How to manage breathlessness with hypoxemia?

Management of Breathlessness with 93% SpO2

For patients with breathlessness and SpO2 of 93%, supplemental oxygen therapy is not routinely required as this saturation level is within normal range. 1, 2

Initial Assessment

• Evaluate for underlying causes of breathlessness despite relatively normal oxygen saturation 2
• Check vital signs including respiratory rate, heart rate, and blood pressure to assess severity 3
• Consider arterial blood gas (ABG) measurement if there is clinical concern about hypercapnia or if the patient appears more unwell than the SpO2 suggests 1, 2

Management Approach Based on Risk Factors

For Patients Without Risk of Hypercapnic Respiratory Failure:

• Target oxygen saturation range of 94-98% 1, 2
• With SpO2 of 93%, close monitoring is appropriate rather than immediate oxygen therapy 2, 4
• If SpO2 drops below 92% consistently, initiate oxygen therapy via nasal cannula at 1-2 L/min 2, 3
• Titrate oxygen to maintain SpO2 within target range 1

For Patients With Risk of Hypercapnic Respiratory Failure:

• Target oxygen saturation range of 88-92% 1, 2
• With SpO2 of 93%, oxygen therapy is not indicated and may potentially be harmful 1, 2
• Monitor closely for signs of deterioration 2
• Risk factors for hypercapnic respiratory failure include COPD, cystic fibrosis, neuromuscular disease, chest wall deformities, and morbid obesity 2

Non-Pharmacological Interventions

• Consider a hand-held fan as first-line treatment for breathlessness when oxygen saturation is normal 1
• Early involvement of physiotherapists for breathing techniques and positioning 1
• Position patients to optimize ventilation (upright position if possible) 1
• For pregnant women above 20 weeks gestation, use left lateral positioning to avoid aortocaval compression 1

Pharmacological Management

• Low-dose opioids should be considered for relief of breathlessness, particularly in palliative care settings 1
• Treat anxiety which may contribute to sensation of breathlessness 1

Special Considerations

Palliative Care Setting:

• Oxygen therapy should be restricted to patients with SpO2 consistently <90% or those reporting significant relief from oxygen 1
• Non-pharmacological measures and opioids should be tried before oxygen in non-hypoxemic patients 1
• Oxygen therapy should not be continued in the absence of patient benefit 1

Monitoring:

• Record oxygen saturation, delivery system, and flow rate on patient monitoring charts 2
• Reassess frequently if breathlessness persists despite normal oxygen saturation 2
• Consider urgent clinical reassessment if oxygen requirements increase 2

Common Pitfalls to Avoid

• Assuming all breathlessness requires oxygen therapy; normal SpO2 (93%) generally doesn't require supplemental oxygen 2, 4
• Overlooking non-oxygen interventions for breathlessness when saturation is normal 1
• Failing to recognize that hyperoxia may be harmful, especially in patients with COPD or at risk of hypercapnic respiratory failure 1, 5
• Not considering that pulse oximetry may be misleading in certain conditions (e.g., carbon monoxide poisoning, severe anemia) 6