FA 7031 Pulse Oximetry to Guide Supplemental Oxygen in COPD - SyR

Conflict of Interest Declaration

The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.

The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest Committee: none applicable.

CoSTR Citation

Macneil F, Williamson F, Lim SH, Cassan P, Berry DC, Birkun A and Singletary E; on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. The use of pulse oximetry to titrate oxygen flow in first aid administered supplementary oxygen in patients with COPD: Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium. International Liaison Committee on Resuscitation (ILCOR), September 2026. Approved by SAC 22 October 2026

Background

The continuous evidence evaluation process to produce this Consensus on Science with Treatment Recommendations (CoSTR) followed the methodological processes described by ILCOR1.

The process began with a First Aid Task Force scoping review of the use of supplementary oxygen in first aid in 20252 which identified the possibility of using pulse oximetry to titrate the flow of supplementary oxygen administration to patients with chronic obstructive pulmonary disease (COPD), including the patients with acute exacerbation of their COPD (AECOPD). Following that review, the Task Force made two Good Practice Statements:

1. When a first aid provider trained in oxygen use administers oxygen for acute difficulty breathing to a person who confirms they have chronic obstructive pulmonary disease, it is suggested to use pulse oximetry and titrate the oxygen to maintain an oxygen saturation between 88 – 92%.
2. Although high flow oxygen should in general be avoided for patients with chronic obstructive pulmonary disease with difficulty breathing in the out-of-hospital setting, it should not be withheld in the presence of life-threatening hypoxia (oxygen saturation <88%).

The Task Force felt that the evidence seen in the scoping review warranted a systematic review of the question of whether pulse oximetry should be used to titrate oxygen flow in first aid supplementary oxygen administration to patients with suspected COPD.

The Task Force acknowledged that first aid treatment of COPD with supplementary oxygen is not possible in low resource settings. However supplementary oxygen is being administered by first aid providers more often in countries with the resources to do this, making the question relevant in this setting. It was expected that the evidence was likely to be indirect for first aid, although the first aid providers with the resources to administer supplementary oxygen are usually “trained” and thus the evidence would be relevant to this group. The Task Force noted that the protocol for a randomised trial has been registered3 but will not close enrolment till 2027 and that a systematic review is needed before this trial is published. The Task Force also acknowledged the Cochrane review in 20204 which commented on the paucity of data. The Task Force sought to broaden the study inclusion criteria to capture relevant observational studies and studies performed in the EMS setting due to the paucity of direct evidence for first aid.

All evidence identified as part of the conduct of this systematic review was considered by the First Aid Task Force and is described below. Discussion points and highlights of the evidence-to-decision process are also included. All data were considered when formulating the Treatment Recommendations. Data tables and the Evidence-to-Decision framework are provided as attachments. The task force acknowledges Dr David Majewski for statistical analysis and preparation of forest plots.

Review Citation

Macneil F, Williamson F, Lim SH, Cassan P, Djarv T, Berry DC, Birkun A and Singletary E, on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. The use of pulse oximetry to titrate oxygen flow in first aid administered supplementary oxygen in patients with COPD: a systematic review (in draft)

PICOST

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

Population:  Adults with known or suspected chronic obstructive pulmonary disease receiving supplementary oxygen in the out-of-hospital setting by first aid providers

Intervention: Pulse oximetry used to titrate oxygen delivery

Comparators:  No pulse oximetry with oxygen delivery

Outcomes: Survival, length of stay in hospital, rate of admission to ICU, rate of use of ventilatory support

Study Designs: Randomised controlled trials (RCTs), non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies with more than 50 patients enrolled). Letters to editor with more than 50 patients. All relevant publications in any language are included as long as there is an English abstract.

Timeframe:  All years

Registration: PROSPERO Registration CRD4200251160501

Consensus On Science

A total of 462 unique references were identified in the databases. A total of 30 references were identified for full text screening, and a further two found with manual searching of the reference lists of the included studies.
We did not identify any studies on the use of pulse oximetry to titrate supplementary oxygen in first aid for patients with COPD. Therefore, we included indirect evidence from three studies investigating the use of pulse oximetry to titrate supplementary oxygen in EMS transport of patients with COPD: one cluster-RCT5 and two observational before-and-after studies.6,7

The cluster-RCT5 randomised ambulance crews transporting patients with a history of COPD to use pulse oximetry to titrate the flow of supplementary oxygen to achieve oxygen saturations of 88-92% or to continue to use high flow oxygen.
The observational studies were retrospective register6 and audit studies7 respectively of patients transported to hospital with suspected or known COPD and given oxygen therapy during transport before and after introduction of titration of oxygen with pulse oximetry to achieve oxygen saturations of 88 – 92%. One observational study6 reported on all 707 patients with suspected COPD as well as 188 patients later confirmed to have COPD as the primary final diagnosis. A second one 7 only reported on the 211 patients with a primary final diagnosis of COPD.

For the critical outcome of survival, we identified low-certainty evidence (downgraded for serious risk of bias and indirectness) from one cluster randomised trial5 of the use of pulse oximetry to titrate oxygen flow to achieve oxygen saturations of 88-92% in patients with a history of COPD, showing higher survival in the titrated oxygen therapy group compared to the high-flow oxygen group (Odds Ratio (OR) 2.52, 95%CI 1.1-6.1, P= 0.02). This beneficial effect was more pronounced in the subgroup of people subsequently confirmed to have AECOPD (OR 4.9, 95%CI 1.1-22.8, P= 0.04). A single observational study6 provided very low-certainty evidence (downgraded for critical risk of bias, indirectness and imprecision) showing a nonsignificant trend for higher survival in all patients with suspected COPD who received oxygen titrated by pulse oximetry to an SpO2 of 88 – 92% (OR, 1.24; 95% CI, 0.74 - 2.10; P = NS). A single observational study6 showed an improved survival with an OR of 5.13 (1.79 – 14.69) in patients with confirmed COPD who received oxygen titrated by pulse oximetry to an SpO2 of 88 – 92%. The meta-analysis of the two observational studies reporting survival for people with AECOPD (i.e. people transported to hospital with supplementary oxygen administration and a confirmed (primary) diagnosis of COPD)6,7 showed a nonsignificant trend to higher survival with titrated oxygen (pooled OR 2.28, 95%CI 0.51 – 10.25, P = NS). This analysis was not statistically significant probably due to the heterogeneity between the included studies with a Cochran’s Q score of 5.31 for just two studies. For the important outcomes of use of ventilatory support and length of hospital stay, there was no benefit to the use of pulse oximetry to titrate the oxygen flow for patients with suspected COPD in the single RCT5, both for all patients and the patients with AECOPD. There was no benefit found with the use of pulse oximetry to titrate the oxygen flow for patients with suspected COPD in the one observational study6 for the important outcomes of ventilation, admission to intensive care and length of stay for all patients and for patients with AECOPD. There was no benefit found with the use of pulse oximetry to titrate the oxygen flow for patients with AECOPD in a second observational study7 for the important outcome of assisted ventilation.

Treatment Recommendation or Good Practice Statement

We suggest the use of pulse oximetry, compared with no pulse oximetry, to titrate the flow of supplementary oxygen administered by those trained in the use of supplementary oxygen in first aid to persons with known or suspected COPD (conditional recommendation, low-certainty of evidence).

Technical Remark: Supplementary oxygen was titrated in the included studies to target a pulse oximetry reading between 88 and 92%.

This recommendation replaces the both of the 2025 Good Practice Statements2, i.e.:

1. When a first aid provider trained in oxygen use administers oxygen for acute difficulty breathing to a person who confirms they have chronic obstructive pulmonary disease it is suggested to use pulse oximetry and titrate the oxygen to maintain an oxygen saturation between 88 – 92% compared to no use of pulse oximetry to control the flow of oxygen.
2. Although high flow oxygen should in general be avoided for patients with chronic obstructive pulmonary disease with difficulty breathing in the out-of-hospital setting, it should not be withheld in the presence of life-threatening hypoxia (oxygen saturation <88%).

Justification and Evidence to Decision Framework Highlights

• First aid training organisations in some countries are increasingly providing training in the administration of supplementary oxygen in first aid courses. In a person with known or suspected COPD who is having an acute exacerbation, sustained high-concentration oxygen without titration can cause harm by increasing arterial CO₂, worsening respiratory acidosis, and contributing to respiratory failure. An ILCOR scoping review in 2025 identified studies of the effect of titrating the oxygen flow to achieve saturations of 88 – 92% on pulse oximetry. Preventing avoidable harm from excessive oxygen is a priority when oxygen is already being administered. The AHA/Red Cross first aid guideline identifies oxygen administration resulting in saturation above 92% in known COPD as potentially harmful8.

• WHO estimates that COPD caused 3.4 million deaths worldwide in 2023.9 COPD exacerbations represent a substantial EMS workload, and excess oxygen exposure has been documented among ambulance-treated patients. However, the global number transported with hypercapnic respiratory failure, and the global burden of harm attributable to untitrated oxygen, has not been reliably quantified. The Task Force felt that guidance on this question was needed given the evidence available.

• The intention to treat all patients with possible/suspected/confirmed COPD is more aligned with the capability of first aid providers than the a priori group of the patients with proven AECOPD. In the group of all COPD patients, there was a survival benefit seen in the single RCT5 of the effect of titrated oxygen in the EMS out of hospital setting. This effect was more pronounced in the group with confirmed AECOPD suggesting a benefit to this group amongst the patients with suspected COPD. This benefit was also seen in the one observational study of use of pulse oximetry to titrate the flow of oxygen to patients with suspected COPD6, although the confidence interval overlaps the null effect. All included studies show an OR >1.

This benefit to titrating oxygen flow in patients with COPD to saturations of 88 – 92% is also seen in other health settings such as the benefit of air vs oxygen driven nebulisers10 and the GOLD report11 on COPD, reinforcing the decision to make this Treatment Recommendation.

• The search looked for all studies using pulse oximetry to titrate oxygen flow in supplementary oxygen administration to persons with known or suspected COPD in the prehospital setting. The only studies identified in the search titrated the flow to target pulse oximetry readings of 88 – 92%’.

• All included studies suggest a survival benefit to titrated oxygen although the observational studies confidence intervals overlap the null effect. In comparison the RCT5 had a higher certainty of evidence and showed a clear benefit. The observations in the Durrington study7 were collected in 2002 and 2003 when the technology of the pulse oximeters was different from that in current use and 51% of the patients in this study were receiving “low concentration oxygen therapy” in the initial “high concentration” period and this only increased to 75% in the “low concentration” period. Thus, the effect of the introduction of “low concentration” oxygen and titration to SpO2 of 88 – 92% may have been diluted compared to a study of 0 to 100% per protocol. The Task Force felt that the treatment recommendation should be made based on the benefit demonstrated in the other 2 included studies and the OR of the Durrington paper7 still favouring a benefit as well.

• It should be noted that the pulse oximeters used by first aid providers are typically consumer grade devices and less accurate than the devices used in EMS or hospitals, but this does not negate the likely benefits of titrating oxygen flow to patients with suspected or known COPD. An ILCOR scoping review in 2023 and subsequent evidence update in 2025 of the first aid use of oximeters found insufficient evidence to recommend a systematic review to advise for or against their use in first aid12, but the indirect evidence in the current review suggests a benefit in this specific setting. It should also be noted that this scoping review made the following recommendations:

• First aid providers who use pulse oximeters for the assessment of acute illness or injuries should be proficient in their use and understand their limitations, including equipment factors, environmental considerations, and patient-specific factors that may produce inaccurate and unreliable readings.

• The use of a pulse oximeter for first aid assessment should not supersede or replace physical assessment

• Pulse oximetry and training in its use is acceptable in the settings that afford the oxygen administration. The AHA/American Red Cross already supports pulse oximetry as part of a complete first aid assessment (Hewett Brumberg 2024, section 5.4). BTS recommends an 88–92% target in most known COPD pending blood gases (O’Driscoll 2017, recommendation A3). Guideline endorsement is not direct stakeholder acceptability evidence. However, this advice is not universal even within International Red Cross and other first aid training authorities.

• The limitations related to the accuracy of pulse oximetry include the effect of SpO2 underestimation associated with states of low peripheral perfusion, skin thickness or low skin temperature, nail polish or tattoos, anaemic hypoxia, or high-altitude conditions (low barometric pressure, e.g. during flight); SpO2 overestimation due to skin pigmentation, hemoglobinopathies, high skin temperature, or smoking; as well as photoplethysmography signal distortion caused by motion artifacts, incorrect sensor placement, light contamination, electromagnetic interference, and irregular cardiac rhythms 13.

• The task force noted that provision of supplementary oxygen in the first aid setting is a relativel expensive option and may limit resources available for other care in the same setting as well as increasing disparity in equity in some countries. However, the cost of supplementary oxygen supply has been reducing. Also, emergency oxygen courses are offered in several countries, particularly for response to diving injuries, lifeguards, and first responders. Whilst resource requirements include not just the equipment, but the training needed for use of titrated oxygen, supplementary oxygen is becoming more accessible.

Two methods of delivering supplementary oxygen are relatively commonly available, portable oxygen concentrators (starting at USD1,000) and refillable bottles (generally size D containing 350-400 L of oxygen). The latter start at USD100 but have the added expense of regular refilling. In the USA, the cheapest initial cost of hardware needed for titrated oxygen delivery is estimated at USD100 before oxygen filling (data from internet prices), although most devices cost USD2,500 – 3,500.

The cost includes adjustable oxygen regulator and disposable adult nasal cannula, but does not include a secure carrying setup, spare supplies, taxes, and training. The incremental cost of suitable oximeter, training, cleaning, batteries, maintenance, documentation, and quality assurance is not included here. Establishing an entirely new oxygen service adds cylinders or concentrators, regulators, refills, storage, and staffing as well.

The fingertip oximeter is much cheaper starting at USD12 for the cheap devices and up to USD149 for a high-end consumer device with an alarm. The cost in Canada is similar to the USA when converted to USD. In France the costs are similar, but many first aid providers hire the equipment rather than purchase outright. Pulse oximeters cost €20 – 30. These devices are even cheaper in Russia, where most pulse oximeters cost <RUB1,000.

The task force noted that the additional cost of pulse oximeters and training was relatively small where supplementary oxygen was already in use.

The task force noted that the retail equipment prices do not constitute a cost benefit analysis

• Titrating oxygen flow to achieve saturations of 88-92% will prevent concerning hypoxia in patients with and without COPD. The Task Force also re-iterated the Good Practice Statement (GPS) that although high flow oxygen should in general be avoided for patients with chronic obstructive pulmonary disease with difficulty breathing in the out-of-hospital setting, it should not be withheld in the presence of life-threatening hypoxia (oxygen saturation <88%). This statement follows GRADE guidance for GPSs grounded in ethics and human rights.

• It should also be noted that supplementary oxygen is not indicated for patients with known or suspected COPD and oxygen saturations of >92%11.

Knowledge Gaps

• First aid providers’ ability to recognise the possibility of COPD and AECOPD

• The accuracy of pulse oximetry in use by first aid providers

• Can first aid providers appropriately interpret pulse oximeter readings?

• The ability of first aid providers to titrate oxygen flow based on oximetry readings

Evidence to Decision Table (EtD)

FA 7031 EtD Pulse Oximetry to Guide Supplemental Oxygen in COPD_October2026

References

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