97% O2 with NRM

Keep_Calm · Apr 18, 2015

In my opinion, if he was sating 97% on 2L with a NRM, then maybe he didn't really need it in the first place...? You mentioned he was a frequent flyer. I had a pt. once who was so SOB and we couldn't figure out why. His sats were fine. He continued to c/o SOB and seemed very distressed so we did blood gases. While he was in xray, his son came forward and reported to us that his father "acts this way every time he is in the ER." And what do you know, his blood gases showed that he had actually put himself into respiratory alkalosis by trying so hard to be SOB! Long story short, we took the O2 off and gave him a xanax and he was fine. Maybe this is a psychosomatic issue your pt. is having. Is he holding his breath on purpose to de-saturate. (Is that possible, lol?) Does the attention and the NRM have a placebo effect on him? It is hard to say without more to the story. What did his lungs sound like? What was his WOB like? Chest Xray? PMH? Does he have COPD? Does he need the NRB to increase his hypoxic drive?

iluvnoodles · Apr 18, 2015

I tried to put him back on the nasal cannula, & he would desat once again. Lungs were clear, no changes in mental status. Only issue was that off of the NRM he would desat. He does have COPD, CXR ordered, already on Xanax.

Altra, BSN, RN · Apr 18, 2015

I think I must be misunderstanding your question, as I am reading that you had him on the same 2L, via a nasal cannula and a nonrebreather mask.

Nonrebreathers are not even functional at that low flow rate.

blackvans1234 · Apr 18, 2015

Anyone concerned with putting a COPD'er on a NRM?

GrannyRRT · Apr 18, 2015

Anyone concerned with putting a COPD'er on a NRM?

I am more concerned about someone putting anyone on a NRM at 2 LPM.

Even 97% SpO2 on a nonrebreather does not give a clear picture especially if the A-a gradient could be >300 mmHg.

Sun0408, ASN, RN · Apr 18, 2015

NRB at 2L?? Something doesn't sound right. OP can you explain please

MunoRN, RN · Apr 18, 2015

A non-rebreather mask only works correctly when there is sufficient O2 flow to expel the exhaled CO2, otherwise the patient is actually re-breathing their own CO2 with a little bit of oxygen mixed in.

If you're looking to give the patient more oxygen than 2L NC, why are you not just turning up the NC flow (to 3, 4, 5 or 6)?

akulahawkRN, ADN, RN, EMT-P · Apr 18, 2015

It could be a positional (in bed) thing. If the patient is sitting in bed but the hinge in the bed for raising the HOB up isn't at the hips, the patient could be bent somewhere near the bottom of the ribs, in effect, reducing the depth of each breath just a little bit. If the patient doesn't feel all that short of breath, they'll desat to the 80's, even if on oxygen. Putting the patient on a NRB might not be all that comfortable for the patient and if there's not a good fit, then they're effectively breathing room air + a couple %. That discomfort might make them think about their breathing a bit and therefore they don't desat because they're somewhat consciously taking deeper breaths despite sitting up in just the wrong spot.

Just remember, nasal cannulas can go (usually) to about 6 LPM. If you put a mask on the patient, you'll want about 10 LPM. If you put them on a non-rebreather, then you're looking at 12+ LPM (usually 15+ LPM) to maintain a fairly high FiO2. In other words, if you use a mask, don't go below 10 LPM without a darned good reason and if the mask is a pretty good fit, then the patient won't get anywhere near enough oxygen when below 10 LPM.

GrannyRRT · Apr 18, 2015

if you use a mask, don't go below 10 LPM without a darned good reason and if the mask is a pretty good fit, then the patient won't get anywhere near enough oxygen when below 10 LPM.

It is not so much the FiO2 which can cause the harm but the rebreathing of CO2. This will not be noticed by the SpO2 value until it is too late.

I am going to be the "2 L" thing has to do with the old training of no more than 2L for COPD patients regardless of device.

Because of so much confusion in O2 devices, NRMs and Simples masks ( and even Venti masks) should be banned. The Oxymask is safer.

Christy1019, ASN, RN · Apr 18, 2015

It is not so much the FiO2 which can cause the harm but the rebreathing of CO2. This will not be noticed by the SpO2 value until it is too late.
I am going to be the "2 L" thing has to do with the old training of no more than 2L for COPD patients regardless of device.
Because of so much confusion in O2 devices, NRMs and Simples masks ( and even Venti masks) should be banned. The Oxymask is safer.

Okay so I had no idea what an oxymask was so I looked up a picture. It looks cool but would you be willing to explain what it is and how it works?

GrannyRRT · Apr 18, 2015

It is an open light weight mask with a shallow cup like piece in the center directing oxygen at the patient.

OxyMaskâ„¢ Adult | Medical Supplies | Southmedic

This site provides great info. Read the FAQs section and use it as a reference if your facility is interested or finally gets the Oxymask.

It has been around for over 10 years. It is great for ER patients because you don't have a tangled mess of different masks. The patient can still be examined, NT or oral suctioned, sip water and be weaned or increased without changing equipment. I love it for broncoscopy_ where I don't have to hold a mask near the patient when the nasal cannula is not enough.

It is great for bloody and packed noses aa well as mouth breathers.

And, it can be used with a humidifier. But, that part rarely gets mentioned if the facility still has NRB and simple masks around to avoid serious mishaps.

It is also available in pedi sizes and with an ETCO2 option.