COPD 96% on RA hypoxic?

[NorthernNurse BSN,RN]

Hello everyone! I am a new grad just off orientation and had a question about a situation I had at work a week ago.

My COPD patient told me they were feeling short of breath, so I sat them up and did some coughing and deep breathing exercises with them and they stated they felt better. The whole time their O2 sat was at 96%. I asked if they ever use oxygen at home and they said no, only sometimes at night. They had a scheduled RT session in 30 minutes so I found the RT and asked him to see my patient sooner rather than later. Fifteen minutes later, the nurse orienting me went into the room and put the patient on 4 L NC of O2 because they said they were feeling short of breath again, O2 sat still at 96%. Then, he called me to the room and in front of the patient told me my interventions were not enough, the patient is very hypoxic and needed to be placed on O2 earlier when they were complaining of SOB.

Obviously, I'm very new to nursing and I'm concerned that some of my clinical judgment stems from information I learned in nursing school that simply doesn't apply to all situations. Anyways, my question is can a patient be hypoxic at 96%? Does hypoxia stem from them verbalizing they're SOB or a measurable finding like O2 sat of 96%? I clearly made the wrong choice, and I think that patient lost some faith in me and then started questioning everything I did and asking to speak to the "real nurse" haha! Yes, I need to speak to the "real nurse" too! I'm nervous to be off of orientation... Thanks in advance for any advice you have for me!

[KatieMI, BSN, MSN, RN]

I asked if they ever use oxygen at home and they said no, only sometimes at night

First, re. this:

- do you have diabetes?

- no

- why do you take insulin?

- it's for my SUGAR!

If patient needs additional oxygen, he is on it. Whatever the circumstances, whatever he said.

Now about the subject. SaO2 of 96% is, by different sources, either low normal or mild hypoxemia (NOT "hypoxia", which is tissue-level partial oxygen pressure; "hypoxemia" is oxygen bound with Hb which is still in blood, and that's what SaO2 sensor measures). In patients with COPD, the most important cause of hypoxemia is VP mismatch. The fact that the patient did not have SaO2 increased after starting 4 l O2 (which would give FiO2 of about 36 - 38% vs. 21% in room air) tells that the mismatch between ventilation and perfusion was there (some blood was definitely flowing through the lungs but did not get more oxygen in the process). The patient was not "deeply hypoxic", but definitely had minimal degree of hypoxemia. In addition to this, VP mismatch causes hypercarbia (CO2 cannot ge removed from blood), which is firstly perceived as SOB (increased central respiratory drive). In this situation, bronchodilation (that's what RRT does) could help, as well as prevent CO2 retaining and pushing patient into hypoxic drive. The latter thing, for some reason, makes people thinking that these patients do not need oxygen; "hypoxic drive", or hypercarbia, firstly, seen most commonly in patients with advanced COPD (expected SaO2 within high 80th - low 90th at rest on their "normal" oxygen level); secondly, is a medical diagnosis that needs to be documented by ABGs; thirdly, these people do NOT complain on SOB; and, forth, it is treated by removing CO2 (i.e. CPAP/BiPAP) AND oxygen.

Hypoxemia in patients with COPD: cause, effects, and disease progression

Overall, your actions were correct VERY first step, and the other nurse's were correct NEXT first step, second one being RRT and bronchodilation, and third one being ABG (if needed). I wouldn't necessarily approve the way it was handled, though. Next time, try to treat patient, not the number, whether it will be "normal" or not

[NurseSpeedy, ADN, LPN, RN]

Wow. Too much O2 for a COPD patient can actually harm them. If they are truely 96% on room air (considering this is accurate), then they do not need O2. To throw a whopping 4L on them is overkill.

Many COPD patients live in an 88-92% O2 sat. Many of the orders that I see are to titrate O2 to keep it in this range for this group of patients as less is more (helpful) in this case. More O2 will make breathing harder and their ABGs will look like crap. I had a patient who was refusing their BiPap machine and kept putting their NC on the minute staff left the room by help of their family. BiPap alarm would go off ratting then out and they had their NC back on at 5L. Looked like crap, confused, O2 sat 97%...ABG CO2 now 112. (The rest of the numbers were crappy too)Patient was a full code. Earned themselves a trip to the unit, ventilator (family agreeable) and sedation since they would not wear the darn BiPap and put down the extra O2.

[MunoRN, RN]

A lot of people mistakenly believe that dyspnea is driven by hypoxia, which isn't typically the case. Hypercapnea is actually a more likely cause of increased respiratory effort, and particularly in COPD it's certainly possible to be neither hypoxic nor hypercapneic yet be short of breath, so long as their increased respiratory effort is maintaining normal levels, the concern is if they don't feel they can keep that level of effort up then those levels will eventually become abnormal. In your scenario, supplemental oxygen was of no help because it wasn't likely the cause of the dyspnea.

[blondy2061h, MSN, RN]

I swear nasal cannulas are a great placebo. I had a patient years ago that woukd wear it turned off and ambulate with it not even plugged in.

[mmc51264, BSN, MSN, RN]

I was taught that COPD should NOT be above 95%. Most of ours have goals around 90%

[NorthernNurse BSN,RN]

Hypoxemia in patients with COPD: cause, effects, and disease progression

Overall, your actions were correct VERY first step, and the other nurse's were correct NEXT first step, second one being RRT and bronchodilation, and third one being ABG (if needed). I wouldn't necessarily approve the way it was handled, though. Next time, try to treat patient, not the number, whether it will be "normal" or not

Thanks KatieMI for this thoughtful reply. I read through that article and learned a lot from it. I remember my professor saying to treat the patient not the number and this was certainly a great lesson on why that is important!

[kiszi, RN]

Anecdotally, it seems many COPD-ers deal with some degree of anxiety which can contribute to feelings of SOB. Cautious use of anxiety meds could be discussed with the doctor.