Oxygen and the rebreather mask question

We had a pt with O2 of 90. Hand are warm and this is a hospital grade pulse ox.
Dr says get oxygen and set it at 2 litters. The head managers and other head staff started barking orders too and say he’s on a rebreather not a nasel candela so it should be 10 litters and the bag should blow up.

I don’t now about how many liters I just follow Doctors orders. But I thought the rebreather bag did not have to be full?

anyone want to educate me.

Why were they on a nonrebreather and not a nasal cannula? I’m confused.

[amoLucia]

pOx of 90 is not so bad for everyone.

There's gotta be more clinical info that we just don't have here in this post.

1. A pulse ox reading of 90 does not warrant a non-rebreather mask.

2. When using a non-rebreather O2 flow must be between 10-15 lpm but the bag does not have to be fully inflated.

Edited Jul 18, 2020 by Wuzzie

Agree...not clear why this patient needs an NRB, period.

7 hours ago, Slipping CMA said:

We had a pt with O2 of 90. Hand are warm and this is a hospital grade pulse ox.
Dr says get oxygen and set it at 2 litters. The head managers and other head staff started barking orders too and say he’s on a rebreather not a nasel candela so it should be 10 litters and the bag should blow up.

I don’t now about how many liters I just follow Doctors orders. But I thought the rebreather bag did not have to be full?

anyone want to educate me.

Was PO2 low?

(I’m trying to learn more about critical care nursing. Please bear with me 😁)

We aren’t using nasal candula because of covid. Don’t ask me why it was a rule handed down by the higher ups.

as for why the oxygen it was ordered by the doctor because of his o2 level and patient felt dizzy.

[canoehead, BSN, RN]

I would start with nasal cannula at 2lpm and titrate up. The nonrebreather would come after maxing out the prongs, and yes, the bag must be inflated.

1 hour ago, Nurse GreenBean said:

Was PO2 low?

(I’m trying to learn more about critical care nursing. Please bear with me 😁)

I was told anything below 94-93 isn’t a good sign. So 90 was low. But fake nails, nail polish cold hands can affect the O2 reading.

2 hours ago, Slipping CMA said:

I was told anything below 94-93 isn’t a good sign. So 90 was low. But fake nails, nail polish cold hands can affect the O2 reading

That’s my understanding as well, though usually an NC would be OK for that.

I was asking about the partial O2 blood has because my understanding is that with some Covid patients, their SaO2 can appear to be in normal range but the blood gas PO2 level can be down in the 50s, so I was wondering if that was why an NRBM was being used on someone with 90% SaO2.

keeping in mind blood gasses are new to me and I haven’t looked at them since nursing school, go easy on me 😂

15 hours ago, Slipping CMA said:

We aren’t using nasal candula because of covid. Don’t ask me why it was a rule handed down by the higher ups.

They sound utterly uneducated about what they're doing and need to get with the program. Either that or staff has misunderstood. This is not correct and they can't just make policies to administer unnecessary and incorrect treatment because covid.

13 hours ago, Slipping CMA said:

I was told anything below 94-93 isn’t a good sign.

That's simply not universally true. It all depends on the clinical situation. An SpO2 of 93-94 might be a reasonable (but very general) guideline for when you should report to an RN, but then the RN (and possibly medical provider and/or RRT) will assess the patient to determine the significance of the finding.

15 hours ago, Slipping CMA said:

We aren’t using nasal candula because of covid. Don’t ask me why it was a rule handed down by the higher ups.

Just for your own info 🙂, this ^ stemmed from concern about causing viral particles (SARS CoV-2) to be aerosolized (blown out into the air) by "blasting" oxygen into the airways through nasal cannula prongs. To the extent that this is a concern, it refers almost exclusively to high flow nasal cannula, not low flow like we would be talking about with this patient at least initially. Also, patients can wear a simple mask over their face (not an oxygen mask but like a basic surgical mask) while receiving hi or low flow NC oxygen.

[amoLucia]

OP - are you working in the States? I ask as you comment 'head staff and head manager'?

Never quite heard them called that here in the States?

What was the medical problem that the patient sought care for? Did the situation you referred to take place in the hospital or an outpatient setting? Had the patient received a medical diagnosis for the problem they sought care for? Did the patient have a history of cardiac or respiratory problems?

Edited Jul 19, 2020 by Susie2310

This is an outpatient care setting with a walk in care clinic. But I work in immediate care. The patient was just in for a regular 6 month follow up. He was walking with the assistance of a cane and looked down for a second and that made him dizzy. I sat him down right away and took vitals. I reported all of them to the doctor but asked if I should get the oxygen because the O2 was 90. Doctor said yes. At the time my manager happened to be in the department and called other managers in because of her concerns for the patient but IMHO doctor is the one in charge of the situation because well he’s the doctor. The managers of the building and department started correcting the doctors.
the managers are the ones who also decided to take away the nasal candelas because of covid. Not my decision I just have to deal with it.

[pmath_RRT]

Non-rebreather masks should not be set lower than 15L. You run it any lower than that you will cause the patient to rebreathe their CO2. The bag MUST be inflated at least 2/3rds full on peek inspiration.

Is the pts SPo2 on the NRM 90%? If yes then yah they need it. My hospital only allows temporary NRM and will need to transition the pt to a more appropriate device like HFNC or BiPAP. Unless this is a COVID+ pt where we were allowing NRM + NC on. But that was my hospitals policy.

From, your friendly respiratory therapist

[Robmoo, ADN, BSN, RN]

On 7/18/2020 at 11:05 AM, Slipping CMA said:

We had a pt with O2 of 90. Hand are warm and this is a hospital grade pulse ox.
Dr says get oxygen and set it at 2 litters. The head managers and other head staff started barking orders too and say he’s on a rebreather not a nasel candela so it should be 10 litters and the bag should blow up.

I don’t now about how many liters I just follow Doctors orders. But I thought the rebreather bag did not have to be full?

anyone want to educate me.

First lets start with the primary drive to breath in the normal (healthy) person. This is governed by CO2 level. Respiratory rate and depth are controlled by the need to rid the body of excess CO2. Why? Because hypercapnia is bad. Bad as in if the blood level of CO2 gets too high the patient will suffer altered mental status. If the condition is not corrected the patient will lose consciousness and die. You have a non-rebreather mask covering the mouth and nose with 2L a small trickle of oxygen into this system. What is happening to the Co2 that the patient is exhaling? With a low level of O2 flow the patient is rebreathing their own exhaled CO2. CO2 is building up in the blood stream. That is why many O2 delivery systems have minimum flow listed. Whether the patient is on 2L or a NRBM is a medical decision, but if they are on the NRBM then there has to be O2 flow to wash out the CO2. Whether 90% is good or bad depends on clinical condition. Someone with advanced COPD might live in the high 80's. Give a patient with advanced COPD too much oxygen and they may quit breathing. You can Google hypoxic drive. For someone in your ED because of carbon dioxide poisoning? Put that O2 on and crank it up no matter what the sat probe says. The bag on the NRBM lets you know that the flow is high enough to meet the patient's ventilation needs and that they are truly getting 100%. Why use a NRBM when in the doctor's judgement all the patient needs is 2L of O2? There had better be a policy or standing delegated order (SDO) that specifies a NRBM or you could be practicing medicine without a license by putting the patient on a NRBM. When you have a few minutes ask one of the more experienced nurses the rationale for having the patient on a NRBM. Without knowing the entire clinical picture it is tough to know.