How many liters of O2 can a patient with COPD be on?

[ChristopherH]

I recall being told by an instructor during my nursing clinicals that a patient can be on up to 4L of O2 but no more due to the retention of CO2 and loss of respiratory drive if they have COPD. A colleague of mine today told me that she was told that it shouldn't go over 2 Liters however. What is the correct answer, or is it one of those things that is more individualized to meet the needs of the specific patient? Also if anybody has any good sources or links to studies for this info it would be a bonus.

[BBFRN, BSN, PhD]

CPAP also does the trick at times in these cases.

I would bump up the O2 if I had to wait for a CPAP to come up, though. The first thing I would tell COPD'ers and their families would be to bring in their own CPAP at any rate.

[Tweety, BSN, RN]

I find your postings on this subject very didactic and not based on current practice. Nursing isn't set in stone and by the time you take consulting with others, cranking the O2 up by 0.5 lpm, your patient could be dead. I find this practice very frightening

I find nurses who practice medicine without a license and arbitrarily bump up patients oxygen a bit frigthening as well. As I've said, I've seen outcomes when a patient is tolerating being 90% (which by definition is hypoxic) and the nurse cranks it up only to obtund then with a CO2 past 100.

Again, it's common sense that if a patient is actively in distress, or critically hypoxic, you oxygenate without dillydallying around.

Other than that the NP Act in Florida says an RN can only prescribe 2L. I think collorbation is very much the current standard of practice, at least it is with me.

[Altra, BSN, RN]

I find nurses who practice medicine without a license and arbitrarily bump up patients oxygen a bit frigthening as well. As I've said, I've seen outcomes when a patient is tolerating being 90% (which by definition is hypoxic) and the nurse cranks it up only to obtund then with a CO2 past 100.

Again, it's common sense that if a patient is actively in distress, or critically hypoxic, you oxygenate without dillydallying around.

Other than that the NP Act in Florida says an RN can only prescribe 2L. I think collorbation is very much the current standard of practice, at least it is with me.

Tweety, you raise an important point. This question has been debated in previous allnurses.com threads.

There are 2 scenarios here ...

1) The COPDer who does indeed tolerate SpO2 of 88-90% or so ... at rest and at baseline. Absolutely these patients should be on the minimum of O2 necessary to continue to be asymptomatic per their baseline. I was once a clueless student who on day 1 of hospital clinicals tracked down my RN because the patient's SpO2 was 91%. I was given an *enthusiastic* refresher lesson on the COPD disease process ...

2) The other scenario is some respiratory distress, or even a chronic COPDer who has now deviated from baseline d/t fever, pain, exertion, etc. There are posters here at allnurses.com who firmly insist that even in this scenario they would not turn up O2 or would only titrate it in tiny increments. As I now spend time on an ambulance working towards being a pre-hospital RN, I have arrived at LTC facilities to find patients nearly thrashing in bed, cyanotic ... and on a whopping 3L of O2.

These nurses do indeed frighten me.

[Tweety, BSN, RN]

Thanks MLOS, I think we're in agreement here. It is indeed frightening how uneducated we can be in this matter.

[discobunni]

I was just discussing this with a very experienced RT yesterday. He told me that if you know you are getting close to knocking out their respiratory drive to breathe if their O2 sats do not change despite increase in upping the O2. He said this is a very rare occurance, but you have to be especially careful with COPDers that have had the disease for several years.

[ready4crna?]

May I interject with some physiology here- Central respiratory receptors are what everyone is worried about when talking about copder's and oxygen. These receptors are less sensitive to changes in CO2 as disease progresses, thus "hypoxic drive" peripheral receptors take over respiratory stimulus over extended disease progression. Everyone agrees on this, No?

Everyone can also agree that oxygen is a neccessary molecule for life maintenence, no?

Now, as obstructive disease progresses the body "tolerates" lower Spo2's due to a shift to the right (increased CO2) of the dissociation curve which effectively allows for better tissue extraction of O2 from Hgb. This does have it's limits though, as oxygen does have to be initially available for extraction.

SO... a compromise for all views as follows:

First rule of health care:Increase your FiO2 as high as you want for any patient exhibiting Hypoxia (Circumoral cyanosis, SpO2

Second rule:Be aware that when you do this you are responsible for monitoring the patients response to the therapy. For those of us in outpatient settings, this may mean calling 911.(Nursing 101)

Third rule: If rule 1 patient happens to be a COPD person, continue to kick and scream up the chain of command until someone intervenes for and fixes whatever is causing said decompensatory need for increased FiO2, but do NOT deny the patient oxygen. (People can be intubated and mechanically ventilated if they lose their respiratory drive, but it is real hard to raise the dead. Not impossible, just reeeaaaalll hard.)

[laurelkimberly]

In order to answer this question the type of O2 therapy being implemented should give you that answer. For example from the Fundamentals of Nursing, Craven text 5th edition, p. 855 outlines the device and the % of O2 capability. For ex: with the nasal cannula device the O2 capacity is 22% - 44% when operated at 1 -6L/min with an emphasis that O2 concentration varyies depending on the patients breathing pattern. With the simple mask device (40% - 60% when operated at 6 -10L/min) it is suggested that this route not be used in a COPD patient because of potential for excessive oxygenation. This was a long winded response... goes hand and hand being a first year nursing student. I hope I am on the right track in answering this question.

[dbihl, BSN, RN]

if you got a COPD'er on more than 2-3 liters, you better be assessing them for mental status changes. IF they are sleeping, wake em up and really check em for loopiness, if they are gettin loopy, you need ABG's, Bipap, or a vent, also some breathing treatments, steroids, etc....

[dbihl, BSN, RN]

because we all *know* high flow O2+Copd, can cause increase CO2 retention, which = loopiness (mental status changes). which = ABG time, get the CO2 down to WNL before the pH drops to incompatibility with life.

[BBFRN, BSN, PhD]

I find nurses who practice medicine without a license and arbitrarily bump up patients oxygen a bit frigthening as well. As I've said, I've seen outcomes when a patient is tolerating being 90% (which by definition is hypoxic) and the nurse cranks it up only to obtund then with a CO2 past 100.

Again, it's common sense that if a patient is actively in distress, or critically hypoxic, you oxygenate without dillydallying around.

Other than that the NP Act in Florida says an RN can only prescribe 2L. I think collorbation is very much the current standard of practice, at least it is with me.

Very good post- especially the part about the COPD'er tolerating sats at 90%. Lots of COPD'ers stay in that range.

[leslie :-D]

interesting that you can read a lot of literature amongst the specialists, about o2 levels.

most do support giving more oxygen but there are a handful that do not.

my take on it?

forget the numbers and your didactics, and crank that baby up!

monitor your patient and not the machine!

until they get medically stabilized, you give them the max.

long-term, hi-flo will kill them.

but in a crisis situation, 3 lpm will also kill them.

if they are gasping for air, then GIVE THEM THE AIR.

yes...common sense.

leslie

[FireStarterRN, BSN, RN]

One thing I will always do is coach the patient on breathing. I will tell them to concentrate on a long exhalation, reminding them that their main problem is getting old air out so they can get the new air in. I'll demonstrate and breathe with them, telling them that their exhalation should be twice as long as their inhalation. It really helps to remind them of this and they always appreciate it.

I'm alway surprised how many COPDers have never been instructed in purse lipped breathing....