Best choice for emergent desaturation in COPD

Specialties Med-Surg

Updated:   Published

So I'm a fairly new nurse And I don't have in depth knowledge about the best O2 therapy modes. Recently I had a patient with COPD on 4L hi humidity NC satting 98% when I got on shift. They took a turn for the worst (56% on random check when she was unresponsive) and in the midst of calling the MD I placed nonrebreather (not great for COPD). Is there another form of O2 that would have been a better choice? on regular med surg floor

1 Votes
Specializes in Critical Care.

The first step would be to assess for the cause of hypoxia, which in a COPD'r is typically upper airway constriction, which is usually best treated with a bronchodilator. Also keep in mind that while supplemental O2 will help treat the hypoxia, there is also likely hypercapnia, which isn't treated with supplemental oxygen.

1 Votes
Specializes in Float Pool - Med-Surg, Tele, Psych.

You still need to treat the hypoxia whether the patient has COPD or not. I agree with using a nonrebreather in this situation.

2 Votes
Specializes in Burn, ICU.

Do you have the option of a rapid response team? In my hospital, that calls a respiratory therapist in addition to a hospitalist and the RT can initiate CPAP or BiPAP if it seems warranted, in addition to drawing an ABG that could guide further intervention. (Also, the RTs give breathing treatments in my hospital, not the RNs.)

In the short term while waiting for a doctor (or even before calling, if no one else can call for you) you gotta use what you have available. Did the non-rebreather help? Was the patient truly unresponsive even to stimuli? Did they have a respiratory rate > 10? They certainly could have had CO2 narcosis (especially if they'd been 98% before...might be well above their normal and driven down their respiratory rate so they retained more CO2 than normal). But it they were truly unresponsive (and especially with a sat of 56%,) you could have bagged them. (My logic being that if they are barely breathing, you can put any mask you want on them but the O2 won't get inside if they don't breathe!) If they didn't perk up at least a little with the stimulation of being bagged, a Code is probably warranted. Even if they did perk up, it sounds like they needed more respiratory help than you had readily available. What happened to the patient in the end?

1 Votes
Specializes in Family Nurse Practitioner.

In an emergency situation in a patient without an advanced airway a non rebreather is the first choice unless the patient is not really breathing which in case you use an ambu bag. An oxygen saturation of 56% is bad for anyone, COPD or not.

If there is a rapid response team this would be the time to call and then notify the MD.

1 Votes

Hand ventilate with wall O2, call code blue, have charge RN check code status.

1 Votes
Specializes in Hematology-oncology.

I agree with Offlabel after reading your post a second time. If a patient is not just hypoxic, but also *unresponsive*, it's time to call a code before they decompensate further into cardiac arrest.

1 Votes
Specializes in Respiratory Care.
marienm, RN, CCRN said:
Do you have the option of a rapid response team? In my hospital, that calls a respiratory therapist in addition to a hospitalist and the RT can initiate CPAP or BiPAP if it seems warranted, in addition to drawing an ABG that could guide further intervention. (Also, the RTs give breathing treatments in my hospital, not the RNs.)

In the short term while waiting for a doctor (or even before calling, if no one else can call for you) you gotta use what you have available. Did the non-rebreather help? Was the patient truly unresponsive even to stimuli? Did they have a respiratory rate > 10? They certainly could have had CO2 narcosis (especially if they'd been 98% before...might be well above their normal and driven down their respiratory rate so they retained more CO2 than normal). But it they were truly unresponsive (and especially with a sat of 56%,) you could have bagged them. (My logic being that if they are barely breathing, you can put any mask you want on them but the O2 won't get inside if they don't breathe!) If they didn't perk up at least a little with the stimulation of being bagged, a Code is probably warranted. Even if they did perk up, it sounds like they needed more respiratory help than you had readily available. What happened to the patient in the end?

Sorry, no BiPAP for someone who is unresponsive. Patient cannot protect their airway with a mask strapped to their faces. Bipap requires patient participation as it is only for spontaneously breathing pts. NRB good choice if pt was able to maintain sats within normal range, but the pt needed to be intubated if truly was unresponsive. Also contrary to the popular belief, Albuterol doesn't revive unresponsive pts, latch on to that evil CO2 and pull it from the patients lungs. Nor does it cure every thing. Did the pt get overdosed on pain meds or were sneaking their home meds? Narcan maybe?

1 Votes
Specializes in Emergency Department.
CraftyKitten said:
So I'm a fairly new nurse And I don't have in depth knowledge about the best O2 therapy modes. Recently I had a patient with COPD on 4L hi humidity NC satting 98% when I got on shift. They took a turn for the worst (56% on random check when she was unresponsive) and in the midst of calling the MD I placed nonrebreather (not great for COPD). Is there another form of O2 that would have been a better choice? on regular med surg floor

A SpO2 of 56% and being unresponsive is a very big deal. In that situation, you'd better know the patient's code status because if the patient isn't a DNR/No Code, then you probably should have initiated your local emergency procedures. In my practice, that person is going to get an OPA and I'm going to grab the BVM, and I'm going to call a Code for that patient. A non-rebreather isn't going to fix this one... as that doesn't deal with ensuring the airway is patent and it doesn't actually ventilate.

In the emergent setting, it's OK to put a COPD patient on a high concentration of oxygen. It's not the oxygen that's going to kill them. A patient that's COPD isn't suddenly on Oxygen Drive, their CO2 drive (that everyone else runs on) just slowly becomes less and less effective. If a COPD patient has to be put on high concentration of oxygen, you must simply be prepared to take over ventilation with a BVM if it slows too much.

1 Votes
Specializes in Med-surg, telemetry, oncology, rehab, LTC, ALF.

Depends on their code status...we had this very same issue a couple of weeks ago on my unit. Pt became unresponsive with O2 sat of 76%. End stage COPD. Pt was a DNI (do not intubate). Thankfully RT was steps away from the room when it happened. RT initiated BIPAP, and after the rapid response was over, that was what the pt ended up staying on.

Had they been a full code, I could have easily seen the pt being intubated and transferred to ICU.

FYI a nonrebreather in an emergent situation is fine if it's all you have and RT isn't around. Your next move should be to call a rapid response or code blue. An MD will always show up to one of those - so will RT.

1 Votes

So when you think about the pathophysiology if COPD, you know how fast it is that they crash and burn. If it were me( which it was at one point) for sats in the 50's we need to oxygenate in the setting of unresposiveness I would've went straight to a NRB. I'm sure the patient needs to be Intubated and I'm curious if the co2 in the ABG, but after that I would've called a RRT.

1 Votes
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