High Flow O2 on COPD pts

[EarnMoneySleeping]

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.

 

[NYMedic828]

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

 

[medicdan]

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

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

 

[Farmer2DO]

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.

 

[Farmer2DO]

I just found a link, with references:

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

 

[bobbyd3423]

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.

 

[bobbyd3423]

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

 

[Farmer2DO]

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

 

[Christopher]

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."

 

[AnthonyM83]

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.

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?

 

[epipusher]

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.

 

[mycrofft]

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.

 

[DPM]

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.

 

[epipusher]

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!

 

[AnthonyM83]

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....

 

[Tigger]

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...

 

[DPM]

Who becomes a nurse for the money...?

 

[usalsfyre]

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.

 

[DPM]

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?

 

[EarnMoneySleeping]

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.