COPDer de-satting? What do you do?

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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.

Specializes in MICU, SICU, CICU.

How recently has the patient had a cardiac workup? Cor Pormonale occurs with COPD and this new apparent activity intolerance makes me concerned for heart failure. Have they had a recent ECHO?

Regardless the patient's symptoms are consistent with hypoxia and they should be given oxygen. It may be prudent at this point to decrease the amount of activity in his rehabilitation until a more thorough workup can be completed.

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Specializes in Med-Surg, Emergency, CEN.

Call the MD and respiratory therapy.

... No RT? Call EMS.

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It's been over a decade since I worked in acute rehab, but in my days that patient would have been transferred out to an acute floor. Over an hour and still satting mid 70's is an emergency.

The only other thing I would add is, aren you sure your pulse ox is accurate? I have also had patients for which it's nearly impossible to get an accurate pulse ox on a finger. That said, your patient sounds like they are symptomatic as well, which is probably more important. If you don't have acute care abilities send them out ASAP.

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Fix hypoxia with oxymask or non-mech vent and prepare for eventual hypercapnia. Get an ICU bed ready and intubate.

Get an ABG, his CO2 might climb too high for the bipap to be effective if they become somnolent or obtunded.

Acute hypoxic respiratory failure in the setting of hypercapnia and COPD exacerbation. Vented for a day or so usually. It really depends on ABG on how they respond to oxygenation measures.

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Specializes in Hospice.

Alternatively, advocate for a palliative consult. This level of activity intolerance verges on being end stage, hospice appropriate disease.

Meanwhile, it's LTAC, which may or may not have facilities and staff available for an emergent intubation. But ... with crackles and persistent hypoxia, speedy medical evaluation is necessary. Oxygen alone isn't going to fix this. I think you need to get the responsible provider and available resources involved asap, or get the pt out to the ER. Meanwhile, get as close to 100% O2 delivery as you can ... you can always blow or bag it off later, if necessary. As someone else pointed out, death or anoxic brain injury is far more permanent than transient hypercapnea. Know the patient's code status. A good iv and a monitor couldn't hurt, either.

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Small rehab with no RT - I'd call EMS and stat page the MD. Focus on ABCs. Is there an order to maintain sat greater than %?

Even if patient is a retainer, that sat plus accompanied symptoms and cyanosis is entering the critically ill realm.

If accessible I'd request stat ABG, CXR, EKG and labs - CBC, BMP and Mg. Make sure all lytes are in check and HH good. The ABG will aid in directing oxygen therapy and mode of delivery.

CXR is see if pulm edema. May need a round of diuretics, and again drawing lytes is good to have ready in case of this.

EKG - rhythm? (Of course check pulse and feel if its regular, brady, tachy) Lots of ectopy? (especially given that just had activity with therapy) maybe lytes need replacing if ectopy or further cardiac workup.

Patient needs higher level of care.

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When in doubt, send them out.

Definite medical assessment was needed.

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Small rehab with no RT - I'd call EMS and stat page the MD. Focus on ABCs. Is there an order to maintain sat greater than %?

Even if patient is a retainer, that sat plus accompanied symptoms and cyanosis is entering the critically ill realm.

If accessible I'd request stat ABG, CXR, EKG and labs - CBC, BMP and Mg. Make sure all lytes are in check and HH good. The ABG will aid in directing oxygen therapy and mode of delivery.

CXR is see if pulm edema. May need a round of diuretics, and again drawing lytes is good to have ready in case of this.

EKG - rhythm? (Of course check pulse and feel if its regular, brady, tachy) Lots of ectopy? (especially given that just had activity with therapy) maybe lytes need replacing if ectopy or further cardiac workup.

Patient needs higher level of care.

At some point nurses should be taught Basic Life Support as it pertains to administering oxygen correctly.

A patient could die even in the hospital with an inhouse lab and xray if you want to wait for the lab results. A patient is symptomatic with an SpO2 of 70% in the original scenario.

I have seen nurses waste time even with that same scenario trying to get a sat and focus totally on positioning the probe without ever looking at the patient.

I have seen nurses place a patient on only 2 L saying that's the what the order says while the SpO2 stays at 70%.

Seriously you do not need a lot of data to respond to this scenario. The first responders with little more than a first aide course will probably be able to initiate oxygen therapy quickly and correctly.

Learn to spot respiratory distress. An SpO2 of 70% is not normal even for some kids with CHD. On transport we even give them oxygen if their SpO2 is lower than expected. But not even the worse COPD patient would have 70% as normal. Do nurses really need an order to get the SpO2 above 70%?

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head of bed up, put on pulse ox, slap on mask, crank up oxygen, call respiratory therapist for recommendation

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Specializes in NICU, PICU, Transport, L&D, Hospice.

I am seconding or thirding the concept that advocacy for palliative treatment and perhaps even hospice EOB should be considered...at least discussed ASAP for this suffering patient.

Is there some reason that this COPDer cannot be provided an opiate to palliate symptoms? Especially before/after therapy?

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At some point nurses should be taught Basic Life Support as it pertains to administering oxygen correctly.

A patient could die even in the hospital with an inhouse lab and xray if you want to wait for the lab results. A patient is symptomatic with an SpO2 of 70% in the original scenario.

I have seen nurses waste time even with that same scenario trying to get a sat and focus totally on positioning the probe without ever looking at the patient.

I have seen nurses place a patient on only 2 L saying that's the what the order says while the SpO2 stays at 70%.

Seriously you do not need a lot of data to respond to this scenario. The first responders with little more than a first aide course will probably be able to initiate oxygen therapy quickly and correctly.

Learn to spot respiratory distress. An SpO2 of 70% is not normal even for some kids with CHD. On transport we even give them oxygen if their SpO2 is lower than expected. But not even the worse COPD patient would have 70% as normal. Do nurses really need an order to get the SpO2 above 70%?

What were you disagreeing with me on?

Some patients need to get to at least 85 and others 90, depends on a lot of factors and what the MD wants.

I never said WAIT for those results.

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I had a patient a few weeks ago who had an order to keep sats >74%. He lived between 75 and 83 normally.

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