Patient flirting with respiratory failure; what's your treatment?

[NPO]

I'm going to run you through a call I ran, my assessments, my treatments, and my afterthoughts. I hope to learn something from the comments I receive, as I usually do.

I responded for a 50s year old male at home with difficulty breathing. Patient was found in a recliner, reclined, on both a NC at 4LPM, and a NRB at 15LPM, for a total of 19LPM. The patient is A/Ox4. Family reports he is having increased SOB and had several brief syncopal episodes. They report he has a SPO2 monitor ($10 finger clamshell) which has been reading very low. Patient is noted to have slight cyanosis to his lips, but nothing immediately alarming. His home SPO2 reads about 80% with good waveform.

FD arrives, and their body language indicates they don't notice anything wrong and think we can handle it, so I ask them to stick around for a few minutes. Patient took a few steps to the gurney and was put on our cardiac monitor. HR and BP, as well as ECG were all within normal limits, although I don't recall specifics. His SPO2 however has dropped to 40% with good wave form. As we buckle him in, he looks up to me and says, with some difficulty, "DNR." I asked his family for the DNR but they said he didn't have one.

Patient was hastily moved to the ambulance and an emergent transport started. Lung sounds were clear bilaterally. The patients only history; pulmonary fibrosis. At the time, I knew very little about this pathology and had to treat with my findings. I still don't have a firm grasp, but I have a better understanding now, having researched after this call.

Upon getting in the unit, I followed our respiratory protocol and placed the patient on CPAP and called the hospital to get a base order to honor the DNR request, which they agreed to, and give them a heads up. Patient then received EPI IM, and I set up a Mag drip and called for an order for the Mag, which they gave. Patient ended up being uncompliant with CPAP. My protocol has the option to give Versed with CPAP, but I was uneasy about this in this patient because it an uncommon practice. SpO2 came back up to about 90% upon arrival.

Like I said, I didn't know much about his pathology, which it sounds like he's battled before, so all I could do was follow my respritory compromise protocol for dry lungs, however after having read about it more, I'm not sure these treatments would provide much relief given how the disease process works.

Is there anything better to do for these patients? I figure, at a minimum, the treatments may allow the functional lung tissue to compensate for the injured tissue, but I can't see it making a huge difference.

I welcome insight on future management of these patients and other comments.

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[VFlutter]

Pulmonary Fibrosis is a horrible disease and extremely frustrating to manage, especially IPF. Most patients spend their last days in the ICU on a vent or slowly fading away on high flow 02, constantly symptomatic. The syncopal episodes are ominous of severe pulmonary HTN and RV dysfunction commonly associated with PF, or possibly a PE. Unfortunately there is not much you can offer this patient except supportive care and supplemental oxygen. As the disease progresses supplemental oxygen becomes less effective and even on High Flow devices (60L/100%Fi02) these patients remain profoundly hypoxic. Anxiolytics would probably help.

Good article
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220036/

 

[Akulahawk]

Chase is probably more of an expert in these patients that I am, that being said, I doubt there's more that really can be done for PF patients in the field that you have done.

 

[VentMonkey]

Pretty much what Chase, and Akulahawk have said. I watched my grandmother die a very slow, and uncomfortable death due to PF. It was essentially supportive care with round the clock O2, and bronchodilators. Your best bet is roughly what you did. I probably would have forgone the Epi, and/ or Mag, in favor of a lock, and continuous Duonebs, CPAP or not. It's supportive care, and a truly awful way to watch someone die; along the lines of Lou Gehrig's (ALS).

 

[Akulahawk]

OP: given that your protocols allowed for sedation (Versed) for CPAP, it may have helped your patient become more compliant with the mask. Remember that often these patients don't tolerate the mask because they think they can't breathe with the mask on, so they fight it. One of the more serious respiratory failure patients I had did pretty much the same thing. He didn't tolerate the mask well either (we tried Bi-PAP on him, actually) so our next 3 options were to try continuous nebs and hope his lungs finally open up enough, sedate him and put him on Bi-PAP with nebs to open his lungs up, or RSI. He came within a couple minutes of sedation/Bi-PAP and probably within 15 minutes of RSI. He finally realized he needs to fight his instincts, stop moving (lowers O2 demand), force deep breathing with the nebs and slowly his SpO2 (and actually his EtCO2 also) began trending toward normal.

Too close that one was!

 

[NPO]

Pretty much what Chase, and Akulahawk have said. I watched my grandmother die a very slow, and uncomfortable death due to PF. It was essentially supportive care with round the clock O2, and bronchodilators. Your best bet is roughly what you did. I probably would have forgone the Epi, and/ or Mag, in favor of a lock, and continuous Duonebs, CPAP or not. It's supportive care, and a truly awful way to watch someone die; along the lines of Lou Gehrig's (ALS).

I am sorry to hear. I was with my patient for all of 15 minutes, and I'd hate to watch a loved one endure that for any amount of time, let alone the entire progression.

I did get an IV, and I can't imagine I didn't give bronchodilators, since I went down that protocol, but I don't specifically remember, it was a few months ago.

This truly sounds like an awful disease.

OP: given that your protocols allowed for sedation (Versed) for CPAP, it may have helped your patient become more compliant with the mask. Remember that often these patients don't tolerate the mask because they think they can't breathe with the mask on, so they fight it. One of the more serious respiratory failure patients I had did pretty much the same thing. He didn't tolerate the mask well either (we tried Bi-PAP on him, actually) so our next 3 options were to try continuous nebs and hope his lungs finally open up enough, sedate him and put him on Bi-PAP with nebs to open his lungs up, or RSI. He came within a couple minutes of sedation/Bi-PAP and probably within 15 minutes of RSI. He finally realized he needs to fight his instincts, stop moving (lowers O2 demand), force deep breathing with the nebs and slowly his SpO2 (and actually his EtCO2 also) began trending toward normal.

Too close that one was!

I will keep that in mind. It's a small subtext in our protocol and advises severe caution because they stress CPAP as an attempt to make ETI less likely, and, well, versed could lead to ETI. Thankfully, all of my subsequent CPAP patients have been more tolerant.

I tend to like CPAP, because I was taught to lean on it as a powerful tool. Many here seem not to like it however.

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[Akulahawk]

Done appropriately, you would be able to provide sufficient anxiolysis to make the patient tolerate the CPAP and yet still be able to not have to worry about intubating the patient. That being said, patients that need anxiolysis are pretty far down the failure pathway that the next step really is ETI.

 

[hometownmedic5]

You have a tough nut to crack here. Clearly your patient is aware of his condition, what lies ahead, and what he wants and doesn't want. While DNR certainly doesn't mean do not treat, there's exists a fine line between resuscitation and treatment in a case this advanced. I can't say I would have done anything grossly different than what you did, but I would have battled myself internally for sure.

Sedating CPAP patients is common in my practice, but it is without a doubt an aggressive treatment path. Which side of the line is it on? That's going to depend on the patient. Does he want everything up to a tube or is he ready to go? If he wants to be treated aggressively then CPAP, meds as noted etc are all appropriate. If he doesn't want the full tickle, then O2, nebs and hope you get to the hospital before he boxes.

 

[VFlutter]

At this point in the patient's disease process I am not sure how much CPAP would actually help. His lungs are likely stiff and fibrotic so extra pressure probably won't increase recruitment much.

Also, Morphine is extremely helpful in patient's like this. It makes them much more comfortable and they perceive less dyspnea.

 

[Midazzled]

Sounds like a very tough call. I can't say I would change much from what you did. I might try BiPAP, if available (probably wasn't). If I had standing orders (I don't) for Versed to improve CPAP tolerance, I would probably give him a bit of that. I would use ETCO2 monitoring and maybe duoneb treatment instead of, or in conjunction with, epi or mag. ETCO2 would probably not be particularly beneficial, it's just something I try to do with all of my respiratory, cardiac, or pain management/sedation patients. Sometimes it guides my treatment, sometimes it just helps me have an accurate RR count.

There's just not much I (or you) can do for this patient, except drive.

Edit: after reading Chase's post, morphine seems like a very good idea. Axiolysis plus hypercarbia tolerance. There's absolutely no way I would be allowed to use it for this indication at my current agency(s).

 

[VentMonkey]

I am sorry to hear. I was with my patient for all of 15 minutes, and I'd hate to watch a loved one endure that for any amount of time, let alone the entire progression.

This was well over 10 years ago, but thanks. Something that may go without saying, but I have seen plenty providers forget (I'm sure you didn't), is please sit these patients up. There really isn't a whole lot to be done for these patients depending on how far along in their disease they're in.

It's a small subtext in our protocol and advises severe caution because they stress CPAP as an attempt to make ETI less likely, and, well, versed could lead to ETI. Thankfully, all of my subsequent CPAP patients have been more tolerant.

I tend to like CPAP, because I was taught to lean on it as a powerful tool. Many here seem not to like it however.

I do, too and tend to agree that many people "don't like" to use it, this I find ridiculously frustrating and flat out dumb.

As far as CPAP in these patients I don't know that I would increase the PEEP past 5-10 especially with a short enough ETA to the ED.

There's hardly anything we carry, or a cure, that will stop their hypersecretions. Their lungs are the epitome of stiff. I can't imagine compliance being particularly phenomenal. Pain management is a good idea, but with them I may be a little cautious and judiciously titrate to just the right amount of comfortable.

 

[VFlutter]

Pain management is a good idea, but with them I may be a little cautious and judiciously titrate to just the right amount of comfortable.

Morphine is effective at treating air hunger and dyspnea at lower doses that typically used for pain management. 1mg of Morphine IV can do wonders. Many of the patients will be on PO Morphine at home so take that into account as well.

 

[Midazzled]

Morphine is effective at treating air hunger and dyspnea at lower doses that typically used for pain management. 1mg of Morphine IV can do wonders. Many of the patients will be on PO Morphine at home so take that into account as well.

Would fentanyl have the same effect at similarly small doses?

 

[VFlutter]

Would fentanyl have the same effect at similarly small doses?

Not sure, a lot of the articles mentioned Opiods in general but most of the literature specifies Morphine or Hydromorphone. I am sure it would help if that is the only option you have available.

 

[NPO]

Morphine is effective at treating air hunger and dyspnea at lower doses that typically used for pain management. 1mg of Morphine IV can do wonders. Many of the patients will be on PO Morphine at home so take that into account as well.

Our protocols are very easy on pain management, and our medical director takes the stance of "justify it, and do it." So a small dose of morphine wouldn't bat any eyes down at EMS.

Good to know.

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[bakertaylor28]

You have a tough nut to crack here. Clearly your patient is aware of his condition, what lies ahead, and what he wants and doesn't want. While DNR certainly doesn't mean do not treat, there's exists a fine line between resuscitation and treatment in a case this advanced. I can't say I would have done anything grossly different than what you did, but I would have battled myself internally for sure.

Sedating CPAP patients is common in my practice, but it is without a doubt an aggressive treatment path. Which side of the line is it on? That's going to depend on the patient. Does he want everything up to a tube or is he ready to go? If he wants to be treated aggressively then CPAP, meds as noted etc are all appropriate. If he doesn't want the full tickle, then O2, nebs and hope you get to the hospital before he boxes.

The thing is that it can be technically said that if you Don't have a properly DNR form sitting in front of you on paper or on a computer scan, you DON'T have a DNR period. No state in the union allows verbal DNR. Rather, a DNR is a proper legal pleading that must be properly executed and properly placed in the chart. Also, in some states DNR does not apply to first-responders at all, as we're not qualified to determine whether or not an arrest was inevitable or merely just caused by some outside intervening factor that will pass. If the latter is the case, the DNR will likely not apply to the situation, depending upon the applicable state law.

 

[NomadicMedic]

The thing is that it can be technically said that if you Don't have a properly DNR form sitting in front of you on paper or on a computer scan, you DON'T have a DNR period. No state in the union allows verbal DNR. Rather, a DNR is a proper legal pleading that must be properly executed and properly placed in the chart. Also, in some states DNR does not apply to first-responders at all, as we're not qualified to determine whether or not an arrest was inevitable or merely just caused by some outside intervening factor that will pass. If the latter is the case, the DNR will likely not apply to the situation, depending upon the applicable state law.

Where do you find these amazing facts?

 

[Carlos Danger]

The thing is that it can be technically said that if you Don't have a properly DNR form sitting in front of you on paper or on a computer scan, you DON'T have a DNR period. No state in the union allows verbal DNR. Rather, a DNR is a proper legal pleading that must be properly executed and properly placed in the chart. Also, in some states DNR does not apply to first-responders at all, as we're not qualified to determine whether or not an arrest was inevitable or merely just caused by some outside intervening factor that will pass. If the latter is the case, the DNR will likely not apply to the situation, depending upon the applicable state law.

So you are saying that we should only honor patient's wishes if they had the foresight to put them in writing and have them blessed by an attorney?

 

[VFlutter]

Every patient that comes into the ICU we ask about rescucitation if they are competent. If they say they do not want life support then we honor that and consult palliative care to get an official DNR. Also, if the patient is not competent or has no family then two physicians can declare a DNR if resuscitation is considered futile.

Again this is one of those situations where I wish prehospital providers had to spend more time in the ICU or shadowing Palliative care. It is a hard enough decision for families to agree to a DNR but what is even worse is withdrawing support. Even if the patient had a valid DNR and was intubated most struggle with the decision to "pull the plug" and can no do it even though they know it is exactly what their loved one wanted in the first place.

 

[bakertaylor28]

So you are saying that we should only honor patient's wishes if they had the foresight to put them in writing and have them blessed by an attorney?

What I'm saying is that the law flat out doesn't recognize a verbal DNR. Hence if you rely on a verbal DNR you may as well not have one in the first place. Each state has a particular form and manner that must be used to properly initiate a DNR. If its not done properly, a court of law won't recognize it, simply put. Plus, with a patient that is profoundly hypoxic you can't trust their decision making skills either, while in such a state.