What are the next steps for a patient maxed out on oxygen therapy as indicated by an oximeter?

Next Steps for Patients Maxed on Oxygen Therapy

When a patient is maxed out on oxygen therapy as indicated by an oximeter, the next step is to escalate care by considering non-invasive ventilation (NIV), high-flow nasal oxygen (HFNO), or transfer to a higher level of care for possible mechanical ventilation, depending on the clinical scenario and underlying cause of hypoxemia. 1

Assessment of Patient Status

• Check that the oxygen delivery system is functioning correctly, including proper placement of the oximeter, correct oxygen flow rate, and that oxygen cylinders are not empty 1
• Confirm the patient is clinically stable by assessing physiological parameters using an Early Warning Score (EWS) system such as NEWS (National Early Warning Score) 1
• Consider arterial blood gas (ABG) measurement to assess for hypercapnic respiratory failure, especially in patients with COPD or other risk factors for CO2 retention 1
• Evaluate the underlying cause of deterioration if a patient requires a higher oxygen concentration than before to maintain the same target saturation range 1

Escalation Options

For Patients Without Risk of Hypercapnic Respiratory Failure:

• Consider high-flow nasal oxygen (HFNO) therapy as an alternative to reservoir mask treatment in patients with acute respiratory failure 1
• For patients with pulmonary edema, consider Continuous Positive Airway Pressure (CPAP) to improve gas exchange 1
• Transfer to a higher level of care (HDU or ICU) if the patient shows signs of critical illness (e.g., NEWS score 7 or above) 1
• Consider mechanical ventilation if other measures fail to maintain adequate oxygenation 1

For Patients With Risk of Hypercapnic Respiratory Failure:

• Obtain urgent ABG measurement within 30-60 minutes of maximal oxygen therapy to assess PCO2 levels 1
• Consider Non-Invasive Ventilation (NIV) if the patient has hypercapnia with respiratory acidosis 1
• Target a lower oxygen saturation range (88-92%) to avoid worsening CO2 retention 1
• Consult respiratory specialists or critical care for further management 1

Monitoring During Escalation

• Monitor oxygen saturation continuously in critically ill patients 1
• Reassess the patient's clinical status frequently, including respiratory rate, work of breathing, and level of consciousness 1
• Repeat ABG measurements after 30-60 minutes in patients at risk of hypercapnic respiratory failure 1
• Track physiological parameters using EWS systems in addition to pulse oximetry 1

Special Considerations

• For patients with chronic cardiopulmonary disease, it may be appropriate to alter the target saturation range following senior review 1
• Some patients may have episodic hypoxemia (e.g., after minor exertion or due to mucus plugging) and may need intermittent oxygen therapy rather than continuous escalation 1
• Be cautious with high-concentration oxygen in patients with COPD, as this may worsen hypercapnia 1
• Consider the potential harmful effects of hyperoxia in certain conditions such as stroke, myocardial infarction, or carbon monoxide poisoning 2

Documentation and Communication

• Document the reason for escalation, target saturation range, and plan for ongoing monitoring 1
• Communicate clearly with the healthcare team about the patient's status and the need for escalation of care 1
• Ensure the prescription for a target saturation range remains active even if oxygen therapy is temporarily discontinued 1

Remember that oxygen is a drug that requires careful titration to avoid both hypoxemia and hyperoxia. The goal is to maintain the patient's oxygen saturation within the target range while addressing the underlying cause of respiratory failure 3, 4.