How many liters of O2 can a patient with COPD be on - page 6

by ChristopherH

97,101 Views | 62 Comments

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... Read More


  1. 2
    Quote from ginger58
    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
    NurseBobbyJack and ginger58 like this.
  2. 4
    sharona97, Tweety, leslymill, and 1 other like this.
  3. 1
    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.
    Angie O'Plasty, RN likes this.
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    Quote from ginger58
    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..
  5. 0
    Quote from cardiacRN2006
    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.
  6. 1
    Quote from cardiacRN2006
    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.
    cardiacRN2006 likes this.
  7. 0
    Quote from ginger58
    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.
  8. 5
    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/lrPresentation.../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
  9. 2
    Quote from cwigley
    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.:spin:
    Last edit by PageRespiratory! on Oct 29, '07 : Reason: finger - brain asynchrony
    Angie O'Plasty, RN and Tweety like this.
  10. 3
    Quote from cwigley
    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/lrPresentation.../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.
    Last edit by Tweety on Oct 29, '07


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