# Contraindication of oxygen?



## lisha (Sep 27, 2013)

So I have this homework assignment that includes the contraindications of oxygen, after much reading I have only come across contraindications for long term use of oxygen therapy. Is there really any contraindication of I guess what would be called as pre-hospital oxygen therapy?


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## STXmedic (Sep 27, 2013)

Precautions? Sure. Indications? Definitely. Contraindications? Not really.


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## Carlos Danger (Sep 27, 2013)

Pre-term infant with a ductal-dependent lesion.


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## samiam (Sep 27, 2013)

Halothane said:


> Pre-term infant with a ductal-dependent lesion.



Why?


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## technocardy (Sep 27, 2013)

lisha said:


> So I have this homework assignment that includes the contraindications of oxygen, after much reading I have only come across contraindications for long term use of oxygen therapy. Is there really any contraindication of I guess what would be called as pre-hospital oxygen therapy?



This might sound silly but if the patient doesn't need oxygen, it's contraindicated.

A chest pain patient who has an SpO2 of 96% does _not_ need O2.

Besides a patient with an adequate (>94%) SpO2, I'm not familiar with any.


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## VFlutter (Sep 27, 2013)

Yes, supplemental oxygen is contraindicated in normoxemia.


I would also add pulmonary fibrosis as a relative contraindication.


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## ABCDEFG (Sep 27, 2013)

there is indeed a contraindication of oxygen:

For a normal person, our bodies are triggered to breath by the levels of carbon dioxide detected in our blood by the brain. As funny as it may sound, our bodies are actually breathing to remove the carbon dioxide, not to get new oxygen. However, in many patients who have COPD, the body get used to the high levels of the carbon dioxide and there is nothing to trigger their bodies to breath. Therefore, it is the lower oxygen levels that cause these patients to breath.

So, giving these patients oxygen could actually cause them to stop breathing all together, which would no doubt be a contraindication!


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## Mariemt (Sep 27, 2013)

If the patient is on fire.

And of course if the patient doesn't need it


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## technocardy (Sep 27, 2013)

ABCDEFG said:


> there is indeed a contraindication of oxygen:
> 
> For a normal person, our bodies are triggered to breath by the levels of carbon dioxide detected in our blood by the brain. As funny as it may sound, our bodies are actually breathing to remove the carbon dioxide, not to get new oxygen. However, in many patients who have COPD, the body get used to the high levels of the carbon dioxide and there is nothing to trigger their bodies to breath. Therefore, it is the lower oxygen levels that cause these patients to breath.
> 
> So, giving these patients oxygen could actually cause them to stop breathing all together, which would no doubt be a contraindication!



What? This is NOT a contraindication for emergency use of supplemental oxygen in the pre-hospital setting!

High-concentration oxygen should *not* be withheld when required only because the patient _might_ be a carbon dioxide retainer and stop breathing. In reality, this is quite unusual. Just make sure you closely monitor your patients neurologic status and respiratory effort.


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## STXmedic (Sep 27, 2013)

Chase said:


> Yes, supplemental oxygen is contraindicated in normoxemia.



After looking up the actual definition, I was being more strict on my interpretation. I could side with this line of thought.

And no to the hypoxic drive. If they're hypoxic and actually need oxygen, they'll get it. If they do decide to stop breathing (not likely), my service carries this really cool little gadget we're trialling called a "BVM". I'll probably just whip that fancy thing out and breathe for them. I'm not sure if other systems are carrying these yet or not, but they seem to work great when a person stops breathing... :unsure:


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## VFlutter (Sep 27, 2013)

ABCDEFG said:


> there is indeed a contraindication of oxygen:
> 
> For a normal person, our bodies are triggered to breath by the levels of carbon dioxide detected in our blood by the brain. As funny as it may sound, our bodies are actually breathing to remove the carbon dioxide, not to get new oxygen. However, in many patients who have COPD, the body get used to the high levels of the carbon dioxide and there is nothing to trigger their bodies to breath. Therefore, it is the lower oxygen levels that cause these patients to breath.
> 
> So, giving these patients oxygen could actually cause them to stop breathing all together, which would no doubt be a contraindication!



You may want to read some modern literature on the subject. It is definitely over exaggerated and only happens rarely in a very specific subset of patients who you will likely not see outside of an ICU.


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## lisha (Sep 27, 2013)

samiam said:


> Why?



I read online that high levels of oxygen for an infant causes blindness by promoting overgrowth of the new blood vessels obstructing sight.


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## STXmedic (Sep 27, 2013)

lisha said:


> I read online that high levels of oxygen for an infant causes blindness by promoting overgrowth of the new blood vessels obstructing sight.



You know what else causes blindness?





Nevermind.....


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## Akulahawk (Sep 27, 2013)

ABCDEFG said:


> there is indeed a contraindication of oxygen:
> 
> For a normal person, our bodies are triggered to breath by the levels of carbon dioxide detected in our blood by the brain. As funny as it may sound, our bodies are actually breathing to remove the carbon dioxide, not to get new oxygen. *However, in many patients who have COPD, the body get used to the high levels of the carbon dioxide and there is nothing to trigger their bodies to breath.* Therefore, it is the lower oxygen levels that cause these patients to breath.
> 
> So, giving these patients oxygen could actually cause them to stop breathing all together, which would no doubt be a contraindication!


True hypoxyic drive to breathe is very, very rare and it takes a while to overcome. In other words, in the prehospital environment, if your patient needs a high concentration of oxygen, you give them the oxygen. If you shut down their respiratory drive, you simply non-nonchalantly grab the BVM and go to work.


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## JPINFV (Sep 27, 2013)

samiam said:


> Why?




Ductal dependent lesions (i.e. transposition of the great vessels, anomalous pulmonary venous return, hypoplastic left heart syndrome, etc) depend on the fetal circulatory bypasses (foramen ovale, ductus arteriosus) in order to get oxygenated blood to the systemic circulation. Oxygen helps in closure of the ductus arteriosus. 


Now in regards to oxygen therapy and EMS there's a few issues. First, how are you going to know that the child has unrepaired ductal dependent lesions? Next, if they do have such a lesion, then they need to be on prostaglandin to keep the ducts open anyways. Finally, it's more of a precaution than a contraindication. The goal SpO2 is 85%, so if the SpO2 is much lower, then oxygen should be given to reach that goal.


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## JPINFV (Sep 27, 2013)

STXmedic said:


> You know what else causes blindness?
> 
> 
> 
> ...




So... are women's razors or men's razors better for keeping those palms hair free?


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## lisha (Sep 27, 2013)

:rofl::rofl::rofl::rofl: thank you!! 





JPINFV said:


> So... are women's razors or men's razors better for keeping those palms hair free?


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## Achilles (Sep 27, 2013)

O2 is contraindicated at 1 bar ^_^

Lol jp


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## Aprz (Sep 28, 2013)

Paraquat poisoning.


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## lisha (Sep 28, 2013)

Aprz said:


> Paraquat poisoning.



I was going to use Paraquat Poisoning as a contraindication but when I saw the time frame for when people could have been exposed I didn't think it was relevant to my assignment.


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## mycrofft (Sep 28, 2013)

STXmedic said:


> Precautions? Sure. Indications? Definitely. Contraindications? Not really.



Money shot. 

The CONTRAindications for field administration are very few and maybe not discoverable at the time by the prehospital tech (poor history being the biggest barrier). You practice by witholding when there is no indication ("Do no harm", right?), and if it is running and the reaction is not what you expected, don't redouble the LPM, think for a few seconds and maybe stop it. (Yes, there are scientific papers and convincing articles about prehospital O2 being harmful, but the tech is bound by protocols and they will be slow to give up universal O2, especially when the patient can be charged for it).

Most people who will stop breathing due to too much O2 are not going to be up and around, and those who are will exhibit chronic dyspnea, fatigue etc. but have no oxygen running from a little concentrator or cylinder up their nose.

Neonates who can develop exaggerated vascularity of their retinas are generally not going to be crawling around the carpet or at the fair in a stroller. (No accounting for parents' choices, is there?).

Here's your Paraquat. Future, google your key phrase and tack on "NIH":

http://www.ncbi.nlm.nih.gov/pubmed/6933951


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## Rialaigh (Sep 28, 2013)

Akulahawk said:


> True hypoxyic drive to breathe is very, very rare and it takes a while to overcome. In other words, in the prehospital environment, if your patient needs a high concentration of oxygen, you give them the oxygen. If you shut down their respiratory drive, you simply non-nonchalantly grab the BVM and go to work




Define "Needs a high concentration of oxygen". Also as far as true hypoxyic drive being very rare I don't know how your defining "true". 

I know at our local hospital we see ~205 patients a day in the ER. And at least 3-5 times a week EMS brings in a COPD patient that was ~92% on 4 liters at home, they felt the need to do 15 liters on a non rebreather, and during the 30 minute transport time (which the patient was satting 100% now) the patients LOC became diminished and the patient started to become lethargic. Upon arrival to the ER a ABG is drawn and the patients CO2 is almost always over 100 at this point, they now require Bipap or Cpap, and admission to the hospital for observation and evaluation. 


I would much rather leave 4 liters on a COPD'er satting 85-90% then put them on a non rebreather (assuming I don't have the option of a venti mask). assuming there work of breathing has not increased


I think EMS underestimates just how often 30 minutes to an hour on 100% O2 completely tanks a COPD patient. Cause around here I would say it is at least 3-5 times a week.


There are more and more articles and research coming out that are pretty clear and straightforward on the HARMS that pre hospital O2 causes in COPD patients. And not even long term, we are talking as little as 30 minutes of high flow O2


It all comes down to how you define need, I think a lot of people think that a patient "needs" high flow O2 when they are satting 88% on 4 liters comfortably with no increased work of breathing. This is just flat out wrong....

IMO for severe COPD patients if a nasal cannula is not doing it, and you don't have access to a venti mask, I may just be considering Bipap at that point and avoiding a non rebreather all together, especially with any diminished LOC or lethargy or any other signs of elevated CO2 level.


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## Akulahawk (Sep 28, 2013)

Rialaigh said:


> Define "Needs a high concentration of oxygen". Also as far as true hypoxyic drive being very rare I don't know how your defining "true".
> 
> I know at our local hospital we see ~205 patients a day in the ER. And at least 3-5 times a week EMS brings in a COPD patient that was ~92% on 4 liters at home, they felt the need to do 15 liters on a non rebreather, and during the 30 minute transport time (which the patient was satting 100% now) the patients LOC became diminished and the patient started to become lethargic. Upon arrival to the ER a ABG is drawn and the patients CO2 is almost always over 100 at this point, they now require Bipap or Cpap, and admission to the hospital for observation and evaluation.
> 
> ...


That COPD patient that got an SpO2 of ~92% on 2L at home, I'm going to maybe bump them up a little at a time, if at all. As I see it, their oxygenation is actually likely pretty good. Now then, if their work of breathing is increased, I'm going to want to provide them albuterol and atrovent, if available, and have them on a quantitative EtCO2. 

As to hypoxic drive (that result in sudden hyperoxive respiratory shutdown), I mean those cases where you apply a high concentration of oxygen and suddenly the patient's SpO2 goes way up and they nearly stop breathing at all. In those patients, no matter the retained CO2 level, they're just not going to breathe until the O2 level drops sufficiently.  I'm not saying that hypoxyic drive isn't present in hypercapnic COPD patients, it's just that the body gets used to the higher CO2 level and is still a breath is still triggered by CO2 levels.

Now then, your ER sees on average, about 1400 patients per week. How many of those are COPD patients or have it in their history? I'd hazard a guess that quite a few do. Two-three out of 1400 total per week is pretty rare, IMHO, and even then they're still breathing and their bradypnea probably hasn't shown up in the ambulance yet. Could their bradypnea be due to exhaustion? 

As to which patients need high concentration of oxygen, I think very few actually do, but when they do, it's going to be relatively obvious. Even those should be weaned off as soon as possible though.


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## Rialaigh (Sep 28, 2013)

Akulahawk said:


> That COPD patient that got an SpO2 of ~92% on 2L at home, I'm going to maybe bump them up a little at a time, if at all. As I see it, their oxygenation is actually likely pretty good. Now then, if their work of breathing is increased, I'm going to want to provide them albuterol and atrovent, if available, and have them on a quantitative EtCO2.
> 
> As to hypoxic drive (that result in sudden hyperoxive respiratory shutdown), I mean those cases where you apply a high concentration of oxygen and suddenly the patient's SpO2 goes way up and they nearly stop breathing at all. In those patients, no matter the retained CO2 level, they're just not going to breathe until the O2 level drops sufficiently.  I'm not saying that hypoxyic drive isn't present in hypercapnic COPD patients, it's just that the body gets used to the higher CO2 level and is still a breath is still triggered by CO2 levels.
> 
> ...




I'm not talking about patients that suddenly stop breathing all together, I'm talking about people that left to their own devices would be fine on the way to the hospital, but we tend to (EMS as a whole) cram O2 down their throat and instead of an outpatient ER visit requiring some breathing treatments and maybe a steroid these patients end up on Bipap or Cpap inpatient, some requiring intubation. These patients don't suddenly stop breathing, they get more lethargic over 30 minutes to an hour and by the time they reach the hospital their LOC is diminished and their CO2 is through the roof while their respirations have not increased at all and likely decreased some. This requires Bipap or a tube in most cases.


It's about not directly causing harm and extended hospital stays with higher mortality to patients that we interact with. 


As far as it being "rare" 3/1400 is an incidence of .2%. That's more then we see femur fractures in a week. I would say each paramedic in this system probably comes into contact with a CO2 retainer like this every month, and some are handled correctly and some are terribly mismanaged.


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## Aprz (Sep 28, 2013)

I like the British Thoracic Society's guidelines. They recommend for patients with COPD that the target oxygen saturation is 88-92%.



			
				Thorax by British Thoracic Society said:
			
		

> For most patients with known chronic
> obstructive pulmonary disease (COPD) or
> other known risk factors for hypercapnic
> respiratory failure (eg, morbid obesity, chest
> ...


Source: http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Emergency oxygen guideline/THX-63-Suppl_6.pdf


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