Falling O2 sats.....on CPAP?

[needsleep]

I've been practicing EMS for only 5 months, so forgive me if this is a dumb question. My medic and I responded to a DIB call. 65 Y/O M Pt with PMH of CHF, Type 2 DM, and Renal failure. Pt is tripoding upon our arrival and appears very anxious. We get him on the rig and give him 3 rpm nasal canula while we prepare a 2.5 mg albuterol treatment. Sats go from 83 to 94. Pt begins to lean forward and starts saying , "I can't breathe! I can't breathe!" Sats begin dropping. At 79% we put Pt on CPAP. Pt begins sweating and sats DROP to 70%!
After "thereupetic touch" and breathing coaching, he gets to 82% by the time we get to the ER.

Question: in school we were taught CPAP is the end-all be-all solution for DIB for CHF/COPD. I always thought it was the ace card you always had in your deck if things got sketchy. Now I don't have that confidence in it. Also, this was my first time ever seeing it used.

Any theories on the pathophys. behind this?

 

[Gurby]

What if it wasn't CHF or COPD?

What were the lung sounds? BP and HR? ETCO2?

CPAP is sweet but it definitely isn't the end-all be-all solution to anything. It's just something else to try before intubation...

 

[TXmed]

In airway & respirstory emergencies there is NO end all be all.

What did your breath sounds reveal ? Do you think it was bronchoconstriction or pulmonary edema? Or did you go to a treatment without a field diagnosis? There is other pathologies ie PE that will play out like this. If he wasnt accepting cpap you could try versed/ativan/ valium at a very low, anti-anxiety dose. Always be planning your next move.

 

[NomadicMedic]

An SpO2 reading is nice, but it’s only half of the picture. What was the patient’s end tidal CO2? What did the waveform look like? Was there actually a good plethora with the pulse ox? Respiratory rate? Lung sounds? Why did you use albuterol? You didn’t mention anything in the PHX about COPD or any reactive airway issue. What time of day was it?

Lots of unanswered questions, but this smells like a PE.

 

[needsleep]

Also, forgot to add HTN to PMH.

Upon loading into the truck:
BP: 250/110
P: 105
RR: a lot and shallow
BGL: 195
Breath sounds: bilateral, muffled uppers w/ bilateral rales and "wet" lowers. Again, I'm so new, it sounded to me like someone blowing bubbles through a straw into a glass of Coke.

As far as EtCo2, the only way we have to monitor this is via the attachment/connector piece between the airway tube and BVM which then goes in to the monitor. Forgive my inexperience and ignorance, but how would that have factored into this specific case? PT was obviously going to be very acidotic, but would that change the direction of immediate treatment? I would imagine it would still just be high flow oxygen to clear those "drowning" alveoli.

Thank you to all for such quick, thorough replies! Im learning so much.

 

[NomadicMedic]

Well, from your description, it’s CHF. This patient needs NTG and CPAP, not albuterol.

 

[DrParasite]

BP: 250/110
[snip]
Breath sounds: bilateral, muffled uppers w/ bilateral rales and "wet" lowers. Again, I'm so new, it sounded to me like someone blowing bubbles through a straw into a glass of Coke.

In my experience, super high BP + bilateral rales (with the occasional "I can't breath") = flash pulmonary edema. Solution? CPAP, and Nitro.

ETO2 would be nice, especially if you have those nasal canulas that do ETO2.

Why are you giving Albuterol?

 

[needsleep]

Would EtCo2 readings change treatment choices? Anyway to construct my own NC type EtCo2 detector, via combining the top half of a NC and the bottom half of the EtCo2 connector piece hose that inputs into the monitor?

To no surprise, my medic called the hospital a few hours later and the Pt's RN said that upon arrival his EtCo2 was in the 70s. They said they "gave him 2 bottles of NTG" and that he was "maxed out" on BiPAP.


As far as albuterol, I'm not sure. My medic just grabbed it and administered. My (limited) understanding is why not?

 

[DrParasite]

Would EtCo2 readings change treatment choices? Anyway to construct my own NC type EtCo2 detector, via combining the top half of a NC and the bottom half of the EtCo2 connector piece hose that inputs into the monitor?

This was what I was referring to. And sometimes ETCO2 can change a treatment path

As far as albuterol, I'm not sure. My medic just grabbed it and administered. My (limited) understanding is why not?

I'm only a dumb firefirefighter, but even I know "Why not" is a horrible reason to do something, especially if administering that medication can have unwelcome side effects on your sick patient.

Your an AEMT; didn't they cover why you give albuterol in class? I'm pretty sure rales and hypertension are not indicators to give it. Does your medical director give you different protocols to follow? Isn't albuterol within your AEMT scope? so shouldn't you know when you should and should not give it?

 

[needsleep]

Absolutely agreed. When I said "why not" I meant that in a "why would it not be a treatment option" context. I would never just think "why not?" when administering any medication. My medic initiated that treatment.

With all of that said, I am aware that there is no contraindication to albuterol....except hypersensitivity to albuterol, which Pt did not mention.

 

[NomadicMedic]

Albuterol is indicated for bronchoconstriction, which would be indicated by expiratory wheeze and a shark fin morphology of the end tidal waveform.

Pulmonary edema may have a wheezing component, but you’d be more likely to hear crackles in the bases if the patient was sitting up. The treatment for this is always CPAP and NTG. It’ll also present with a non obstructive end tidal waveform. So yes, capnography can help guide the treatment. And you can’t roll your own, you need to purchase the nasal capnography cannula. They fit under a CPAP mask and together with SpO2, it can give you a much better sense of the patient’s respiration, not just ventilation.

However, this case is basic clinical correlation. The signs all scream pulmonary edema, not anything reactive that would be treated with Albuterol. That should be QIed as a protocol violation and the medic should get a little refresher on reactive airways vs CHF.

 

[VFlutter]

Agree with everyone else that it sounds like pulmonary edema. Albuterol probably didn’t help the situation.

Do you remember the CPAP settings? Probably wasn’t aggressive enough given the situation. And given that he was also hypercapnic Bipap would have been better if you have it.

 

[DrParasite]

Skipping the reply from @NomadicMedic (which is 100% correct btw)

Absolutely agreed. When I said "why not" I meant that in a "why would it not be a treatment option" context. I would never just think "why not?" when administering any medication. My medic initiated that treatment.

I think the better question is, why would it be a treatment option?

With all of that said, I am aware that there is no contraindication to albuterol....except hypersensitivity to albuterol, which Pt did not mention.

While you might be right, there is no contraindication to using it, the better question is what indications were there to use it? I will agree with you that there was no reason you couldn't give the medication, but is there a reason you should have given albuterol? You're an AEMT, isn't albuterol in your scope of practice? if your medic had told you to give the albuterol, would you have?

I know I'm not as educated as you, the AEMT, but based on the situation you described, it appears your medic gave the incorrect medication for this patient, and should probably get flagged by QA/QI

 

[medichopeful]

Well, from your description, it’s CHF. This patient needs NTG and CPAP, not albuterol.

And probably a tube.

 

[NomadicMedic]

And probably a tube.

Nope. These folks usually turn around with agressive CPAP and NTG administration.

 

[medichopeful]

Nope. These folks usually turn around with agressive CPAP and NTG administration.

Agreed that many (probably even most) do. But one of the OP's posts stated:

To no surprise, my medic called the hospital a few hours later and the Pt's RN said that upon arrival his EtCo2 was in the 70s. They said they "gave him 2 bottles of NTG" and that he was "maxed out" on BiPAP.

If that information is true, I see a tube in his future unless he makes a miraculous turn-around (or the information isn't correct).

 

[VFlutter]

https://emcrit.org/emcrit/scape/

Important to note the difference between a “SCAPE” patient vs CHF exacerbation with Pulmonary Edema. The former really requires aggressive intervention, usually outside the comfort zone of most providers.

 

[TXmed]

Sometimes CPAP needs more time to work. On SCAPE patients its really gonna push your comfort zone for how long to try cpap and how much nitro to push. But youll learn to be more patient the more experience you get. On some cpap msaks youncan attach the inline etco2 between the mask and the tubing.

If its night/dawn, slightly cool with fog mist in the air. Most likely CHF, these conditions are ripe for pulmonary edema/copd.

 

[E tank]

https://emcrit.org/emcrit/scape/

Important to note the difference between a “SCAPE” patient vs CHF exacerbation with Pulmonary Edema. The former really requires aggressive intervention, usually outside the comfort zone of most providers.

Pretty interesting stuff...in my clinical setting, the NTG doses he's talking about would be lethal for a bunch of reasons. I've never heard of this strategy and I notice the post is about 8 years old.

Anyone else aware of this kind of NTG use these days?

 

[VFlutter]

Pretty interesting stuff...in my clinical setting, the NTG doses he's talking about would be lethal for a bunch of reasons. I've never heard of this strategy and I notice the post is about 8 years old. With the advent of nitric oxide and something called Flolan, it isn't something that is commonly practiced where I am at all (at least I'm not aware of it).

Anyone else aware of this kind of NTG use these days?

Those dosages are used exclusively for the hypersympathetic flash pulmonary edema patients with significant hypertension. Usually those whom have diastolic dysfunction but no other significant cardiac conditions.

Inhaled or IV Flolan? I’ve used inhaled for ARDS V/Q mismatch and intravenous or intra PA for significant PAH. Never used it specially for APE. It seems like selectively reducing pulmonary pressures without addressing the excessive systemic afterload first wouldn’t be the most effective strategy tho.