Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD)Oxygen TherapyRecommendation 4.0:Nurses will assess for hypoxemia/hypoxia and administer appropriate oxygen therapy forindividuals for all levels of dyspnea. (Level of Evidence =1b-IV)Discussion of Evidence:During an acute exacerbation of COPD, individuals experience an increase in the work of breathing due tothe ongoing disease progression and the acute underlying pathology. This may cause difficulty inmaintaining adequate oxygenation. The goal of oxygen therapy during an acute event is to reach ormaintain arterial blood saturation between 89-90% and oxygen tension in the artery – PaO 2 at 60 mmHg orgreater (Denniston, O’Brien & Stableforth, 2002; Goldstein, 1996; Gorecka, Gorzelak, Sliwinski, Tobiasz & Zielinski, 1997;Medical Research Council, 1981; Wedzicha, 1996; Wijskstra, Guyatt, Ambrosino, Celli, Guelli, Muir et al., 2001). Oxygen flowrates should be titrated to the lowest optimal oxygenation to minimize respiratory acidosis (PCO 2 < 45mmHg; pH > 7.35)( Murphy, Driscoll, & O’Driscoll, 2001).Acute/Unstable DyspneaNocturnal (nighttime) dyspneaExercise-induced dyspnea(Level of Evidence = III)(Level of Evidence = III)Usual treatment should include appropriate controlled oxygen therapy via a high flow system (e.g., Venturior Vickers mask) to maintain oxygen saturation > 90%-92% (Agusti, Carrera, Barbe, Munoz & Togores, 1999). Inpatients who cannot tolerate a face mask during an acute event, a less controlled form of oxygen therapymay be administered via nasal prongs. Inappropriate oxygen therapy may precipitate hypercapnia.In a systematic review of the literature, Murphy et al. (2001) suggest that clinical status should bemonitored carefully by continuous oximetry and arterial blood gases (ABG) measurement upon arrival toemergency department. ABG’s should be checked every 60 minutes, or more if status deteriorates. If pHfalls below 7.26, PaCO 2 rises above 80 and patient becomes drowsy, then non-invasive ventilation shouldbe implemented. Ventilatory support is considered when there is evidence of respiratory muscle fatigue,inability to maintain a clear airway, increasing hypoxemia and respiratory acidosis, deterioration in level ofconsciousness, and inability to breathe spontaneously.Oxygen therapy for individuals experiencing acute dyspnea may be complicated by the presence of anumber of co-morbidities such as asthma, heart failure, pneumonia, pleural effusion, pulmonaryembolism, pneumothorax, and sleep apnea. These individuals may require higher concentrations ofoxygen therapy. Intense monitoring of their respiratory status is essential (Murphy et al., 2001). In end-stagedisease, oxygen therapy may be used in conjunction with non-invasive or invasive mechanical ventilation.40