Giving high flow oxygen to COPD patients

[dolphinmonkey]

I was caring for a patient with COPD, who was normally on long term oxygen therapy (low flow) at home. I was on the night shift and during the day she had become unwell, increased respiratory rate, increased O2 requirement.

She had been settled but then began to c/o breathlessness, her oxygen sats were 65%. I have been trained that when a patient's O2 saturations are that low, you should administer 15L 02 via a non rebreathe mask until sats within target range. I have been told during training sessions that this also applies to COPD patients.

Normally I hesitate in giving O2 to these patients and will try different positions/deep breathing/nebuliser if say, their sats are 80-84% (most COPD patients have target range 88-92%). However as this patient was unwell and sats so low, I applied non rebreathe mask 15L-sats quickly increased and I titrated O2 down however patient clearly became increasingly unwell. Blood gas showed increased c02 - patient had type 2 respiratory failure caused by high flow oxygen.

Do you think this was a poor judgement and I should have slowly increased O2 with venturi? Would you ever apply high flow O2 to a COPD patient?

[dolphinmonkey]

The high flow O2 was administered for no more than 2 minutes.

[cleback]

Yes, if their sats are that low. I am unfamiliar with type two resp failure caused by high flow oxygen. Do you have a link for that? But if her blood gas has increased co2, the doc would've switch to a bipap or intubated, depending on how unwell the patient was. My understanding is that the high co2 is due to the mechanisms of copd and the inability to ventilate and get rid of co2, not necessarily the high flow of o2. Bipap or intubation require the doc, so you did what you could as an rn.

[smf0903]

You're using the term "high flow", and I'm not sure if you're using it in reference to the 15L NRB or actual high flow.

We use high flow nasal cannulas relatively frequently on our COPDers, especially after extubation. Studies have shown a decrease in reintubation when using high flow immediately after extubation. Many times our patients will be on high flow while awake and on bipap while sleeping. The RRT titrates the FiO2 to usually keep them between 88-92%.

[AnnieOaklyRN, BSN, RN, EMT-P]

I think this is poor judgement because unless the patient wishes to be hospice or has an order for no hospital transport, 911 should have been called!!!

This patient was clearly deteriorating from her baseline, and that warrants a trip to the ER for intervention BEFORE the patient gets to respiratory failure! She was more then likely in need of medications for bronchodilation and BiPap, thus a Non rebreather isn't going to solve the underlying cause of the hypoxia and hypercarbia. Please call an ambulance sooner rather then later next time, as long as the patient does not have an order against it.

It is very unlikely that a non rebreather caused the patient to worsen, it was that you did not recognize her need for further treatment in a hospital setting sooner. I know this sounds mean, but you need to work on educating yourself more on recognizing patients that require treatment outside of their home.

Annie

[Triddin]

AnnieOaklyRN said:

I think this is poor judgement because unless the patient wishes to be hospice or has an order for no hospital transport, 911 should have been called!

This patient was clearly deteriorating from her baseline, and that warrants a trip to the ER for intervention BEFORE the patient gets to respiratory failure! She was more then likely in need of medications for bronchodilation and BiPap, thus a Non rebreather isn't going to solve the underlying cause of the hypoxia and hypercarbia. Please call an ambulance sooner rather then later next time, as long as the patient does not have an order against it.

It is very unlikely that a non rebreather caused the patient to worsen, it was that you did not recognize her need for further treatment in a hospital setting sooner. I know this sounds mean, but you need to work on educating yourself more on recognizing patients that require treatment outside of their home.

Annie

It kind of sounds like the patient was already in the hospital, at least that was my take away. 15L for that short of time would not cause hypercapnic failure, it sounds like her condition was worsening. With sats of 65%, I would have done the same, and then called the doctor and the RT immediately.

I've worked with intensivists who swear hypercapneic failure due o2 is a myth, and I've read evidence which supports it.

[JKL33]

Annie - re-reading it, the OP first sentence could be ambiguous; I read it as "I was caring for this patient who is usually on oxygen at home" not "I was caring for this patient who is usually on oxygen, at [her] home."

OP I hope that you weren't chastised or instructed by someone that your application of two minutes of HFO2 is what caused this patient's problem. The patho mechanisms of COPD itself cause both chronic and acute respiratory failure. An immediate measure to correct the acute hypoxia is the correct first move.

Did you call an RRT while performing your initial interventions? If so I see no problem here (unless there were earlier signs of acute deterioration that were overlooked).