O2 Usage in the field

[VentMedic]

Albuterol has a great safety profile and rarely causes side effects that are worse then what the albuterol is being given for (hypoxia).

You might want to do a little literature search on that.

Albuterol is not being given for hypoxia but rather for the relaxation of smooth muscle which is primarily for ventilation. Pulmonary vasoconstriction usually results from the hypoxia which then creates the dead space and V/Q mismatch issues.


Also, do you put your patients who are on MAOIs on a cardiac monitor when administering albuterol?

 

[VentMedic]

I don't think its fair to say "EMS is slow to change"... its higher level healthcare providers that have embraced this concept and practiced it and taught it to EMS.

Those higher level healthcare providers have moved on as new evidence has been found and the textbooks have changed to reflect acceptance of a new way of viewing the advances in medicine.

 

[ResTech]

That info is pretty current that you posted right? If the rest of the medical community has moved on then why is it necessary to still teach that hypoxic drive is just a myth? Just a question that comes to mind.

Its still fresh in peoples minds... like I said... we were taught this in school last semester and is explained on page 216 of the latest edition of the Essentials of Paramedic Care Textbook (Brady, Second Edition) which is authored by Dr. Bryan Beldsoe.

 

[VentMedic]

That info is pretty current that you posted right? If the rest of the medical community has moved on then why is it necessary to still teach that hypoxic drive is just a myth? Just a question that comes to mind.

Its still fresh in peoples minds... like I said... we were taught this in school last semester and is explained on page 216 of the latest edition of the Essentials of Paramedic Care Textbook (Brady, Second Edition) which is authored by Dr. Bryan Beldsoe.

You could email Dr. B and ask him when he is putting the other explanation into his book or at least explain why it is harmful to withhold O2 from a patient when you believe in this hypoxic drive theory.

Another link for you from the nursing profession:
http://findarticles.com/p/articles/mi_m0FSS/is_2_13/ai_n17206920/pg_3/

 

[ResTech]

You might want to do a little literature search on that.

Albuterol is not being given for hypoxia but rather for the relaxation of smooth muscle which is primarily for ventilation. Pulmonary vasoconstriction usually results from the hypoxia which then creates the dead space and V/Q mismatch issues.

Also, do you put your patients who are on MAOIs on a cardiac monitor when administering albuterol?

Yes, albuterol is indicated for bronchoconstriction of which affects both oxygenation and ventilation, correct? If a patient is severely bronchoconstricted they likely will have air trapping which compromises ventilation due to difficult expiration and a increased residual volume.

And if a patient cannot ventilate because their lungs aren't able to recoil, diffusion is gonna be effected, cells are gonna be deprived of oxygen, which then leads to hypoxia. So really albuterol is given for hypoxia.

MAOI's are a class of antidepressants that are rarely prescribed anymore which in the majority of the population, wont be affected.

Im not trying to be argumenative... your experience and knowledge vastly exceeds mine. I just wanna be sure I am understanding correctly..... and plus debating does actually help me recall and remember stuff...lol..

 

[Shishkabob]

It's 12:30 so my mind isn't all that, but does that basically mean the maxim

"Never withhold oxygen from a hypoxic patients"

hold true?

 

[VentMedic]

Yes, albuterol is indicated for bronchoconstriction of which affects both oxygenation and ventilation, correct? If a patient is severely bronchoconstricted they likely will have air trapping which compromises ventilation due to difficult expiration and a increased residual volume.

And if a patient cannot ventilate because their lungs aren't able to recoil, diffusion is gonna be effected, cells are gonna be deprived of oxygen, which then leads to hypoxia. So really albuterol is given for hypoxia.

MAOI's are a class of antidepressants that are rarely prescribed anymore which in the majority of the population, wont be affected.

Im not trying to be argumenative... your experience and knowledge vastly exceeds mine. I just wanna be sure I am understanding correctly..... and plus debating does actually help me recall and remember stuff...lol..

Very few of my COPD or Asthma patients require much O2 and the HeliOx is usually in concentrations of 80/20 or 70/30 with the higher number being helium.

You would be surprised by the number of people that are on MAOIs. I rarely will withhold albuterol unless there is a greater chance that the orgin is cardiac. I will then give only if on a monitor and even if it is respiratory related, if in the back of a truck or in the ED, they get a monitor.

Now for the hypoxic drive theory, I've given you some good links so that you can through and see how this concept applies to your patients.

 

[VentMedic]

It's 12:30 so my mind isn't all that, but does that basically mean the maxim

"Never withhold oxygen from a hypoxic patients"

hold true?

Except when I am stressing them in a High Altitude Simulation Test....

 

[ResTech]

But with Heliox, the helium actually works to deposit the O2 deeper and allow greater absorption than without, right? So because of the helium, a higher concentration of O2 would not be required to drive the rate of diffusion as in situations where heliox is not practical.

 

[Shishkabob]

Well, was told that back in EMT, as and we all know, some of the things they teach you in EMT get thrown out in medic, so even though my EMT school is considered one of the better ones in Texas, I'm still double checking all the facts as I go.







So that's a yes?

 

[CAOX3]

Except the heart can cause wheezing as well, and the assesment of that condition is beyond the scope of EMT training. Giving albuterol comes with a lot more responsability and the need for advanced assesment.

As in failure and determing the difference between the two as I stated above.

 

[VentMedic]

But with Heliox, the helium actually works to deposit the O2 deeper and allow greater absorption than without, right? So because of the helium, a higher concentration of O2 would not be required to drive the rate of diffusion as in situations where heliox is not practical.

No, not quite. HeliOx decreases work of breathing. In turbulent flows, the pressure necessary to generate a given flow rate is dependent on the density of the inspired gases. Helium has a density that is significantly lower than that of air (nitrogen and oxygen). Breathing HeliOx leads to a reduction in resistance to flow within the airways, and consequently to a decrease in the WOB, particularly in disorders that are characterized by increased airways resistance

 

[VentMedic]

So that's a yes?

Yes with the exception of infants with a ductal dependent lesion (Cyanotic Heart Disease) that have not had meds to keep the ductus open started but hopefully you won't encounter this without a Neo team present.

 

[usafmedic45]

Except the heart can cause wheezing as well

Heart failure can when it causes fluid to back up into the lungs. Saying the heart causes it is not technically correct since you can have a heart that is technically structurally and mechanically normal simply overloaded by excessive fluid from kidney failure or overzealous fluid administration (normally it's a diseased heart pushed past the point of compensation by fluid or electrolyte abnormalities, etc). It is the fluid that causes the problem, just as happens in pulmonary causes of edema formation. In these cases, there is a fine balance to be struck between the effect of the presence of the fluid in the airway causing the wheezing and the bronchoconstriction actually produced by the presence of the fluid which can irritate the small to medium airways.

Regardless of mechanism, the focus is on fixing the underlying problem (diuresis, improving cardiac function if that's an issue and possibly CPAP/BiPAP as an adjunctive therapy) which will alleviate the wheezing. In the case of someone with significant underlying cardiac disease, I am loathe to administer even a drug such albuterol with a decent safety profile in a normal patient. The last thing you want to do is add anything to the mix that is going to further tax the heart without a significant benefit. In this case, albuterol simply does not give you that return. Simply because you are doing something to the patient doesn't mean you're doing something for the patient. As one of my EMS instructors was fond of saying, the best providers are the not the ones who know when to do something or when to give a drug but rather know when not to.

This is a very simplified review but gets the major points across. VentMedic already ran with most of the really interesting and complicated topics....that's what I get for not checking in earlier.

 

[46Young]

Oh, my fault I was assuming that people that may have to give an albuterol treatment may actually know the difference between a wheeze and rales or asthma and CHF.

Sorry my bad.

As EMT's in NY we learned to differentiate L/S. BLS albuterol was in protocol. Here in VA the EMT curriculum is sorely lacking. Our monthly training matrix includes a BLS cardiac powerpoint. It's so oversimplified and basic that it's laughable. I need to address this with the EMS Capt.

 

[VentMedic]

Originally Posted by CAOX3
Oh, my fault I was assuming that people that may have to give an albuterol treatment may actually know the difference between a wheeze and rales or asthma and CHF.

Sorry my bad.

As EMT's in NY we learned to differentiate L/S. BLS albuterol was in protocol. Here in VA the EMT curriculum is sorely lacking. Our monthly training matrix includes a BLS cardiac powerpoint. It's so oversimplified and basic that it's laughable. I need to address this with the EMS Capt.

Many times you are NOT going to be able to differentiate between PNA, atelectasis, CHF, one of the 'osis diseases with inflamation and Asthma as well as wheezes caused by crackles or rales or whatever you happen to be calling them. Often it is unknown if the asthma or the PNA exacerbated the CHF or if the chicken laid the egg that hatched the......

This is why many other assessment factors are necessary and even then only a BNP and CXR will tell us what we are hearing.

 

[Foxbat]

In turbulent flows, the pressure necessary to generate a given flow rate is dependent on the density of the inspired gases.

I might be wrong but I think it's true for laminar flows as well.

Rho is the density term. This equation should apply for laminar and turbulent flows, you just adjust friction factor f.

 

[usafmedic45]

I might be wrong but I think it's true for laminar flows as well.

Rho is the density term. This equation should apply for laminar and turbulent flows, you just adjust friction factor f.

Ah....someone's a geek for physics.

 

[CAOX3]

Many times you are NOT going to be able to differentiate between PNA, atelectasis, CHF, one of the 'osis diseases with inflamation and Asthma as well as wheezes caused by crackles or rales or whatever you happen to be calling them. Often it is unknown if the asthma or the PNA exacerbated the CHF or if the chicken laid the egg that hatched the......

This is why many other assessment factors are necessary and even then only a BNP and CXR will tell us what we are hearing.

I can sure as heck narrow it down, based on history, assessment and presentation.

You should be able to walk in someones house and in 30 seconds be able to determine for the most part by what you see and hear what is going on.

COPDers live a certain way, CHFers live a certain way, diabetics and so on, everyone tailors their living arraignments based on their medical conditions, especially the elderly.

 

[CAOX3]

And yes I made up those words CHFers and COPDers, and I like them.