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

Specialties Pulmonary

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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.

Specializes in Emergency & Trauma/Adult ICU.
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.)

Amen. :bow:

Not a very helpful post, unless you clarify. Thanks.

Yes sorry, I did'nt have time to clarify.

" 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.... "

I assume by loopy the OP means CO2 narcosis, and yes depending on the gas, ventilatory support may be indicated, but I fail to see how the administration of a bronchodialator or anti-inflammatory would be indicated (unless Pt. is wheezing). Bipap is typically used to foster ventilation, not oxygenation but may be indicated in the hypoxic Pt. BTW - Bipap is a vent, and most machines CAN be used on an intubated Pt. if neccessary.:idea:

Also: Any Pt. on a NC or simple mask at ANY flow rate has an indeterminable Fio2, it will vary with effort, anatomy ect. Usually titrated by pulsox.

The terms "high flow" and low flow" have very specific meanings, a high flow system (like a venturi style entrainment system) is an exact Fio2, while a low flow sysytem (NC, Blow-by, simple mask) has an unknown Fio2. Just a note about Venti masks, lowering the flow rate without changing the entrainment cartridge will raise the Fio2, twice I've had people with good intentions make that mistake. Once was no biggie, but another time was on a heavy duty retainer and 3 hours later he was sufficiently narcotized!

And whoever had the RT walk off the floor with a Pt's HR in the 40's, Ugh, sounds like a crappy therapist to me:uhoh3:

Titrating oxygen with an order is practicing nursing with a license and proudly. I have never thought of 90% sat as being hypoxic and I could not find any definition stating such. I think it depends on the patient's condition and/or ABG.

Remember the SpO2 is not the SaO2. But if the pulse-ox is accurate, 90% is equal to a PaO2 of 60mmHg, which is technically hypoxemia.

As per the oxyhemoglobin dissociation curve.

http://rnceus.com/abgs/abgcurve.html

Specializes in Palliative Care, NICU/NNP.

From NRSKarenRN's link above (post #52) "Annotation B3" :

OBJECTIVE

To encourage the use of a high flow controlled oxygen source in an acute exacerbation of COPD when PaCO2 is suspected to be elevated.

ANNOTATION

An SaO2 of 90 percent is optimal. This usually corresponds to a PaO2 of 55 to 60 mmHg. Pulse oximetry alone may be used in this situation once it is clear that PaCO2 is not elevated and acid-base status is known and stable. Use of a Venturi mask, with analysis of arterial blood gases after 20 minutes (earlier if indicated clinically), is the most judicious approach to the management of acute exacerbation of COPD with oxygen in a patient having an elevated PaCO2. If chronic elevation of PaCO2 is not demonstrated and repeated measurement of acid base status is not a clinical concern, pulse oximetry alone to assess adequacy of oxygenation is acceptable, as is the use of nasal prongs or a cannula to deliver oxygen. However, when CO2 retention exists, or when the acid-base status is unclear, assessment of PaCO2 and pH are required. Use of pulse oximetry alone in this situation is to be avoided.

Specializes in Med/surg,Tele,PACU,ER,ICU,LTAC,HH,Neuro.
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

Not didactic at all.

I don't think the OP was talking about a patient in distress. She was asking about the standards of practice for O2 on a COPD pt.

Was it 2l/M or 4L/m. I was giving my rational as to why it is 2L/M. Don't doubt if their in distress we are upping the o2 and trying anything while the VENT is getting set up.

As far as how frightened you are? If I am a pt dont come into my room.

Several posters have pointed out cranking up the O2 too high is what has killed them not the other way around.:uhoh3:.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
I don't consider this practicing medicine. It's a titratable medication just as much as any other kind.

Don't most people have it written in their orders "O2 @ blank, titrate to keep sats at Blank....?

Not really. But if they did, then the nurse is covered.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
When I read the title of this thread, I immediately thought, "as much as they need".

If they lose their hypoxic drive, then we can correct that. But it's a whole lot harder to correct hypoxia/brain damage/death.

That's it in a nutshell. Six pages of posts and we all seem to be in agreement: oxygenate the hypoxic COPD patient, and any patient in distress, end of discussion.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Originally Posted by Tweety

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.

Titrating oxygen with an order is practicing nursing with a license and proudly. I have never thought of 90% sat as being hypoxic and I could not find any definition stating such. I think it depends on the patient's condition and/or ABG.

Titrating oxygen with an order is indeed a nursing action. That's not what I was referring to. I'm talking about not having an order and blindly, on one's own without consultation with the MD and RT bumping someone's oxygen up.

We have a written protocol where I work that covers the RN up to 2L. Anything below 93% allows us to put the patient on (and titrate off) up to 2L. So less than 93% where I work is considered hypoxic. I'm not there to find their source, but it's an evidenced based protocol. Anything more we need a specific order on the individual patient. Without a specific order we don't mess with the o2 without notifying the MD.

Obviously a patient in distress, you're going to oxygenate.

First - I am not a nurse

second - I have COPD

Most of you guys simply terrify me. You guess at the answers to a critical question or quote what you were told by someone who studied many years ago. A number of you gave a good answer but hardly any gave a simple reference that you could check on-line.

So please check this out - the American Thoracic Journal Guidelines for the Treatment of COPD

http://www.ersnet.org/lrPresentations/copd/files/main/contenu/pages/full_text.pdf and check starting at page 180 through to page 184

If I end up in your hospital, I hope you keep giving me oxygen and worry about my pH level rather than my CO2 level!!

And my apologies for butting in!!

Chris Wigley

First - I am not a nurse

second - I have COPD

If I end up in your hospital, I hope you keep giving me oxygen and worry about my pH level rather than my CO2 level!!

Chris Wigley

Ouch, I'm not even touching that one.

No apology nesseccary, you have every right to be here, I'm not a nurse either. This is a great lesson to us all, your practitioner has clearly failed to explain this awful disease to you. I'm glad to see your doing some research on your own. Thanks for the link, I feel it validates most of our responses.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
First - I am not a nurse

second - I have COPD

Most of you guys simply terrify me. You guess at the answers to a critical question or quote what you were told by someone who studied many years ago. A number of you gave a good answer but hardly any gave a simple reference that you could check on-line.

So please check this out - the American Thoracic Journal Guidelines for the Treatment of COPD

http://www.ersnet.org/lrPresentations/copd/files/main/contenu/pages/full_text.pdf and check starting at page 180 through to page 184

If I end up in your hospital, I hope you keep giving me oxygen and worry about my pH level rather than my CO2 level!!

And my apologies for butting in!!

Chris Wigley

Certainly you can butt in.

Most of us "guys" agreed to oxygenate the patient if you take a 2nd look, in fact that's what the majority said. Not many, if any, of us said not to oxygenate. Karen and a couple of others did give references.

About CO2 levels, they go hand and hand with PH so those of us mentioning high CO2 levels are also going to notice changes in ph on the ABGs as well, that's good old nursing 101 again, so if I'm your nurse, please don't worry. Yes, I will be monitoring your ph as well as your CO2 and oxygenation. The reference you gave, on page 183 the third question in the flow chart is "Hypercapnia?" if the answer is no, then you recheck ABG in a couple of hours and the same question is asked "hypercapnia?"....then we look at the ph afte that acorrding to your reference. 15.4.1.3 of you reference on page 184 addresses hypercapnia concerns.

It seems to me that while we oxygenate CO2 levels are indeed a concern.

A nurse that is only concerned with O2 levels is missing part of the picture if that patient. I've seen C02 retainers get into trouble and it's the prudent nurse who is aware of such things. Maybe it's because I've seen patients with CO2's over 100 that makes me more aware that this can happen in a COPDer.

AGAIN LET ME SAY LEST PEOPLE NOT NOTICE. It's a no-brainer (that we all seem to be in agreement about) that you oxygenate the hypoxic COPD patient.

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