# Respiratory alkalosis and O2



## crispy91 (Aug 13, 2012)

Ok... Kinda dumb questiom, but here goes anyway: for pt's in resp. Alkalosis, the aemt book recomends using an NRB at 15 lpm. However, I thought the condition was due to excess CO2 emission caused by hyperventilation. By that logic, wouldn't we use a simple mask, so they retain CO2?


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## STXmedic (Aug 13, 2012)

AEMT's (and both other levels') recommendation for everything is high flow O2.


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## JPINFV (Aug 13, 2012)

crispy91 said:


> Ok... Kinda dumb questiom, but here goes anyway: for pt's in resp. Alkalosis, the aemt book recomends using an NRB at 15 lpm. However, I thought the condition was due to excess CO2 emission caused by hyperventilation. By that logic, wouldn't we use a simple mask, so they retain CO2?




There's not a significant amount of CO2 in room air to begin with, so  unless you plan on just putting a simple mask on with no oxygen running, you aren't going to really increase the FiCO2 anyways. Supplemental oxygen is essentially displacing nitrogen, not CO2.


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## NYMedic828 (Aug 13, 2012)

Oxygen, the duct tape of EMS.


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## medichopeful (Aug 13, 2012)

Unless I'm mistaken, giving oxygen for respiratory alkalosis isn't really going to do much at all.


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## GorillaMedic (Aug 13, 2012)

Increasing the FiO2 won't make a bit of difference for respiratory alkalosis. Not that it's a bad idea, but it's a hypoxia treatment, not an alkalosis treatment. And treatment should be aimed at treating the root cause: while anxiety cause hyperventilation is a common cause, there are other causes out there; we as providers need to use our tools and try to identify what's going on. Common causes of respiratory alkalosis (besides anxiety) are hypoxemia (perhaps due to anemia or hypoxia), sepsis (increased oxygen demand), and aspirin poisoning. Likewise, hyperventilation is a symptom of metabolic acidosis and shouldn't be corrected if it is a compensatory mechanism for something (such as DKA or shock). 

When it comes to treating respiratory alkalosis, the focus is on reducing the pt's minute volume not increasing FiO2. So decreasing rate and decreasing tidal volume (if they are on a ventilator) is key; I find attentive coaching and calming words works well for conscious, awake patients. If protocols allow for it, a small benzodiazepine dose works wonders for anxiety. I'm curious how many people's protocols do allow for this; mine right now don't, but I've gotten online medical control to okay it in the past for a couple exceptional cases.


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## Merck (Aug 14, 2012)

I would caution trying to correct a suspected respiratory alkalosis without having all the details.  In my experience cases of this are acute onset and usually due to anxiety (read:  my boyfriend doesn't love me, my dog got ran over, my parents are mad - some country song anyway), but that is not always the case.

I've seen crews become nonchalant about their treatment of these patients and this always leads to some discussion.  I have many times found patients with the 02 mask on with no flow as the well-intentioned crew tries to 'normalize' breathing.  The problem is as soon as you try to normalize something you've made a diagnosis as to what is wrong.  As was mentioned there are other reasons for the hyperventilation/tachypnea that may not be anxiety based at all.  DKA, ASA od, and other causes of metabolic acidosis may mean that the patient really needs that compensatory respiratory alkalosis to compensate.

Not trying to spout off too much but just bringing up the fact that you always have to be careful.  Providing O2 by a standard mask might not help much (other than by calming them down) but it won't hurt.


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## JakeEMTP (Aug 14, 2012)

Other causes of Respiratory Alkalosis include stroke, head injury and pulmonary emboli. Hypoxemia and a struggle to move as much air as possible to maintain adequate oxyenation will also make a person present with tachypnea. 

Unless you are can do an ABG you will not know it is Respiratory Alkalosis.  Even with an ABG it may be necessary to see more labs to determine the orgin which is why a chem panel for an anion gag is also done in the hospital upon arrival and sometimes even before the arterial stick. 

The tachypnea can be from rising CO2 or a metabolic acidosis where the pH is becoming acidotic. Asthmatics and people with long disease processes are at example as are those who are in the latter stages of respiratory distress and about to go into failure. Children are another example.  Placing their face in a paper or plastic bag like a nonrebreather with inadequate or no O2 flow to rebreathe their CO2 can sometimes be fatal.   

Another bit of confusion is that placing someone on a nonrebreather mask automatically gives them almost 100% O2. If they are moving large tidal volumes and/or have a large overall minute volume, the actual FiO2 delivered may not be much more than a 5 or 6 liter nasal cannula.  Real high flow oxygen devices are capable of delivering over 30 liters per minute to meet demand and maintain a high FiO2.  It is possible whoever wrote the protocols might know the difference between delivery devices and the many causes for tachypneas which are not always "anxiety".  It is impossible to teach all the differentials adequately in a 200 hour course.


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## MSDeltaFlt (Aug 14, 2012)

crispy91 said:


> Ok... Kinda dumb questiom, but here goes anyway: for pt's in resp. Alkalosis, the aemt book recomends using an NRB at 15 lpm. However, I thought the condition was due to excess CO2 emission caused by hyperventilation. By that logic, wouldn't we use a simple mask, so they retain CO2?



The National Registry has to teach some things on certain for the lowest common denominator. Unfortunately some of them still might not be able to grasp the concept. 

On the AEMT level, anything that presents as bad, not so good, unknown, or even "funky"/"hinky", they want you to treat with high flow O2.  So, according to the book, do what the book says.

But for the more cerebral, know this.  The only way they are related is if youre don't breathe, you won't get oxygen.  Jn other words there is no DNA in their relationship. They are distant cousins by marriage only.  Make sense?

Respiratory alkalosis means someone (pt or caregiver) is breathing too fast.  If they're intubated then someone's bagging them too fast.  If they're not intubated then the pt is breathing to fast.  If the former is happening then the bagger needs to slow that @#$% down.  If the latter is happening then usually the pt needs to enhance their calm and sometimes they might need assistance in doing so: removing them from the stressful environment, remove the stressor, or chemically enhance calm (Ativan's good).

Does this help?


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## bigbaldguy (Aug 14, 2012)

crispy91 said:


> Ok... Kinda dumb questiom, but here goes anyway: for pt's in resp. Alkalosis, the aemt book recomends using an NRB at 15 lpm. However, I thought the condition was due to excess CO2 emission caused by hyperventilation. By that logic, wouldn't we use a simple mask, so they retain CO2?



More than likely won't hurt them and many times people who are hyperventilating are doing it because of anxiety whether that anxiety is due to a physical malady or mental one. The mask might give them a little comfort and reduce the anxiety a bit. As others have said coaching them to calm down and breath more slowly is what will actually make the difference. On the test do what the book says.


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## hogwiley (Aug 31, 2012)

This is kind of straying from the original question, but working in a hospital, im always amazed at this near obsession with weaning patients off o2, even when their o2 sat is somewhat low. Obviously the considerations are different when you are talking about a long term solution to the patients situation.

I guess I dont know enough yet to understand the reasons for this, but its definitely a different mindset from EMS, where more o2 is the solution for everything. I work as a PCT and Ive ambulated a patient who is now gasping and their 02 is dropping down to 88 and the EMT in me thinks hey just turn up their o2 a little, but if I did that without getting permission from an RN or RT id be toast.


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## mycrofft (Aug 31, 2012)

SImple mask for CO2 retention: no. Especially mask without O2 flow; that is using the device improperly, you are off then reservation with that one. People can suffocate that way.

It is not impossible to diagnose differentially between psychologically rooted hyperventilatory alkalosis and some other cause of c/o shortness of breath coupled with deep rapid respirations, but then hanging around and figuring out what's causing it and using that data is asking for a fatality. Is the time worth it, and can the average EMT do it? Nope and nope. 

O2 plus alkalosis: pt loses consciousness, and if its psychogenic, the situation resolves. If not, and they do need O2, it's already running.

Sidebar: aspirin: causes _*hyperventilation*_ by stimulating the respiratory center? Dang. And the figure quoted on EMed:"Still, more than 10,000 tons of aspirin are consumed in the United States each year". And "Oil of Wintergreen"" (methyl salicylate): "One teaspoon of 98% methyl salicylate contains 7000 mg of salicylate, the equivalent of nearly 90 baby aspirins and more than 4 times the potentially toxic dose for a child who weighs 10 kg".


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## FLdoc2011 (Aug 31, 2012)

hogwiley said:


> This is kind of straying from the original question, but working in a hospital, im always amazed at this near obsession with weaning patients off o2, even when their o2 sat is somewhat low. Obviously the considerations are different when you are talking about a long term solution to the patients situation.
> 
> I guess I dont know enough yet to understand the reasons for this, but its definitely a different mindset from EMS, where more o2 is the solution for everything. I work as a PCT and Ive ambulated a patient who is now gasping and their 02 is dropping down to 88 and the EMT in me thinks hey just turn up their o2 a little, but if I did that without getting permission from an RN or RT id be toast.



Little different impatient.  A lot of times patients are on O2 and they don't need to be, so it's a constant struggle at times to get nurses to stop putting 2L NC on everyone.   We also at times have to prove there is hypoxia in order to get insurance to cover home oxygen so we may have them ambulated with pulse ox to see if it drops or check an ABG on room air.


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## mycrofft (Aug 31, 2012)

FLdoc2011 said:


> Little different impatient.  A lot of times patients are on O2 and they don't need to be, so it's a constant struggle at times to get nurses to stop putting 2L NC on everyone.



Write an order for the pt to smoke??


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## lightsandsirens5 (Aug 31, 2012)

NYMedic828 said:


> Oxygen, the duct tape of EMS.



Except duct tape actually does something....


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