o2 @ 2L

GreyGull · May 24, 2011

People forget patients can feel air hundry because thier co2 is high and not just because thier oxygen is low! Dont forget the other part of the puzzle! In EMS we can measure conrinuos co2 which is very helpful and I wish more hoapitals would do this as well!
Happy

This has its limitations when it comes to the PaCO2 - PetCO2 gradient or V/Q mismatching where there are many variables involved. In the hospital we do ETCO2 but we also know those variables through CXR, EF or CO measurements and correlation with the ABG. The numbers on the ETCO2 can be misleading if the other factors are not known or if the health care provider is just going by the "numbers". We also know not every patient requires continuous ETCO2 monitoring since there are other assessments that can be done which are sometimes more reliable than the ETCO2. Just like the pulse ox, it has its place but the limitiations should be well known.

You must also know the factors that raise PaCO2 and what deadspace ventilation is as well as shunting.

imintrouble, BSN, RN · May 24, 2011

Sometimes I think I may over simplify these all nurse scenarios.

O2 sats normal on RA

Anxiety

PRN O2

OP didn't specify, but I'll assume clear lungs.

I'll be honest, most of the COPDers we have are repeat customers, and we are familiar with them. What the OP described is not rare with the pts we have. They are anxious. I would be too. The O2 cannula is comfort. Psychologically it's their lifeline.

I'm going to get hammered for this but...........Give the anxiety med, leave the cannula in the nose, but turn the O2 off at the wall without telling the pt. Monitor. If the pt reports feeling "so much better" it might just be simple anxiety. At that point some significant teaching needs to be done.

Disclaimer: I'm not talking about acute exacerbation episode. The pt is improving, steroids weaning down. I would only do the above if the MD and Respiratory were on board too. The MD is your best resource as he/she has a significant history with the COPD patient. I'

ObtundedRN, BSN, RN · May 24, 2011

If the CO2 on a BMP/CMP is rising, you can't say that you know they are retaining. CO2 on your BMP/CMP is different from your PaCO2 on your ABG. On your BMP/CMP, this is really more of an indication of your Bicarb, not carbon dioxide.

GreyGull · May 24, 2011

Due to the disease process of COPD, I don't always expect to hear wheezes even in an exacerbation. If I do and and they are short of breath, a call to the Pulmonologist and a ventilator might be in their very near future. I posted the links earlier for the differences in COPD and Asthma including pathophysiology and treatment. This is not to say there can not be mixed components which the COPD treatment plan takes into consideration.

For LTC patients, either at the LTC facility or in an acute hospital, there should be some things to consider which might go into the nursing orders or comments section.

1. Has the patient been qualified for LTOT(Long Term Oxygen Therapy)?

2. Or, does the patient have a titrate order such as keep SpO2 > 92% Is this just to titrate to their baseline LTOT if in acute or returning from acute?

3. Or, is there a condition for the O2 such as with sleep or activity?

4. Does the patient have other conditions such as cardiac, right heart failure, low EF or pulmonary hypertension?

5. How deconditioned is the patient and will they be getting any form of physical therapy?

6. Lab values and if there is anemia involved.

7. Does the patient also have a restrictive as well as obstructive component with their COPD PFTs?

8. And of course as someone mentioned earlier, their diet.

9. What geographical location and at what altitude are you at?

Many times PT, RT and nursing will be involved in qualifying a patient to Long Term Oxygen therapy (LTOT). We may just be pushing the limit to do so but we know it will be a benefit for them to continue their activity level. It is disheartening to see a patient who PT worked extensively with returning to the acute hospital that was "weaned" to room air but had to stay in bed because they got SOB and anxious each time they attempted to get out of bed so they became a sedated deconditioned vegetable again.

Patients who are deconditioned and who have chronic disease processes do get anxious. Not feeling you are getting enough oxygen either due to crappy lungs or a heart that has lost its kick can definitely cause anxiety. We've had perfectly healthy young people, especially athletes or weekend warriors, who have had sudden onset of SOB with rapid A-fib but whose SpO2 appeared to be "normal" although most pulse oximeters get confused with irregular and/or rapid rates. How many just take the heart rate off the pulse ox or BP machine? I suggest always confirming with heart sounds and an apical rate on patients you are assessing for reasons as to why they are SOB.

Some laughed at my posts on a previous thread about getting ventilator patients out of bed and even ambulating them. We take deconditioning seriously and even after weaned from a ventilator, we may need to put them on a high flow cannula or mask just to sit them up at bedside. We get liberal titrate up orders for PT when they work with some of these patients. If the nursing home patient can over come their anxiety to get to the dining room with a 2 L NC, I would definitely see that rather than sedated and left in bed because that might be the easiest.

I posted this link in the pulmonary section awhile back and I see the links aren't working now.

Here is the updated link to Dr. Tom Petty's book "Adventures of an Oxy-Phile". It is short but informative.

http://www.drtompetty.org/uploads/AdventuresofanOxyphile.pdf

This article of his is excellent in providing in detail a great overview of all the things myself and others have mentioned for dyspnea.

http://www.drtompetty.org/uploads/FrontlineCardiopulmonaryDyspnea.pdf