nonrebreather-how long, and what should be next

Nurses Safety

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I need your help about the nonbreather.

This is the Pt's history: an eldrely pt admitted for pneumonia. He was doing fine, A&Ox2, no fever, bed resting, on PEG feeding and 3-4 IV antibiotics. He went for sacral pressure ulce debridement at noon, and around 4 pm he became totally disoriented, eye open for pain, SOB, O2 sat down to 87%. They doc. and day nurse put him on nonrebreather with O2 95-98% and I got him at 7 pm. PEG eeding was D/Ced, dressing was changed which with no bleeding. The only thing was the nonrebreather and slightly labored breathing I thought was problem. I talked to the doc. and called the RN from RRT. They all said O2 sat was fine leave him alone, "call me if he needs to be intubated," the doc said. I did chest pts and suctions, and he was on that nonrebeather with O2 about 95-97%, whenever it was removed O2 will go down to low 80. I knew non rebreather was for short time use, but don't know how short is short.

A Different nurse came for my district for day shift. When he heard the pt was on nonrebreather for about 15 hours, and next step would intubation, he was very angry.

My questions are: how long usually nonbreather used for pts; what else I, as nurse, can do to void nonrebreather or intubation for pt like this; what I can suggest doc to do.

Thank you in advence for your help and sharing you knowledge.

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Specializes in Cardiac.

My questions are: how long usually nonbreather used for pts; what else I, as nurse, can do to void nonrebreather or intubation for pt like this; what I can suggest doc to do.

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How long to keep a non-rebreather on? As long as it's necessary.

Is the pt a COPD'r?

Still groggy from the meds from surgery?

Try narcan?

Are you performing good pulmonary toileting?

I wouldn't say the next step is intubation for this fella at all. I'd say the next step is coughing and deep breathing and getting the dude as upright as possible (hard to do with a decub though isn't it?) and awake.

Sats of 95 don't warrant intubation.

Now if he's satting much lower while on the NRB and respirations are labored, and gasses look bad then that's another thing.

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Specializes in Critical Care.

One can suffer both neurological and pulmonary effects from oxygen toxicity, but no clear threshold of duration for this exists, to the best of my knowledge.

For reference, the astronauts aboard Gemini and Apollo were kept in an 100% oxygen environment for up to a week and a half without any problems, however, it was at a pressure much lower than atmospheric.

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The bigger problem is the NRB is just there to stabilize a patient until definitive treatment is established. It's a stop-gap measure at best. What did this guy's gasses look like?

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Specializes in ICU/Critical Care.

I am really wondering what the patient's ABGs were, if any were drawn before the NRB mask was placed and after the mask was placed. Even with a saturation of 87%, wouldn't a venturi mask at 50% Fi02 been sufficient? Sounds like the guy need aggressive pulmonary toileting. But really, I think if the patient was lethargic and having respiratory distress, intubation probably would have been better.

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Specializes in Cath Lab, OR, CPHN/SN, ER.

Was a NC attempted? Venti? I'd try to wean down to a venti and then a NC first. IMO, 15 hrs is too long without trying something else.

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thank you for sharing your knowledge.

no gasses after NRB,

not COPD,

groggy maybe, but after 15 hours he was the same, eyes opened to pain.

First time heard "pulmonary toileting", thank you very much. I did, but think I could do more often chest pt and suction. Thank you.

Still wondering if there was something, besides gasses, doc could do (or I could make the doc do) but didn't do.

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Specializes in ICU/Critical Care.

Was the patient on any albuterol/atrovent treatments? How about mucomyst inhalation treatments?

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was on atrovent and xopenex, but not mucomyst. I will remember. thanks.

Also to try weaning down.

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O2 sat alone is not enough to decide if the pt is okay. What were his ABGs? If the pt was groggy its very possible it could have been from elevated CO2 or hypoxia or both. If CO2 is a problem, the NRB only makes it worse, and the worsening decline in LOC/resp drive makes the hypoxemia worse.

I would have went from the NRB to a Venti Mask, titrated down the venti mask until I could put on a NC.

If I was unable to titrate down from the NRB to a Venti, I would have put the patient on Bipap.

If the problem was elevated CO2, I would have went straight to bipap. Then, if the ABG didn't improve after Bipap, we would intubate in my unit.

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Specializes in ICU, Telemetry.

I had a pt who was on a NC, 2lpm, went bad on the next shift, they put her on a 100% rebreather, and she went into respiratory failure....dayshift forgot the pt had emphysema....

Woops!

We've had people on 100% rebreathers for days...of course, usually they are dying DNRs.

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Specializes in Critical Care.
O2 sat alone is not enough to decide if the pt is okay. What were his ABGs? If the pt was groggy its very possible it could have been from elevated CO2 or hypoxia or both. If CO2 is a problem, the NRB only makes it worse, and the worsening decline in LOC/resp drive makes the hypoxemia worse.

I would have went from the NRB to a Venti Mask, titrated down the venti mask until I could put on a NC.

If I was unable to titrate down from the NRB to a Venti, I would have put the patient on Bipap.

If the problem was elevated CO2, I would have went straight to bipap. Then, if the ABG didn't improve after Bipap, we would intubate in my unit.

I agree.

I actually had a patient the other day in clinicals with great saturation on a FiO2 40% 12/5 BiPAP we tried to wean off. The patient's sats would tank to the low 80's just by switching to FiO2 40% Venturi, but would be perfect with a 100% NRB. We settled for continuing the BiPAP.

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Thank you very much NurseBee04, very informative.

there was not ABG done after the NRB started. I should have push the doc to draw ABG.

I understand that NRB delivers high concentation of O2, but not clear about it will worsen elevatd CO2. Please explain and thank you.

By the way I love the relaxed kitten. I have 500 piece puzzle which drives me nut but still love it.

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