Hey guys, so I just got back from Tampa. I went down there to help out in the aftermath of Hurricane Milton. Those of you that don't know, I live in Florida and our state just got hit by two hurricanes back to back in the time span of two weeks. North Carolina was also hit pretty hard by the first hurricane. Hurricane Helene, I had signed up to go help an Asheville but was never deployed. Then I got to call the day after Milton passed through asking for help in Tampa. And immediately my bags were already packed for Asheville. So I hit the road not knowing what to expect. And I absolutely loved caring for people in crisis. And I worked my butt off this past week. But I met so many amazing patients who had just lost everything. I could tell you story after story of the hardships people had faced. Only to be compounded by becoming ill or injured. I will eventually do a whole podcast about nursing and disaster but I won't have time to pull that off for this week. There's a lot that goes in to recording and editing podcasts. So for this week, I am rebooting one of my favorite episodes. It's actually the sixth episode I ever recorded back when it was just me recording in my co-closet. But now I have an awesome editor that makes the audio sound so much better for your listening enjoyment. Shout out to Max. So I sent him my old audio file. He has spruced it up a bit for you. I used to name all my podcast episodes, something that cute and catchy. I'm just not that funny and kind of right out of ideas to continue doing that. Now episodes are just titled by the diagnosis that we're discussing. But sit back and enjoy one of my more embarrassing and nursing stories, which I originally titled COPD and barbecue. Hey there. I'm your host, Sarah Loranzini, a rapid response nurse and educator who loves telling stories to teach critical thinking. This podcast is for nurses who want the knowledge, skills and confidence to respond to any emergency. With almost 20 years of experience in the ER and critical care nursing and a master's degree in nursing education, I have a lot of stories to share and I love to nerd out and break down the path of physiology, pharmacology and nurses role in emergencies. This brings learning to life. It is way easier to learn from and remember the stories that my colleagues and mentors have told me than anything I've read in a textbook. And that is why I made this podcast. Every episode is packed full of exactly what you need to know to handle whatever crisis that could arise on your shift. It's one thing to get the right answer on the test, but knowing how to detect when your patient is declining and what to do when your patient is crashing is what will make or break your day and might just save your patient's life. This particular shift, like many other shifts, was crazy busy with back-to-backed response emergencies and it was like 3 p.m. and I still had not eaten. I finally got a break, but the cafeteria was no longer serving food. I had to go order something from the cafe, I'm the opposite side of the hospital. The hospital I worked for at the time was huge with multiple towers that were actually across the street from each other and all connected by a confusing underground tunnel. So I got the cafe and ordered a black bean burger, smothered in barbecue sauce. And the second I sat down to take a bite, the patient went off again and all of my colleagues were busy with other emergencies. So I knew I would need to respond to this one, but I was starving. So I decided to literally eat and run. I promise that what I had for lunch is relevant to this story. Just stay with me. So I took off on the stairs with my messy burger and hand, barbecue sauce dripping down my fingers. I'm taking bites as I cross the busy street, running through the hospitals, main lobby, then up to stairs for the patient's room. I took the last bite of my burger just as I walked to the patient's room. I looked at how to see my hands covered in barbecue sauce, but conveniently, there's a sink right as I enter the patient's room. So I washed my hands as I was talking to the nurse about her patient's emergency. The conversation was a little like this. Oh, hi, Sarah. Are you okay? You look out of breath. Yeah. I'm good. I just ran here from the cell tower. I was eating my lunch, you know, just the usual. So tell me about what's going on with your patient. Well, he's really struggling to breathe. This is my third day with him and he hasn't been like this and I feel like he's getting progressively worse. He's got COPD and was admitted for pneumonia. We keep having to increase the amount of oxygen he's getting and he's still struggling and super anxious. I call the resident twice now and he says as long as the patient's S.P.O.2 is greater than 90% not to worry about it. But the past hour has been the worst. He's kind of freaking out. He keeps ripping the mask off and just all over the bed. He isn't comfortable sitting up. He won't lay down. The doctor said he gave him some adivine to calm him down, but he doesn't usually act like this or need adivine. Something else is going on. I agree. Thanks for calling the doctor's response. Now, for the sake of this episode, I'm going to call the patient John. But that was not his name. No hip evaluations in this podcast. So I approached the patient. He's sitting halfway on and halfway off the bed and a semi-tripop position. He's a big guy with sweaty, disheveled hair. His eyes wide and scared. He has a non-numerous mask on his face and he's breathing like 40 plus labored breasts per minute using all his accessory muscles. His head bobbing with every breath. His S.P.O.2 was fluctuating between 91% when he kept it on his finger and he kept saying, "I gotta go. How am I gonna get up? I gotta go. I gotta get out of here." So I got down on his level, put my hand on his shoulder and made him make eye contact with me because he was desperately looking all over the room. I said, "John, my name is Sarah and I'm the rapid response nurse. Your nurse called me here because she's worried about your breathing." She interrupted. "Help me. Get this thing off of me as he was pulling the oxygen mask off." I said, "John, I need you to keep the oxygen mask on your face. You need it. It will help your breathing. I can't breathe. I know, John. I'm sorry. I know this is scary. We're gonna take good care of you." I looked at the nurse and said, "Give me the attending physician on the phone, not the resident." Didn't turn back to the patient. John, have you ever had a breathing tube before? He said, "Yes." John, you're working so hard to breathe right now and you look so tired. If you needed a breathing tube again, would that be okay with you? If you get too tired, will you let us put the breathing tube in to help you?" He nodded, "Yes." I made eye contact with the nurse to make sure that she saw the same thing that I did. By that time, the respiratory therapist had arrived and I asked her if she could set him up for BIPAP. The charge starts handing me the phone with the attending physician on the line. Hi, doctor. This is Sarah, the rep response nurse. Your patient, John, is in respiratory distress. I need you to get here now. I think we may need to intubate. The doctor said, "What's his oxygen saturation?" Well, it's 90% on the non-reweather, but he's been on the non-reweather for over two hours and he's just not getting any better. In fact, he's getting worse. His heart rate is 122. He's breathing over 40 times a minute. His blood pressure is soft and he is tired. Are you coming or not? He's just anxious. If a satire revved 90, he doesn't. He needs to be intubated. He has TOPD, so we don't need his oxygen level to be perfect. I'll send my resident. Okay, I will call the ICU then because this kind needs emergent intervention and your resident blew off the nurse who's been trying to advocate for this patient for hours. My next call was to my buddy, the ICU charge nurse. We have a good relationship and he knew me well, so all I had to say was, "Please send the intensiveist. I think we need to intubate this patient." He said, "I'll send them now." At this point, there was nothing within my scuba practice that I could do for this patient right now. He was on the max oxygen that I can give him. The RT was getting the bypass ready. There are no meds I can give in this moment. He's already had duonebs, sawymedral, antibiotics. So my job as a rep response nurse is to prepare for what might come next. So I checked his IV to make sure it was patent. I pulled the bed away from the wall to make space for the MD or respiratory therapist to intubate. I pulled the bag valve mask out of the package to get it ready to pre-oxygenate the patient prior to intubation. I ensured that the suction was working on the wall. I sent the charge nurse to go get the RSI drugs and I recycled the battle signs. Then the resident who had blown the nurse off and his attending showed up. I approached them to update them on the patient's status. And he started trying to educate me on how COPD patients have chronically low SPO2 and how, quote unquote, "He probably lives in the low 90s and doesn't need to be intubated." How he spotted. Doc, I am fully aware of the pathophysiology of COPD and its initial management. But we are past that and this patient is near respiratory failure. His work or breathing is far worse than anyone should ever have in an unrebrither. He is anxious and intermittently confused and the HIPOC-C and hypercapnea. This is not his baseline and his blood pressure is dramatically lower than his baseline. In that moment, the BPCuff finish cycling revealing a blood pressure of 85/40, heart rate of 136 and SPO2 of 86%. To which I pointed to the monitor and said, "He is clearly not improving with BIPAP." Then the intensiveist arrived, took one look at the patient and his work or breathing, and said, "Get me 20 milligrams of Atomidate and 100 milligrams of succinocoline." Which I pulled out of my pocket since I already had the charge to describe it for me. We proceeded to integrate the patient and within minutes his SPO2 improved along with other vital signs.
myself and the ICU charge nurse transported the patient at the ICU and I returned back to the message for to check on the primary nurse and thank her again for advocating for the patient and for help during the emergency. I stopped by the restroom to pee probably for the first time that shift and as I was washing my hands I looked up in the mirror to see a giant drip of barbecue sauce now dried and encrusted on my face. It looked like day old dried blood dripping out of the right side of my mouth and down the side of my chin. I was mortified. Now this was pre-COVID so we did it wear masks with every patient interaction. So everyone saw the barbecue sauce. I thought about how many people I had interacted with the primary nurse, the charge nurse, the patient, the primary physician, the resident, the intensivist and the whole ICU team that I passed the patient off to and no one told me I had barbecue sauce in my face. After I scrub the sauce in my face I walked out to chat with the primary nurse. The charge nurse grabbed me and said, "Oh hey Sarah, thanks for your help with that patient." I said, "Absolutely. I love saving lives with my friends." But what kind of friend doesn't tell you that you have barbecue sauce on your face? She said, "Oh, is that what that was?" I thought it was a scab or something. It looked like dried blood. I wasn't going to tell you, "Hey, you have a nasty looking scab on your face." I responded, "Seriously? You let me talk to all those people looking like a freaking vampire?" She said, "Maybe it was a good thing. The resident needs to learn not to ignore my nurses. Maybe he gave him a little scare." I laughed. Maybe my embarrassment worked in my patient's favor. Quisitantly, as I was returning to the rapid response office to write a note about the event, I passed the same physician and attending in the hallway. They both waved at me and the attending said, "Hey, thanks for helping with that patient. We didn't realize he'd gotten so much worse." I said, "My pleasure. That's the rapid response team is here for." I made sure he saw the right set of my face to see that I don't always have barbecue sauce dripping out of my mouth. I could have said a lot more about how wrong they were, not to respond with the same sense of urgency that the nurses had for the patient, or how I didn't need a lecture on COPD when the patient was crashing. But I value interdisciplinary collaboration, and I know that we would need each other to care for the patient together in the future. I didn't want them to hesitate to call me for help, and I didn't want them to know that I had any heart feelings. I want them to know that I could work alongside them to care for patients together. They seem to have already learned a valuable lesson without me rubbing it in, so I just smiled and said, "See you next time!" All right, there were so many great educational nuggets tucked into each aspect of this story. Now, I want to talk about all of them, but first, let's start with breaking down the basic pathophysiology of COPD. Hey guys, I'll get back to the show in just one second, but before I do, I have a request. If you have ever gotten any value from this podcast, and you want the show to continue to grow, to access more awesome experts in the field, and to keep providing you with more nursing knowledge and inspiration, can you take a minute to leave a rating and a review? Those reviews on Apple and Spotify go a long way in giving those podcasts in the hands of more nurses and bringing new guests to the show. And they just make my day to know that my stories and nerdy patho breakdown are helping other nurses thrive, or at least survive. So if you're filling up to it, I'd love to see a rating and review from you. Thank you so much. Now, back to the show. COPD or chronic obstructive pulmonary disease is characterized by either weak damaged avioli, also known as emphysema, or inflammation, and increased mucus production of the bronchial tubes also known as bronchitis. Or sometimes they have both. It's called chronic obstructive pulmonary disease for a reason, because the air is obstructed from getting out of the lungs. With emphysema, air gets trapped in the weak stretched out stiff avioli. And with chronic bronchitis, the inflamed and mucusy airways are narrowed and obstruct the air from making out of the only exit, the bronchai. Most people with COPD have a combination of both sets of challenges, damaged air sacks, and narrowed airways full of mucus. And most people with COPD developed it from years and years of cigarette smoking. Though other irritants like chemical fumes or air pollution can damage the lungs, also resulting in COPD. The other keyword here besides obstructive is chronic, meaning that disease is not curable. People with COPD can make lifestyle modifications and take all their medications to help them breathe a little easier, but they can expect to still have exacerbations, which means he was a nurse going to expect to care for lots of patients with COPD exacerbations. When COPD is paired with heart failure or pneumonia or other diseases that affect the lungs, it makes for the perfect storm for impaired gas exchange. For a COPD patient who comes to the hospital with shortness of breath and/or cough, but they're maintaining their oxygen level, their baseline mental status, and they're not in respiratory distress, those patients will still likely be admitted for a little COPD tune up, so to speak. A butyl on atrovert often called duoneb to dilate the tight inflamed bronchi and decrease the massive amount of mucus production, and tribune estereroids, usually methyloprenazone to decrease inflammation in the lungs. And if a secondary infection is exacerbating the COPD, then the appropriate antibiotic or antiviral therapy would also be a part of the tune up. But while the COPD patient is experiencing the exacerbation of symptoms, we have to closely monitor their oxygenation and choose the appropriate level of oxygen therapy, so it's not to overdo it, but not allowing for hypoxia either. And that is the hardest part, because so many factors play into this decision, not just the oxygen saturation. I like to start by dispelling the whole quote-unquote "giving COPD or oxygen can be dangerous because of their hypoxic drive," quote-unquote "miss." Well, maybe myth is in the best word. How about misconception or missapplication of knowledge? I was tartanershine school many years ago that I should give COPD patients as little oxygen as possible because if I gave too much, I could shut down their hypoxic drive and they would just stop breathing right there in front of me, scared me to death. I actually argue with a dog one time when I was a baby nurse because he wanted me to put the patient on a non-rebrea there and I said, "What about the hypoxic drive? He could stop breathing," he responded. If he stops breathing, we can just back him. Right now, he needs a 100% oxygen. The hypoxic drive thing, it's real. But how that knowledge is applied has evolved and improved since the start of my career. So let's break that down. Most people without chronically high CO2 levels are triggered to take a breath when their CO2 level is elevated. So as CO2 rises, the body senses that and speeds up respirations take more breaths and blow off the CO2. But COPD patients have chronically high CO2 levels. So that trigger is not a sensitive. Instead, they develop a hypoxic drive that triggers their breath when the partial pressure of oxygen begins to drop. The theory goes that if you give a COPD or oxygen, then they, quote, "lose their hypoxic drive to take breath and then develop high pove ventilation and even apnea." So here's what we know now. COPD patients do have chronically elevated CO2 levels, but the presence of the hypoxic drive has been shown to be a minor contributor to oxygen-induced hypercapnea. There are two other factors at play on the cellular level that could lead to worse and hypercapnea. Increase VQ mismatch in the howl-dane effect. And both of which are much easier to explain with photos and graphs, and I'll link a few resources in the show notes so you can learn more about them. The takeaway is, oxygen therapy should not be avoided in the hypoxic COPD patient. With holding oxygen from someone who's struggling to exchange the gases, will cause more harm than trying to prevent oxygen-induced hypercapnea. A wiser solution is to titrate oxygen delivery to shoot for an Spo2 between 88 and 92%. We are never really shooting for 100% with these patients. But here lies the challenge. What is the best oxygen delivery modality to achieve this goal? Let's go through each option starting with the simplest and least invasive simple nasocanula and work our way up to intubation with mechanical ventilation. So nasocanula is a great. At two liters per minute, your patient's getting about 28% FIO2 or fraction of inspired oxygen. Room Aire is approximately 21%. You can titrate up to give more liters per minute and each liter per minute increases the FIO2 a little bit. But it is impossible to say with accuracy how much FIO2 the patient is actually inhaling to their lungs. How much of a mouth breathers the patient? Every patient is a little different. You can turn out the liters
per minute to about six liters per minute, and then it starts to get uncomfortable for the patient. Oxygen is very drying, so if you're gonna give more than four liters per minute, try to get some humidification added to the line. If an isocanulagist isn't cutting it, and the patient is still really working to breathe, or you aren't achieving the target SPO2, you can use a ventimask or venturi mask. These are great because whether you have a nose breather or a mouth breather, your patient can get the oxygen they need, and you can determine the amount of oxygen by the little dial at the end of the mask. Every manufacturer is different, but for the most part, you can choose the FiO2 that you want, like 40 or 50%, and then the device tells you how high to set the flow on the wall, and liters per minute to achieve that FiO2. But your max FiO2 on a venti is only 50%. Ventimask are a great modality for syrupyty patients, as you can easily adjust the FiO2 based on how your patient's doing at the time, and you can give them consistent and predictable FiO2 and response to their needs. The downside, like all masks, is that it's difficult for the patient to get oral intake of food and water with the mask on. The final upgrade on the low flow list of oxygen delivery methods is a non-rebrither mask. That's the one that has a little bag hanging from the mask. That reservoir fills with a 100% oxygen from the wall, and there are valves built into the mask, so the idea is that the patient will get 100% oxygen from their bag and not re-breed their own X-Hail CO2. But in practice, the patient gets more like 60 to 90% FiO2 from the quote unquote 100% non-rebrither mask. When using the non-rebrither, there are a few common errors that I encounter. First, you have to have it plugged into oxygen with a flow of 15 liters per minute or higher. If you switch to the non-rebrither mask, but keep the same flow on the wall flow meter, you will definitely not help improve your patient's oxygenation. Second, the reservoir bag needs to be puffy and full of oxygen to do its thing. If it's flat, it's not a non-rebrither mask. So make sure that you check that before applying a suffocating mask onto your patient's face. And finally, you should not humidify oxygen delivery through a non-rebrither. Adding humidification with a flow of greater than 10 liters per minute will cause condensate to build up in the small bore tubing of your non-rebrither mask or venting mask with a high flow setting. So tubing full of fluid cannot function the way it was meant to. Make sure to switch it over to the port without the humidification before attaching it to the non-rebrither mask. But after you ensure that the bag isn't flated and the flow is high enough, your next question should be, why does my patient need a non-rebrither mask? This should always be a temporary intervention, a bridge to the next step. Patient should never be left in a non-rebrither for hours and hours. You should either be considering what else you can do to optimize their oxygenation, i.e. give laysticks or a breathing treatment or a chest tube or whatever will fix the issue that got into this point of needing a non-rebrither. Or if you've exhausted all of your options to help downgrade the patient off the non-rebrither, then you should start planning for the next step up. But the non-rebrither mask is not the solution. Do not put your patient on the non-rebrither and go on your lunch break. This is a temporary solution. It is not the final destination just a bridge. Next is the high flow nasal cannula. I really like the high flow nasal cannula, but it's kind of cumbersome to set up, so it's not my go-to for a crashing patient. With the high flow nasal cannula, you set both the flow rate in 20 to 70 liters per minute and the FIO2 at 21 to 100%. And it's usually humidified and heated for comfort of the patient. There are several benefits to the high flow nasal cannula. The first being, it is generally well tolerated and has very few risk or contraindications. Obviously, patients with nasal injuries or nasal packing could have some issues with high flow going through their mayors, but most patients do well with it and for a prolonged period of time. Additionally, patients can eat and talk easily with the high flow nasal cannula. But the biggest benefit of the high flow compared to the regular low flow nasal cannula is that it helps improve both oxygenation and gently supports ventilation. The support of ventilation is achieved through something called dead space wash out. We all have anatomic dead space, meaning the gas that occupies the space in the airway that does not do any gas exchange. So, from your mouth and nose, down to your bronchules, no effective gas exchange occurs. But the body still has to work to move that gas in and out. Well, the high flow nasal cannula air is pouring into the naso and oropharynx. So now, what was once dead space occupied by the previously exhaled CO2 is now acting like a reservoir for oxygen, similar to our non-rebrother mask, but better. So, when they breathe in, there is less dead space to have to deal with or overcome, and all that fresh oxygen and the naso-farynx can make its way down to the avioli with less effort on the part of the patient. And summary, it replaces a portion of your dead space with oxygen-rich air, hence improving breathing efficiency. And in addition to all that, the high flow provides some peep. Peep is an acronym for Positive End Expiratory Pressure, or the amount of pressure the avioli have after you exhale. There are several factors that affect how much peep. And it's not as effective or consistent as a more close system like BiPAP or an intertricle tube, but it does provide a little bit. And a little bit is sometimes all the patient needs. OK, we're almost done here. Two more oxygen delivery modalities to cover. Next is BiPAP. I love BiPAP, especially for your COPD patients. BiPAP is the big, Darth Vader mask that attaches to a ventilator-looking machine, and basically forces air to the patient's lungs without having to intubate them. BiPAP is better than CPAP because you can set two pressures hence the "by" part of the title. The RT will set an inspiratory pressure, so how much pressure the machine will provide when the patient's taking a breath in, and an expiratory pressure, or how much pressure it maintains in the avioli when the patient's breathing out. BiPAP is able to provide not only oxygen, but pressure to take some of the work you're breathing off your tired patient. The patient determines the respiratory rate and length of each breath, but the BiPAP helps get the air into the lungs with less effort on the patient's part. But this pressure comes at a cost. There are risks of forcing air into someone's lungs through a closed mask. So lots of patients aren't the best candidates for BiPAP. It works best with patients who can participate, or are awake enough to be able to pull the mask off their face if they had to vomit, and patients at risk for aspiration or who have already aspirated should probably not be put on BiPAP. There are nasal BiPAP masks, but I honestly have not used them much. And the couple times that I tried it because the patient had a big old beard, we couldn't get a good seal with the full face mask, but the nasal mask didn't really work that much better, honestly. So that's just my experience. I'm sure some folks have had great success with it. Let's dive a little more into the contra-nications because I really want you to think through these before considering BiPAP for your patient. Patients who are somalant are difficult to arouse, carry a high risk of aspiration, think like you're a septic shock or stroke patient. If you don't think they could protect their airway, maybe they needed advanced airway and not BiPAP. But I've used BiPAP on patients who are drowsy, purely from hypercapnea. And we know that because of their history and their current ABG and those patients I've put on BiPAP and watched them perk up in 10 minutes. But that's the key. I watched them. I stay with my patients. So if they were to start vomiting, I was there to get that mask off. So use your assessment skills and your intuition. If your patient can barely hold their head up, maybe they need more than BiPAP. If you're about to take your patient to CT scan where they have to lay flat, maybe BiPAP isn't the safest. If your patient says they're nauseous or they've been vomiting, don't strap a mask to their face and force air in it because if they vomit, the BiPAP machine will help them aspirate that vomitous deep into their lungs. I hear lungs don't like that. As effective as the BiPAP can be, it's only effective if the patient can tolerate it. And not everyone can. When I was the ER educator, we got a new transport event that had a CPAP setting and I was teaching the staff how to use it. I decided to try it on myself for demonstration purposes and I could not tolerate it. Forcing air into your lungs does not feel natural. Honestly, I felt more like I was being suffocated than supported, but I thought, people somehow sleep with this thing on. I can tolerate it for a few minutes. So I toughed it out and kind of learned to work with how it breathes for you rather than against it, but it definitely gave me more empathy for those patients.
who are gasping for air, but then won't cut the by-pap on. If you are in the headspace for it, it's not comfortable and I totally understand what some patients need some gentle sedation to comply with the by-pap. Like I said earlier, don't zonk these people. They have to protect their airway, but a little whiff of fentanyl or even better, a low dose of dexametitamidine can take the edge off and help the patient settle into the support of the by-pap. So how do you know when it's time to escalate to intubation? I would say it depends on the patient. My first trigger is if the patient just can't tolerate the by-pap. If they're ripping it off their face, even with our sedation of choice and there's no talking the patient into working with the by-pap and they're in severe respiratory distress, they will eventually experience diaphragmatic fatigue and respiratory arrest. Ever lifted weights in like the first 20 reps or so or no big deal? By the time you got to 30 or 40 reps, your muscles literally failed and you couldn't lift the weight anymore. The same thing happens with the diaphragm. It can work for a while, but it can reach your point where the muscle itself cannot keep going. We don't want the patient to cross that threshold. I'd rather intubate before they get to that point. But let's say they are tolerating it, but their SPO2 just isn't getting any better with by-pap. For COPD patients, remember, we're okay with lower SPO2, so like 88 to 92%, that's fine. We expect a little high CO2, even the 50s, but if the SPO2 continues to drop and the CO2 continues to rise, maybe it's time for intubation. And my final trigger is worker breathing. Now, the by-pap is not an instant fix, but you should see your patient's worker breathing improve within 20 minutes or so. Maybe not down to the rate of 16 breaths a minute, but if you see improvement and they look a little more comfortable, then let the by-pap keep working as magic. Sometimes it takes a few hours to fully correct the hypercacnea and for the body to catch up enough to slow down the respiratory rate. And those triggers are why I push for intubation for this patient from the story. He was working hard to breathe and he was not improving. Even though I didn't have an ABG yet, I knew he was hypercacnea from his mental status. His SPO2 was not getting better either. It was getting worse. And the big one for me, my intuition. My intuition said he wasn't going to last much longer before he gave out. So I advocated for him to get the support he needed before he got to that point. The final oxygen delivery modality is the endotray heel tube attached to the ventilator. This podcast is already way longer than most of my podcasts, so I won't go into depth on this one, but in summary, the ventilator is the Mach Daddy of oxygen delivery options. There are so many settings that allow you to tailor each breath to exactly what your patient needs to optimize oxygenation and ventilation. And you can learn a lot about how secure patients lungs actually are by looking at the ventilator and seeing how the pressure and volume changes inside the lungs with the types of breath that are being delivered. In fact, there is so much to learn about ventilators that there is an entire profession dedicated just to that. As nurses, we rely heavily on our respiratory therapy colleagues to help us promote effective gas exchange in our patients. But the more we know, the better we can collaborate to make the best decisions for the patients in our care. Whew, we covered a lot. So let's review the main takeaways. First, COPDers have both sick, stiff, avioli, and narrowed airways full of mucus. For that reason, they are chronically hypercaphnic and live at a lower SBA2 level. It's okay to let their SBA2 be a little lower than your other patients. Their bodies used to that. But if the SBA2 is dipping into the low 80s, it's recommended to give your COPD patients some oxygen, but titrate it to a goal of 88 to 92%. Don't give them more than what they need. You can choose from several different oxygen delivery methods based on how they're presenting and how much support they need. Know that by-pap is a great, emergent intervention for COPD, but it carries risk of aspirations to choose wisely and be prepared for puke. And finally, you are the voice for your patient when they cannot speak up for themselves. Know that your advocacy could literally save your patient's life. So don't worry about looking stupid. I was somehow able to advocate for this patient with barbecue sauce smeared on my face. I know it can be a little intimidating to have to call a doctor. I mean, they could find you annoying or think that you're wasting their time. But remember, it's not 1950 anymore and you don't work for the doctor. You and the doctor work together for the patient. You owe it to them to escalate your concerns until you get your patient what they need. I promise it's worth the risk. Before you go, I have an exciting announcement. You can now earn CES for listening to this podcast. That's right. Our Enegade has Tina with podcast toast like me who are delivering amazing content that not only educates, but inspires you to be the best for your patients. You get to learn and earn continuing education credits while adorbing knowledge from thought leaders and innovators in the field of health and medicine. You're already listening to podcasts during your commute at the gym or while unwinding after a long day. So why not earn your CES at the same time? And that's where pod classes come in. Yep, it's just what it sounds like. It's C-E learning through podcast. To learn more, I put a link to the show notes for you. Well, thanks for listening. I hope you learned something that will save a life. Remember, nursing is a team sport. So trust your intuition and don't give up advocating until you are confident you don't what's right by your patient. The views and opinions expressed on this show are that of Sarah Lorenzini's. That's me and mine alone. They are not intended as medical advice and should not take the place of your institution's policies or procedures. Evidence-based practice is ever changing and your patient cares to reflect the current best practice. So if you want to get in contact with me, you can shoot me an email at
[email protected] or on all social media platforms as the rapid response RN.
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