O2 Sat 88%-90%, MD no action, opinions.

I would not override an MD's decision. A recent article in JAMA showed better outcomes for patients who coded with spo2's less than 92%. Unless something else was bothering me, like a change in LOC, increased HR, an spo2 of 88 to 90 seems reasonable.

If the patient was comfortable and was a known CO2 retainer with no other indications of a change in status (i.e.: cyanosis, AMS, tachypnea, tachycardia), then no, I'd leave well enough alone, but perhaps monitor a little more closely.

The MD was right to do nothing in my opinion as long as there were no signs and symptoms of respiratory distress or poor oxygenation. I have worked in the field as an EMT for a long time and pulse oximetry and CO oximetry is nothing new to us. We always teach our folks that those oximeters are simply a diagnostic tool and that we still need to fully evaluate the patient first.

We have a saying when it comes to these devices: "treat the patient and not the numbers". :)

The lowest pulse ox I have seen someone live at is 44-48% they had a rare hemoglobin disorder which also had a symptom of cyanosis. Pt was olderand said she was like that since birth. Monitor your patient and not the machine. That's why they teach You assessment skills.

Putting more O2 on a patient who is a known CO2 retainer can only do more harm than good.

As long as the patient wasn't symptomatic I would have let him be.

If the patient is a CO2 retainer, 88-92% is a good O2 sat. As others said, putting them on more oxygen would cause more harm.

Would absolutely not override that doctor. 88-90% is perfectly acceptable for a COPD'er. As long as the patient is comfortable, no altered mental status, no distress - no problem.

As others have mentioned COPDers need their hypoxic drive and many live at a certain level of sat, and pCO2 that would normally be unacceptable. MDs often order to maintain sats between 88% and 92%, although I have seen orders to maintain greater that 85%.

Since this patient is on a 5L oxymizer with an SpO2 of 88%, that is significant and indicates a widened A-a gradient. This does not appear to be just the run of the mill 2 L NC COPD patient. It was very wise to notify the physician of this patient's SpO2. There seems to be much more going on with this patient which is why "assumptions" that this SpO2 may be fine or even appropriate unless you have more information about labs, cardiac status and X-rays. What amount of oxygen is the patient on for a "normal" day? If the patient is normally on room air or 2 L by regular NC when not in the hospital and now he is on a 5 L oxymizer to maintain what may or may not be a normal SpO2 for him is noteworthy with a good assessment and documentation.

There will be situations where that 88% will not be adequate enough which deals with the oxyhemoglobin dissociation curve and which way it shifts. Very few COPD patients are retainers and sometimes it is necessary to treat whatever else is going on. With COPD patients you must also consider Cor Pulmonale, V/Q mismatch per another pulmonary issue such as pneumonia or PE and wound healing as part of what their "norm" should be.

Some become just focused on the SpO2. Sometimes a doctor may need to be made aware of more than just a "sat" to adequately determine if this oxygenation level is appropriate. Every situation may have a different minimun oxygenation requirement. Sepsis will be situation where more O2 will be needed if a protocol is in place. The SpO2 may need to be above 95% or adjusted for SvO2 if a monitor is in place. A Rapid Response Team may even place your patient on a high FiO2 device like a non-rebreather mask if sepsis is suspected with a protocol ran by lactate levels and not SpO2. Don't be surprised if you get an order to keep the SpO2 greater than 94% on some neuro patients while others with different neuro etiologies may only get room air. Some hospitals are rewriting their standing O2 protocols for 90% for CO2 retainers since many patients are hypoxic at 88% by PaO2 depending on the oxyhemoglobin dissociation curve and having 94% as the minimun for others instead of 92%.

People who are medicated and sedated are also difficult to assess for symptomatic oxygenation levels. This is why some patients may come out of post-op or who are get large doses of pain meds automatically get O2. However, for the post-op there is a goal to get the patient off O2 once they wake up to prevent atelectasis. The Haldane Effect also shouldn't be forgotten for post op patient either.

However, to be on the safe side and to inform others who adjust the O2, ask the doctor if you can write an order for his acceptable SpO2 for that patient. Of course, the patient may become symptomatic at 88% due to other things that affect the PaO2 and people with take that order as the word of law and not properly assess for oxygenation.

Also remember that smokers will have carboxyhemoglobin as part of the SpO2. This is why some RTs and Pulmonary clinics may refuse to titrate for SpO2 for homecare for patients who are smoking by just a walking test. They'll do an ABG and COOX. If you titrate for 88% with SpO2, the actual SaO2 might be 82% and the patient may not be visibly hypoxic but their organs may be noticing it.

The above are just some observations for more thought. Of course you should get the doctor's order but there are things that you may notice that he/she didn't that will affect oxygenation which should be mentioned. Occassionally a Pulmonologist consult may be necessary to adequately see what oxygenation level is appropriate for that patient and their disease process.

Cardiopulmonary diseases, the "hypoxic drive", oxygen and oxygenation are very broad areas to acquire more knowledge.

I would not override an MD's decision. A recent article in JAMA showed better outcomes for patients who coded with spo2's less than 92%.

Do you have a link to that article? During a code we rarely if ever acknowledge an SpO2. Post code we will look at the PaO2 and SvO2 (if a central line is placed). There was an article published for the PaO2 at 24 hours post code and after. However, the article did not mention what other damage was done during the code due to lack of oxygen and circulation such as renal or multi-organ failure and the cause of the cardiac arrest. The finding essentially was that people didn't wean post code patients quickly on the FiO2 even with a PaO2 of 300 mmHg. But then, the SvO2 might have been 40%.

Respectfully,

They additionally placed the patient on a non-rebreather @ 100% due to the sats being in the low 80's (the patient lived at 87,88%).

If the patient is hypoxic, you can not use the hypoxic drive theory as a reason for "knocking out his respiratory drive".

I believe Dr. Kamen had his glory days in the 60s. For the past 25 years we have learned much more about the hypoxic drive theory. More physicians and textbooks now teach about the release of hypoxic pulmonary vasocontriction and V/Q mismatching. The release of the hypoxic pulmonary vasoconstriction when the nebulizer was given may have been what caused your patient to experience a sudden rise in PaCO2 and not the fact that someone was trying to get the patient's SpO2 from the low 80s.

Any Respiratory Therapist who with holds O2 from a patient as you described:

did complain of SOB and was, as usual, extremely dyspnic at rest

******************

due to the sats being in the low 80's

should have their license removed immediately or be demoted to tank jockey in the basement.

If this patient this had a significant PaCO2 rise, he probably had a significant hypoxemia episode with pulmonary vasoconstriction. Some people do need ventilatory assistance but the alternative would be to see how long the cardiac, neuro and renal system can last while one theorizes about the "hypoxic drive". By your description, if nebulizers and O2 had been with held, this patient probably would have been a cardiac arrest and not just respiratory. Do not fear O2 when a patient is symptomatically in respiratory distress. If the patient goes apneic, it was probably inevitable.

And yes, it is possible to bag a patient who has an elevated PaCO2 level down but recognition of the respiratory distress, recovery time, adverse effects of hypoxemia and pulmonary vasculature constriction.