Oxygen Therapy: Lung CA

[Thornbird]

I am hoping to find an article or some other condensed information that may help with my patient care problem before someone irreparably harms this patient.

My patient is a 70 yo Female admitted to a SNF froma major university medical center with a primary diagnosis of non-small cell CA of the lung. She had been admitted to the hospital for resection of the LUL, but the procedure was not performed due to metastasis to the pleura and chest wall. She is now admitted to the SNF for mostly palliative care under the care of a local internist who did not know her previously. She is to be rehabbed to potential for ADl's, amb etc.

She was admitted with an order to titrate O2 to maintain sats = or > 92%. The hospital record indicates that she frequently de-satted there. The problem is that she also has a diagnosis of COPD. There is no indication that she is a retainer or even that her COPD was particularly an issue before the CA. However, as soon as the nursing supervisor saw COPD she requested that the order be changed to "O2 a 2 lpm prn for SOB" and the MD approved this. With minimal exertion (ie, bed to commode) she drops her sat It takes about 15 min for her sat to reach 90% again. I notified the MD of the problem and she increased the O2 order to 3 lpm continuously. The problem of exertion induced hypoxemia continues though less severe. At rest she was doing fine at 2 lpm with sats 92-94%.

I am only the LPN, but I keep up on my education. How can I get the supervisors and the MD to see that the original order was the most appropriate for this patient? She suffers enough from the pain of her advanced CA without being hypoxemic as well. Also she has an order for subQ heparin to continue "until she is ambulating ad lib" which I don't see ever happening. Any comments on that?

Thank you,

Catherine

[leslie :-D]

i think your pt is showing you that her rehab for potential is bed/chair rest.

keep the lady comfortable.

her prognosis is nil.

make the most of her remaining time and screw rehab.

small cell ca is aggressive and this lady's limited o2 is precious.

leave her alone and let her be.

leslie

[leslie :-D]

ok, reread it and realized it is non small lung ca...

depending on what type it is (squamous cell, adenocarcinoma, large cell), current regimen will slightly vary.

but still, with mets to chest wall it doesn't sound good...

and w/copd, even more dismal.

it is affecting her cardiac status and often metastasizes to bones, liver, cns.

honestly, it sounds like she'd be appropriate for a hospice consult.

too many doctors do not make this referral until the very end.

based on my experience and from your post, my instincts are telling me to let her be and try to get that hospice consult.

best of everything.

leslie

[psalm51]

Oxygen is a comfort measure too.

it is ok to titrate oxygen to baseline sat. it's when we go over the patient's baseline sat that, theoretically, we could knock out their hypoxic drive.

[leslie :-D]

Oxygen is a comfort measure too.

definitely.

i was referring to pt partaking in rehab.

i do hope pt's o2 is titrated to comfort, whatever the level is.

leslie

[Thornbird]

Thanks for replies. My feeling is that rehab won't be too aggressively pursued. My problem is with the stupid order to continue heparin until she is ambulatory, an impossibility in my mind.

What I'm really looking for is an article that might educate those above me that her O2 should be titrated for her comfort. I know the old "rule" that COPD'ers shouldn't ever get more than 2 liters is obsolete. But, I can't seem to find an actual article that I can show the supervisors so that the patient gets appropriate O2 orders.

This is the toughest part of being an LPN, when I see something that I know is wrong and is hurting the patient but am powerless to do anything about it. Unfortunately, my state has no continuing ed. requirement, so a lot of nurses don't bother keeping up on things.

Thanks,

Catherine

[DLS_PMHNP, MSN, RN, NP]

Thanks for replies. My feeling is that rehab won't be too aggressively pursued. My problem is with the stupid order to continue heparin until she is ambulatory, an impossibility in my mind.

What I'm really looking for is an article that might educate those above me that her O2 should be titrated for her comfort. I know the old "rule" that COPD'ers shouldn't ever get more than 2 liters is obsolete. But, I can't seem to find an actual article that I can show the supervisors so that the patient gets appropriate O2 orders.

This is the toughest part of being an LPN, when I see something that I know is wrong and is hurting the patient but am powerless to do anything about it. Unfortunately, my state has no continuing ed. requirement, so a lot of nurses don't bother keeping up on things.

Thanks,

Catherine

Your patient is lucky to have you as her nurse. You sound like a very caring individual.

Best,

Diane

[wtbcrna, MSN, DNP, CRNA]

Try looking on pubmed, but this is what I found that may you.

http://ovidsp.tx.ovid.com.lrc1.usuhs.edu/spa/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=00002311-200801300-00052&NEWS=N&CSC=Y&CHANNEL=PubMed

Oxygen therapy and COPD

Respiratory failure results in an inadequate level of circulating oxygen and sometimes an inadequate removal of CO2. It is classified as either type I or type II respiratory failure.

COPD can be associated with type II respiratory failure. However, the use of oxygen therapy for patients with type II respiratory failure with associated COPD remains a confusing and contentious issue (Bateman and Leach 1998, Bennett 2003). To deliver oxygen therapy to patients with COPD safely, Woodrow (2005) stated that it is essential to understand the underlying physiology.

Under normal conditions, CO2 levels in the blood stimulate the respiratory centre. As the CO2 levels rise in arterial blood, the CO2 diffuses across the blood-brain barrier into the cerebrospinal fluid (CSF), until equilibrium is achieved between the blood and the CSF. As the CO2 diffuses into the CSF, the pH of the CSF drops, stimulating the chemoreceptors in the central nervous system (CNS). These chemoreceptors stimulate the respiratory centre in the CNS to increase the rate and depth of breathing to excrete the CO2. Some, but not all, patients with COPD also experience type II respiratory failure (Bateman and Leach 1998). In type II respiratory failure, the sensitivity of the chemoreceptors is lost. Instead of the arterial CO2 stimulating the chemoreceptors, it is the fall in arterial oxygen that stimulates the respiratory centre.

As a consequence, some authors state that giving high concentrations of oxygen to patients with COPD will reduce the respiratory drive, resulting in respiratory depression (Bennett 2003). However, Bateman and Leach (1998) stated that the number of patients with both COPD and type II respiratory failure is only 10-15 %, and that patients with COPD could die as a result of hypoxia if oxygen is withheld because of fear of a raised CO2 level reducing the respiratory drive.

The Resuscitation Council (UK) (2005) advocates high concentrations of oxygen in such patients when they are acutely ill. NICE (2004) guidelines for the management of adult patients with COPD in primary and secondary care recommend that oxygen is delivered at 40% and titrated upwards if oxygen saturations fall below 90%. NICE (2004) also recommends that if the patient becomes drowsy, or if the oxygen saturations rise above 93-94 %, the percentage of oxygen is reduced. This lack of understanding results in a higher proportion of patients with COPD who do not have associated type II respiratory failure being at risk of hypoxia and ultimately death as a result of inadequate oxygen administration (Bateman and Leach 1998).

[HonestRN]

I have never seen high oxygen knock out the hypoxic drive to breathe. I actually had a patient this weekend on 15L O2 via nasal canula with 15L O2 via NRB mask running concurrently. Recent research disputes the old max 5L O2 for COPD due to knocking out hypoxic drive.

[PageRespiratory!]

To the OP, remove the word "only" from your statement "I'm only an LPN", and replace it with "damned good".

[rita359]

Heparin is now used as dvt prevention. We are starting most hospitalized pts on some form of dvt prevention, heparin being one of them. Really see nothing wrong with a heparin order as is. Better than TED hose which are uncomfortable, and scds which would be the same.

[seasonedhospicern]

Thank you for your question which FINALLY gave me the answer. My hospice pt with COPD/CHF requires 10L O2 to maintain stats around 93%. Tried to decrease but could not maintain. No other symptoms noted and he is comfortable. Will pass this info to the facility RN's .