Statements on the Use of Oxygen by Lifesavers

All drowning victims can be in respiratory distress due to hypoxia as a result of asphyxia or pulmonary damage. Immediate oxygen therapy can be life saving.

During mouth-to-mouth ventilation, the expired air from the rescuer consists of 16-18% oxygen. With oxygen treatment, between 21 and 100% oxygen is given. A higher concentration of oxygen will increase the delivery of oxygen to the cells, if ventilation and circulation are effective. Several modalities exist to deliver oxygen to spontaneously breathing victims and to victims in respiratory arrest exist (see table).

The technique of oxygen delivery is likely to be more difficult to learn than Basic Life Support, because of the complex psychometric skills in combination with technical conductance of the equipment which is needed for the delivery of oxygen (oxygen cylinder, pressure regulator, flow meter, oxygen delivery devices as bag or mask). With respect to the education in the use of oxygen, no data are available about the instruction time, the retention time, and the performance in real situations.

Experiences in several countries however show good experiences with the use of oxygen when the lifesaver has received good theoretical and practical training on a regular basis and when on-site supervision is available.

An important element in the appreciation of oxygen delivery devices is the interval between start of BLS by lifesavers and the arrival of a medical team with professional skills in oxygen supply. If this interval is short, the additional value of oxygen delivery by non-medical professionals or lay persons is highly questionable.

Finally, in most countries, strict regulations on the use of oxygen are defined with respect to responsibilities, both for the equipment and the practical performance. These legal aspects have to be considered.

Conclusions

1. The physiological concept of the benefit of providing oxygen to spontaneously breathing drowning victims or during CPR in drowning victims with in respiratory arrest is clear and advocates that oxygen should be used in all drowning victims. The use of oxygen may also benefit other victims, but this is out of the scope of this recommendation.
2. Lifesavers should be aware that mouth-to-mouth ventilation can be provided by a trained person at all places since no specific equipment is needed. CPR without oxygen is always good and absence of oxygen equipment should not defer the rescuer from taking the most appropriate steps.
3. Several organisations use oxygen and oxygen delivery equipment and are satisfied about the availability. In general, two lifesavers are needed to deliver oxygen.
4. The profit to deliver immediate oxygen by lifesavers and not to wait until professional medical person with oxygen equipment are available will depend on the time factor (delay), the maintenance and management of the equipment and the accuracy of the persons who have to give the oxygen treatment.
5. Educational, technical, logistical, juridical and financial aspects have to be considered before a decision is made if and when lifeguards should use oxygen and which equipment should be used.
6. There is a large variation of oxygen delivery equipment. Most equipment can be used in limited but well defined circumstances.
7. The following categorisation with respect to the use of oxygen by non-medical professionals or lay-persons is proposed:
   • Oxygen in spontaneously breathing victims using non-rebreathing masks: CLASS 2A.
   • Oxygen during CPR using facemasks: CLASS 2B.
   • Oxygen during CPR using automatic ventilators: CLASS 2B.

   (According to the American Heart Association Class 2 means "weight of evidence in favour of efficacy and safety and it is probably not harmful". 2A: "Therapeutic option for which the weight of evidence is in favour of its usefulness and efficacy" 2B: "Therapeutic option that is not well established by evidence but may be helpful and probably not harmful").

Recommendations

1. Lifesavers should be allowed to provide oxygen to drowning victims when the responsible organisation has regulations for a selection procedure (to identify the lifeguards with sufficient knowledge, mental strength and dedication to be able to apply for an oxygen delivery course), formal theoretical and practical training courses, an instruction manual, exams, regular refresher courses and a regional or national person responsible for the presence and use of the oxygen equipment. The legal aspects should be regulated.
2. From a practical and educational point of view, the equipment should be simple, unambiguous, reliable, and simple to assemble. This means standardisation. A minimum of variety in oxygen delivery equipment should be available at local, regional and national level. From the available equipment we recommend a non-rebreathing mask with a fixed flow of 15 litres of oxygen per minute for spontaneously breathing victims and a transparent mask with oxygen inlet for patients in ventilatory arrest. The oxygen container should be large enough to allow oxygen delivery until professional medical personnel has reached the scene of injury.
3. An attempt should be made to make a cost-benefit analysis and consider alternative destinations of the money to spend (such as prevention campaigns, improvement of communication devices).
4. Responsibility, quality assurance and jurisdiction should be defined at a local, regional and national level. A responsible person should be in charge of the quality assurance. Quality assurance also includes the regular control of equipment and level of performance. A formal report about each time that the oxygen equipment is used, could be an important element in quality assurance. Ideally, the lifeguard who has given oxygen to a victim should be evaluated after an intervention. The use of oxygen should be reported yearly.