Oxygen therapy in ED

Horseshoe, BSN, RN · May 15, 2018

Horseshoe does make a good point, but it's perhaps not complete. All patients will need a certain amount of oxygen. There is a LOT that goes into determining how much oxygen is sufficient for a given person. Some people don't mentate well at 90%, some mentate just fine at 88% or lower... and above 91% they start having oxygen problems (from too much). You just have to get to understand what's going on and why. Personally I don't worry much about oxygen in the COPD patient unless they're really, really advanced COPD. Experience is and excellent teacher, but lean on those that are specialists and really lean on them if they love to teach...

But not all patients will need supplemental oxygen, which is the subject of the OP. As I said, it depends on the patient's medical history and current condition...

PeakRN · May 15, 2018

This is something that in no way will fit into a single post or thread, but I'll try to start with some basics. First you need to assess what you are trying to support. I think that you might get more benefit out of looking up when certain modalities are indicated. I would include the following in this list for the ED: nasal cannula, venturi mask/oxytyke/oxykid/oxyadult, intermittent vs continuous nebs, simple mask, non-rebreather, heated/humidified high flow nasal cannula, CPAP/BiPAP, And vents including AC/SIMV/PCV, surgical airways, and trans-tracheal jets.

I would also look into PSV settings on vents, when to use paralytics as a vent adjunct (not part of RSI), jet ventilators/oscillators, and when to prone/rotate vented patients. These are more of things to be done in the units but the knowledge will help you a lot.

I would also investigate what medications we use to support airway therapy including albuterol, atrovent, xopenex, racemic epinephrine, IV/PO steroids, inhaled steroids, IM epi, terbutaline, mag, IV epi, and sub-dissociate ketamine. There are far more medications but these are a good starting point for the ED. I would also look at nitric oxide (not nitrous) and why we give it to neonates as a bridge to ECMO but understand that unless you work in a peds specialty hospital you will probably never see it.

A few other thoughts too: Positioning also has quite a bit to do with ventilation, why do we place most patients at 30 degrees? How much lung volume do you loose by laying flat? Why do patients tripod/nasal flare/purse lip? When do you suction, and why deep vs nasal wash vs just oral/superficial nasal? I would learn how to interpret an ABG and VBG, and not just to determine for respiratory/metabolic alkalosis/acidosis like nursing school teaches but rather what they actually mean from a respiratory management standpoint and how to adjust NIPPV/Vents from it.

You should be familiar with some basic disease processes that we see in the ED and the standard course of treatment: Congential heart disease, croup, bacterial tracheitis, reactive airway disease, asthma, CHF, COPD (chronic bronchitis vs emphysema), management of angioedema, and the pulmonary complications of allergic reactions. How do we manage airways during arrests or traumas. When is RSI indicated.

Generally speaking oxygenation is often less of a problem that people think. We typically do not see problems with hypoxia until the patient is below 80% (in healthy patients), think about how we don't worry a whole lot about carbon monoxide unless it is greater than 20% and inclusion critera varies but our hyperbaric chamber doesn't take cases unless they are above 26% or symptomatic (rather they are managed with NRBs or NIPPV with 100% FiO2). At sea level the general recommendation is to be above 93-94% awake and 90% asleep, at elevation we want patients above 90% awake and 88% asleep. That being said sick patients will have increased oxygen demand and we supplement them to help this and to prevent further deterioration. I generally care more about their CO2 than O2 on a ABG.

There is a lot of push to not hyperoxygenate patients, high gas tensions in the plasma can cause vasospasm which is especially detrimental in MIs and strokes. The free radicals also cause damage but are less of a problem in the short term of the ED. Do not let this keep you from throwing a NRB at 15 on a trauma or bagging with 100% FiO2 in a code, let a lone being aggressive in a patient with respiratory distress. We can always pull back, but dead is pretty hard to fix.

Don't be afraid of respiratory equipment, especially if you are in a smaller ED that doesn't have RTs all of the time. Learn how to give nebs including continuous and inline. If you can learn how to draw ABGs, they are huge in the care of very sick respiratory patients. Don't be afraid to ask your RTs questions, they are a huge wealth of knowledge.