Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 81: Let’s Talk Oxygen Titration
There are many steps when dealing with oxygen titration. In this episode, we set the stage for what clinicians need to consider when dealing with a patient on oxygen, including our state practice act, MD orders, available devices, and titration concepts.
As PTs we can take an active role in education, and, oxygen titration to optimize safety and maximize patient outcomes.
In this episode:
- PT State Practice Act
- MD orders for oxygen titration
- Understanding oxygen devices
- Interdisciplinary collaboration
- Oxygen Titration concepts
Join my main newsletter: https://allthingscardiopulm.ck.page/9bb2730421
Want to sign up for a mentoring call with Dr. Burriesci? Sign up here: https://www.allthingscardiopulm.com/mentoring
Interested in Jane?
Jane, is an all-in-one practice management software with helpful features to power your practice. Head to jane.app/burriesci to book a personalized demo. Don't forget, you can use the code CARDIOPULM1MO at the time of sign-up for a 1-month grace period applied to your new account
Find me on:
IG: @all_things_cardiopulm
Threads: @all_things_cardiopulm
Website: www.allthingscardiopulm.com
Twitter: @allcardiopulm
Linked-In: Rachele Burriesci
Text at 913-308-4494
Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is sponsored by Jane. You might already be familiar with the name, but if it's new to you, Jane is a HIPAA-compliant clinic management software and EMR. Chasing down patients for important information isn't anyone's idea of a good time, especially when there are forms to be filled, payments to be processed and consents to be collected. That's why Jane has designed user-friendly online intake forms so you can gather all the information you need prior to the appointment, whether that's health history, insurance details or a credit card on file. Jane will even send a friendly reminder 24 hours before a patient's appointment if they haven't completed their intake forms yet, saving you from having to manually follow up. To see Jane in action, head to the show notes, click that link to book a personalized demo and if you're ready to get started, use the code CARDIOPULM1MO at the time of signup for a one-month grace period applied to your new account. Thanks again, Jane. All right, happy. I think we're up to October 11th. It's Friday. Did I get the date right is always a good question. I am not A&O, it is October 11th. I did it. It's Friday, a little off on my recording time.
Rachele Burriesci:We've had a busy but productive week. Nicki actually had a few days off this week and we purposely planned it because my sister-in-law is getting married or got married, and is having her reception on Saturday, so we wanted to make sure that she had extra hands on deck for anything that might come up. If you've ever hosted a wedding, hosted a reception, hosted a party of some kind, there's always those last minute things that you didn't think of where you need to kind of run and pick some stuff up, planning to bring everything to the actual place. But we wanted to make sure that she had the help that she needed. So we had some days off, and so what we did actually in that time was like split the day Half the day was kind of helping and prepping, and the other half the day has been paper project. So we are moving full steam ahead. We've made a ton of progress in the last few days. I think we have the hardest of the moving parts taken care of. By the way, this is officially a DIY podcast.
Rachele Burriesci:Now we had like these crazy things that we had to do. There's a retaining wall, there's a sitting wall and the sitting wall is really a retaining wall slash, trick of the eye kind of thing. So that is doing great. We have two cinder block rows, you know, in place already. We're going to go to three and then see if we need to add a fourth row, just from like a sitting perspective. But we're probably going to wait until we have the pavers on, because it's just like a weird thing. The backside of it is on a downhill. The right side of it is should be the height, but we'll have to kind of see where the pavers end up.
Rachele Burriesci:So retaining wall needed a drain, which didn't know you needed a drain next to a retaining wall, but apparently you do. It helps prevent rot. So we had to dig out, create like a tunnel. Basically, we have this perforated drain along the side. You have to add rock. So all of the like weird moving parts is almost complete. We just have one more drain thing that we need to work through and I think we can like get going, so hoping on Sunday we're going to actually be able to fully level it, compact it, like do that thing, and then we're like ready to go so full steam ahead.
Rachele Burriesci:I think I said October 23rd was my goal, we might hit that deadline, and I am like full steam, steam ahead, trying to do as much as we can, because we need to like kind of beat the rain it. Once it rains, it gets really soggy and then the ground gets weird. So we need to get everything like done before we have some more storms, and so far we have lucked out. So keep putting some of that good energy out there. What else we got going on? Yeah, so we have a wedding tomorrow, almost ready for that, and they have some like cool things going on.
Rachele Burriesci:It's always fun to kind of see other people's traditions or like things that are important to them that they can incorporate into their wedding. So they're doing a guest book. That's really interesting and I want to share it because I think it's really cute. Um, they they're kind, they're very creative. Um, my sister-in-law specifically, I'm waiting for her to like bust out and do like an etsy kind of thing, because she is just so talented and amazing and very, very crafty and creative. So they're using Legos kind of throughout as a theme and it's very nicely done. They have some flower vases as their centerpieces. That is part Lego, part wood flower and it looks super cute. It's tied in really nicely.
Rachele Burriesci:But they really came up with this great idea for a guest book and what they're going to have is basically a Lego board, like a flat Lego board, and everyone's going to make themselves a minifig, which I had no idea what the hell a minifig was. But a minifig is a minifigureen, like a mini Lego person, and essentially when you're at the wedding you make your minifig right, so there would be like a little Rachel Lego and you could put your whole family together and then that would be, and it's going to be labeled with everyone's name. Every family that comes will have a mini fig, and so that's going to go into a shadow box and it's super cute. So Nikki's been helping with creating the shadow box piece. We have that all done up and ready to go for tomorrow, and today we're going to actually go to the Lego store and make our own minifig so we can be all hands on deck at the wedding and not have to kind of take away from that. Also really great to have an example for people who've never done something like this. It's super cute. I think it's a great idea. I'll post pictures when it's all said and done, but I think it's going to be super cute. So tomorrow, this weekend, super busy, but here we are All right.
Rachele Burriesci:So I want to talk a little bit about oxygen titration. I've had a lot of questions come in. I've had some conversations with my wife just about like trends and who does what, and I've kind of talked about this on a podcast I think it was a tracheostomy podcast but what I really wanted to talk about was just the idea of titration. Like how do you titrate? What do you need to consider as a PT when you are titrating oxygen? So there are a couple of things that, first and foremost, you have to kind of put out there. The rules are different per state, right? So number one always check your state practice act.
Rachele Burriesci:In my opinion, in the three, four states I have lived and worked in, there is usually very vague language in the world of cardiopalm, but it should basically leave the door open for you. With that being said, even if it's allowed in your state, every setting is a little bit different. Hospital settings are different. I know someone who's in Texas who, as a PT, cannot titrate oxygen. Is it a state thing or is it a hospital thing? I should probably confirm that, but that is a possibility. So if you are in a state that it's okay in your practice act and you're in a hospital, that again encourages other professions to titrate, other professions to titrate. The number one thing that you need as a PT to kind of have everything, all your bases covered in this regard is an order set. There should be an MD order that reads something like maintain patient's oxygen greater than SpO2, fill in the blank.
Rachele Burriesci:Usually in you know kind of my hospital settings I've worked in, the goal is typically SpO2 greater than 92%. That is just above the threshold where on the oxyhemoglobin dissociation curve there's a steep drop-off. I'm going to do an oxyhemoglobin dissociation talk one day. I'd have to figure out the right way to do it and I know I've said that before. But I need to just like make sure that as a listener you can follow along without the visual, even though you have the option to see the visual. So I'm just going to work with that.
Rachele Burriesci:But at 90% you have a PaO2 of 60 millimeters of mercury and right on that oxyhemoglobin dissociation curve is where you then have a steep decline and so you're going to have dissociation of hemoglobin much more quickly at that point. So the goal is typically to stay above that 90%, because that 90% marker 60 millimeters of mercury, pao2, is really where we have that decline and where things can kind of rapidly change. There's also a couple other things from a oxygen perspective that's important right at that marker. So staying above that threshold is very common as a blanket statement. So, like blanket statement, md order that's super common to see is maintain SpO2 greater than 92% period. That gives you the opportunity to titrate and what that says is I can titrate to maintain this person's SpO2 greater than 92%. So if I'm not at 92 or above, that means I should be up titrating.
Rachele Burriesci:With that being said, the order should be specific to the patient, and so for patients with COPD you might see maintain SpO2 greater than 88% If they're a CO2 retainer and they have to rely on their oxygen receptors. If you keep their oxygen too high then their oxygen receptor can't kick in to notify them to you know breathe. So for COPDers, who are specifically CO2 retainers, they tend to have a lower oxygen goal. So 88, greater than 88%, sometimes you'll even see like a tight goal for COPD years 88 to 92% and you want to keep them in that window. You don't want them to be at 100%, especially if you're adding oxygen into the mix. So, per patient, per diagnosis, there should be an order specific for you to have a goal.
Rachele Burriesci:And this is one of those things that when I'm chart reviewing, I'm checking what this person's goal oxygen is. When you are titrating, this is the next piece, right? It's understanding what device they're using, understanding what oxygen they're on at rest and then also knowing do I need a backup device? And we're going to talk about devices on the next podcast. I'm going to go through each one, talk about the flow rates and the Fi2 for each device. But this is the thought process that is required, because if you're not thinking about what if, then you can get into a situation where you get stuck and your person is desaturating or declining very rapidly and it can progress quickly. So you definitely want to make sure that when you are working with a patient with oxygen, that you're monitoring their SpO2 throughout activity, that you're utilizing the appropriate amount of oxygen to maintain goal blank right, whatever their goal is greater than 90, greater than 92, greater than 88, whatever is specific for that person greater than 92, greater than 88, whatever is specific for that person.
Rachele Burriesci:One of the things and this is just like a common question is like how do I titrate oxygen? And I feel like this is one of those topics that people typically steer away from and they don't. I find that a lot of people don't want to tell you how to exactly titrate oxygen. The understanding to that is it's not an exact science, right, like it's do, check and then assess. Like what are you doing next? So the biggest thing is understanding that every oxygen device that is being used has an endpoint. It has a max potential. A max potential FiO2%. So if your person is on and I'm just going to use nasal cannula as a quick conversation starter A regular nasal cannula doesn't have a lot of range you can apply.
Rachele Burriesci:It's a low pressure system, it's a low flow system. You can basically apply one to six liters of flow for the person and then you're maxed out. So if your person was at the top of that range, like say, they're resting at six liters and you know that going into the room patient is resting on six liters and they're just maybe teetering their SpO2 goal. Before even walking into that room you need to be having a conversation with the RT and maybe the nurse as to what device do we use if they desaturate after six liters. An easy next device is a high flow nasal cannula. It has a lot more range, has a lot more FiO2 range. It gives you a little more wiggle room if your patient is desaturating. But that's step one, right.
Rachele Burriesci:Step one is you have to know what device you're using. You need to know its max potential and if that person is sitting at their max potential, then you need to have the next device ready. The other question can be is if your patient is a mouth breather, if they're panting, if they're panicking, if they're desaturating very quickly, if they're even having a hard time at rest, your potential for mobility or exercise is already lower. What is it that you're going to do if this progresses? Do you have a higher level device as a backup? And that's a question I'll ask the nurses sometimes before going in knowing they're on maybe let's say they're on 10 liters high flow nasal cannula and they require up titration with activity. I'll ask is there maybe a non-rebreather in the room, just in case? Because if the person starts desaturating quickly, you want to have the just in case ready to go so that it doesn't progress into something else. So step one is knowing what device they're on, what device you have for a backup and overall, just understanding that there is a max potential for each device.
Rachele Burriesci:The next thing that I think is a very common I think is a very common well, how do you physically titrate, right, how much do you increase? This is a touch and go for me. I don't think that you should just up titrate to the top of whatever device you're on to get them to increase their oxygen to near 100% or 100% before doing activity and just going for it. In my opinion, that doesn't allow you good information to understand how much that patient actually needed to do this level of activity, whatever it is. I know I'm speaking in vague terms, so I hope that you can kind of hear around.
Rachele Burriesci:Pre-oxygenating is a concept that can be used where you're increasing, you're up titrating the level of oxygen before doing activity. I feel like pre-oxygenation became a little bit more common during COVID, where you're trying to like really bump them up before doing an activity because you know they're going to desaturate. I think pre-oxygenating can be very beneficial. I just don't think the goal should be put them on max supply, get them as high as you can and then do your activity. Because then my question is still going to be the same what happens when they desaturate and they are maxed out?
Rachele Burriesci:Now, on the device that you put them on Right, because that was the choice that was made, I think if your patient isn't in a dire sort of situation, right, you're seeing a patient, they're stable, they're on oxygen. You know they desaturate with activity to up, titrate to what they require. So if they're resting on two liters nasal cannula, we know we can go to six and say they're resting right at 92, and 92 is their goal. Maybe when they stand, maybe when they do bed Therix, maybe when they walk 10 feet they drop to 90%. Knowing this, say I worked with this person for a few days already I'm going to increase them. Right, what am I going to increase them to? Well, if I've never met the person before, maybe I just increase them up one liter, put them to three, See where their SpO2 is at at that moment and then monitor it with activity, right. With this being said, you are still queuing for breathing exercises. You're queuing for pacing. You probably should have done some breathing exercises before getting going. Right. The more they can do on their own without increasing the FiO2 of oxygen, the more beneficial that's going to be for that person.
Rachele Burriesci:I like to kind of look at oxygen like an assistive device, right? A lot of times when we write goals for patients is you want to ambulate blank number of feet with the least restrictive device, right? You don't want to put someone at the max device. You don't want to put someone in a wheelchair if they can walk with a walker, you don't want someone to walk with a walker if they can walk with bilateral axillary crutches, you don't want to put someone on bilateral axillary crutches. All they need is a cane. Similarly, right trying to keep this analogy going if someone needs two liters of nasal cannula, that doesn't mean I'm going to put them on a non-rebreather, right? You don't want to up titrate to the top thing because you don't know then what they actually need.
Rachele Burriesci:The goal in all of this is to give them enough to do the activity that they need while maintaining their goal, and we're going to just use SpO2 greater than 92% as our standard number here For me. I'm up titrating one liter at a time, typically. I'm not going to up titrate by two, three, four, five, like I'm not going to just bump you up to the top and I'm not going to haphazardly do that, because then I don't know what you actually need Gradual, gradual increase. They're on two, they start dipping. Put them to three. You put them on three. Can they maintain that SpO2 without dipping? No, read can they maintain that SpO2 without dipping? No, I'm bumping them to four. I'm continuing that activity. Are they maintaining above SpO2 92%? Yes, I'm keeping them there. If they're hanging at 93% and we're walking and we're good, I'm going to keep them there. I'm not just going to automatically bump them to five, six, whatever.
Rachele Burriesci:The goal isn't to get them to 100%, the goal is to maintain above the number that was set. Okay, I think this is an important point and I'm going to just kind of say one more thing about being at 100%. 100% is great, 100% is perfect. We'll talk about what that means when we're looking at the oxyhemoglobin dissociation curve. 100% is great when you're not on oxygen, when you're just breathing remare. When we're breathing remare, we're breathing FiO2 21%.
Rachele Burriesci:If you have someone on oxygen and you have them, let's say, three, four liters, whatever it is, and their SpO2 is at 100%, you need to down titrate Because once you're at 100%, you don't know what they're actually at. Are they at a hundred percent? Are they at 105%? Are they 110%? What is that PAO2 actually looks like? You don't know, because your your pulse ox is only going to go up to a hundred percent. So if you have them on four liters and your patient is at 100%, now we need to start talking about down-tidrating them, because 100% is not the goal. Having them above 92% is the goal. And when they're at 100%, you have no idea how hyperoxygenated they actually are. They're on too much oxygen.
Rachele Burriesci:Oxygen is a drug. Oxygen is a medication. You don't want to give more than what they need. You want to give enough. You want to give an FiO2 that's going to support their activity, their mobility, without tanking every time.
Rachele Burriesci:Right, there's two ends of the spectrum and I feel like I see this a lot, right, like person's on oxygen, and they're at 100%. I'm like, okay, why are we at 100%? What's the goal here? We're giving them too much. They don't need that much. Sometimes, patients. I feel better at four, four liters. I'm like this is not a feeling sort of situation, right? This is an education point that you have to have with your patients and I have this quite often.
Rachele Burriesci:I'll have patients who are on oxygen and let me tell you they do not give good instructions when they drop those devices off at houses. And I've I think I've told the story before with a pulmonary ild patient that I had and they just like dropped the concentrators off and didn't explain anything, didn't make sure that the concentrator actually would support how much oxygen this person actually needed. So you know, they kind of just figure it out. You can't titrate oxygen on feeling. It is not a subjective thing. This is as objective as you get. This is this number and there's that number and if this number is less than 92%, well then I'm allowed to increase this number. But you can't just increase how many liters or FiO2 of oxygen you're getting based on how you feel we should be checking. So if you have a patient who's on oxygen, a lot of the education that I give is do you have a pulse ox at home? If the answer is no, then I ask well, how do you know when to increase your oxygen. They're like well, if I feel short of breath, I just put it up.
Rachele Burriesci:That's not really how this works, okay, the other side of the coin and it's just amazing how extreme the two sizes of this can be is the person who takes their oxygen off to do the activity. And this happens in the hospital setting too. This is not just a patient thing at home In the hospital. One of the conversations I have so frequently is when the person is going to do activity, they shouldn't be taking their oxygen off. And I can't tell you how many times I've had staff say oh, we're just going to take that off. I'm like oh, hey, oh, why are we taking that off? Well, because you're going to go walk, yeah, so if your person needs oxygen at rest to maintain their SpO2 goal at rest, needs oxygen at rest to maintain their SpO2 goal At rest, just their regular metabolic energy to maintain life, to sustain just, you know, organ perfusion, that kind of thing they need oxygen.
Rachele Burriesci:They're not doing anything else, they're laying in bed, they're not even sitting in the chair. If your person needs oxygen at rest, your person needs oxygen with activity period. End of story. I don't want to hear anything else, because all you're going to do in those moments is tank, right. So you're going to take your oxygen off. You're going to do the activity, you're going to drop below level. We're just going to dissociate the hemoglobin, right, just crashing on our oxyhemoglobin dissociation curve. And now your patient has to play catch up. So they tank, they're short of breath, they're probably in a panic, they get back to bed, they put their oxygen back on, and they do this at home too.
Rachele Burriesci:Or you have the opposite. You have the person who has the oxygen on. They do activity like no, I'm a little short of breath. Let me bump that up to six. No, this is not how this works. You want to give the amount of oxygen that is required to maintain goal for the activity that they're doing. And if you're doing a higher level activity, you can expect to increase oxygen more. And if you're doing a higher level activity, you can expect to increase oxygen more.
Rachele Burriesci:And if you're at the top of your oxygen threshold, on whatever device you're using, if you're using a nasal cannula, if you're using a high flow nasal cannula, if you're on a face mask, if you have an oxy mask and you're at the top of that mask with rest. Then you have to have a backup device. And this is a conversation that I love to have with the RTs, right, because in most places the RTs are the keeper of the oxygen devices. This is a communication thing. This is interdisciplinary collaboration. Hey, I have this patient. We're going to do this thing today. We're going to try to progress ambulation, we're going to try stairs, but every time we increase, we drop below goal, we're at the top of our whatever device you're on, what's our plan for a backup? What do you think we can use? Or my patient can't breathe through their nose. Everything we do they start mouth breathing, especially when we're exercising. What do you think we can do for having a higher level device that is more mouth covering versus nose covering, so this person can do more? Have those conversations Be part of the conversation. Know what devices you might be able to use. Know what the max of those devices are capable of right, this is part of the conversation.
Rachele Burriesci:And knowing what the patient's goal is at the end of it, whether it's an activity goal, an SpO2 goal. You have to match those two things up. You have to understand that every device has a max FiO2 potential and your patient has this goal. They have to maintain. We're not trying to stay under 92%, 90%, 88%, whatever their goal is. We're trying to mobilize, exercise, do daily life, maintaining above that goal. You have to have the appropriate device to do that, you need to be monitoring to assess it. To do that, you need to be monitoring to assess it and you have to up titrate to support them. So two sides of this coin. We don't want to up titrate and keep them at a hundred percent. That is not the goal. They're at a hundred percent.
Rachele Burriesci:You actually don't know what their SpO2 truly is because we're just utilizing a pulse ox. You can actually see this with ABGs. So you'll see this commonly when a patient is on mechanical ventilation. So patients on mechanical vent, it's very common, like post-surgery, they're still on a vent. They're getting some level of FiO2, some level of support and when you look at their PaO2, their PaO2 is like 120. So this person is probably in the ICU. Their SpO2 is 100% on monitor. So they look good right. When they pull an ABG, their PaO2 is actually like 120, 112. You'll see those higher numbers. They're hyperoxygenated. What typically happens is that person's about to be extubated. All is good. You know nothing, nothing extreme there. Same concept, though If you have a person who's on a high level oxygen, or even low level oxygen, and they're satting at a hundred percent, down titration is just as important as up titration right, less.
Rachele Burriesci:If they need less, give them less. If they need more, give them more. But you want to give the appropriate amount. So there's no exact science to this. It is literally do, assess, titrate, and my recommendation is to titrate up and down very tightly One liter, two liter, so on and so forth. We're not trying to get to a hundred, we're trying to maintain above goal and we're trying to do as much as they can with maintaining above goal. So we're not taking the oxygen off to do activity and we're not titrating to put them at a hundred percent.
Rachele Burriesci:Okay, we are titrating to keep them above goal, because then that person is going to be able to progress appropriately, preferably with less shortness of breath, preferably doing more, and then, as they're doing more, they may require less again. And then you back off, right, everyone has a different reason why they're on oxygen. Sometimes it's temporary, during an exacerbation, sometimes it's progressive disease, and you have to expect that continuous increase. So you want to kind of have these things in the back of your mind, but you also want to make sure that you're utilizing an appropriate device to help this patient maximize their goals. So hopefully that wasn't beating around the bush too much.
Rachele Burriesci:I just really wanted to start this conversation because next episode, what we're going to do is we're going to talk about each device and their typical FiO2 goals, the level of flow that is required to achieve that FiO2.
Rachele Burriesci:We'll get a little bit more into the nitty gritty of what it means, like what does FiO2 actually mean and how does that relate to, like, room, air, and then understanding the devices in that sort of sense, and then we can kind of build this conversation a little bit more and then I think that'll be a good segue into oxyhemoglobin dissociation without kind of overloading and, you know, being too lectury, so to speak. So hopefully this was helpful. If I was not clear, please let me know, because I am just chatting to the abyss at this point and I want to make sure that what information I'm putting out there is actually helpful for you and that you're then able to utilize it in clinic or with your patients or whatever setting you're in. So reach out to me, let me know if this was helpful. Next week we're going to talk about devices and then, hopefully, we're going to have some fun and talk about that oxyhemoglobin dissociation curve. All right, I hope you all have a wonderful day and whatever you have to do, I get after.
