High Flow O2 on COPD pts

[KellyBracket]

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!

 

[zzyzx]

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.

 

[DPM]

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!

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.

 

[Christopher]

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".

 

[DPM]

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.

 

[Meursault]

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.

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.

 

[Bullets]

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

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

 

[KellyBracket]

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!

 

[medicdan]

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!

Thanks, a fascinating read, as always!

 

[VFlutter]

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.

 

[KellyBracket]

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}."

 

[VFlutter]

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??

 

[NomadicMedic]

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

 

[AnthonyM83]

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?

 

[Sandog]

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

 

[firetender]

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!

 

[KellyBracket]

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.

 

[JakeEMTP]

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.

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

 

[KellyBracket]

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.

 

[Farmer2DO]

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.