How to manage a patient with no desaturation who is thriving?

Management of a Thriving Patient Without Desaturation

If a patient is thriving clinically and maintaining adequate oxygen saturation without supplemental oxygen, no oxygen therapy is indicated and the patient should be monitored with routine vital signs only. 1

Clinical Assessment Framework

Define "Thriving" Status

• Stable vital signs: Respiratory rate <24 breaths/min, heart rate <100 beats/min, systolic blood pressure >90 mmHg, temperature <37.8°C 2
• Adequate oxygen saturation: SpO2 ≥94% on room air for patients without risk of hypercapnic respiratory failure 1
• Normal mental status and ability to maintain oral intake 2
• Absence of respiratory distress: No use of accessory muscles, no tachypnea, no subjective breathlessness 3

Confirm No Desaturation

• Target saturation range 94-98% for most patients without COPD, neuromuscular disease, chest wall deformities, morbid obesity, cystic fibrosis, or bronchiectasis 1
• Pulse oximetry monitoring should show consistent readings within or above target range 1
• No supplemental oxygen required if saturation maintained on room air 1

Management Approach

Monitoring Requirements

• Record "A" for air on both the drug chart and observation chart when patient is on room air at time of assessment 1
• Routine vital signs monitoring including SpO2 and physiological variables (such as NEWS score) measured four times daily for stable patients 1
• No repeat blood gas measurements needed for stable patients maintaining target saturation on room air without risk factors for hypercapnia 1

When to Reassess More Frequently

• Any clinical deterioration including new symptoms, increased respiratory rate, or falling saturation 1
• Development of breathlessness despite normal oxygen saturation warrants evaluation for underlying causes beyond hypoxemia 3
• Signs of critical illness (NEWS score ≥7) require continuous monitoring and possible escalation to higher level of care 1

Special Considerations for Specific Populations

Peritoneal Dialysis Patients

• If a patient is not thriving despite adequate dialysis dose, consideration should be given to increasing dialysis dose even when other parameters appear adequate 1
• This principle applies when no other identifiable cause exists for failure to thrive 1

Cardiac Patients

• Do not routinely administer oxygen if SpO2 ≥94% in patients with acute coronary syndrome, as supplemental oxygen in normoxemic patients increases myocardial injury, infarction size, reinfarction rates, and cardiac arrhythmias 4

Palliative Care Patients

• Oxygen therapy should be restricted to patients with SpO2 consistently <90% or those reporting significant relief from oxygen 3
• Non-pharmacological measures (hand-held fan, positioning) and low-dose opioids should be tried before oxygen in non-hypoxemic patients with breathlessness 3

Common Pitfalls to Avoid

Do Not Over-Treat

• Avoid prescribing oxygen for patients with normal saturation, as unnecessary oxygen therapy can cause harm in certain populations (particularly cardiac patients) 4
• Oxygen is not indicated for breathlessness alone when saturation is adequate 3

Maintain Appropriate Documentation

• Sign the observation chart with "A" for air rather than leaving it blank, which could be misinterpreted as missing documentation 1
• Keep oxygen prescription in place even when discontinued, in case of future deterioration requiring rapid reinitiation 1

Monitor for Deterioration

• Do not assume stability will continue - maintain regular monitoring schedule to detect early signs of clinical decline 1
• Lower threshold for reassessment if patient has underlying conditions that could lead to rapid deterioration 1