At what oxygen saturation level would you admit a Chronic Obstructive Pulmonary Disease (COPD) patient to the hospital?

From the Guidelines

Patients with COPD should generally be considered for hospital admission when their oxygen saturation falls below 88-90% despite supplemental oxygen therapy, especially if this represents a significant drop from their baseline. For COPD patients with chronic hypoxemia, admission decisions should be based on changes from their personal baseline rather than absolute values alone. Additional factors that would strengthen the case for admission include respiratory distress, altered mental status, inability to maintain adequate oral intake, failure of outpatient treatment, significant comorbidities, or lack of adequate home support. It's essential to note that unlike other respiratory conditions, excessive oxygen supplementation in COPD patients can be dangerous due to the risk of hypercapnic respiratory failure, as some COPD patients rely on hypoxic drive for respiratory stimulation. Therefore, oxygen should typically be titrated to maintain saturations between 88-92% in these patients, as recommended by the 2023 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1. The decision to admit should always be individualized, considering the patient's overall clinical condition, baseline functional status, and available outpatient resources for follow-up care. Key considerations include:

• Maintaining target oxygen saturation ranges to avoid hypercapnic respiratory failure
• Monitoring for signs of respiratory distress or deterioration
• Adjusting oxygen therapy based on individual patient needs and response to treatment
• Collaborating with healthcare teams to ensure comprehensive care and follow-up.

From the Research

Saturation Levels for COPD Patients

• The European and British guidelines endorse oxygen target saturations of 88%-92% for hospitalized patients with exacerbation of Chronic Obstructive Pulmonary Disease (COPD), with adjustment to 94%-98% if carbon dioxide levels are normal 2.
• In patients with COPD receiving supplemental oxygen, oxygen saturations above 92% were associated with higher mortality and an adverse dose-response 2.
• The practice of setting different target saturations based on carbon dioxide levels is not justified, and treating all patients with COPD with target saturations of 88%-92% will simplify prescribing and should improve outcome 2.
• Current recommendations suggest an inspired oxygen level (FiO2 ) < 0.28, aiming for saturation (SpO2 ) of 88-92% until arterial blood gas analysis is available 3.

Hospital Admission Criteria

• Patients with COPD exacerbations can be admitted to the hospital with oxygen saturation levels below 88% 3.
• High-flow oxygen is often used for the initial treatment of COPD exacerbations, but only 53% of patients are recognized as having COPD 3.
• A larger study would be required to assess any possible harm of this approach, but education of those involved in the care of COPD patients may reduce the risk of complications of hypercapnia 3.

Management of COPD Exacerbations

• Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life 4.
• Various pharmacologic and non-pharmacologic strategies are used to manage COPD exacerbations, including inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, and pulmonary rehabilitation 4.
• Invasive mechanical ventilation is sometimes necessary for patients with severe COPD exacerbations, and novel cost-effective strategies such as high-flow oxygenation or extracorporeal carbon dioxide removal may improve clinical outcomes and functional recovery 5.