Hypoxia and High flow NC

BelgianRN · Sep 7, 2012

Working a general ICU in my hospital we frequently encounter this problem. Without knowing about your specific institution I can only comment on mine. For an empty bed in my ICU there are usually anywhere between 2 and 5 candidates waiting to be admitted.

The problem for me isn't that they're on the floor receiving high flow oxygen. If the medical situation is under control and the patient is aggressively managed more often than not their oxygen demand will go down in the next 24 to 48 hours. E.g. if proper ABX has been started and inflammatory parameters are going down it is reasonable to expect that their pneumonia they came in with is resolving and their lungs will start improving. If they respond well to their diuretics the excessive fluid in the lungs will resolve as well. Etc.

The problem is usually getting the floor MDs (in my hospial anyway) motivated to start aggressive management on these patients. Often there is a very expectant attitude towards these types of patients and they fail to improve in a proper timeframe and they end up in the ICU with MODS needing to be intubated basically because the patient used up all their reserves in the previous days with MDs considering 20 mg of furosemide aggressive diuretic therapy or thinking amoxicillin will cure anything!

I agree completely with you if their oxygen demand doesn't go down and they remain with low sats for multiple days they need to be transferred to ICU and a place has to be created for these patients, room or not. That's generally when us poor general ICU's look angry towards our mixed trauma ICU/PICU or CTICU to get off their asses and admit the plebs patients as well. Or alternativey we start using our PACU as an overnight sleepover party for the more stable ICU patients awaiting discharge in the morning.

It is true that oxygen has many toxic side effects. But these effects will just be as bad on the floor as in ICU. Only difference is that ICU has a few tricks up their sleeve to avoid giving this much oxygen and have ways of creating some CPAP wiithout need for intubation thereby decreasing oxygen toxicity. I completely agree that if patient keeps on needing this much oxygen and the problem isn't correctable sometimes sedating them and tubing them is the approprate action because it dramatically decreases oxygen consumption.

I recently wrote a review on current guidelines/insights concerning ARDS for my department. Sadly it's in Dutch so you probably wouldn't be any wiser if I posted the section on oxygen toxicity here. Tried looking for a handy article on Medscape about oxygen toxicity but couldn't find it. If your facility has UpToDate® try looking it up there it has some great info. I agree that oxygen is very toxic but there is not a lot we can do about that except making sure the cause of their need for supplemental oxygen is removed ASAP by aggressive management.

detroitdano · Sep 7, 2012

Sounds like you've just got issues with a small facility; sick patients that would usually end up in an ICU stay on your floor due to space. If you have concerns you could always contact the house manager and see if an outside transfer is possible, if there are no ICU beds.

On a side note, sometimes patients DO sat 88% and it is their baseline. Pulmonary fibrosis patients, for example, usually live around that, and even when they desat into the 70's they don't look distressed at all, they just somehow adjust to it. I can't imagine your entire unit is PF patients though!

MomRN0913 · Sep 7, 2012

Why not Bipap? It's usually the last stop before intubation, but can be effective without using so much o2.

I agree with belgian RN, which waiting, agressively treating the underlying cause, if there is one, such as pneumonia, CHF, COPD would be the best thing to do on your floor and monitor response to treatment, if not, off to ICU.

07302003, ASN, RN · Sep 9, 2012

I get it, boy do I get it. As a nurse, I always think, if that was my family member on the bed what would I want done? And what about my license, by the way?

Having worked Tele with 4-6 patients, the issue is that the patient on NRB is circling the drain and the nurse does not have time to manage agressive interventions (and balance the needs of 5 other patients, 1 a drug seeker on call light, 1 with a difficult family, 2 that are total care bedbound / peg, and another with dementia trying to fall out of bed all day - I GET the picture!).

That is why these patients belong in an ICU if they are full code, for even 24 hours to get treated agressively and straightened out. And as others have mentioned, Bi-Pap is an EXCELLENT way to manage patients in respiratory distress, to avoid intubation and help them oxygenate, non-invasive and MUCH better that high flow for chronic lung disease. If your hospital does not do this on the floor, they belong in an ICU.

If the system of the hospital you're at lets patients like this sit on the floor, I would suggest moving to the ICU, or, another hospital. It's your license.

07302003, ASN, RN · Sep 9, 2012

And I also work at a major teaching hospital (>800 beds) - no more step downs there - they needed the ICU beds. So it's either ICU (medical, cardiac, neuro, surgical) or the floor. Period.