Oxygen administration with COPD patients

[Krazziekid78]

I'm a new grad working in a rehab facility. We get a lot of patients with COPD who seem to always de-sat. Nursing school pounded it into my brain to be very cautious about administering too much oxygen to ensure patients don't lose their drive to breathe. However, I have seen so many COPDers and up to 10 L of oxygen! I had a gentleman's sats drop to the low 60s today after therapy. The nurse I was working with turned his oxygen up to 10 on a non rebreather, sats improved, then we titrated him back down. My question is- what is the best way to get a patients sats back up when they have COPD? Does the oxygen LPM really matter? Or is it mostly a focus on the o2 sats, making sure they don't climb above 93%? Is it that common to see COPDers on more than the recommended 3lpm?

[guest538567]

Thank you for asking this question. It is important as a new graduate that your practice be evidenced based. There are many myths and misconceptions that abound in nursing and with many things the truth can be "in the middle". I have included a citation and link for an article that discusses COPD and hypoxia.

Abdi, W. F. & Heunks, L. (2012). Oxygen-induced hypercapnea in COPD: Myths and facts. Critical Care, 16(5), 323. Oxygen-induced hypercapnia in COPD: myths and facts

Quote

During our medical training, we learned that oxygen administration in patients with chronic obstructive pulmonary disease (COPD) induces hypercapnia through the 'hypoxic drive' mechanism and can be dangerous. This mindset frequently results in the reluctance of clinicians to administer oxygen to hypoxemic patients with COPD. However, this fear is not based on evidence in the literature. Here, we will review the impact and pathophysiology of oxygen-induced hypercapnia in patients with acute exacerbation of COPD and recommend a titrated oxygen management.

The article recommends:

Quote

In patients with COPD, hypoxic pulmonary vasoconstriction is the most efficient way to alter the Va/Q ratios to improve gas exchange. This physiological mechanism is counteracted by oxygen therapy and accounts for the largest increase of oxygen-induced hypercapnia. A titrated oxygen therapy to achieve saturations of 88% to 92% is recommended in patients with an acute exacerbation of COPD to avoid hypoxemia and reduce the risk of oxygen-induced hypercapnia.

[Krazziekid78]

Thank you for your reply. This answered my question. Rather than focusing on a amount of oxygen being delivered, it's best to titrate to the 88-92%. I was just shocked at the amount of COPDers receiving up to 8-10 LPM, none the rest on a rehab floor! í ½í¸± I had always heard it was unsafe for COPDers to be more on 3 L. But you gotta do what you gotta do to keep their sats up

[LPN27713]

Krazziekid78 said:

Thank you for your reply. This answered my question. Rather than focusing on a amount of oxygen being delivered, it's best to titrate to the 88-92%. I was just shocked at the amount of COPDers receiving up to 8-10 LPM, none the rest on a rehab floor! I had always heard it was unsafe for COPDers to be more on 3 L. But you gotta do what you gotta do to keep their sats up

8-10 seems like allot, I would make sure there is a specific doctors order for that much o2!

[BR157]

Krazziekid78 said:

I'm a new grad working in a rehab facility. We get a lot of patients with COPD who seem to always de-sat. Nursing school pounded it into my brain to be very cautious about administering too much oxygen to ensure patients don't lose their drive to breathe. However, I have seen so many COPDers and up to 10 L of oxygen! I had a gentleman's sats drop to the low 60s today after therapy. The nurse I was working with turned his oxygen up to 10 on a non rebreather, sats improved, then we titrated him back down. My question is- what is the best way to get a patients sats back up when they have COPD? Does the oxygen LPM really matter? Or is it mostly a focus on the o2 sats, making sure they don't climb above 93%? Is it that common to see COPDers on more than the recommended 3lpm?

For this situation it is the nurse who could cause the CO2 retention and NOT the oxygen. Incorrect use of the nonrebreather is dangerous. I agree with the person who posted somewhere that the Simple Mask and the Nonrebreather should never be used where people are not trained in their use and recommended a different mask to prevent such failures in use. Here, 10 L on an adult with a nonrebreather is inappropriate. The flow must be adequate to flush the CO2 from the mask. If not, the CO2 goes up but not from the oxygen. For Simple and Nonrebreather masks you must run at the recommended amount and not try to titrate flow for weaning. If you want to decrease the amount of oxygen given, use a different and more correct device.

EMS is constantly running to emergencies in nursing homes because a patient was placed on less than the recommended amount of flow appropriate for a mask. Some of the reasons the nurses have given have been "don't want to give much more than 2 L because of the hypoxic drive" or "but they were on 2 L by NC before the fell asleep and started mouth breathing". They fail to see how they almost or did kill the patient by their lack of knowledge about how to give oxygen and by what device correctly.

The LPM will depend on the oxygen device to run the device correctly to obtain a certain FiO2 and how fast or deep the patient is breathing which is called tidal volume and minute volume for 1 minute. A patient without distress breathing a normal rate of 14 on a 6 LPM nasal cannula will have a higher FiO2 delivered than someone breathing 30x a minute struggling for breath who actually needs more FiO2.

There are a lot of threads here which have great information posted about "hypoxic drive the myth" and oxygen administration for V/Q mismatch which obviously were posted by a Respiratory Therapist. A search for those will lead you to more knowledge. Right now, it seems the nurses at your facility need a lot of training on just how to use oxygen masks appropriately with the correct liter flow for patients. Remember, that is a plastic bag you are sticking their face into.

[BR157]

LPN27713 said:

8-10 seems like allot, I would make sure there is a specific doctors order for that much o2!

8 - 10 L on a nonrebreather mask is not enough. Too little flow of oxygen will cause the CO2 to rise and not the oxygen itself.

Just following a doctor's order but not knowing how to use the oxygen device will harm the patient more than the possibility of knocking out the hypoxic drive as most here still seem call it. You can not blame the hypoxic drive myth on your mistakes for incorrect use of an oxygen device.

[classicdame, MSN, EdD]

I recommend the DON arrange for an in-service from a respiratory therapist. I do this for new nurse orientation in our hospital. It is very enlightening!

[chare]

BR157 said:

For this situation it is the nurse who could cause the CO2 retention and NOT the oxygen.

Really? And you base this statement on what? The OP stated that the oxygen was titrated to 10 LPM on a NRB, however did not mention with what device, and what flow they started. I didn't necessarily read that to mean that they started at 1 or 2 LPM on a NRB. If that is in fact what they did, then yes, that could have contributed to CO2 retention.

BR157 said:

8 - 10 L on a nonrebreather mask is not enough. Too little flow of oxygen will cause the CO2 to rise and not the oxygen itself.

[BR157]

chare said:

Really? And you base this statement on what? The OP stated that the oxygen was titrated to 10 LPM on a NRB, however did not mention with what device, and what flow they started. I didn't necessarily read that to mean that they started at 1 or 2 LPM on a NRB. If that is in fact what they did, then yes, that could have contributed to CO2 retention.

Why are you confusing the issue? No, do not start a nonrebreather mask at 1 to 2 Liters. H## yes putting somebody's face in plastic at 1 Liter flow will cause CO2 retention. Most textbooks will say no less than 10 L/M for an adult. But in case you missed it, I did explain about minute and tidal volume. In EMS updates and if you ask a Respiratory Therapist, they will say not to just go by the reservoir bag since rarely is there an adequate seal to make a difference in the bag deflation. Usually the patient is taking in room air from around the mask which then gives a much lower FiO2 regardless of what the textbooks says. Air goes the path of least resistance and often that is from around the mask. Why do you think you are seeing less nonrebreather and almost no simple masks in some ERs and hospital floors?

Many nursing and EMS textbooks still say never give more than 2 Liters to any patient with COPD and still preach knocking out the hypoxic drive also.

So please do not put the Nonrebreather on any less than 10 liters for safety sake especially for those who are on this forum with questions about oxygen. If you want to use less flow, consider another device.

Take classicdame's advice and consult with a Respiratory Therapist.

[Krazziekid78]

Wow okay. Should have been more specific. We OBVIOUSLY tried to titrate through the NC, once we hit 6 Ls and patient was sill in the 70s, we started the non-rebreather on 10 lpm, when his sats finally started to rise. Once he was stable and non-symptomatic at 89-90%, we put him back on a NC and brought him back down to his usual and ordered 4 lpm. He was only hooked up to the non rebreather at 10 for about 5 minutes. Just was scary and wanted info on how to manage de-satting COPD patients when you don't have the luxury of a RT or rapid response team. We are a very small facility and when stuff gets rough, we send them out to ER.

[Abby10]

We had the best masks they were oxymask, open ones so that you could run 1-10L in them and not worry about CO2 retaining because it was just a bit of plastic and a bunch of wholes. And besides the need to have a safe delivery method if a COPDer need it they need it. Just remember O2 is a drug and one of the rights really should be right delivery method for the dose. And just watch if they are mouth breathing just slipping the NC in their mouth for a couple minutes to get them up tends to work.