COPDer de-satting? What do you do?

[Krazziekid78]

I'm throwing out a scenario. Please tell me what you would do (especially regarding oxygen therapy...how much to give and through what device)

Patient with COPD is found with oxygen saturation of 62% after working with therapy. Lungs have fine crackles in bilat lower lobes, c/o feeling light headed and SOB. Cyanosis to lips. Currently on 4 L (baseline for patient) on a NC. Patient placed in high fowler position and encouraged to cough and deep breathe. Oxygen saturation raises to 70%. Ordered PRN duoneb (q4h) was given 1 hour ago. Increased oxygen, and sats sit in mid 70s at 6L. Do you go to a non-breather or face max at a high rate of oxygen per lpm and risk hypercapnia? Or do you focus more on getting their o2 up?

Note- I am in a small rehab facility with no RT or rapid response team.

[L♡vER]

What is patient's baseline O2 sat? Is the sob resolved now that patient has come up to the mid 70s? How are other vitals? Do you have the ability to check a quick ekg?

[BR157]

Patient with COPD is found with oxygen saturation of 62% after working with therapy. Lungs have fine crackles in bilat lower lobes, c/o feeling light headed and SOB. Cyanosis to lips. Currently on 4 L (baseline for patient) on a NC. Patient placed in high fowler position and encouraged to cough and deep breathe. Oxygen saturation raises to 70%. Ordered PRN duoneb (q4h) was given 1 hour ago. Increased oxygen, and sats sit in mid 70s at 6L. Do you go to a non-breather or face max at a high rate of oxygen per lpm and risk hypercapnia? Or do you focus more on getting their o2 up?

Note- I am in a small rehab facility with no RT or rapid response team.

The patient has symptomatic hypoxia. Do you think that is good for the patient? The longer the patient is hypoxic the more risk they are for hypercapnia due to respiratory and CARDIAC failure. The patient has crackles. Is this normal or is the patient already experiencing pump failure? You can always use a BVM on a patient in hypercapneic failure but if the patient has organ failure from hypoxia, the patient will not have a good outcome and the Paramedic will have no choice but to inform the State that you with held oxygen from a patient with an SpO2 of 70.

https://paramedicblog.wordpress.com/2009/11/19/hypoxic-drive-theory-myth-the-why-and-how/

One more thing that has been pointed out in several discussions, very few COPD patients are actual CO2 retainers.

Hypoxia kills, hypercapnia happens.

https://drcrunch.wordpress.com/2012/08/17/why-are-there-no-guidelines-for-inpatient-hyperglycemia/

[Krazziekid78]

Baseline is 88-92%. SOB resolves after resting in upright position. BP was 140s/90s. HR was in 95-100 (usually runs tachy). Respirations were about 25. These vitals are typically baseline for patient. Respirations were elevated above baseline (usually 18-20). And no- we don't have the ability to check a quick ekg

i might add add that patient has been de-satting frequently with therapy only ambulating short distances. Today was the first time he dropped into the 60s

[calivianya, BSN, RN]

I would definitely focus more on getting his O2 sat up first. If he gets hypercapnic, you can always fix that with the BiPAP later.

Although, if he desats that badly just from working with therapy, my honest question is if he's appropriate for therapy in the first place. It sounds like he's end stage if his activity intolerance is that severe. Is palliative/hospice consulted?

[VANurse2010]

I'm throwing out a scenario. Please tell me what you would do (especially regarding oxygen therapy...how much to give and through what device)

Patient with COPD is found with oxygen saturation of 62% after working with therapy. Lungs have fine crackles in bilat lower lobes, c/o feeling light headed and SOB. Cyanosis to lips. Currently on 4 L (baseline for patient) on a NC. Patient placed in high fowler position and encouraged to cough and deep breathe. Oxygen saturation raises to 70%. Ordered PRN duoneb (q4h) was given 1 hour ago. Increased oxygen, and sats sit in mid 70s at 6L. Do you go to a non-breather or face max at a high rate of oxygen per lpm and risk hypercapnia? Or do you focus more on getting their o2 up?

Note- I am in a small rehab facility with no RT or rapid response team.

Yeah, you need to slap that non-rebreather on and raise them quickly. They are going to die from hypoxia a lot faster than hypercapnia.

Not all COPD patients are CO2 retainers, either.

[RescueNinjaKy]

Is he having any edema or any signs of fluid overload? I had a patient with chf who had low hgb and was getting transfused with prbcs, and was getting sob, de satting, crackles and wheezing, gave some lasix and he did a lot better.

[RN403, BSN, RN]

I agree with other posters. Focus on getting their O2 saturation up first and worry about the CO2 later. I couldn't imagine sitting there watching my patient stating in the 70s and not pull out more O2 no matter the background.

Now, in another case scenario, if my COPDer is satting 88-89% I don't go running for O2. In this case I would be more conservative as a lot of them are in this range normally anyway.

[blondy2061h, MSN, RN]

If this patient wanted full treatment and didn't recover to at least the 80's fairly quickly, I would think they would need to be acuted out. I can't claim to have LTC experience, though. In most med surg settings the situation you described would be reason for a rapid response.

[thevez]

Hold therapy for a few days or do bedside therapy until pt is stable enough with the pt O2. Was the pt having crackles as per admission assessment? Is it new? Definitely treat hypoxia if pt is symptomatic.

[ScrappytheCoco]

Cardiac/respiratory arrest r/t hypoxia is less fixable than a little hypercapnia:)

[floridanurse1983]

Do they have previous abg's? You'd be able to see if they were chronic retainers.