Contraindication of oxygen?

[mycrofft]

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

 

[Rialaigh]

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.

 

[Akulahawk]

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

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.

 

[Rialaigh]

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.

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.

 

[Aprz]

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

For most patients with known chronic
obstructive pulmonary disease (COPD) or
other known risk factors for hypercapnic
respiratory failure (eg, morbid obesity, chest
wall deformities or neuromuscular disorders),
a target saturation range of 88–92% is
suggested pending the availability of blood
gas results

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