What are the next steps for a patient with hypoxemia, initially with an oxygen saturation of 97%, then decreasing to 85%, and currently stabilized at 91% on 6 liters per minute (L/min) of oxygen?

From the Guidelines

I strongly recommend continuing oxygen therapy at the current flow rate of 6 liters per minute and closely monitoring the patient's oxygen saturation, as the current saturation of 91% is still below the target range of 94-98% for most patients, according to the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. The patient's oxygen saturation has dropped from 97% to 85%, which is concerning as it indicates significant hypoxemia. While increasing to 6 liters has improved saturation to 91%, this is still below the target of 95% or higher for most patients. The patient likely needs medical evaluation to determine the cause of the oxygen desaturation, which could include conditions like pneumonia, pulmonary embolism, heart failure exacerbation, or COPD flare. Some key points to consider in the management of this patient include:

• The recommended target saturation range for acutely ill patients not at risk of hypercapnic respiratory failure is 94-98% 1.
• For patients with known chronic obstructive pulmonary disease (COPD) or other known risk factors for hypercapnic respiratory failure, a target saturation range of 88-92% is suggested pending the availability of blood gas results 1.
• Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range (and eventually discontinued as the patient recovers) 1.
• Patients who have a target saturation of 88-92% should have their blood gases measured within 30-60 min to ensure that the carbon dioxide level is not rising 1.
• Stable patients on oxygen treatment should have SpO2 and physiological variables (eg, NEWS) measured four times a day 1. While waiting for medical help, position the patient upright if possible to optimize lung expansion, continue oxygen therapy, and monitor vital signs closely including respiratory rate and level of consciousness. Oxygen saturation below 90% can lead to tissue hypoxia and organ damage if prolonged, making prompt intervention essential. It is also important to note that the patient's oxygen saturation should be monitored for at least 5 min after starting oxygen therapy or for patients who require an increased concentration of oxygen and after oxygen therapy has been decreased or stopped 1. Additionally, if the patient's oxygen saturation is consistently lower than the prescribed target range, there should be a medical review and the oxygen therapy should be increased according to an agreed written protocol 1. The patient's condition should be closely monitored, and medical attention should be sought immediately if the saturation continues to drop or the patient shows signs of respiratory distress such as increased work of breathing, confusion, or cyanosis.

From the Research

Patient Status

The patient's oxygen saturation has decreased from 97% to 85% and is currently stabilized at 91% on 6 liters per minute (L/min) of oxygen.

Next Steps

• Monitor peripheral oxygen saturation (SpO2) as a surrogate for arterial oxygen saturation (SaO2) 2
• Titrate the delivered oxygen fraction to maintain SpO2 within a target range 2, 3
• For patients without risk factors for oxygen-induced hypercapnia, oxygen therapy should be started when SpO2 is ≤92% and stopped when it is >96% 2
• Since the patient's current SpO2 is 91%, which is below the upper limit of 96%, oxygen therapy can be continued 2
• Consider arterial blood gas (ABG) analysis for a more comprehensive assessment of oxygenation and acid-base status, especially if SpO2 levels fall below 90% 4

Target Oxygen Saturation Range

• For patients without risk factors for oxygen-induced hypercapnia, the target SpO2 range is between 92% and 96% 3
• For patients at risk of hypercapnia, the target SpO2 range is between 88% and 92% 2, 3

Oxygen Therapy

• High-flow oxygen therapy should only be used in specific diseases such as carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax 2, 3
• For acute hypoxemic respiratory failure, high-flow oxygen therapy may not be associated with reduced in-hospital mortality compared to conventional oxygen therapy 3