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.

[BR157]

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

Did he have a congenital heart defect or severe pulmonary hypertension with a 75% - 85% SpO2 expectation? That is not that uncommon now. Even in EMS this is taken into consideration. You can usually tell by the meds they are taking.

toomuchbaloney

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?

Why would you give up on someone just because they have an SpO2 of 70% when exercising? Ask any PT or RT about 6 minute walks and home O2 qualifications and you will see this is not that unusual even without another acute problem. I've seen patients go home on 6 Liters of oxygen to move around in the house a little and can increase the oxygen to 10 liters to go up a couple of steps. They can still have some quality of life with their families.

Some seem to just focus on an SpO2 and aren't really taking into consideration that there might be a very fixable problem like adjusting their diuretic or treating a possible PNA. Even if a patient is a DNR, it does not mean Do Not Treat. If the patient is still motivated to do PT, he or she should be forced into palliative care. But then I will say again this is where the Community Paramedic will be a big benefit with assessment and oxygen skills which seems to be missing outside of the acute hospital by some. Going into the nursing homes and rehab facilities might be another avenue for the Community Paramedics to assist with assessment and teach the nurses.

[heron, ASN, RN]

Both palliation and aggressive treatment are valid options. The specific combination will vary widely depending on individual situations, timing and patients' own priorities.

Nothing wrong, and a lot right, with having a decent quality of life while dealing aggressively with life-limiting illness.

[toomuchbaloney]

Did he have a congenital heart defect or severe pulmonary hypertension with a 75% - 85% SpO2 expectation? That is not that uncommon now. Even in EMS this is taken into consideration. You can usually tell by the meds they are taking.

toomuchbaloney

Why would you give up on someone just because they have an SpO2 of 70% when exercising? Ask any PT or RT about 6 minute walks and home O2 qualifications and you will see this is not that unusual even without another acute problem. I've seen patients go home on 6 Liters of oxygen to move around in the house a little and can increase the oxygen to 10 liters to go up a couple of steps. They can still have some quality of life with their families.

Some seem to just focus on an SpO2 and aren't really taking into consideration that there might be a very fixable problem like adjusting their diuretic or treating a possible PNA. Even if a patient is a DNR, it does not mean Do Not Treat. If the patient is still motivated to do PT, he or she should be forced into palliative care. But then I will say again this is where the Community Paramedic will be a big benefit with assessment and oxygen skills which seems to be missing outside of the acute hospital by some. Going into the nursing homes and rehab facilities might be another avenue for the Community Paramedics to assist with assessment and teach the nurses.

What do you mean by "giving up"?

I don't give up on people, I advocate for them.

What are you talking about; "forced into Palliative Care"? When is it appropriate for health professionals to "force" cognitively intact patients into any sort of care or treatment? Are you under the impression that Palliative Care is only appropriate for some patients with symptom management issues but not others? What criteria would you utilize to make that determination. Did you know that participating in a Palliative Care program does not disqualify one from PT or OT or any other intervention?

Are you aware that both Palliative Care and Hospice have goals of improved quality of life at the center of their function? The treatment plans in those specialty areas are generally primarily concerned with quality of life.

[BR157]

What do you mean by "giving up"?

I don't give up on people, I advocate for them.

What are you talking about; "forced into Palliative Care"? When is it appropriate for health professionals to "force" cognitively intact patients into any sort of care or treatment? Are you under the impression that Palliative Care is only appropriate for some patients with symptom management issues but not others? What criteria would you utilize to make that determination. Did you know that participating in a Palliative Care program does not disqualify one from PT or OT or any other intervention?

Are you aware that both Palliative Care and Hospice have goals of improved quality of life at the center of their function? The treatment plans in those specialty areas are generally primarily concerned with quality of life.

Bottomline here: The patient had been exercising and now has an SpO2 of 70%. Now is not the time to ask the patient about "Palliative Care". Talk to whoever you have to for some protocol to allow nurses to place patients on an adequate amount of oxygen and with more education to ensure it is the correct device. If you don't know how to or have to wait for a doctor's order, CALL EMS and let the EMTs or Paramedics take over the care of this patient. Then if the patient refuses care, the Paramedics will be able to discuss with a doctor about the next step.

[NamasteN]

For COPD higher amnounts of O2 are not the answer, but delivery system is. Use a non-rebreather at no more than 4-6L/min. Face mask is useless. Give a neb tx, sit upright, slow deep breaths. If it's only on exertion, need to rethink PT

[eroc]

It's sad most people don't know the difference between hospice and palliative.

[Altra, BSN, RN]

For COPD higher amnounts of O2 are not the answer, but delivery system is. Use a non-rebreather at no more than 4-6L/min. Face mask is useless. Give a neb tx, sit upright, slow deep breaths. If it's only on exertion, need to rethink PT

NRBs should not be used at flow rates less than 6L/min.

[vintagemother, BSN, CNA, LVN, RN]

It's sad most people don't know the difference between hospice and palliative.

I'm a new nurse. Please explain. 😀

I know palliative is to relieve pain and hospice is to ensure dignity (including pain relief) is maintained.

I do not know the difference.

Thank you.

[BR157]

For COPD higher amnounts of O2 are not the answer, but delivery system is. Use a non-rebreather at no more than 4-6L/min. Face mask is useless. Give a neb tx, sit upright, slow deep breaths. If it's only on exertion, need to rethink PT

Besides the incorrect liter flow for the non-rebreather, you must understand that COPD patients can not take slow deep breaths. They have air trapping. They take a quick breath in and then can take 10 - 30 seconds to exhale. Most will never completely exhale and have large residual volume still in their lungs. This is why they purse lip breathe. This splints their airways to allow trapped gas out and they can exhale a little more for the next breath. When a patient is short of breath and appears to be panting, they are seriously air trapped. These patients do best in whatever position allows them to use their accessory muscles which is sometimes in a tripod position. Years of air trapping all gives them a barrel shaped chest and changes in their spinal column which makes sitting upright difficult.

[BR157]

Palliative vs Hospice;

Hospice Vs. Palliative Care

The differences.

For the scenario presented, it still does not change my decision to give the appropriate oxygen to treat the hypoxia. The idea of comfort is to make the patient comfortable especially if it is a reversible situation such as from activity. If there was a specific order to with hold all oxygen as there sometimes is for hospice patients, then that is another matter totally. No specific order then I will go by the wishes of the patient and my assessment to provide treatment until I speak with the patient's doctor.

[toomuchbaloney]

Bottomline here: The patient had been exercising and now has an SpO2 of 70%. Now is not the time to ask the patient about "Palliative Care". Talk to whoever you have to for some protocol to allow nurses to place patients on an adequate amount of oxygen and with more education to ensure it is the correct device. If you don't know how to or have to wait for a doctor's order, CALL EMS and let the EMTs or Paramedics take over the care of this patient. Then if the patient refuses care, the Paramedics will be able to discuss with a doctor about the next step.

I beg to differ.

When a COPD patient is experiencing significant exacerbation of symptoms with exercise/PT (which they apparently choose to pursue), it makes perfect sense to formally discuss the plan for palliation of those unpleasant and uncomfortable symptoms. Frankly, the addition of a low dose opiate to the POC might improve that individual's ability to successfully participate in such therapy while relieving some of their symptoms and improving their quality of life.

I do not believe anyone here, much less me, is suggesting that we simply allow the person to struggle with a low SpO2. I am suggesting that Palliative Medicine has something to offer this individual and others in a similar boat. I also am suggesting that sometimes the patient benefits from hearing what their options might include relative to their medical care. They deserve our honesty, not information filtered through our own personal biases.

If the patient is end stage, he or she deserves the honesty of that information, no matter how difficult that might be. If the reality is that the person is likely to be in the last year or so of their life, perhaps knowing that, they might prefer to spend their time doing something besides PT.

Our patients deserve honesty and the ability to choose for themselves with our advocacy.

[toomuchbaloney]

Palliative vs Hospice;

Hospice Vs. Palliative Care

The differences.

For the scenario presented, it still does not change my decision to give the appropriate oxygen to treat the hypoxia. The idea of comfort is to make the patient comfortable especially if it is a reversible situation such as from activity. If there was a specific order to with hold all oxygen as there sometimes is for hospice patients, then that is another matter totally. No specific order then I will go by the wishes of the patient and my assessment to provide treatment until I speak with the patient's doctor.

I have worked in the field of hospice and palliative medicine and nursing for a spell now.

I have never seen an order to withhold oxygen for a hospice patient. NEVER

I have had family members ask to have it removed when their loved one is unresponsive or otherwise unable to object.