O2 question: 80s on room air?! What to do?!?!

[Summers3]

Hello everyone! I have a silly O2 question that I just can't find the answer to.

The nurse I was shadowing admitted a patient due to pneumonia with hx of COPD and was in the 82-84 on room air. I was taught that anything below 90 is like OMG, RED FLAG!

The patient was having just A LITTLE bit of trouble breathing but the nurse just completed all the admit paperwork first and only put on 2L of O2 on nasal cannula about 20 minutes later. Yes, the pt's saturation slowly climbed up to the 90s in a little bit....

So I guess my question is..... for someone with O2 on room air in the 80s, is 2L on NC really going to do any good (although it worked for this patient)? And.... was my panic wasn't necessary?

I would have think (as a student) that you get something more potent in delivering O2 like face mask RIGHT AWAY. Or is it because the pt has hx of COPD so therefore cannot tolerate more than 5-6L of O2 so Nasal cannula is the only way to go? Or maybe the patient wasn't symptomatic (she was only breathing a little bit heavy)?

I apologize, I just feel that from school, anything under 90% is HUGE concern and that Nasal cannula is NOT going to do anything.... but apparently I was wrong for this patient?

THis is the critical thinking as a nurse I am still lacking. Please give any advice I can to improve my thinking.

Thanks for the feedback!

[Xlorgguss]

Depends on what the patient's baseline was. Many COPD patients "live" at 87-88% on room air. How was the circulation for their SpO2 probe? Poor circulation can skew that number. As far as cranking the oxygen, each liter of air adds 3% O2. So 2 liters would add 6% to the 84 to give 90% so that seems completely appropriate.

[vanilla bean]

As far as cranking the oxygen, each liter of air adds 3% O2. So 2 liters would add 6% to the 84 to give 90% so that seems completely appropriate.

That's *not* how that works. You are confusing two different measurements. Each liter of oxygen adds approximately 4% of oxygen to the percent of oxygen in *room air* (after 1L). Room air is 21% O2. A nasal cannula at 1L is approx 24%, 2L approx 28%, etc. It is not a guide to determine how many liters of oxygen to give to increase the SpO2 by a set amount.

[Esme12, ASN, BSN, RN]

There are several things to consider with this patient. First and foremost...patient history. Second...you can be alarmed at something as a nurse. Panic is not Okay. If you have to panic...don't panic in front of the patient.

Think about your respiratory COPD patients. Remember hearing that there are pick puffers and blue bloaters? This is a great overview. Chronic obstructive pulmonary disease (COPD) | McMaster Pathophysiology Review

Some patients with COPD are CO2 retainers and therefore have a CO2 drive to breathe instead of an O2 drive. NO if a patient is severely hypoxic and struggling desperately to breathe you WILL give them the oxygen necessary to save their life. So, a blanket statement to say you never give a COPD CO2 retainer higher levels of O2 is not appropriate. Here is a great review for oxygen delivery and O2 delivered.

Oxygen Therapy

It is best to ask questions while you are in clinical. I know students are sometimes do not like to ask the nurse questions. Some nurses are willing to teach and the ones who don't probably do not know how to answer your questions so ask your instructor. What you tell us about this patient is that they were admitted for pneumonia and have a history of COPD. The patients O2 sat is in the 80's..something to be concerned about however the patient is not have extreme distress breathing and states they are having a"a little" trouble. If the patient isn't retracting and can talk in full sentences I would be sure to be judicious in the use of oxygen. The goal of treating patients is to obtain the best result at the lowest effort/amount.

Start low and increase according to orders, patient history, and patient need.

[Xlorgguss]

That's *not* how that works. You are confusing two different measurements. Each liter of oxygen adds approximately 4% of oxygen to the percent of oxygen in *room air* (after 1L). Room air is 21% O2. A nasal cannula at 1L is approx 24%, 2L approx 28%, etc. It is not a guide to determine how many liters of oxygen to give to increase the SpO2 by a set amount.

Oh well that's how I was taught. I'm not saying that those two liters will definitely get that patient up to 90, And they won't go higher than 90. But that's how we were taught to approach it and then see the therapeutic effect.

[HIPAAPotamus, BSN, RN]

From my experience, COPD patients are generally given NC as opposed to a face mask, due to a concern about oxygen toxicity. Their bodies have acclimated to higher CO2 and lower O2, so a higher stream of O2 can be dangerous.

[mrsboots87]

In an asymptomatic patient, I would not run for the mask and pump the O2 up past 6L. While I don't want *most* of my patients in the mid 80's, if they aren't in distress it's not at the top of my priority list.

The critical thinking king you will learn over time is how to apply the whole scenario, not just one value. Your patient was not in distress. They have COPD, and the nurse didn't walk away, they just weren't aggressive with the O2 delivery. You will find with practice, that 2L is all you need to start with for most patients in the 80s to get them up above 90. You really can deliver to much O2 and it become toxic for a patient. Unless the patient is retracting, turning blue, dyspnic, etc, you don't need to start at a high rate.

What the nurse may have been doing with the admit, is looking for the O2 orders. You will find with COPDers with a detailed history, the physician may have O2 delivery perimeters outside of the "normal" range. Like "2L per NC PRN to keep O2 sats between 87-91" or whatever because that is the saturation level proven to be best for that patient.

[Here.I.Stand, BSN, RN]

Remember too, that the 2L *did* bring the SpO2 up -- so in hindsight you can see that a more aggressive delivery system was in fact not indicated.