Normal Range Oxygen Saturation readings in CHF Patients

Thanks Systemnt, Well put. Ultimatly what I took out of that is that every problem does'nt need and or can be fixed in the field. I guess im kind of high strung in that regard. Thanks for the input all.
 
TYMEDIC said:
Thanks Systemnt, Well put. Ultimatly what I took out of that is that every problem does'nt need and or can be fixed in the field. I guess im kind of high strung in that regard. Thanks for the input all.
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Cool. Glad it was useful. Hope I didn't come across as being too aggressive. I wasn't try to be.
 
TYMEDIC said:
Looking for a little insight here. I had a patient suffering from a prolonged pneumonia accompanied with CHF/pulmonary hypertension. Audible congestion noted, auscultated sounds of scattered rhonchi, rales, slight expiratory wheeze. Vitals assessed, initial spo2 reading of 89. high flow nrb=98%. ETc02-poor wave form, slight rep. alkalosis. rapid, shallow, respirations at 34. 12-lead revealed bifisicular block, LVH.
18g IV established.
Now I wanted to splint the airways open with CPAP. Got into an argument with my Partner. He wanted to keep the NRB on and TX. There was clear signs of distress there, but he opted to treat as such due to normal saturation levles. There is a differance between hypoxia and hypoxemia.
Has anyone ever seen such a patient? Was NRB better than CPAP? False readings in CHF Patient's?
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I've been reading this thread for a while and it seems that there is something that has been needing mentioning but has either been forgotten, overlooked, or never learned/realized in the first place.

Oxygenation and ventilation are two completely different things. You can be in respiratory failure and still have a SpO2 of 99%. That would be because your PACO2 is probably over 65 and I'm betting 80's - 100's.

And then there's the psychological component of fear. When your lungs are full, you're going to be air hungry. If if you are breathing adequately, you won't feel like you are.

You guys have covered hypoxia and hypoxemia very well. But you have not quite covered ventilation.

NRB won't work nearly as well as CPAP. First off a tachypneic adult pt can have inspiratory flow rates/demands (the speed in which they can suck air into their lungs) of 300 L/min. A 15 L/min NRB will as useful as mammory glands on male swine. What the pt really needs here with supplemental oxygen is pressure and flow. Some EMS flow systems can deliver flow rates of up to 140 L/min. Not the best, but better than a NRB.

Along with that, the pt needs diuresis if CHF, and hydration, abx, and pulmonary toilet if pneumonia.
 
with the usual suspect CHF, that was diagnosed with Hyperkelemia. Wouldnt the normal use of diuretics be detrimental to the patient? I agree with the ventilation input, def. agree with the use of positive pressure with flow. With the kidneys already working overtime with the compansation of of the increased pH by retaining H+, ultimatly excreting a ton of HCO3. I feel that the lasix would cause even more of an influx in the acid-base. With what I was observing, the patient was compensating for the respiratory issue further creating a huge issue with the kidneys. I understand it is a long drawn out compenstation measure with the kidneys and resp. but who knows if this is acute or chronic.
 
TYMEDIC said:
with the usual suspect CHF, that was diagnosed with Hyperkelemia. Wouldnt the normal use of diuretics be detrimental to the patient? I agree with the ventilation input, def. agree with the use of positive pressure with flow. With the kidneys already working overtime with the compansation of of the increased pH by retaining H+, ultimatly excreting a ton of HCO3. I feel that the lasix would cause even more of an influx in the acid-base. With what I was observing, the patient was compensating for the respiratory issue further creating a huge issue with the kidneys. I understand it is a long drawn out compenstation measure with the kidneys and resp. but who knows if this is acute or chronic.
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Unless you have actual lab results, the only prehospital sign I can think of to indicate the possibility of hyperkalemia would be the observance of peaked T waves. With the absence of either of those you have to look at history with regarding meds. Question. Should withhold Lasix in a CHF pt without the signs/symtpoms of pulmonary infection, could you back up Your decision?

If you can't back it up in black and white, do it.
 
The patient did indeed have an infection which I believe was inconjunction with an esacerbation of the CHF. 100% agree with you. It all is black and white in prehospital. more or less I think, which is gonna kill this patient faster. The resp failure, or hyperkelemia? I agree, id give the furosmide along with CPAP, even with the both. The infection was being treated with antibotics. I couldnt do any of it because i wasnt running lead and had to watch a NRB ride the patient all the way into the er. I thank you for the insight on the ventilation vs. oxygenation.
 
TYMEDIC said:
The patient did indeed have an infection which I believe was inconjunction with an esacerbation of the CHF. 100% agree with you. It all is black and white in prehospital. more or less I think, which is gonna kill this patient faster. The resp failure, or hyperkelemia? I agree, id give the furosmide along with CPAP, even with the both. The infection was being treated with antibotics. I couldnt do any of it because i wasnt running lead and had to watch a NRB ride the patient all the way into the er. I thank you for the insight on the ventilation vs. oxygenation.
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Also, if the pt was showing signs/symptoms of infection with auscultated rales, you probably shouldn't give lasix. As the pt diureses the fluid being pulled from the lungs will dry the infiltrates making them harder to remove thus increasing the pt's hospital stay. Best thing to do is CPAP, and NTG if the pt is hypertensive.
 
agreed. Scattered rales, with rhonchi. Profound congestion. audible.
 
Mike, the main issue with the disgussion, was that my partner that is a blundering fool. We had a critical patient, prolonged pneumonia accompaning CHF. the patient was tachnepic, tachycardic, high congestion, rales, slight exp. wheeze. He said no to the CPAP. along with others. This has been escalated. He then contacted the er and pretty much told me and my mentor that he was admitted for hyperkelemia. A metabolic issue he stated. He has no idea about anything, makes me upset. on top of that, he didnt use CPAP per his statement, "he wasnt belly breathing and o2sp was within normal parameters." haha
 
Understood. Just attempting to clarify from all of the imperical data that was accurate, but not quite on target regarding oxygenation versus ventilation.
 
What led to the suspicion of CHF? I've had patients whose lungs were full of fluid with really bad bilateral pneumonia.

If pt. still had increased work of breathing after the NRB I would have went to CPAP. Take the work off the patient, decrease pt's. energy expenditure, recruit collapsed alveoli, increase surface area for diffusion, and if it is CHF, the CPAP will help reduce afterload as well.

CPAP is pretty harmless overall.
 
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