebreathing Mask in Patients With Respiratory Failure

BACKGROUND

Liberal oxygen therapy might increase the mortality rate of patients. Non-rebreathing masks (NRM) are a high-flow, non-invasive oxygen device that can provide oxygen concentration up to 95%. This study aimed to determine the impact of using NRM in patients with respiratory failure.

METHODS

This retrospective cohort study was conducted in four medical institutions in Taiwan from January 2010 to December 2016. The association between mortality and NRM use before receiving ventilator support in patients with respiratory failure in the emergency department was analyzed. Patients were divided into the NRM treatment and no NRM treatment groups. A 1:4 propensity score matching was conducted. Regarding the duration of NRM use, treatments were grouped as 0 h, 0-1 h, 1-2 h, and >2 h.

RESULTS

A total of 18,749 patients were included, with 1074 using NRM. After propensity score matching, 1028 patients using NRM (0-1 h: 508, 1-2 h: 193, and >2 h: 327) and 4112 patients not using NRM were analyzed. The 30-day mortality rates were 29.1%, 28.5%, 27.5%, and 35.5% in the 0 h, 0-1 h, 1-2 h, and >2 h treatment groups, respectively. Patients with respiratory failure due to pulmonary disease using NRM over 2 h had a higher mortality rate than patients not using NRM (hazard ratio: 1.3, 95% CI: 1.01-1.66).

CONCLUSIONS

Prolonged use of NRM in patients with respiratory failure due to pulmonary disease possibly increases mortality.

Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

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.

Acute oxygen therapy: a cross-sectional study of prescribing practices at an English hospital immediately before COVID-19 pandemic

BACKGROUND

Approximately 14% of UK hospital in-patients receive supplemental oxygen therapy, only 57% have valid prescriptions. Oxygen must be optimally prescribed to ensure maximal therapeutic response whilst minimizing adverse outcomes (including fatality). This study investigates prescription compliance.

METHODS

All adults admitted to medical wards (18 February to 3 March 2020) were included. Analyses present proportions, descriptive statistics, and hypothesis testing. Ethical approval was unnecessary for this audit.

RESULTS

Of the 636 patients admitted, 66 (10%) were receiving oxygen therapy. Ages ranged from 34 to 100 years with 36 (54.5%) males and 30 (45.5%) females. The prescription was not documented in the oxygen section of the drug chart (n = 37, 56.1%, p = 0.389), nor did it have the physicians signature (n = 40, 60.6%, p = 0.110) nor date (n = 46, 69.7%, p = 0.002). Thirteen chronic obstructive pulmonary disease (COPD) patients (19.7%) were at risk of hypercapnic failure (p = 1.582x10^-6). Target oxygen saturation (SpO2) range had been documented for 30 (45.5%) patients. A target SpO2 range of 88-92% was documented for 9 patients (13.6%), a 94-98% range documented for 11 patients (16.7%). All patients had an invalid prescription.

CONCLUSION

We present real-world practice in naturalistic settings, immediately before pandemic-lockdown. Enhanced compliance is advocated to reduce risks of harm and mortality.

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.

Pragmatic randomised controlled trial of a personalised intervention for carers of people requiring home oxygen therapy

We used a pragmatic randomised controlled trial to evaluate a behavioural change strategy targeting carers of chronically hypoxaemic patients using long-term home oxygen therapy. Intervention group carers participated in personalised educational sessions focusing on motivating carers to take actions to assist patients. All patients received usual care. Effectiveness was measured through a composite event of patient survival to hospitalisation, residential care admission or death to 12 months. Secondary outcomes at baseline, 3, 6 and 12 months included carer and patient emotional and physical well-being. No difference between intervention (n = 100) and control (n = 97) patients was found for the composite outcome (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 0.89, 1.68; p = 0.22). Improved fatigue, mastery, vitality and general health occurred in intervention group patients (all p values < 0.05). No benefits were seen in carer outcomes. Mortality was significantly higher in intervention patients (HR = 2.01, 95% CI = 1.00, 4.14; p = 0.05; adjusted for Australia-modified Karnofsky Performance Status), with a significant diagnosis-intervention interaction (p = 0.028) showing higher mortality in patients with COPD (HR 4.26; 95% CI = 1.60, 11.35) but not those with interstitial lung disease (HR 0.83; 95% CI = 0.28, 2.46). No difference was detected in the primary outcome, but patient mortality was higher when carers had received the intervention, especially in the most disabled patients. Trials examining behavioural change interventions in severe disease should stratify for functionality, and both risks and benefits should be independently monitored. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000177459).

Implementing target range oxygen in critical care: A quality improvement pilot study

Background

Iatrogenic hyperoxaemia is common on critical care units and has been associated with increased mortality. We commenced a quality improvement pilot study to analyse the views and practice of critical care staff regarding oxygen therapy and to change practice to ensure that all patients have a prescribed target oxygen saturation range.

Methods

A baseline measurement of oxygen target range prescribing was undertaken alongside a survey of staff attitudes. We then commenced a programme of change, widely promoting an agreed oxygen target range prescribing policy. The analyses of target range prescribing and staff survey were repeated four to five months later.

Results

Thirty-three staff members completed the baseline survey, compared to 29 in the follow-up survey. There was no discernible change in staff attitudes towards oxygen target range prescribing. Fifty-four patients were included in the baseline survey and 124 patients were assessed post implementation of changes. The proportion of patients with an oxygen prescription with a target range improved from 85% to 95% (χ² = 5.17, p = 0.02) and the proportion of patients with an appropriate prescribed target saturation range increased from 85% to 91% (χ² = 1.4, p = 0.24). The improvement in target range prescribing was maintained at 96% 12 months later.

Conclusions

The introduction and promotion of a structured protocol for oxygen prescribing were associated with a sustained increase in the proportion of patients with a prescribed oxygen target range on this unit.

Oxygen alert wristbands (OxyBand) and controlled oxygen: a pilot study

Despite the introduction of Oxygen Alert Cards, guidelines and audits, oxygen therapy remains overused in NHS practice, and this may lead to iatrogenic mortality. This pilot study aimed to examine the use of Oxygen Alert Wristbands (OxyBand) designed to alert health professionals who are delivering oxygen to patients to ensure that the oxygen is administered and titrated safely to the appropriate target saturations. Patients at risk of hypercapnic acidosis were asked to wear OxyBands while presenting to paramedics and health professionals in hospitals. Inappropriate prescription of oxygen reduced significantly after the OxyBands were used. A questionnaire-based assessment showed that the clinicians involved had a good understanding of the risks of uncontrolled oxygen. Forty-two patients found the wrist band comfortable to wear, and only two did not. OxyBands may have the potential to improve patient safety over Oxygen Alert Cards.

Stigma and the in(visible) perspectives and expectations of home oxygen therapy among people with chronic breathlessness syndrome: A qualitative study

Background:

Chronic breathlessness syndrome in the context of advancing disease is distressing for all concerned. Oxygen is commonly prescribed in this setting; however, little is known about the perspectives of breathless people who either are on oxygen or are yet to have it prescribed.

Aim:

To understand and describe the perspectives and experiences of breathless people towards oxygen use at home.

Design:

This qualitative study utilised an interpretive description approach using semi-structured interviews and thematic analysis.

Setting/participants:

A total of 19 people with chronic breathlessness syndrome living in South Australia participated in semi-structured interviews. Participants were divided into sub-groups according to whether they were chronically breathless and (1) not using home oxygen ( n = 6), (2) using funded home oxygen for severe hypoxaemia ( n = 7) and (3) using home oxygen for palliation outside of funding guidelines ( n = 6).

Results:

Three main themes were identified: (1) managing distress and living with chronic breathlessness syndrome, with or without oxygen, requires a range of self-management strategies; (2) expectations of oxygen use: ‘Not as good as I thought it would be’; and (3) the stigma of using oxygen: the visible and invisible.

Conclusion:

People living with chronic breathlessness struggle daily with both the progression of the underlying disease and the distressing nature of the syndrome. While oxygen does provide benefit for some people, its use and the perceptions of its use are often associated with both the visible and invisible manifestations of stigma. Clinicians need to promote self-management strategies and give careful thought to the prescribing of home oxygen, especially outside the current funding guidelines.