# Shortness of breath question



## Dillon Baker (Nov 7, 2014)

We were called to a residence for shortness of breath. We did our assessment and began transporting, vitals normal o2 sat was 97% so I wasn't  concerned. I put pt on o2 via nasal cannula @5 lpm and took her to the hospital. Upon arrival to the er the nurse came in and I gave my report, then she looked at me weird and immediately took the pt off our o2, I didn't ask why I just got my signature and left. I'm still somewhat new to the field and I'm just wondering if I made a bad decision with the oxygen, I thought it was bls protocol to treat shortness of breath with o2, am I wrong?


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## teedubbyaw (Nov 7, 2014)

As BLS it's fine. Hospitals have different protocols.


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## Ewok Jerky (Nov 7, 2014)

Most providers don't flinch at a pulse ox of 97.  BLS with a complaint of shortness of breath, sure throuh some O2 on if your protocols say so, but 5L is a little much. 1L would be fine. 

As a new EMT, heck even as an old EMT, don't be afraid to ask questions.  Maybe the nurse was just getting a room air sat, but a simple "I'm new at this, do you thithinxygen was indicated?" will do.


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## gnosis (Nov 7, 2014)

O2 sat of 97 is great. If there's no symptoms of SOB, there's no real reason to give O2. To use the old phrase, treat the patient not the machine/call/complaint. Also, 5L through a cannula is a lot. It feels like someone blowing up your nose with a straw. It's a good idea to try it on sometimes to get an idea of how it feels. I find anything over 3lpm through a cannula is pretty uncomfortable. But I may just have a sissy nose...


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## Tigger (Nov 7, 2014)

Was the patient actually showing signs of respiratory compromise?


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## DesertMedic66 (Nov 7, 2014)

As some other people already stated why give the patient supplemental O2 if they have normal vital signs and a SpO2 of 97%?


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## EpiEMS (Nov 7, 2014)

Dillon Baker said:


> We were called to a residence for shortness of breath. We did our assessment and began transporting, vitals normal o2 sat was 97% so I wasn't  concerned. I put pt on o2 via nasal cannula @5 lpm and took her to the hospital.



Room air SpO2 of 97% absent other signs of respiratory distress doesn't necessitate/suggest a need for oxygen administration. However, rarely is BLS oxygen administration in the EMS setting likely to cause harm (¿non?). NYS protocols would have encouraged 15 lpm via NRB, which is ridiculous. CT protocols would encourage the same. Common sense and good judgement suggest otherwise: no oxygen would likely be OK, and a nasal cannula at 2lpm would be more than enough.

Would I have administered oxygen? No, probably not, as it doesn't appear to be clinically indicated based on the presentation as described. Is it wrong (i.e. breaking from the standard of care or otherwise) to administer oxygen as the OP has described? No, I sincerely doubt it.

OP, you did nothing *wrong*, but next time, consider being more judicious in your administration of oxygen.


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## chaz90 (Nov 7, 2014)

^Love this reply. I felt like my "like" alone wasn't enough to express my agreement.


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## EpiEMS (Nov 7, 2014)

chaz90 said:


> ^Love this reply. I felt like my "like" alone wasn't enough to express my agreement.



Obrigado!

(Caveat: I don't actually speak/write/read Portuguese)


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## avdrummerboy (Nov 22, 2014)

Short answer, no, you didn't do anything wrong, you're not going to do much harm to someone by giving them oxygen, even at 5LPM! As has been hounded above, there was no real need to give O2 based on what we heard. Sure, you can give O2 as a comfort measure, but unless the pt asked, I wouldn't have worried about it.

As to why the nurse freaked out, who knows, should have asked, may she saw a ghost, you never know, I can't think of any reason.


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## OnceAnEMT (Nov 22, 2014)

avdrummerboy said:


> As to why the nurse freaked out, who knows, should have asked, may she saw a ghost, you never know, I can't think of any reason.



Just to add to this. As mentioned above, it could very well be in order to obtain a sat on room air. If the patient isn't in severe respiratory distress, we will hold oxygen for a little while just to get that room air sat as a baseline, then put them on oxygen, generally starting at 2L and advancing as necessary. 

Some nurses unfortunately still cringe at the thought of COPD patients receiving any high concentration oxygen, perhaps he/she made an assumption.


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## 18G (Nov 26, 2014)

Was the patient actually having shortness of breath or is that just what you were dispatched for? I wouldn't let the nurse bother you too much. Sometimes they like to get a room air sat. Would I have put this patient on O2? Prob not based on what is reported. 

Just remember that oxygen is not a cure all and is a drug that can harm as much as it can help.


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## Tigger (Nov 26, 2014)

avdrummerboy said:


> Short answer, no, you didn't do anything wrong, you're not going to do much harm to someone by giving them oxygen, even at 5LPM! As has been hounded above, there was no real need to give O2 based on what we heard. *Sure, you can give O2 as a comfort measure*, but unless the pt asked, I wouldn't have worried about it.
> 
> As to why the nurse freaked out, who knows, should have asked, may she saw a ghost, you never know, I can't think of any reason.



That is not an indication for O2 administration. Nor is it comfortable.


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## EMT11KDL (Nov 26, 2014)

without actually seeing your patient, it is hard to say if I would have put the patient on oxygen or not, also without knowing the patients history, it also makes it a little difficult.  But if my patient is not having any signs or symptoms of resp distress/SOB, I probably would not have put the pt on oxygen.  Now if the patient is complaining of SOB, and most likely would be hyperventilating, I would but a NC on at 2 or 3 and coach her breathing down, but once again without actually seeing, it is hard for any of us to say what we would or wouldn't have done.  

Now I do not see anything wrong with what you have done by applying oxygen and transporting.


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## ipkes (Dec 30, 2014)

maybe the nurse freaked out because you were flowing a cannula @ 5lp...who knows


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## OnceAnEMT (Dec 30, 2014)

ipkes said:


> maybe the nurse freaked out because you were flowing a cannula @ 5lp...who knows



Textbook I have says 4-6. We do 4 to 5 from time to time on patients in the ED I'm at.


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## Handsome Robb (Dec 31, 2014)

Where did the nurse "freaking out" come from? I read it as she had a puzzled look and removed the O2...that's far from freaking out.

Others have said it but unless there where signs/symptoms of respiratory compromise I wouldn't have put this patient on oxygen. It's pretty rare I put people on more than 2lpm via a cannula unless they're on a higher flow rate on their home O2.


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## RocketMedic (Dec 31, 2014)

Tigger said:


> That is not an indication for O2 administration. Nor is it comfortable.


Somewhat disagree. O2 can indeed be a comfort measure in some isolated settings. Anecdotally,  I find it helps with nausea, and in the 8-10 percent of patients with new ticagrelor prescriptions that experience  a profound sensation of dyspnea, oxygen is a massive comfort measure.


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## NomeProvider (Jan 12, 2015)

I don't have any sources other than things my instructors have said in class (which I completed recently) so take all this with a grain of salt:

What I've been told is that the movement is towards not giving O2 unless SPo2 < 94%.  O2 is essentially a drug and as a BLS community, it's been overused.  There is little indication that it does the patient any good if they are above 94% SPo2, and o2 toxicity is a possibility (especially on a long transport). 

On a side note, after having thrown a cannula on myself and cranked it up to 6lpm, I won't go over 4lpm on a patient with a cannula.  I find it uncomfortable unless it's humidified, and then it's going to be a mask anyways. I'll go to an NRB instead; that's personal preference though.


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## johnrsemt (Jan 12, 2015)

Always treat the patient not the monitor:  If they say they are having problems breathing and are showing signs of it, treat them for it.
When I am breathing normally I have a SPO2 of about 90-93%;  when my asthma is acting up and I am have a rough time breathing it is usually 96-98% (last time I was breathing 60 times a minute and had stopped wheezing just after due to not moving enough air {SPO2 then dropped into the 80's%}):  strange I know, but a co worker told me it is probably because I am working so hard to breathe that I am moving more O2 to the extremities than normal;  as long as I am compensating I do better, when I start to crash I crash hard and drop low (68% in the ED one day just before I was admitted for 4 days).


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## Alpiner (Jan 21, 2015)

Pulse oximeters can give a falsely high reading in the presence of carbon monoxide binding to haemoglobin about 250 times more strongly than oxygen and, once in place, prevents the binding of oxygen. It also turns haemoglobin bright red. The pulse oximeter is unable to distinguish between haemoglobin molecules saturated in oxygen and those carrying carbon monoxide. False high readings are also always obtained from smokers - readings are affected for up to four hours after smoking a cigarette. Other sources of carbon monoxide include fires, car-exhaust inhalation and prolonged exposure to heavy-traffic environments.


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## Alpiner (Jan 21, 2015)

As others have said, I believe that's a good point why to treat the patient and not the machine and I've also heard nurses are notorious for trusting Spo2 readings without even realizing how inaccurate they can be.

I'm just a student and textbook says 4-6 cannula and 12-15 NRB but some patients can feel smothered by NRB which turns you to cannula and adjust to the patients comfort, I've heard that rest home patients are generally on 2lpm so that might be the comfort range as others have mentioned.


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## chaz90 (Jan 22, 2015)

Alpiner said:


> As others have said, I believe that's a good point why to treat the patient and not the machine and I've also heard nurses are notorious for trusting Spo2 readings without even realizing how inaccurate they can be.
> 
> I'm just a student and textbook says 4-6 cannula and 12-15 NRB but some patients can feel smothered by NRB which turns you to cannula and adjust to the patients comfort, I've heard that rest home patients are generally on 2lpm so that might be the comfort range as others have mentioned.



How about treating the patient using a complete assessment complete with important clinical information obtainable only by data from "machines"? It's not just nurses that trust sometimes inaccurate SpO2 readings. It happens to all levels of providers with a variety of experience levels, but frankly I've seen it more from EMS colleagues than anyone else. 

SpO2 readings are accurate most of the time. There are confounding variables, but check for a good pleth waveform to correlate, be on the lookout for rare and strange presentations that can change SpO2 values, and use trending values.


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## STXmedic (Jan 22, 2015)

chaz90 said:


> How about treating the patient using a complete assessment complete with important clinical information obtainable only by data from "machines"? It's not just nurses that trust sometimes inaccurate SpO2 readings. It happens to all levels of providers with a variety of experience levels, but frankly I've seen it more from EMS colleagues than anyone else.
> 
> SpO2 readings are accurate most of the time. There are confounding variables, but check for a good pleth waveform to correlate, be on the lookout for rare and strange presentations that can change SpO2 values, and use trending values.


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## Ewok Jerky (Jan 22, 2015)

A word of advice, as a student I would refrain from critisizing nurses or any other healthcare professional. EMS is not the be all end all of medicine, and nothing would happen if doctors didn't have a team of professionals getting things done for them.

It's an easy EMS trap to fall into, crapping on nurses, don't do it.


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## Carlos Danger (Jan 23, 2015)

Alpiner said:


> Pulse oximeters can give a falsely high reading in the presence of carbon monoxide binding to haemoglobin about 250 times more strongly than oxygen and, once in place, prevents the binding of oxygen. It also turns haemoglobin bright red. The pulse oximeter is unable to distinguish between haemoglobin molecules saturated in oxygen and those carrying carbon monoxide. False high readings are also always obtained from smokers - readings are affected for up to four hours after smoking a cigarette. Other sources of carbon monoxide include fires, car-exhaust inhalation and prolonged exposure to heavy-traffic environments.



So just what _is_ the incidence of clinically important carboxyhemoglobinemia as opposed to the incidence of clinically important hypoxemia that is accurately quantified by pulse oximetry?

Dyshemoglobinemias (met-, sulfe- and carboxy-) and their potential effect on pulse oximetry is an important concept to understand and keep in mind when you are pulling patients out of burning buildings and chemical plants, but is seriously overstated as a problem in patient assessment.

The folks who emphasize carboxyhemglobinemia as a reason why pulse oximetry "can't be trusted" both dramatically overestimate the extent of that problem and entirely miss the point of "look at the patient, not the monitor".


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## Nightmare (Feb 4, 2015)

By the sounds of it your patient was not having the symptoms of SOB but might have been thinking they had SOB, may be almost some form of an anxiety issue (i wouldn't call it an attack)...most people with this issue who don't have a medical background will think that they are getting better if they get extra O2...did you do anything wrong? no, absolutely not. did you help the patient? clinically, there doesn't appear to be much you could help. Mentally, you helped them out quite a bit i think.

As for the nurse giving you a strange look, may be the patient is a frequent flyer, or since the patient's SpO2 was fine she might have judged you a little. Bottom line, be a patient advocate, treat your patient, not your monitor, if they are presenting with SOB then give them oxygen. For the short amount of time you are with them it will not harm them.

Also keep in mind the patient that likes you, won't sue you. So if, in their mind, you did the best you could to help them they will be significantly happier than if you just told them to have a seat on the stretcher and did the chart on the way to the hospital.


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## ThadeusJ (Feb 4, 2015)

I always taught healthcare professionals (RT's, paramedics and nurses) that a great role of the oximeter is measuring pulse rate.  I discovered this after watching a patient with an ECG reading of 80 but having a pleth of 40.  People were wondering why the BP was low and the patient was SOB.  I also have had to tell staff NOT to chart a pulse of 300 bpm just because that's what the oximeter said.  

Undetected COHb does happen  but not necessarily common.  The RAD57 devices have been known to detect high levels of CO in patients exhibiting flu-like symptoms.  Some of these have been cases where the CO detectors don't alarm at chronically low but present levels of carbon monoxide.


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