# High Flow O2 on COPD pts



## EarnMoneySleeping (Jul 10, 2012)

So I had a pt the other week that we diverted for SOB. While en route to dialysis, she said she had a hard time breathing and had to lean forward. She was already on 3lpm via NC. I gave her 15lpm via NRB. We diverted to the ED and the nurse told me never to administer high flow O2 to a COPD pt bc it will "kill their drive to breathe". I understand that COPD pts have a hypoxic drive to breathe, but she was clearly distressed at 3lpm. It should be noted I'm on a BLS ambulance, and that our private company doesn't have a pulse ox.


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## NYMedic828 (Jul 10, 2012)

You did the right thing. The nurse is blatently wrong.

Thats an old myth that giving O2 to a COPD'r will worsen their condition.

The fact is, that in the time you spend with them per-hospitally you will do them more good by giving them the oxygen they need.

99.9% of patients will never experience a "knocking out" of their hypoxic drive. Most have never, and will never see it occur.

http://www.oxyview.com/Articles/CommonMythsRegardingOxygenTherapy.aspx


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## medicdan (Jul 10, 2012)

NYMedic828 said:


> You did the right thing. The nurse is blatently wrong.
> 
> Thats an old myth that giving O2 to a COPD'r will worsen their condition.
> 
> ...



... and even if you do "knock out" this drive, you should be recognizing it quickly and reminding the patient to breathe. That's it.


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## Farmer2DO (Jul 10, 2012)

I've been in EMS for 22 years, and a paramedic for 14.  I've never seen a COPD patient lose their respiratory drive due to hyper-oxygenation, and I don't know any other EMS providers who have either.  From what I understand, it's mostly a theory, and requires long term exposure to high flow (longer than we have with the patient).

That doesn't mean I think we should throw oxygen at everyone just because we can.  Quite the opposite.  I think we need to be judicious.  This is a case where you need to go on clinical assessment.  How was her color?  Was she diaphoretic?  How was her capillary refill?  How were her lung sounds? Could she have been in pulmonary edema?  Anytime I see a patient who needs dialysis that is short of breath, I am diligent for assessing for pulmonary edema secondary to fluid overload.

Remember also that COPD patients generally don't have a problem oxygenating, they have a problem ventilating, while CHF/pulmonary edema patients are the opposite.

Another thing to remember is that if the patient's CO2 becomes too high, they may become sedated and their respiratory drive may suffer, requiring assistance.  Again, problem of ventilation, not oxygenation.

In the end, you used the tools you had available to you.  I'm not sure you needed that much oxygen (I wasn't there) but I also don't think you did a lot of harm.


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## Farmer2DO (Jul 10, 2012)

I just found a link, with references:

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


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## bobbyd3423 (Jul 10, 2012)

I am new to this and i have not experienced it in the field yet but referring to our text book it instructs 15lpm via NRB and monitor because it "MAY" eliminate their stimulus to breath not "WILL". These pt's obvioulsly need the O2. So i guess long story short i think you were in the right.


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## bobbyd3423 (Jul 10, 2012)

Well put Farmer. I guess i overlooked the "ventillation" vs. "oxygenation" Ya learn something new everyday.


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## Farmer2DO (Jul 10, 2012)

I'm still learning.  I think you have the right attitude.


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## Christopher (Jul 10, 2012)

EarnMoneySleeping said:


> So I had a pt the other week that we diverted for SOB. While en route to dialysis, she said she had a hard time breathing and had to lean forward. She was already on 3lpm via NC. I gave her 15lpm via NRB. We diverted to the ED and the nurse told me never to administer high flow O2 to a COPD pt bc it will "kill their drive to breathe". I understand that COPD pts have a hypoxic drive to breathe, but she was clearly distressed at 3lpm. It should be noted I'm on a BLS ambulance, and that our private company doesn't have a pulse ox.



Fun fact, if you truly knock out their hypoxic drive due to high flow O2...just withhold O2! They'll start breathing again.

If they don't...I'll bet it wasn't your high flow O2 which killed them. Let's see, COPD/dialysis patient with sudden onset trouble breathing? Pulmonary embolism, myocardial infarction, pericarditis, pleural effusion, COPD exacerbation, the list goes on and on.

Re-evaluate your patient, starting with ABC's just like you did. If you feel like they're dyspneic because, while their airway is patent, they're not exchanging oxygen efficiently, then certainly bump up the O's. Next work down the list of reasons why they aren't exchanging O2 well (I listed some common causes above) and attempt to troubleshoot what you can.

Hint: taking a patient to a hospital is certainly one way to troubleshoot a breathing problem you are not equipped to treat fully.

Wait, I think this is exactly what you did. Don't sweat people caught up in half truths like "high flow O2 will make a COPD patient stop breathing."


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## AnthonyM83 (Jul 10, 2012)

We had a very intelligent RT on the board explain that only a tiny fraction of COPD patients rely on their hypoxic drive to breathe. Out of that small percentage, most will take hours to days for the high concentration oxygen to start decreasing their breathing. It really should not be that high of a concern...THOUGH it SHOULD be on your mind.

I've asked around and have been able to find only a single story from another RT who had his patient stop breathing within seconds of applying high concentration oxygen. BUT the patient also regained his breathing moments after discontinuation of the oxygen (matching what Christopher mentioned). His patient was in the hospital setting already.







Farmer2DO said:


> That doesn't mean I think we should throw oxygen at everyone just because we can.  Quite the opposite.  I think we need to be judicious.  This is a case where you need to go on clinical assessment.  How was her color?  Was she diaphoretic?  How was her capillary refill?  How were her lung sounds? Could she have been in pulmonary edema?  Anytime I see a patient who needs dialysis that is short of breath, I am diligent for assessing for pulmonary edema secondary to fluid overload.


 So, if all the previous clinical assessments (mentioned above) turned up "normal", how would that alter your oxygen intervention for this scenario mentioned?


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## epipusher (Jul 10, 2012)

That is just an example of an R.N. justifying the ridiculous amount of education they must have to obtain their degree, yet not be able to do anything with it. I'm speaking from experience as a nursing student btw.


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## mycrofft (Jul 10, 2012)

epi, I'm not sure I universally agree, but for some individuals, it is possible. More likely it is a way to browbeat someone she/he sees as being below him/ her on the carreer ladder and hence unable to reply to her ignorant bullying.
Speaking as a RN.


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## DPM (Jul 10, 2012)

epipusher said:


> That is just an example of an R.N. justifying the ridiculous amount of education they must have to obtain their degree, yet not be able to do anything with it. I'm speaking from experience as a nursing student btw.



For a nursing student you seem to have quite a chip on your shoulder about nurses...

I can speak from my first ever EMT-B ride along and say that it can knock out their hypoxic drive. It wont always, but there is the real possibility that it will happen, and it sounds like the OP has experienced this too. I know it's rare and so far I'm the only person I've ever met that has seen it, but it can happen.

The correct answer has already been given though, if you have someone with COPD on high flow O2 and their SOB get's worse, then remind them to breathe and take them off the O2. It doesn't take long to change things.


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## epipusher (Jul 10, 2012)

The amount of subjects regarding the human body I must learn to pass this program will serve me no purpose as a nurse. I just want the money!


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## AnthonyM83 (Jul 10, 2012)

That nurse was probably recalling what she had learned in school and from preceptors (just as most of us do and will) but perhaps applied it to the wrong situation or wasn't train with enough breadth/depth on topic or took the bit of knowledge out of context (as we have and probably will do). 

Can you think of a situation in which you as a newer EMT or Medic freaked out about a situation because someone had told you it was emergent...yet when you got to the ER and the doctors and nurses didn't seem phased by it (because they see it all the time and can judge severity)? Point is, just because people make those mistakes doesn't mean their whole training is worth crap....


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## Tigger (Jul 11, 2012)

epipusher said:


> The amount of subjects regarding the human body I must learn to pass this program will serve me no purpose as a nurse. I just want the money!



Remind me to stay out of Indianapolis then...


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## DPM (Jul 11, 2012)

Who becomes a nurse for the money...?


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## usalsfyre (Jul 11, 2012)

DPM said:


> I can speak from my first ever EMT-B ride along and say that it can knock out their hypoxic drive. It wont always, but there is the real possibility that it will happen, and it sounds like the OP has experienced this too. I know it's rare and so far I'm the only person I've ever met that has seen it, but it can happen.



Was it hypoxic drive or just hypercapneia getting the better of the patient? Cause between myself and a other experienced medics I know and trust no one has seen it happen in 10k+ patient encounters. Yes I know, not scientific but I wouldn't say there's strong enough literature on it to firmly say it is something EMS truly has to worry about anyway.


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## DPM (Jul 11, 2012)

Ok, explain this to me. I know what you mean, it makes sense, but I can't quite get my head around it.

I can't help but think that a COPD or Asthma patient would be more suseptible to hypercapnia and that high flow O2 could still knock them out... just a different way?


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## EarnMoneySleeping (Jul 11, 2012)

AnthonyM83 said:


> That nurse was probably recalling what she had learned in school and from preceptors (just as most of us do and will) but perhaps applied it to the wrong situation or wasn't train with enough breadth/depth on topic or took the bit of knowledge out of context (as we have and probably will do).
> 
> Can you think of a situation in which you as a newer EMT or Medic freaked out about a situation because someone had told you it was emergent...yet when you got to the ER and the doctors and nurses didn't seem phased by it (because they see it all the time and can judge severity)? Point is, just because people make those mistakes doesn't mean their whole training is worth crap....



I totally understand where you are coming from there, but I doubt it was like that. She definitely seemed as is she was there a while, and the condescending attitude also leads me to believe that she has been there a while. The pts SpO2 was 100% upon entering the ED so I can sort of see why she took her off right away. However, I was treating the symptoms I was presented with in the field, which was pt tripoding, using accessory muscles, complaining of SOB. Again we don't have pulse ox on our ambulance so that kind of sucks, but our transport time was only 5 mins. So I wasn't really worrying about my 5 mins of high flow O2 causing any real danger. Had been a longer transport and her condition improved I might have reduced the O2. But to tell me to NEVER administer high flow O2 to a pt SOB with a Hx of COPD is retarded.


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## KellyBracket (Jul 11, 2012)

The evidence is ... interesting. I intended to answer with a quick reference or two, but now I'm hooked.

For now, I'll just point out two things. One, there are a number of studies out there that have failed to show the purported adverse effects of oxygen administration in COPD patients.

Second, the "best" clinical evidence out there for EMS and COPD was a trial done in Tasmania by a friend of mine. We were, for a short while, the only 2 paramedics in Barlett, New Hampshire.

His study, *Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial*, is probably the best evidence out there, but there are some interesting wrinkles in it. It deserves a better examination than I can afford here - I'll get back with an evidence review for EMS!


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## zzyzx (Jul 11, 2012)

Where's VentMedic when you need her?!!!

Here's a great article on the myth of the hypoxic drive:

http://respiratorytherapycave.blogspot.com/2012/02/hypoxic-drive-theory-history-of-myth.html

I'm not surprised by the nurse's reaction. Every nurse that I've worked with, even the really super smart ones, all have a firm believe in the danger of supposedly knocking out someone's respiratory drive with oxygen. It's something that has become ingrained in a nurse's way of thinking, probably because at some point every nursing student or new nurse has had some older nurse yell at them because they set a patient's nasal cannula at 4 LPM and instead of 2. 

That said, I have also know many RT's that believe in the danger of giving too much oxygen for patient's with COPD.

A basic rule you can apply is that if you are on a BLS ambulance and a patient with COPD complains of being short of breath, it is okay to bump up their nasal cannula a little bit. If they are in real distress, then give them a high-flow mask and divert to the closest ER. That's a reasonable approach and no one should give you a hard time for it.


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## DPM (Jul 11, 2012)

KellyBracket said:


> The evidence is ... interesting. I intended to answer with a quick reference or two, but now I'm hooked.
> 
> For now, I'll just point out two things. One, there are a number of studies out there that have failed to show the purported adverse effects of oxygen administration in COPD patients.
> 
> ...



I like this. Maybe our worries about hypoxic drive should really be worries about hypercapnia? With the prevemtion of the two problems being the same it sounds like people are possibly preventing hypercapnia by trying to preserve the hypoxic drive.


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## Christopher (Jul 11, 2012)

DPM said:


> I like this. Maybe our worries about hypoxic drive should really be worries about hypercapnia? With the prevemtion of the two problems being the same it sounds like people are possibly preventing hypercapnia by trying to preserve the hypoxic drive.



Our real worry is their work of breathing and their V/Q mismatch. The hypercapnia is merely a "sign".


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## DPM (Jul 11, 2012)

From the Tasmanian study:



> Despite published guidelines, the lack of clear evidence showing the benefit of titrated oxygen treatment may be responsible for the lack of widespread cultural change among practitioners, authorities, and opinion leaders. The difficulty in modifying practice in the prehospital setting is compounded by the lack of equipment capable of delivering controlled oxygen treatment while administering nebulised drugs in ambulances



I'm pretty sure we've all thought this! I can't count how many times the old and bold on here have explained the idea of titrating oxygen delivery to us young wipper-snappers. Hopefully this is evidence of a culture shift, not only in the way we treat COPD but the way we deal with all oxygen therapy.


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## Meursault (Jul 12, 2012)

OP, this isn't even about oxygen. When you're at the absolute bottom of the pyramid, people will yell at you as stress relief. Learn to handle it in a way that feels good _and_ looks good.



zzyzx said:


> I'm not surprised by the nurse's reaction. Every nurse that I've worked with, even the really super smart ones, all have a firm believe in the danger of supposedly knocking out someone's respiratory drive with oxygen. It's something that has become ingrained in a nurse's way of thinking, probably because at some point every nursing student or new nurse has had some older nurse yell at them because they set a patient's nasal cannula at 4 LPM and instead of 2.



It's especially fun when those nurses go right to SNFs, do not pass go, do not collect meaningful mentoring. 10 years later, I find a patient bubbling away on 4 LPM via empty nebulizer mask and get lectured about how he was getting "more oxygen" that way after I switch back to nasal cannula. 

Not that we can criticize anyone for using seriously outdated dogma in place of evidence or clinical judgment.


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## Bullets (Jul 13, 2012)

MrConspiracy said:


> Not that we can criticize anyone for using seriously outdated dogma in place of evidence or clinical judgment.



Uhhh, yes we can...just because my service/state/medical director can't get out of the 1970s doesn't mean I can't. Their policy also is not something I have a lot of control over. We should be pushing those to change



EarnMoneySleeping said:


> However, I was treating the symptoms I was presented with in the field, which was pt tripoding, using accessory muscles, complaining of SOB. Again we don't have pulse ox on our ambulance so that kind of sucks, but our transport time was only 5 mins.



you don't need a pulse ox if the patient was presenting as you say, you treated appropriately


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## KellyBracket (Jul 13, 2012)

So this thread prompted me to write a review of the evidence regarding oxygen use in COPD. The review is broken down into two sections. 

The first goes over some studies in the ICU, giving higher levels of oxygen to COPD patient who were either intubated, or in danger of being intubated. Check out *COPD: Is EMS Killing Patients with Oxygen? (1)*


Long story short - oxygen doesn't appear to cause hypoventilation, acidosis, or much of anything. But you all knew that already!


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## medicdan (Jul 13, 2012)

KellyBracket said:


> So this thread prompted me to write a review of the evidence regarding oxygen use in COPD. The review is broken down into two sections.
> 
> The first goes over some studies in the ICU, giving higher levels of oxygen to COPD patient who were either intubated, or in danger of being intubated. Check out *COPD: Is EMS Killing Patients with Oxygen? (1)*
> 
> ...



Thanks, a fascinating read, as always!


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## VFlutter (Jul 13, 2012)

This is still taught in nursing school however my teacher described it as a relative contraindication. Basically if they are in distress give them all the oxygen they need but monitor closely and wean down as soon as possible. I think the problem is some nurses who slap a NRB @ 15 lpm on a COPD patient and leave it on all night while they sleep.


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## KellyBracket (Jul 13, 2012)

ChaseZ33 said:


> This is still taught in nursing school however my teacher described it as a relative contraindication. Basically if they are in distress give them all the oxygen they need but monitor closely and wean down as soon as possible. I think the problem is some nurses who slap a NRB @ 15 lpm on a COPD patient and leave it on all night while they sleep.



It just occurs to me this could be a Mad-Libs.

"I think the problem is some {_health-care workers_} who slap a {_medical device_} on a {_serious chronic illness_} patient and leave it on all night while they {_non-productive activity_}."


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## VFlutter (Jul 13, 2012)

KellyBracket said:


> It just occurs to me this could be a Mad-Libs.
> 
> "I think the problem is some {_health-care workers_} who slap a {_medical device_} on a {_serious chronic illness_} patient and leave it on all night while they {_non-productive activity_}."




LPN, traction splint, Bilatetal AKA, cough??


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## NomadicMedic (Jul 13, 2012)

KellyBracket said:


> It just occurs to me this could be a Mad-Libs.
> 
> "I think the problem is some {_health-care workers_} who slap a {_medical device_} on a {_serious chronic illness_} patient and leave it on all night while they {_non-productive activity_}."



CRNA, KED, Ureteral neoplasm, collect food stamps


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## AnthonyM83 (Jul 14, 2012)

Farmer2DO said:
			
		

> That doesn't mean I think we should throw oxygen at everyone just because we can. Quite the opposite. I think we need to be judicious. This is a case where you need to go on clinical assessment. How was her color? Was she diaphoretic? How was her capillary refill? How were her lung sounds? Could she have been in pulmonary edema? Anytime I see a patient who needs dialysis that is short of breath, I am diligent for assessing for pulmonary edema secondary to fluid overload.



So, if all the previous clinical assessments (mentioned above) turned up "normal", how would that alter your oxygen intervention for this original scenario mentioned?


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## Sandog (Jul 14, 2012)

There seems to be some misconceptions about COPD. Not all COPD patients are barrel chested elderly men strapping an O2 tank to their walker. 

After some 30 years of smoking, I have COPD and I am very much active. Now I do experience shortness of breath at times but I still have lung function. 

Now what some providers might see when administering O2 to a COPD person is a rapid increase in HR and RR, this is not hypoxic drive, rather panic drive.

Let me explain; In my line of work I am required to take a yearly lung function test and a SCBA FIT test. Well when I first put on a SCBA mask, my COPD driven brain gets a bit panicky and I start to breath rapidly and feel as though I am being suffocated. Well I know from past experience, this is just my COPD brain kicking in, I calm myself and I start breathing normal again. 

The point? Well, often times what might be perceived as a COPD person having difficulty breathing in O2 mask is from panic, not medical. After time you see, the COPD person knows their lung capacity is impaired, and as such, become protective of their airspace, things like a mask can freak them out.

Just thought I would point that out. BTW, I did quit smoking


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## firetender (Jul 14, 2012)

Sandog said:


> BTW, I did quit smoking


 
Good for you!

I also very much like that you're willing to share some reality with those of us who have much to learn. You don't find stuff like this in textbooks!


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## KellyBracket (Jul 27, 2012)

Managed to finish part 2 of my review of using oxygen in COPD exacerbation.

In *COPD: Is EMS Killing Patients with Oxygen? (2)* I review the 2010 trial done in Australia. It was a randomized trial of high-flow or titrated oxygen during prehospital treatment for COPD attacks. It was published in BMJ, a big journal, and the lead author is a MD/paramedic.

Astonishingly, it showed a *5*% absolute difference in mortality. A couple of issues in the trial gave me pause however, and I briefly cover those.

I'll give you what I think is the bottom line now, however: It's not about oxygen, it's about carbon dioxide and ventilation. If they're really sick, the need some *non-invasive ventilation*, like CPAP. Importantly, the Tasmanian Ambulance service (the agency in the study) did not have CPAP at the time of the trial.


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## JakeEMTP (Jul 27, 2012)

KellyBracket said:


> Managed to finish part 2 of my review of using oxygen in COPD exacerbation.
> 
> In *COPD: Is EMS Killing Patients with Oxygen? (2)* I review the 2010 trial done in Australia. It was a randomized trial of high-flow or titrated oxygen during prehospital treatment for COPD attacks. It was published in BMJ, a big journal, and the lead author is a MD/paramedic.
> 
> ...


That was at first an interesting article with a catchy title  but when you read the whole article as other big names did, it didn't have the same impact.

Apparently the hospital also did not have access to CPAP or made no mention of using it in the full article. The study was incredibly flawed as mentioned in editorials  since  ABGs were not done consistently as part of the study to establish a baseline. What was missed was the ventilation part (as you mentioned) and a rise in CO2 due to deadspace with the administration of O2 in a hypoxic situation. This is why non-invasive ventilation has been popular in the hospitals for over 50 years. 

What is also relevant is that in the 5%, there were probably other co-morbidities which existed. I doubt if the deaths were just a single disease COPD although mismanaged Asthma could also fall into that category


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## KellyBracket (Jul 27, 2012)

Yeah, in an ideal world I'd like to see it replicated, but with an EMS service (and hospital) that uses non-invasive ventilation. 

Don't really care about the ABGs, but I know the critical care folks love those numbers! As long as there is some clear & practical outcomes data, that would be good.


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## Farmer2DO (Jul 27, 2012)

AnthonyM83 said:


> So, if all the previous clinical assessments (mentioned above) turned up "normal", how would that alter your oxygen intervention for this original scenario mentioned?



It depends on her oxygen: is she on that chronically, or did the facility start her on it?  If she's not normally on oxygen, I would probably leave where she is.  If she's normally on 3 LPM, I might bump it up a little.  Either way, if everything else appeared normal, I would probably go with 2-6 LPM.


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## JakeEMTP (Jul 27, 2012)

KellyBracket said:


> Yeah, in an ideal world I'd like to see it replicated, but with an EMS service (and hospital) that uses non-invasive ventilation.
> 
> Don't really care about the ABGs, but I know the critical care folks love those numbers! As long as there is some clear & practical outcomes data, that would be good.



Just the use of noninvasive ventilation in the Emergency Department has numerous articles of documented data over the past several decades. The survival and avoidance of intubation are well documented even if NIV was not started in the field.  Those in EMS should not disregard this data even if it was not done in an ambulance. The way to change is to see what others are doing and see if it can be applied in the field or at least understand the reasons behind it with the disease process.  

ABGs are a great way to determine CO2 retention. Statistically very few COPD patients are retainers. There are other points such as fatique and deadspace which will determine endpoint for need of additional support.

You might ask the lab to pull up the number of ABGs drawn in the ED.  You might be surprised at the number done. Alot of patients in the ED do end up in the ICU. There are alot of reasons to draw them besides CO2. If used appropriately by someone who understands the numbers and how to correlate them to other data, ABGs should not be discounted as just numbers.


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## AnthonyM83 (Jul 28, 2012)

Farmer2DO said:


> It depends on her oxygen: is she on that chronically, or did the facility start her on it?  If she's not normally on oxygen, I would probably leave where she is.  If she's normally on 3 LPM, I might bump it up a little.  Either way, if everything else appeared normal, I would probably go with 2-6 LPM.



Okay, gotcha. That first post made it seem like you wouldn't give any oxygen at all for dyspnea unless they had more signs/symptoms/abnormal-vitals.


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## ironco (Jul 28, 2012)

I agree with everyone else. I once had an IFT where five minutes away from the transferring facility the guys o2 dropped to 65% and resp increased to around 32/min. He had COPD. This guys exact words were "can you help me breathe" I threw a bvm on 25lpm and started assisting him and turned around back to the ED. If while bagging him I had him at 96% if I stopped for a split second he would drop all the way back down. When we walked in the nurse absolutely jerked that bvm out of my hand and proceded to chew me and put him on a nc. When the doc came in and the guy was satting 63% on a nc the doc said "WHY AREN'T YOU BAGGING HIM" lmao then came a first. The pt states "can you tube me" lol Doc says sure thing


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