What should be done for a patient with hypoxemia at 84 percent who needs oxygen now?

Management of Patient with Hypoxemia at 84% Oxygen Saturation

A patient with oxygen saturation of 84% requires immediate oxygen therapy with a reservoir mask at 15 L/min to rapidly increase oxygenation while simultaneously assessing for hypercapnic respiratory failure risk. 1

Initial Management

Immediate Actions

• For SpO₂ <85%, start oxygen therapy with:
  • Reservoir mask at 15 L/min for most patients 1
  • Target SpO₂ 94-98% for most patients
  • Target SpO₂ 88-92% for patients at risk of hypercapnic respiratory failure (COPD, neuromuscular disorders, obesity hypoventilation) 1

Risk Assessment for Hypercapnic Respiratory Failure

• Identify if patient has conditions that increase risk:
  • COPD
  • Neuromuscular disorders (e.g., Duchenne muscular dystrophy)
  • Morbid obesity
  • Chest wall deformities
  • Bronchiectasis 2

Monitoring Requirements

• Continuous oxygen saturation monitoring
• Monitor respiratory rate and heart rate (more sensitive indicators of deterioration than visible cyanosis) 1
• Assess for signs of respiratory distress:
  • Tachypnea
  • Use of accessory muscles
  • Paradoxical breathing
  • Altered mental status

Device Selection Based on Severity

Severity	Device	Initial Flow Rate	Target SpO₂
Severe hypoxemia (SpO₂ <85%)	Reservoir mask	15 L/min	94-98% (or 88-92% if risk of hypercapnia)

Critical Considerations for Hypercapnic Risk Patients

For patients with known or suspected risk of hypercapnic respiratory failure:

• Monitor CO₂ levels via arterial/capillary blood gas or transcutaneous monitoring 3
• Avoid excessive oxygen administration as it can worsen hypercapnia 3, 2
• If patient has known COPD or other risk factors, adjust target to 88-92% 1
• Consider early use of Non-Invasive Ventilation (NIV) if:
  • Hypoxemia persists despite oxygen therapy
  • Signs of hypercapnia develop
  • Patient shows signs of respiratory fatigue 1

Escalation of Care

When to Consider NIV

• Persistent hypoxemia despite controlled oxygen therapy
• Development of hypercapnia (pCO₂ >45 mmHg/6 kPa)
• pH <7.35 or [H+] >45 nmol/L
• Increased work of breathing 1

When to Consider Intensive Care/Critical Care Admission

• High or increasing oxygen requirement
• Failure to maintain target oxygen saturation
• Development of respiratory acidosis
• Altered mental status
• Hemodynamic instability 3, 1

Common Pitfalls to Avoid

1. Administering high-flow oxygen without monitoring for hypercapnia - This can lead to worsening respiratory acidosis in at-risk patients 3, 2

2. Delaying escalation of care - A SpO₂ level of less than 90% is a clinical emergency 4

3. Failing to identify and treat the underlying cause - Oxygen therapy treats hypoxemia but not the underlying condition 1

4. Overlooking the need for NIV - NIV should be considered early for patients with hypercapnic respiratory failure 1

5. Relying solely on oxygen saturation without clinical assessment - Factors such as anemia, peripheral vasoconstriction, and skin tone can affect SpO₂ readings 4

Remember that while treating the hypoxemia is the immediate priority, identifying and addressing the underlying cause of respiratory failure is essential for definitive management.