FA 7030 Use of Supplementary Oxygen in First Aid: FA ScR

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The Task Force members report no conflicts of interest.

Task Force Synthesis Citation

Macneil F, Chang WT, Orkin A, Djarv T, Singletary E and Carlson J on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.

Use of Supplementary Oxygen in First Aid. First Aid Task Force Synthesis of a Scoping Review Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2022 November 24, 2022. Available from:

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a 2015 systematic review of the use of supplementary oxygen by first aid providers conducted by the ILCOR First Aid Task Force. As this topic has not been updated in the interim, a scoping review of the use of supplementary oxygen by first aid providers was conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered by the First Aid Task Force.

Scoping Review

Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children who exhibit symptoms or signs of shortness of breath, difficulty breathing or hypoxia outside of a hospital

Intervention: Administration of oxygen by a first aid provider

Comparators: No administration of oxygen

Outcomes: Functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, length of hospital stay, resolution of symptoms or signs, patient comfort, therapeutic endpoints (e.g., oxygenation, ventilation)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), case series and reports are eligible for inclusion. Grey literature, social media, non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols are eligible for inclusion. Only English language is included.

Timeframe: January 2000 to July 2022

FA 7030 Search Strategies Attached

FA 7030 Search Strategies

FA 7030 PRISMA diagram AttachedFA 7030 PRISMA

FA 7030 Data tables attached FA 7030 tables

Task Force Insights

1. Why this topic was reviewed.

  • The ILCOR First Aid task force elected by consensus in 2022 to undertake a scoping review on the use of oxygen in first aid in 2022.
  • The Task Force noted the systematic review in 2015 on the same question, with a search last conducted in November 2014.
  • The Task Force wished to determine whether there have been publications in the intervening years relevant to the question.
  • Recent systematic reviews on the use of oxygen in the management of suspected heart attack {Nikolaou 2015 e121} and ROSC post resuscitation of sudden cardiac arrest {Wyckoff 2022 e645] have found evidence of harm with administration of oxygen. There are a number of conditions where oxygen is still recommended, such as following carbon monoxide poisoning, drowning and resuscitation of divers who have used compressed gas.
  • First Aid provider organizations are increasingly training and equipping their members to give supplementary oxygen, hence there is a need-to-know what benefits and harms are associated with the use of supplementary oxygen in the first aid setting.

2. Narrative summary of evidence identified

  • This scoping review did not identify any articles directly addressing the PICOST.
  • This search did not identify the papers identified in the ILCOR CoSTR of 2015 {Zideman 2015 e225] because all but one of those papers related to the use of supplementary oxygen palliative care initiated by medical officers and one was an audit of patients treated by EMS.
  • The papers identified related to the use of high flow vs titrated supplementary oxygen in out of hospital patients with suspected, proven or acute exacerbation of chronic obstructive pulmonary disease (COPD) ie moderate heterogeneity of the patient population.
  • One paper {Austin 2006 Cd005534} was a Cochrane review of EMS use of high flow oxygen vs titrated oxygen which found no published papers directly related to the question but noted that two studies were underway.
  • One paper {Wijesinghe 2011 618} was a retrospective study which found increased oxygen flow was associated with increased risk of death, assisted ventilation, or respiratory failure with an OR of 1.2 (95% CI 1.0-1.4) per 1 L/min increase in oxygen flow. Increasing PaO2 was associated with a greater risk of poor outcome with an OR of 1.1 (95% CI 1.0-1.3) per 10 mmHg higher PaO2.
  • One paper {Austin 2010 c5462} described a cluster randomized trial of high flow vs titrated oxygen (saturations 88-92%) by EMS on mortality rate in COPD which found a RR of 4.5 in AECOPD.
  • One paper {Cameron 2012 684} was a retrospective study which compared mortality between PaO2 on ABG within 4 hours of arrival of <88%, 88-96% and >96% in patients brought to hospital by EMS and found a hazard ratio of 9 for saturation >96% and 2 for saturations <88%.
  • One paper {Lumholdt 2017 A8} reported a retrospective study of the oxygen saturation of 111 patients with respiratory conditions brought to ED by EMS and found to have acidosis and CO2 retention. They found the 11 patients with CO2 retention had a mean oxygen saturation of 84% on presentation to EMS and 95% on arrival in ED. They inferred this was due to excessive oxygen administration before arrival in hospital.
  • One paper {Bentsen 2020 76} was a retrospective study of 30-day mortality of 707 patients with COPD brought to hospital with either high flow or oxygen titrated to saturations of 88-92%. They found a RR of 4 for 30-day mortality for high flow oxygen in 178 with acute exacerbation of COPD, but no significant difference in the whole group with COPD They noted differences from Austin et al due to different patient groups.
  • The last included paper {Barnett 2022 262} is the Australia and New Zealand Thoracic Society Guidelines for oxygen administration. This is based on a "targeted literature review." The key recommendations relevant to the current PICOST are: assess oxygenation, oxygen requires prescription and to set oxygen saturation targets of 88-92% for potential hypercapnia, 92-96% for others.

3. Narrative Reporting of the Task Force Discussions

  • There is no direct evidence to suggest or suggest against routine administration of oxygen in adults or children exhibiting signs or symptoms of shortness of breath, difficulty breathing, or hypoxia outside of a hospital.
  • If first aid providers (who are trained to use oxygen) are administering supplementary oxygen to a person with known COPD, they should titrate the supplementary oxygen to maintain an oxygen saturation to between 88 and 92%.
  • All the evidence in the 2015 review {Zideman 2015 e225} was indirect and mostly related to the use of oxygen in patients in palliative care, but was the most applicable. The current review has yielded evidence that supplementary oxygen is harmful in patients with acute exacerbations of chronic obstructive pulmonary disease in the setting of EMS and needs to be titrated to the patient’s oxygen saturation. The evidence of harm is a higher mortality rate if high flow oxygen rather than oxygen flow titrated to produce saturations of 88-92%.
  • The search did not reveal evidence of benefit of supplementary oxygen in the first aid setting; this may be because this question, oxygen vs none, has not been asked. This review specifically excluded the use of supplementary oxygen in acute coronary syndrome {Nikolaou 2015 e121}, suspected stroke {Singletary 2020 S284}, drowning {Bierens 2021 205} and after return of spontaneous circulation following cardiac arrest{Wyckroff 2022 e645} because these indications have been covered in recent reviews.
  • We excluded highly specialized physiological circumstances with respect to the use of oxygen, including but not limited to the use of compressed gas in diving (eg: SCUBA) and carbon monoxide poisoning. These circumstances were excluded because first aid practices and providers in these contexts are more specialized and the use of oxygen in these conditions should not be determined by more general first aid practices.
  • This has major implications for first aid providers given the CoSTR in 2015 permitted the use of oxygen in patients displaying symptoms of hypoxia or shock. It would seem prudent to urge caution when there is a possibility of COPD in guidelines concerning administration of oxygen by first aid providers and possibly that supplementary oxygen should only be given to achieve a target saturation of 88-92%, but we acknowledge that recognition of COPD and possibly the use of pulse oximetry may be beyond the skill set of first aid. However, some organizations teaching advanced first aid or first aid oxygen courses to lay responders do include teaching on the use of pulse oximetry (e.g., St John Ambulance Australia), so there may be circumstances where the supplementary administration of oxygen by first aid providers is common practice. It should also be noted that the use of pulse oximetry by first aid providers is the subject of a separate search by the First Aid Task Force.
  • The First Aid Task Force agreed that there was insufficient evidence to pursue a systematic review of first aid oxygen use for symptoms or signs of shortness of breath, difficulty breathing, or hypoxia not related to stroke, acute coronary syndrome/chest pain, carbon monoxide poisoning and/or diving emergencies.

Knowledge Gaps

  • Does administration of oxygen in the out of hospital setting improve survival in patients presenting with shortness of breath or hypoxemia other than the specialist indications such as carbon monoxide poisoning or divers who have used compressed gas?
  • Does administration of different concentrations of oxygen outside of a hospital in specialized group of patients (e.g., COPD with acute exacerbation or acute asthma) have different outcomes?
  • Can first aid providers distinguish COPD?
  • Can first aid providers use pulse oximetry accurately to target oxygen administration to 88-92%?


Austin M, Wood-Baker R, Oxygen therapy in the pre-hospital setting for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006(3); Cd005534.

Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. High flow oxygen increases mortality in COPD patients in a pre-hospital setting: A RCT. BMJ. 2010; 341: c5462

Barnett A, Beasley R, Buchan C, Chien J, Farah CS et al. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology, 2022; 27(4): 262-276.

Bentsen LP, Lassen AT, Titlestad IL, Brabrand M A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study. Acute Med. 2020; 19(2): 76-82

Bierens J, Abelairas-Gomz C, Barcala Fuerelos R, Beeman S, Claesson A et al. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021. 162: 205-17

Cameron L, Pilcher J, Weatherall M, Beasley R, Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgrad Med J. 2012; 88(1046): 684-9

Lumholdt M, Cresiolo E, Monti A, Sorensen LR, Damgaard K, Pre-hospital oxygen therapy and CO2 retention in patients admitted through the emergency department. BMJ Open. 2017; 7(Supplement 3): A8

Nikolaou NI, Welsford M, Beygui F, Bossaert L, Ghaemmaghami C et al. Part 5: Acute coronary syndromes 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Resuscitation. 2015; 95: e121-e146.

Singletary EM, Zideman D, Bendall JC, Berry DC, Borra V et al. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2020; 142(16_suppl_1): S284-s334

Wijesinghe M, Perrin K, Healy B, Hart K, Clay J et al. Pre-hospital oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Intern Med J. 2011; 41(8): 618-22.

Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, et al, 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.Circulation. 2022; 145(9): e645-e721.

Zideman DA, Singletary EM, De Buck ED, Chang W-T, Jensen JL et al., European Resuscitation Council Guidelines for Resuscitation 2015 Section 9. First aid. Resuscitation. 2015; 95:

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