A response to ‘Routine pre‐oxygenation – a new “minimum standard” of care?’

It is difficult to decide which aspect of Dr Bell’s editorial [1] on pre-oxygenation is more irritating, the almost impenetrable syntax or the sentiments expressed. A number of increasingly ludicrous scenarios are discussed, e.g. if a patient refused to co-operate in pre-oxygenation with a trainee, the patient should be counselled, the case should default to a consultant and a critical incident form be submitted. The conclusion seems to be that routine pre-oxygenation offers identifiable safety benefits and could be recommended to the profession. Furthermore ‘It will be interesting to observe...how those practitioners who argue against or ignore any recommendations might be managed’. As I count myself in this latter category and have no wish to be ‘managed’ by those who think like Dr Bell, may I be permitted a few observations? The editorial adduces no evidence in support of ‘identifiable safety benefits’ in otherwise fit patients. Many years ago in my final fellowship, I was asked by Prof. Alistair Spence what were the benefits of giving oxygen in recovery. He countered all my suggestions such as diffusion hypoxia and I have pondered the question for the next 27 years. I have concluded that the only benefit is that the condensation on the clear mask enables the staff to see that the patient is breathing. Adding oxygen only delays recognition of hypoventilation and we had an example of this at our most recent audit meeting. I fear that routine pre-oxygenation of fit patients will also delay recognition of problems, though now that we have CO2 monitoring in all anaesthetic rooms this is less likely than it was in the past. I am all for pre-oxygenating patients that need it such as emergency GA sections, but I think that giving oxygen by a tight fitting face mask for four time constants to a fit day case gynae patient is neither sensible nor supported by evidence.