# O2 Usage in the field



## keith10247 (Sep 7, 2008)

Good Morning everyone.  I have a question about using O2 in the field.  I recently got my cert and am back to riding in the back of the unit instead of being up front driving.  In my EMT class, they stressed O2, O2, O2!  Stubbed your toe?  15lpm by NRB.  Chest pains? 15lpm by NRB.  They said EVERYONE should be put on 15lpm of O2 by NRB.  We actually would have failed the state test if we forgot to put O2 on every patient we touched.  We didn't get the option to use a NC *unless* the patient wouldn't tollerate a NRB.

My question...is this normal?  The past year and a half I have been riding, I have never seen O2 be put on a patient who stubbed his toe or who cut their arm.  To me, just getting in to the swing of things, it seems excessive!

Am I missing something?


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## Flight-LP (Sep 7, 2008)

No, you're not missing anything. Your educators and the system as a whole is missing something. Its called the ability to educate. The ciriculum has been so watered down that they try to standardize a methodology of treatment for every patient scenerio. Problem is life doesn't work out that way. Stubbed your toe? No you are not getting oxygen. Having a stroke? Then you will probably get some oxygen, but it will probably be via nasal cannula. Having an MI? Then you too may get a cannula. There are too many variable to make a blanket statement like that. Unfortunately, our educational system fails to identify that.


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## Ridryder911 (Sep 7, 2008)

Sorry. Really. Either your state system or educational or maybe both.. sucks. Oxygen is a drug/medication. As such, it should not be taken lightly. True it is one of the safest medications, and is is usually harmless but still the emphasis should be placed on proper treatment. 

Is the patient in need or will the drug help the person? In other words is it warranted? 

Again, one has to perform under protocols but there is a way to get those changed and I would start working to do so.

Good luck, and thanks for noticing the flaw rather than to be a mindless sheep and just following the lead. 


R/r 911


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## MAC4NH (Sep 7, 2008)

Ridryder911 said:


> Sorry. Really. Either your state system or educational or maybe both.. sucks. Oxygen is a drug/medication. As such, it should not be taken lightly. True it is one of the safest medications, and is is usually harmless but still the emphasis should be placed on proper treatment.
> 
> Is the patient in need or will the drug help the person? In other words is it warranted?
> 
> ...



I totally agree. While it's not harmful, its not always indicated.  Glucose is harmless to most patients too but I don't give it every patient either.

In which state do you practice?


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## Sasha (Sep 7, 2008)

I was the same as you! When I got out into my ride times, I wanted to slap a NRB on every patient! Oh you just wanted a ride, and are going to change your mind and refuse transport right outside the mall so you get out? O2 for you!

But nearly everytime I went to grab a mask, I was either told its not necessary or to grab a cannula instead.

When I got to medic and started riding at a different station they only give O2 if the person is having chest pains or appears to be having difficulty breathing.


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## MSDeltaFlt (Sep 7, 2008)

keith10247 said:


> Good Morning everyone.  I have a question about using O2 in the field.  I recently got my cert and am back to riding in the back of the unit instead of being up front driving.  In my EMT class, they stressed O2, O2, O2!  Stubbed your toe?  15lpm by NRB.  Chest pains? 15lpm by NRB.  They said EVERYONE should be put on 15lpm of O2 by NRB.  We actually would have failed the state test if we forgot to put O2 on every patient we touched.  We didn't get the option to use a NC *unless* the patient wouldn't tollerate a NRB.
> 
> My question...is this normal?  The past year and a half I have been riding, I have never seen O2 be put on a patient who stubbed his toe or who cut their arm.  To me, just getting in to the swing of things, it seems excessive!
> 
> Am I missing something?



Here's the deal about the National Registry on testing; especially for basics.  They will test to see how you treat the worst case scenario in which case you will be giving 15lpm NRM.  In real life, however, that will not necessarily be the case because the majority of your calls will not be the worst case scenario with regards to O2 administration.

Remember, they are not only testing you (as intelligent as you and your crews may be), but also testing the lowest common denominators.  Passing any standarized test only means one thing: *that you have successfully completed the minimal requirements*.

True learning begins with experience.  And you cannot teach experience.


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## VentMedic (Sep 7, 2008)

Unfortunately the basics of oxygen delivery are not taught. Therefore, without this understanding it is difficult to choose the appropriate delivery device for the patient. Too many rely on cookbook recipes which state 2 L NC = 28% or that a NRBM is a high flow mask (which it is not by true definition). They then are at a lost when they don't get the same results for every patient that have had these devices in use. Thus, instead of teaching the basic principles of how each device works and the limitations, it is often easier to just give a blanket recipe which may or may not be necessary and appropriate for all.


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## MMiz (Sep 7, 2008)

VentMedic said:


> Unfortunately the basics of oxygen delivery are not taught. Therefore, without this understanding it is difficult to choose the appropriate delivery device for the patient. Too many rely on cookbook recipes which state 2 L NC = 28% or that a NRBM is a high flow mask (which it is not by true definition). They then are at a lost when they don't get the same results for every patient that have had these devices in use. Thus, instead of teaching the basic principles of how each device works and the limitations, it is often easier to just give a blanket recipe which may or may not be necessary and appropriate for all.


I understand that you are saying, but what do you expect for the EMT-Basic? They spend a class or so on each topic and then move on.  The EMT-Basic is like a survey course compared to the EMT-Paramedic.


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## VentMedic (Sep 7, 2008)

MMiz said:


> I understand that you are saying, but what do you expect for the EMT-Basic? They spend a class or so on each topic and then move on. The EMT-Basic is like a survey course compared to the EMT-Paramedic.


 
Unfortunately few Paramedics get the basic principles in their class. Very few even understand Minute Ventilation. Few understand hyperventilation, hypoventilation, hypoxic, hypoxic drive and hyperoxygenation. Rarely are the descriptive terms like tachypnea used. Thus, to explain the entrainment and flow principles (Venturi and Bernoulli) would be difficult for some to grasp. FFs usually do the best here believe it or not.


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## keith10247 (Sep 7, 2008)

Thanks for the replies.  I am glad to know that I did not sleep through something!  

I am in the state of VA.  I just checked local protocols and it lists the following:

Indications:
-Confirmed or suspected hypocia
-Ischemic chest pain
-Respritory insufficiency
-Confirmed or suspected CO poisoning
-Any cause of decreased tissue oxygenation

Side effects:
Resp: Drying of mucous membranes

There is a protocol consideration that lists the following:

-Minor illnesses or injuries, if required:
Dose: Adult and Ped. - Low concentration via administration by NC at 1-6lpm

-Severe illnesses or injuries:
Dose: Adult and ped. - 100% or high flow administration via NRB (>10lpm or other high-flow O2 via delivery device.


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## keith10247 (Sep 7, 2008)

Oh,
One other question:  In my EMT cirriculum, they taught a lot about the FROPVD (Flow restricted oxygen powered ventillation device (I believe)).

We actually had a question about this device on the written test.  

I have never seen one used!  I have seen pictures in the book..just not in real life.  Is this device actually used in the field?


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## BossyCow (Sep 8, 2008)

Strictly from an administrative point of view, slapping a NRB at 15lpm is going to run through O2 a lot faster.


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## VentMedic (Sep 8, 2008)

keith10247 said:


> Oh,
> One other question: In my EMT cirriculum, they taught a lot about the FROPVD (Flow restricted oxygen powered ventillation device (I believe)).


 
These demand valve devices have their problems which center around the expertise of the user.

They are taking a back seat to ATVs to become compliant with suggestions from the AHA guidelines. The CareVent EMT is very simplistic but provides simple ventilation with preset rates and volumes. However, as with all powered ventilation devices, one must continue to assess the patient for breath sounds and chest rise.


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## traumateam1 (Sep 8, 2008)

Flight-LP said:
			
		

> Having an MI? Then you too may get a cannula.


Just wondering why an MI would possibly get a cannula. I can understand cut or stubbed toe.. but O2, isn't that, at a BLS level like really important. I mean our treatment options are limited to ASA, Nitro, Entonox and O2 mostly? 
I've been taught that 10 Lpm via NRB is important with an MI. So why is this? Just curious.


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## traumateam1 (Sep 8, 2008)

Ok, my last post doesn't really make sense.. I was kinda busy while typing it up so I'll re do it.



			
				Flight-LP said:
			
		

> Having an MI? Then you too may get a cannula.


Why would you give an MI patient a cannula with 4 Lpm. I can understand not giving a cut, or stubbed toe O2, I mean why would you? But someone having an MI, wouldn't that warrant 10 -15 Lpm via NRB. I was taugh that if they are satting at close to 100 on the SpO2 than still give 10 - 15 Lpm. (Treat the p/t not the machine"). Anyways.. whats your reasoning to cannula? Thanks!


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## Jon (Sep 8, 2008)

traumateam1 said:


> Ok, my last post doesn't really make sense.. I was kinda busy while typing it up so I'll re do it.
> 
> 
> Why would you give an MI patient a cannula with 4 Lpm. I can understand not giving a cut, or stubbed toe O2, I mean why would you? But someone having an MI, wouldn't that warrant 10 -15 Lpm via NRB. I was taugh that if they are satting at close to 100 on the SpO2 than still give 10 - 15 Lpm. (Treat the p/t not the machine"). Anyways.. whats your reasoning to cannula? Thanks!


Oh no.. not again.


From an ALS perspective - if the patient is NOT obviously hypoxic - espicially if their pulse oximitry reading is good... then there is no reason they need high-flow O2.


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## VentMedic (Sep 8, 2008)

Jon said:


> Oh no.. not again.
> 
> 
> From an ALS perspective - if the patient is NOT obviously hypoxic - espicially if their pulse oximitry reading is good... then there is no reason they need high-flow O2.


 
That would depend on the clinical appearance of the patient. If the patient is working hard to maintain their SpO2, then more O2 may be required. It the cardiac output and myocardium are starting to fail, who knows what the patient will require. 100% O2 by ventilator and IABP could be in their future very easily. 

Some patients will do very well on 2 - 4 liter depending on their WOB. The AHA is not opposed and many cardiologists still may want supplemental O2 for first 6 hours during an MI or with the initial clinical indication of an MI. Depending on how much O2 is required will later determine the free radicals. More pharmacological and surgical intervention may be required to improve the MVO2 and eventually reduce the requirement for supplement O2. Regaining coronary blood flow and perfusion will be what determine the outcome. O2 will be supportive care to maintain a good SpO2 and decrease work of breathing. 

http://www.emedicine.com/med/byname/myocardial-ischemia.htm

Again, it is about education for the proper use of the medication (O2) at hand and not memorization from an index card. No two patients may present the same. There are other diseases that mimic an MI so again the recipe may not always apply to everyone.


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## traumateam1 (Sep 8, 2008)

Jon said:
			
		

> From an ALS perspective


I *wasn't* talking ALS though, I was talking BLS.


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## Jon (Sep 8, 2008)

traumateam1 said:


> I *wasn't* talking ALS though, I was talking BLS.


Point.

I'm BLS too... HOWEVER, around here, BLS is trained to follow "if A, do B" protocols... so they give high flow O2 to every patient.

If the patient isn't going to really need the additional O2, and are just in need of a LITTLE O2... no sense covering their face with a big mask, and raising their anxiety and stress, as well as making it harder to understand them.


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## traumateam1 (Sep 8, 2008)

Thanks Vent,
You answered my question pretty well. If the patient is satting well on R/A or NC and not working hard for O2 than no need for NRB, however if they aren't satting well with R/A or NC than 10-15 Lpm via NRB is good.


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## traumateam1 (Sep 8, 2008)

Jon said:
			
		

> Point.
> 
> I'm BLS too... HOWEVER, around here, BLS is trained to follow "if A, do B" protocols... so they give high flow O2 to every patient.
> 
> If the patient isn't going to really need the additional O2, and are just in need of a LITTLE O2... no sense covering their face with a big mask, and raising their anxiety and stress, as well as making it harder to understand them.



Same here.. I mean, I understand if the patient is satting well on R/A and not working hard than NC would work. It's weird tho.. cuz in class, the teacher said O2 O2 O2 for MI's.


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## mycrofft (Sep 8, 2008)

*There ought to be a new categorization of EMT's based on setting:*

Ten minute EMT's, 1 hour EMT's, twelve hour EMT's...so much depends upon how long you have the pt and the benefit/risk ratio of on scene versus in-transit/in hospital treatment. Heck, working on pts at altitude or in-flight is a whole new ball of wax versus say the Salton Sea or Chicago at ground level. Much more finesse of oxygen therapy is needed for a neonate or a long-distance haul for somone with a fresh MI, and less for the guy who choked on a bolus of ribeye at Logan's a block from the hospital.

Blanket protocols are for people the administrators are afraid of and call "technicians". Keep on learning.


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## JPINFV (Jul 8, 2009)

MMiz said:


> I understand that you are saying, but what do you expect for the EMT-Basic? They spend a class or so on each topic and then move on.  The EMT-Basic is like a survey course compared to the EMT-Paramedic.



Is it too much to expect from basics what should be expected from all providers? Namely the ability to logically pick and choose treatments including, but not limited to, dose and route, as well as explain both why that treatment is needed and how that treatment works?


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## CAOX3 (Jul 8, 2009)

keith10247 said:


> Good Morning everyone.  I have a question about using O2 in the field.  I recently got my cert and am back to riding in the back of the unit instead of being up front driving.  In my EMT class, they stressed O2, O2, O2!  Stubbed your toe?  15lpm by NRB.  Chest pains? 15lpm by NRB.  They said EVERYONE should be put on 15lpm of O2 by NRB.  We actually would have failed the state test if we forgot to put O2 on every patient we touched.  We didn't get the option to use a NC *unless* the patient wouldn't tollerate a NRB.
> 
> My question...is this normal?  The past year and a half I have been riding, I have never seen O2 be put on a patient who stubbed his toe or who cut their arm.  To me, just getting in to the swing of things, it seems excessive!
> 
> Am I missing something?



Yes, anatomy and physiology.  Dont frett, so is the majority of everyone else that you work with.  You can take these two classes at your community college.  It will be beneficial to you and your patients.


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## johnnyreb132 (Jul 8, 2009)

Since y'all are on the topic of oxygen for Basics, is it alright to go ahead and put a NRB on a patient with COPD if their breathing is not the CC or related?


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## VentMedic (Jul 8, 2009)

johnnyreb132 said:


> Since y'all are on the topic of oxygen for Basics, is it alright to go ahead and put a NRB on a patient with COPD if their breathing is not the CC or related?


 
Do they have a problem with cardiac output, perfusion, V/Q mismatch, decreased carrying capacity or something other than oxygen bound to their Hb?

If none of the above is confirmed, why do you want to put O2 on the patient?


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## MSDeltaFlt (Jul 8, 2009)

johnnyreb132 said:


> Since y'all are on the topic of oxygen for Basics, is it alright to go ahead and put a NRB on a patient with COPD if their breathing is not the CC or related?



Just because a pt is diagnosed with COPD does not necessarily mean they will automatically have a "known hypoxic drive" along with any "known CO2 retention".  That being said, why would you want to if they are not complaining about CP/SOB?


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## johnnyreb132 (Jul 8, 2009)

VentMedic said:


> Do they have a problem with cardiac output, perfusion, V/Q mismatch, decreased carrying capacity or something other than oxygen bound to their Hb?
> 
> If none of the above is confirmed, why do you want to put O2 on the patient?



I was told that, no matter what, if the patient appears to have difficulty breathing and/or abnormal sounds in the lungs, then they get NRB at 15 lpm, despite of the COPD. However, I'm afraid of the off of chance messing up their respirations with the patient's hypoxic drive. 

This too brought to you by the Commonwealth curriculum.


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## VentMedic (Jul 8, 2009)

johnnyreb132 said:


> Since y'all are on the topic of oxygen for Basics, is it alright to go ahead and put a NRB on a patient with COPD if their *breathing is not the CC or related*?


 


johnnyreb132 said:


> I *was told that, no matter what, if the patient appears to have difficulty breathing and/or abnormal sounds in the lungs, *then they get NRB at 15 lpm, despite of the COPD. However, I'm afraid of the off of chance messing up their respirations with the patient's hypoxic drive.


 
Difficulty breathing or not?

If the person is having difficulty breathing, you do whatever you can within the limited scope of the EMT-B to alleviate it.  If the person is hypoxic, it is senseless to worry about knocking out the "hypoxic drive".  If the patient ceases to breathe in the very short time you are with them, it is probably not due to the "hypoxic drive" but rather respiratory failure and exhaution.  Use can then use your BVM.  The person would probably have required intubation regardless of the 100% hypoxic drive theory. 

CO2 retention only occurs in about 5% of all COPD patients.  

Here's a good thread for you to review.

http://www.emtlife.com/showthread.php?t=4225&highlight=hypoxic+drive


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## JPINFV (Jul 8, 2009)

johnnyreb132 said:


> I was told that, no matter what, if the patient appears to have difficulty breathing and/or abnormal sounds in the lungs, then they get NRB at 15 lpm, despite of the COPD.



To be honest, "abnormal lung sounds" is a little too broad for a NRB. Difficulty breathing, shortness of breath, etc, then yea, go with oxygen at a rate and device appropriate for your assessment. 


> This too brought to you by the Commonwealth curriculum.



Meh, kick all of the commonwealths out of the country. It's the "United States," not "United Commonwealths!"


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## CAOX3 (Jul 8, 2009)

Abnormal sounds in the lungs?   Those sounds have names and meanings or do they not teach that anymore.


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## Ridryder911 (Jul 8, 2009)

CAOX3 said:


> Abnormal sounds in the lungs?   Those sounds have names and meanings or do they not teach that anymore.



Actually, it is not normally taught or required in the basic EMT curriculum. I agree that many are and should be, but currently not in the scope of the EMT. 

R/r 911


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## ResTech (Jul 9, 2009)

johnnyreb132.... dont be afraid to administer oxygen to a COPD patient. A hypoxic patient is a hypoxic patient... If they need oxygen, they need oxygen so give it to them without hesitating. AS others have already said, its highly unlikely your going to make them go into respiratory arrest in the short amount of time you are caring for them. And if they do, breathe for them.  

In terms of respiratory drive and need for oxygenation, the only difference between a COPD patient and a non-COPD patient, is their biochemical trigger of respiration. Regardless of what the patients underlying condition is, the cells still require a sufficient level of oxygen to function... which is why we NEVER withhold oxygen.  

What they won't teach you in your EMT program and expands on your question:

*NORMAL, NON-COPD PATIENT*
A non-COPD patient (you and I) breathe based on the level of CO2 or more specifically the hydrogen level sensed within the cerebral spinal fluid. When our bodies sense a rising CO2 level, our receptors sense this rise and our breathing center kicks in to make us breathe faster or just to breathe period to keep the CO2 level normal and maintain homeostasis.  

*COPD PATIENT*
A COPD patient has chronically elevated levels of CO2 (or more specifically hydrogen) and as a result, the receptors become desensitized to these high levels of CO2 which forces the body to disregard this increase since this newly aquired high CO2 level is now the bodies norm. Since the receptors are desensitized and ignore the CO2 level, a new drive (or biochemical trigger) needs to come into play... which becomes the patients oxygen level (or PaO2). 

So now, when the oxygen level gets low (hypoxic), the body triggers respiration. And if the body senses too much oxygen, the body basicly says... "hold up, too much oxygen, lets slow down breathing"... this is the hypoxic drive. Sometimes when the body gets flooded by a NRB, the body shuts down breathing all together to try to maintain what it thinks should be normal.

Treat your patient based on your ASSESSMENT of them... if they have COPD and are Asymptomatic, then why give O2 by NRB? That's the question you need to ask yourselve. Remember, the majority of COPD patients are always short of breath with a decreased SpO2 (89-92% is normal for some COPDers). Ask the patient about any changes from their baseline like, "any increase in SOB"?, increased w/ exertion?,  increased cough with nasty (perulant) sputum changes? fever or increased maliase (weakness)? more frequent use of their nebulizer/inhalers? have they self-increased their home O2?... just a few questions to keep in mind to establish deviation in baseline COPD status and to see if they are having an exacerbation of their COPD from perhaps a bacterial infection. A large percentage of the time, COPD exacerbations result from infection... so look there too for cause.  

For some reason this concept confuses me sometimes but it is important to understand to grasp the answer of your question.


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## CAOX3 (Jul 9, 2009)

Ridryder911 said:


> Actually, it is not normally taught or required in the basic EMT curriculum. I agree that many are and should be, but currently not in the scope of the EMT.
> 
> R/r 911



Oh, my fault I was assuming that people that may have to give an albuterol treatment may actually know the difference between a wheeze and rales or asthma and CHF.  

Sorry my bad.


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## VentMedic (Jul 9, 2009)

ResTech said:


> In terms of respiratory drive and need for oxygenation, the only difference between a COPD patient and a non-COPD patient, is their biochemical trigger of respiration. Regardless of what the patients underlying condition is, the cells still require a sufficient level of oxygen to function... which is why we NEVER withhold oxygen.
> 
> What they won't teach you in your EMT program and expands on your question:
> 
> ...


 
This is part of the "hypoxic drive myth". And again, only 5% of all COPD patients are CO2 retainers. If does not explain the rise in PaCO2 accurately.

Refer to the link I posted earlier from a past discussion on this forum.

And this site:
http://www.learnmoresavelives.com/b...c-drive-mediated-sudden-hyperoxic-death-oh-my



> So again: Hypoxia kills. Hypercarbia happens. Sick COPD patients die first and foremost of hypoxia, and while, as we will discuss, sudden increases in hypercarbia may contribute to sudden cardiac arrest, they are not the result of oxygen induced apnea. Instead, by believing that the only way these people will die is if they go apneic from the oxygen, we completely miss that the respiratory failure is what kills them and forget that assisted mechanical ventilation and not just oxygen is the treatment of choice for respiratory failure.
> 
> Now, the short answer to the question is that the fact that people act based on the myth of the “hypoxic drive oxygen induced apnea” is actually far more lethal than the oxygen. Patients with COPD (or chronic asthma) have a whole body oxygen deficit at baseline and are essentially in compensated respiratory distress. Now worsen their pulmonary function and they go into decompensating and ultimately decompensated respiratory failure and die of hypoxia.


 


> However, it is important to understand that the rise in PaCO2 is mostly from normal physiologic response to restoration of alveolar oxygen levels, increased deadspace, changes in pulmonary capillary blood flow, and decreased CO2 elimination; only a small amount in a minority of individuals can be blamed on decreased minute volume. This sudden increase in CO2 can be harmful (possibly even fatal) but remember, we have ways of helping people get rid of CO2; those methods are known as assisted or mechanical ventilation. But before we starting blaming ourselves for not expecting this sudden non-apneic increase in CO2, remember that these patients started out in respiratory failure and while high flow oxygen may improve their oxygenation status, respiratory failure is much bigger than just oxygen levels and that little bit of oxygen you’ve added doesn’t fix the respiratory failure


*The Death of the Hypoxic Drive Theory*

http://home.pacbell.net/whitnack/The_Death_of_the_Hypoxic_Drive_Theory.htm

*Hypoxic Drive in COPD: Is the fear of Oxygen based on Fact or Myth?*
Mark Siobal (UCSF)
http://www.idasrc.org/Hypoxic_Drive.ppt


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## daedalus (Jul 9, 2009)

Except the heart can cause wheezing as well, and the assesment of that condition is beyond the scope of EMT training. Giving albuterol comes with a lot more responsability and the need for advanced assesment.


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## ResTech (Jul 9, 2009)

> its highly unlikely your going to make them go into respiratory arrest in the short amount of time you are caring for them. And if they do, breathe for them.



I'm not necessarily saying I subscribe totally to the "hypoxic drive theory", but from what we were taught in class and what is printed in the Paramedic textbook, this is still a modern concept and a physiological possibility.


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## ResTech (Jul 9, 2009)

Albuterol has a great safety profile and rarely causes side effects that are worse then what the albuterol is being given for (hypoxia).


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## VentMedic (Jul 9, 2009)

ResTech said:


> I'm not necessarily saying I subscribe totally to the "hypoxic drive theory", but from what we were taught in class and that is printed in the Paramedic textbook, this is still a modern concept and a physiological possibility.


 
EMS is always slow to change. If you look in the nursing textbooks for the last 10 years, you will see the explanation the links are providing. 

In the Pulmonary Lab I put known CO2 retainers on 100% Oxygen for 20 - 30 minutes to perform shunt studies. The 100% O2 is not delivered by a NRBM, which is not high flow and does not guarantee 100% O2, but by a Douglas Bag or closed circuit demand system. I do a baseline ABG at room air and then repeat another ABG at the end of the test on 100%. Even for those who do show they are CO2 retainers on their ABG, their PaCO2 levels don't raise with the test and I have yet to have one quit breathing during the test in 20 years.


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## ResTech (Jul 9, 2009)

I don't think its fair to say "EMS is slow to change"... its higher level healthcare providers that have embraced this concept and practiced it and taught it to EMS.


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## VentMedic (Jul 9, 2009)

ResTech said:


> Albuterol has a great safety profile and rarely causes side effects that are worse then what the albuterol is being given for (hypoxia).


 
You might want to do a little literature search on that. 

Albuterol is not being given for hypoxia but rather for the relaxation of smooth muscle which is primarily for ventilation. Pulmonary vasoconstriction usually results from the hypoxia which then creates the dead space and V/Q mismatch issues. 


Also, do you put your patients who are on MAOIs on a cardiac monitor when administering albuterol?


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## VentMedic (Jul 9, 2009)

ResTech said:


> I don't think its fair to say "EMS is slow to change"... its higher level healthcare providers that have embraced this concept and practiced it and taught it to EMS.


 
Those higher level healthcare providers have moved on as new evidence has been found and the textbooks have changed to reflect acceptance of a new way of viewing the advances in medicine.


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## ResTech (Jul 9, 2009)

That info is pretty current that you posted right? If the rest of the medical community has moved on then why is it necessary to still teach that hypoxic drive is just a myth? Just a question that comes to mind. 

Its still fresh in peoples minds... like I said... we were taught this in school last semester and is explained on page 216 of the latest edition of the Essentials of Paramedic Care Textbook (Brady, Second Edition) which is authored by Dr. Bryan Beldsoe.


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## VentMedic (Jul 9, 2009)

ResTech said:


> That info is pretty current that you posted right? If the rest of the medical community has moved on then why is it necessary to still teach that hypoxic drive is just a myth? Just a question that comes to mind.
> 
> Its still fresh in peoples minds... like I said... we were taught this in school last semester and is explained on page 216 of the latest edition of the Essentials of Paramedic Care Textbook (Brady, Second Edition) which is authored by Dr. Bryan Beldsoe.


 
You could email Dr. B and ask him when he is putting the other explanation into his book or at least explain why it is harmful to withhold O2 from a patient when you believe in this hypoxic drive theory.

Another link for you from the nursing profession:
http://findarticles.com/p/articles/mi_m0FSS/is_2_13/ai_n17206920/pg_3/


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## ResTech (Jul 9, 2009)

> You might want to do a little literature search on that.
> 
> Albuterol is not being given for hypoxia but rather for the relaxation of smooth muscle which is primarily for ventilation. Pulmonary vasoconstriction usually results from the hypoxia which then creates the dead space and V/Q mismatch issues.
> 
> Also, do you put your patients who are on MAOIs on a cardiac monitor when administering albuterol?



Yes, albuterol is indicated for bronchoconstriction of which affects both oxygenation and ventilation, correct? If a patient is severely bronchoconstricted they likely will have air trapping which compromises ventilation due to difficult expiration and a increased residual volume. 

And if a patient cannot ventilate because their lungs aren't able to recoil, diffusion is gonna be effected, cells are gonna be deprived of oxygen, which then leads to hypoxia.  So really albuterol is given for hypoxia. 

MAOI's are a class of antidepressants that are rarely prescribed anymore which in the majority of the population, wont be affected. 

Im not trying to be argumenative... your experience and knowledge vastly exceeds mine. I just wanna be sure I am understanding correctly..... and plus debating does actually help me recall and remember stuff...lol..


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## Shishkabob (Jul 9, 2009)

It's 12:30 so my mind isn't all that, but does that basically mean the maxim

"Never withhold oxygen from a hypoxic patients"

hold true?


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## VentMedic (Jul 9, 2009)

ResTech said:


> Yes, albuterol is indicated for bronchoconstriction of which affects both oxygenation and ventilation, correct? If a patient is severely bronchoconstricted they likely will have air trapping which compromises ventilation due to difficult expiration and a increased residual volume.
> 
> And if a patient cannot ventilate because their lungs aren't able to recoil, diffusion is gonna be effected, cells are gonna be deprived of oxygen, which then leads to hypoxia. So really albuterol is given for hypoxia.
> 
> ...


 
Very few of my COPD or Asthma patients require much O2 and the HeliOx is usually in concentrations of 80/20 or 70/30 with the higher number being helium.

You would be surprised by the number of people that are on MAOIs. I rarely will withhold albuterol unless there is a greater chance that the orgin is cardiac. I will then give only if on a monitor and even if it is respiratory related, if in the back of a truck or in the ED, they get a monitor.

Now for the hypoxic drive theory, I've given you some good links so that you can through and see how this concept applies to your patients.


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## VentMedic (Jul 9, 2009)

Linuss said:


> It's 12:30 so my mind isn't all that, but does that basically mean the maxim
> 
> "Never withhold oxygen from a hypoxic patients"
> 
> hold true?


 
Except when I am stressing them in a High Altitude Simulation Test....


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## ResTech (Jul 9, 2009)

But with Heliox, the helium actually works to deposit the O2 deeper and allow greater absorption than without, right? So because of the helium, a higher concentration of O2 would not be required to drive the rate of diffusion as in situations where heliox is not practical.


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## Shishkabob (Jul 9, 2009)

Well, was told that back in EMT, as and we all know, some of the things they teach you in EMT get thrown out in medic, so even though my EMT school is considered one of the better ones in Texas, I'm still double checking all the facts as I go.







So that's a yes?


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## CAOX3 (Jul 9, 2009)

daedalus said:


> Except the heart can cause wheezing as well, and the assesment of that condition is beyond the scope of EMT training. Giving albuterol comes with a lot more responsability and the need for advanced assesment.



As in failure and determing the difference between the two as I stated above.


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## VentMedic (Jul 9, 2009)

ResTech said:


> But with Heliox, the helium actually works to deposit the O2 deeper and allow greater absorption than without, right? So because of the helium, a higher concentration of O2 would not be required to drive the rate of diffusion as in situations where heliox is not practical.


 
No, not quite. HeliOx decreases work of breathing. In turbulent flows, the pressure necessary to generate a given flow rate is dependent on the density of the inspired gases. Helium has a density that is significantly lower than that of air (nitrogen and oxygen). Breathing HeliOx leads to a reduction in resistance to flow within the airways, and consequently to a decrease in the WOB, particularly in disorders that are characterized by increased airways resistance


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## VentMedic (Jul 9, 2009)

Linuss said:


> So that's a yes?


 
Yes with the exception of infants with a ductal dependent lesion (Cyanotic Heart Disease) that have not had meds to keep the ductus open started but hopefully you won't encounter this without a Neo team present.


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## usafmedic45 (Jul 9, 2009)

> Except the heart can cause wheezing as well



Heart failure can when it causes fluid to back up into the lungs.  Saying the heart causes it is not technically correct since you can have a heart that is technically structurally and mechanically normal simply overloaded by excessive fluid from kidney failure or overzealous fluid administration (normally it's a diseased heart pushed past the point of compensation by fluid or electrolyte abnormalities, etc).  It is the fluid that causes the problem, just as happens in pulmonary causes of edema formation. In these cases, there is a fine balance to be struck between the effect of the presence of the fluid in the airway causing the wheezing and the bronchoconstriction actually produced by the presence of the fluid which can irritate the small to medium airways.  

Regardless of mechanism, the focus is on fixing the underlying problem (diuresis, improving cardiac function if that's an issue and possibly CPAP/BiPAP as an adjunctive therapy) which will alleviate the wheezing.  In the case of someone with significant underlying cardiac disease, I am loathe to administer even a drug such albuterol with a decent safety profile in a _normal _ patient.  The last thing you want to do is add anything to the mix that is going to further tax the heart without a _significant_ benefit.  In this case, albuterol simply does not give you that return.  Simply because you are doing something _to_ the patient doesn't mean you're doing something _for_ the patient.  As one of my EMS instructors was fond of saying, the best providers are the not the ones who know when to do something or when to give a drug but rather know when _not_ to. 

This is a very simplified review but gets the major points across.  VentMedic already ran with most of the really interesting and complicated topics....that's what I get for not checking in earlier.


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## 46Young (Jul 9, 2009)

CAOX3 said:


> Oh, my fault I was assuming that people that may have to give an albuterol treatment may actually know the difference between a wheeze and rales or asthma and CHF.
> 
> Sorry my bad.



As EMT's in NY we learned to differentiate L/S. BLS albuterol was in protocol. Here in VA the EMT curriculum is sorely lacking. Our monthly training matrix includes a BLS cardiac powerpoint. It's so oversimplified and basic that it's laughable. I need to address this with the EMS Capt.


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## VentMedic (Jul 9, 2009)

> Originally Posted by *CAOX3*
> 
> 
> _Oh, my fault I was assuming that people that may have to give an albuterol treatment may actually know the difference between a wheeze and rales or asthma and CHF. _
> ...





46Young said:


> As EMT's in NY we learned to differentiate L/S. BLS albuterol was in protocol. Here in VA the EMT curriculum is sorely lacking. Our monthly training matrix includes a BLS cardiac powerpoint. It's so oversimplified and basic that it's laughable. I need to address this with the EMS Capt.


 
Many times you are NOT going to be able to differentiate between PNA, atelectasis, CHF, one of the 'osis diseases with inflamation and Asthma as well as wheezes caused by crackles or rales or whatever you happen to be calling them. Often it is unknown if the asthma or the PNA exacerbated the CHF or if the chicken laid the egg that hatched the......

This is why many other assessment factors are necessary and even then only a BNP and CXR will tell us  what we are hearing.


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## Foxbat (Jul 9, 2009)

VentMedic said:


> In turbulent flows, the pressure necessary to generate a given flow rate is dependent on the density of the inspired gases.


I might be wrong but I think it's true for laminar flows as well.





Rho is the density term. This equation should apply for laminar and turbulent flows, you just adjust friction factor f.


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## usafmedic45 (Jul 10, 2009)

Foxbat said:


> I might be wrong but I think it's true for laminar flows as well.
> 
> 
> 
> ...


Ah....someone's a geek for physics.


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## CAOX3 (Jul 10, 2009)

VentMedic said:


> Many times you are NOT going to be able to differentiate between PNA, atelectasis, CHF, one of the 'osis diseases with inflamation and Asthma as well as wheezes caused by crackles or rales or whatever you happen to be calling them. Often it is unknown if the asthma or the PNA exacerbated the CHF or if the chicken laid the egg that hatched the......
> 
> This is why many other assessment factors are necessary and even then only a BNP and CXR will tell us what we are hearing.


 
I can sure as heck narrow it down, based on history, assessment and presentation.

You should be able to walk in someones house and in 30 seconds be able to determine for the most part by what you see and hear what is going on.

COPDers live a certain way, CHFers live a certain way, diabetics and so on, everyone tailors their living arraignments based on their medical conditions, especially the elderly.


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## CAOX3 (Jul 10, 2009)

And yes I made up those words CHFers and COPDers, and I like them.


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## VentMedic (Jul 10, 2009)

CAOX3 said:


> I can sure as heck narrow it down, based on history, assessment and presentation.
> 
> You should be able to walk in someones house and in 30 seconds be able to determine for the most part by what you see and hear what is going on.
> 
> COPDers live a certain way, CHFers live a certain way, diabetics and so on, everyone tailors their living arraignments based on their medical conditions, especially the elderly.


 
Have you read why lasix is no longer widely used in EMS?

 People with no smoking hx with COPD?  Know the different types of COPD? Ever hear of Alpha-1 antitrypsin deficiency?  CF?  Seen young people, 20 and younger in CHF?  Left vs Right Heart failure?  High vs low output cardiac failure? 

Lifestyle can also be very deceiving and making assumptions can lead you down the wrong path. Granted, the treatment at the EMT-B level will probably be the same regardless of what the working diagnosis might be. 

BTW, the terms COPDer and CHFer have been around for a long time.  However, in respectful medical conversation we still try to identify the patient as a person and not an object by their disease.


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## VentMedic (Jul 10, 2009)

Foxbat said:


> I might be wrong but I think it's true for laminar flows as well.
> 
> 
> 
> ...


 
This is similar to Poiseuille’s Law which be used to compare the radius and pressure of a respiratory tube to the amount of resistance encountered within the tube.


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## CAOX3 (Jul 10, 2009)

VentMedic said:


> Have you read why lasix is no longer widely used in EMS?
> 
> People with no smoking hx with COPD?  Know the different types of COPD? Ever hear of Alpha-1 antitrypsin deficiency?  CF?  Seen young people, 20 and younger in CHF?  Left vs Right Heart failure?  High vs low output cardiac failure?
> 
> ...




Wait the medical field treating people like people?  They are treated like diseases and injuries.

Whos MI is this, who/s fx hip is this, I need the belly in ultrasound, get that head bleed to CT scan.  Sound all familiar? Anyway.

Understood, however COPD patients that dont smoke and 20 year old failure patients are the exceptions not the rule.

Your right at the BLS level it probably isn't going to change the treatment, however I like to have an idea of what I'm walking in the ER with and yes I know the difference between left and right sided heart failure.

Lifestyle is a very good indicator of medical hx. Sure it can be deceiving but people are also creatures of habit. 

The patient, their surroundings and assessment will lead me where I need to go.


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## Hockey (Jul 10, 2009)

I've only put a NRB on maybe 10 patients to be honest...

The book emphasizes that O2 for EVERYBODY

Then, I entered the real world


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## VentMedic (Jul 10, 2009)

CAOX3 said:


> Understood, however COPD patients that dont smoke and 20 year old failure patients are the exceptions not the rule.
> 
> Actually many of the patients seen for COPD have never smoked.  They may have been exposed to 2nd hand smoke at their employment or home life.  Asthma patients who have had extensive airway remodeling to where they are now chonically obstructed may have never smoiked.  As well, many patients who have CF, Alpha-1 antitrypsin deficiency and bronchiectasis have never smoked.
> 
> ...


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## paccookie (Jul 10, 2009)

johnnyreb132 said:


> I was told that, no matter what, if the patient appears to have difficulty breathing and/or abnormal sounds in the lungs, then they get NRB at 15 lpm, despite of the COPD. However, I'm afraid of the off of chance messing up their respirations with the patient's hypoxic drive.
> 
> This too brought to you by the Commonwealth curriculum.



Even on the off chance of "messing up" the hypoxic drive, you can always use a BVM if the pt is unresponsive or talk to the frontal lobe and tell the pt to breathe.  It works very well.  Say "Mr Whatever, I need you to breathe with me.  In through the nose, out through the mouth."  It requires you to sit with the pt and actually pay attention to him, rather than doing paperwork during transport, but it does work.  

That said, I'd do some reading and studying on your own or take some more classes and further your education.  O2 is not needed on every call and a NRB is not the only option for O2 delivery.  Have you ever seen a Venturi mask?  Those are one of the best O2 devices for a COPD pt with difficulty breathing.  You get the high air flow needed and precise control of the amount of O2.  Most of my pts that need O2 do well on a nasal cannula.  Very few actually require a NRB.


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## VentMedic (Jul 10, 2009)

paccookie said:


> Have you ever seen a Venturi mask? Those are one of the best O2 devices for a COPD pt with difficulty breathing. You get the high air flow needed and precise control of the amount of O2. Most of my pts that need O2 do well on a nasal cannula. Very few actually require a NRB.


 
Venturi masks are nice because they are a true high flow device unlike the NRBM.  However, in an acute emergency, one shouldn't be waiting time finding all the little colored adapters or twisting the O2 setting. There are more important issues at hand.  Getting the exact percentage of O2 is not nearly as important as meeting the patients respiratory needs and those of the other body systems.


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## paccookie (Jul 10, 2009)

VentMedic said:


> Very few of my COPD or Asthma patients require much O2 and the HeliOx is usually in concentrations of 80/20 or 70/30 with the higher number being helium.
> 
> You would be surprised by the number of people that are on MAOIs. I rarely will withhold albuterol unless there is a greater chance that the orgin is cardiac. I will then give only if on a monitor and even if it is respiratory related, if in the back of a truck or in the ED, they get a monitor.
> 
> Now for the hypoxic drive theory, I've given you some good links so that you can through and see how this concept applies to your patients.



(not addressing YOU vent)  It's not just MAOIs.  Tricyclics have bad interactions with albuterol, as can digoxin and beta blockers.  Your pt should be on the monitor any time you give a drug because you don't know how that pt will react.  Each pt is different and may be on different drugs or have different pre-existing conditions.  Electrolytes may be off in your pt and you may push them over the edge with your treatment.  The point is that you never know.  Albuterol may seem harmless, but it does affect the heart too and some pts can't tolerate it.


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## eynonqrs (Jul 10, 2009)

Here is my thoughts:

It is absurd that they teach that way, and that is the way they do it in PA now, too. When I took my EMT, we were taught the proper way, in every aspect. We were shown how to use a cannula, venturi mask, simple face mask and an NBR. I first take vitals, and then do the pulse ox, you have to remember that some pt that has poor profusion (i.e., low bp or other factors) will lead you to false readings or no readings. pt's will get more O2 concentrations on a mask than a NC. 2 LPM is nothing more than "room air". 4 lpm is more the norm and generaly works well in pt's that need it, but don't require any more. I have seen charts on concentration levels, 6 lpm via simple face mask will give more than 6 lpm nasal. Besides, why would you want to blow that much pressure through the nose ? 6 to 10 on a simple mask is also a good choice also depending on the situation.


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## KB1MZR (Jul 13, 2009)

Some things to think about:

CVA/TIA, MI (or other cardiac episode), head injuries, difficulty breathing...

These are what you need to be worried about.  In CVA/TIA one major component in most cases is ischemia, and how do we correct ischemia on a BLS level - OXYGEN!, in high concentration.  These are patients who require a NRB on 15lpm.

AMI and other cardiac episodes - again, related to ischemia therefore high concentration oxygen.

Head Injuries - If their oxygen saturation drops below 90% their mortality rate if they do have a closed head injury increases 2-3X (same with their systolic BP dropping below 90, but entirely different story).

Difficulty Breathing - Is it CHF, Pulmonary Edema, Pnemounia, Exacerbation of COPD, Asthma, Allergic Reaction.  You know individual treatments for these scenarios but most of these require high concentration oxygen.  Especially with your asthma pt. who has bilateral expiratory wheezing and is complaining of chest tightness, ALS is not available and BLS doesn't have albuterol or another bronchodilator to solve the problem.  On the COPD side of things be careful, yes they need oxygen but if you remember back to class a COPD patient functions based on their hypoxic drive instead of their carbon dioxide retention, therefore - too much oxygen equals the pt. believes they no longer need to breathe.  Congrats, their goes their respiratory drive.  Again, oxygen is a med so don't take it lightly.

If your service (like most services are) is using pulse oxymetry...

remember what is mild, moderate, and severe hypoxia and treat for the indicated.  BUT --- there is always a but... REMEMBER PLEASE do NOT rely on the machine rely on your pt. first and foremost and rely on your assessment to determine how to treat, the machine may not be accurate in both ways.  Cold hands and a sat of 70% in a pt. with an RR of 16 unlabored and clear lung sounds that's pink/warm/dry doesn't need to be bagged, but your cyanotic asthma attack that's reading 97% does.

AND FINALLY - NEVER DENY ANY PT. EXPERIENCING DYSPNEA OXYGEN!!!


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## daedalus (Jul 13, 2009)

KB1MZR said:


> Some things to think about:
> 
> CVA/TIA, MI (or other cardiac episode), head injuries, difficulty breathing...
> 
> These are what you need to be worried about.  In CVA/TIA one major component in most cases is ischemia, and how do we correct ischemia on a BLS level - OXYGEN!, in high concentration.  *These are patients who require a NRB on 15lpm.*


If you re read this thread, you will be surprised to find out that you are very wrong. In fact, the current literature is teaching us to *not* give 15L O2 to patients with suspected TIA vs CVA unless they are hypoxic. You will find adequate reading material on this on other pages in this thread, as well as on JEMS under Dr. Bledsoe's column. Please also see VentMedic's post regarding said article, it is also in this thread on an earlier page.


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## Smash (Jul 13, 2009)

KB1MZR said:


> Some things to think about:
> 
> CVA/TIA, MI (or other cardiac episode), head injuries, difficulty breathing...
> 
> ...



It's not as simple as that I'm afraid.

The evidence for giving supplemental oxygen to anyone who is not hypoxic is scant, and there is some suggestion that supplemental oxygen may in fact be harmful to these patients.

CVA/TIA:  As previously noted by several others here, high flow O2 is probably actually detrimental to CVA/TIA patients.

AMI/ACS:  Again, potentially detrimental. ACS occurs due to mechanical obstruction i.e blood not flowing to the affected area.  No amount of supplemental oxygen will change that fact.  The amount of O2 dissolved in plasma is negligible at atmospheric pressure and the change that we can induce is even more negligible.  Increasing the concentration of O2 will also cause vasoconstriction thereby potentially achieving the direct opposite of what you think you are doing.

In heart failure high concentration O2 decreases cardiac output and stroke volume and increases systemic vascular resistance (exactly what we don't want)  Someone with heart failure needs nitrates and CPAP (generalising here for purposes of discussion) and that CPAP is not provided with an FiO2 of 1 for very good reason.

i'm sure VentMedic can correct me or expand upon this, but to state that everyone with CVA/ACS or whatever automatically needs 15l via NRB is not only wrong it is potentially harmful.


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## daedalus (Jul 14, 2009)

I think that she (Venty) will also point out that the amount of oxygen you give someone is based on their cardiopulmonary status including work of breathing. While blanket statements like 15 for everybody are wrong, it is also wrong to give everyone 2 LPM NC. Use sound clinical judgement incorporating the latest research. For example, a chest pain patient with severe dyspnea and low sats should probably get the good stuff by mask, while the uncomplicated chest pain will get the cannula. In the hospital, o2 administration will be guided by ABGs and the intelligence of intensivists and RRTs. 

I am but a mere mortal compared to the critical care experience of others here but this is my three cents.


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## CAOX3 (Jul 14, 2009)

The old O2 for CVA patients argument. 

All I can say is assessment.


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## Ridryder911 (Jul 14, 2009)

Unfortunately, it goes back to the old school of _.."hey their out there, they have to do something"...._ Not treating a true hypoxia's situation versus short duration of oxygen at 15 lpm. So a blanket treatment is made for it is better to error for the greater of the community, instead of teaching patho and understanding respiratory physiology and arterial receptors sites.

With the new curriculum, there will be more emphasis upon anatomy but of course it will not be enough as needed. I do hope though that it at least will open the door of changing blanket treatments and develop more discussion and changes for individual treatment and care. 

Even such courses as ACLS, ITLS, PHTLS and so on needs to be reviewed and modified. As those courses have became watered down and enforces blanket treatment and non-specific rationales. Such knowledge of oxygen therapy has been wide known for decades but we still continue to push and promote such material.

I do not why it is continues to be so difficult to change the method of our teaching. Why EMS is still so resistant to do things the right way?

R/r 911


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## VentMedic (Jul 14, 2009)

KB1MZR said:


> These are what you need to be worried about. In CVA/TIA one major component in most cases is ischemia, and how do we correct ischemia on a BLS level - OXYGEN!, in high concentration. These are patients who require a NRB on 15lpm.


 
If they are short of breath, yes. However, if their Spo2 falls it is because of they may be losing their ability to maintain their airway and secretions. Often, by just clearing the airway and repositioning their SpO2 will increase.



> AMI and other cardiac episodes - again, related to ischemia therefore high concentration oxygen.


The ischemia is due to a clot. No matter how much O2 you put into that person, it will not dissolve that clot. However, if the cardiac output is failing you need to add meds to increase it without overloading the heart with too many fluids. That will bring the SpO2 up more efficiently than oxygen and increase perfusion. 


> Head Injuries - If their oxygen saturation drops below 90% their mortality rate if they do have a closed head injury increases 2-3X (same with their systolic BP dropping below 90, but entirely different story).


 
That depends on whether there is bleeding or ischemia. This is also why we monitior the SjvO2 of TBIs. There are other factors involved which determine our parameters for these patients. 


> Difficulty Breathing - Is it CHF, Pulmonary Edema, Pnemounia, Exacerbation of COPD, Asthma, Allergic Reaction. You know individual treatments for these scenarios but most of these require high concentration oxygen. Especially with your asthma pt. who has bilateral expiratory wheezing and is complaining of chest tightness, ALS is not available and BLS doesn't have albuterol or another bronchodilator to solve the problem. On the COPD side of things be careful, yes they need oxygen but if you remember back to class a COPD patient functions based on their hypoxic drive instead of their carbon dioxide retention, therefore - too much oxygen equals the pt. believes they no longer need to breathe. Congrats, their goes their respiratory drive. Again, oxygen is a med so don't take it lightly.


 
All with different etiologies and all require different interventions which are more effective than just O2. With CPAP, you may go from an FiO2 of 1.0 to 0.21 with a CHF patient. 



> On the COPD side of things be careful, yes they need oxygen but if you remember back to class a COPD patient functions based on their hypoxic drive instead of their carbon dioxide retention, therefore - too much oxygen equals the pt. believes they no longer need to breathe. Congrats, their goes their respiratory drive. Again, oxygen is a med so don't take it lightly.


 
Please read my many posts on this subject. If the patient is hypoxic, why are you concerned about a hypoxic drive? Also you should be familar with hypoxemia. Just giving a high concentration of oxygen does not necessarily equate to a high PaO2 due to V/Q mismatching.




> If your service (like most services are) is using pulse oxymetry...
> 
> remember what is mild, moderate, and severe hypoxia and treat for the indicated. BUT --- there is always a but... REMEMBER PLEASE do NOT rely on the machine rely on your pt. first and foremost and rely on your assessment to determine how to treat, the machine may not be accurate in both ways. Cold hands and a sat of 70% in a pt. with an RR of 16 unlabored and clear lung sounds that's pink/warm/dry doesn't need to be bagged, but your cyanotic asthma attack that's reading 97% does.


 
As well, if you are looking at a patient you assume to have COPD by the cigarette in their mouth, remember they may have a higher level of COHb that is measured by the pulse ox as a total. The SpO2 may be 95% but with 10% COHb, their actual SaO2 might be 85% or less if you as a couple of percentages points for Methemoglobin with nitrate meds. 



> AND FINALLY - NEVER DENY ANY PT. EXPERIENCING DYSPNEA OXYGEN!!!


 
Asssessment coupled with a decent understanding is always best.

Essentially, these are all arguments for higher education and a higher level of provider for emergencies or even IFTs that are medical.


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## Shishkabob (Jul 14, 2009)

I was SO with all Vent was saying until she said "COHb".  

^_^


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## HotelCo (Jul 14, 2009)

15lpm via NC. hehe.

Seriously though, no, you don't need to put 15lpm on every patient. Use your judgment.


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## Shishkabob (Jul 14, 2009)

I spent a week in the hospital.


I know what 6lpm NC is like.



It sucks.... err.. blows.


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## KB1MZR (Jul 14, 2009)

My train of thought was coming from my notes from class.  I guess now things have gone otherwise.  I'm not a big fan of "Everyone needs O2" either but that's what I was taught.  Now with this in front of me it gives me a better view on assessment.  Thanks for pointing that out!

Also - here we cannot use BLS CPAP...


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## usafmedic45 (Jul 14, 2009)

> she



Wow....I feel really stupid....all the PMs that have gone back and forth between Vent and myself and I never realized I was talking to a woman.  :lol:


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## JPINFV (Jul 14, 2009)

daedalus said:


> I think that she (Venty) will also point out that the amount of oxygen you give someone is based on their cardiopulmonary status including work of breathing. While blanket statements like 15 for everybody are wrong, it is also wrong to give everyone 2 LPM NC. Use sound clinical judgement incorporating the latest research. For example, a chest pain patient with severe dyspnea and low sats should probably get the good stuff by mask, while the uncomplicated chest pain will get the cannula. In the hospital, o2 administration will be guided by ABGs and the intelligence of intensivists and RRTs.



I think the issue here is understanding that diseases are not always one or the other. You can be hypoxic and having ACS at the same time. You can have CHF and a CVA at the same time. Just because a treatment might not be indicated (note sports fans: "not indicated" does not equal "contraindicated") by one condition does not mean that it isn't indicated by a separate condition.


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## JPINFV (Jul 14, 2009)

usafmedic45 said:


> Wow....I feel really stupid....all the PMs that have gone back and forth between Vent and myself and I never realized I was talking to a woman.  :lol:



Now you know why she's always right...


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## usafmedic45 (Jul 14, 2009)

JPINFV said:


> Now you know why she's always right...


....other than the fact that's she's the smartest RT I've ever had the pleasure of knowing.


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## VentMedic (Jul 15, 2009)

JPINFV said:


> Now you know why she's always right...


 
Rid realized this long ago.   He's learned some lessons in life very well.


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