Resp failure ift pt

mrhunt

Forum Crew Member
88
11
8
Hey so had a kinda interesting call today where i second guessed myself and wanted to share i guess.

80 something yo f, A&0X4 GCS15 transfer for +Flu, CHF new onset, NSTEMI , Pneumonia. pt came in originallly for difficulty breathing, transfer for higher level of care. in er pt decomps on NRB @ 15lpm and placed on bipap at like 7mm/h20.

Placed pt on cpap at 10lpm or about 8mm/h20, She tolerates fine. BP maintains in 130's roughly. Sinus in 80's to 90's.sp02 ranges from 94 to 96% at best. pt is just chilling with no pain, resp complaints. Skins pink/warm/dry with cap refill about 2 seconds, No labored breathing. She IS tachypnic in high 20's to low 30's but this is baseline since picking her up. Pt has NO complaints of breathing while on mask.....When pt has to transfer off mask she'll immediately decomp to Low 80's SP02 but aside from this she's FINE.

I check an ETC02 and she's acidotic from the get go at around 15 to 20 the whole time......
So i treated the pt and not the monitor.....she maintained find at the rate of cpap she was on and checked her frequently, all vitals maintained and she has no complaints. Even though she's tachypnic theres no accessory muscle use and she even starts sleeping near end of transport.

Who here would have increased cpap to a max setting? Or done something differently to try to lower her resp rate and hopefully her acidotic nature? Or would increasing the cpap rate of even DONE anything except possibly tank her bp? guess im just looking for some reassurance. Lol.
 

Tigger

Dodges Pucks
Community Leader
7,040
2,097
113
Is the patient's EtCO2 low because there is some sort of metabolic issue causing tachypnea or is the tachypnea from a respiratory etiology? If the patient does have some sort of metabolic acidosis, is the tachypnea a normal compensatory response?
 

DesertMedic66

Forum Troll
10,408
2,742
113
I would imagine your patient probably has some metabolic acidosis going on and is breathing fast to cause respiratory alkalosis (EtCO2 <35 is alkalotic) to offset it. If she is tolerating the CPAP well and has a SpO2 >93% I am not going to change much at all. CPAP helps with oxygenation much more than ventilation. BPAP helps with both oxygenation and ventilation.
 
OP
M

mrhunt

Forum Crew Member
88
11
8
the pt had MULTIPLE respiratory etiologys, Sending hospital stated pt was speaking in 3 to 4 word sentences at baseline and that was an improvement for her apparently. So yes the tachypnea was a normal compensatory response
 
OP
M

mrhunt

Forum Crew Member
88
11
8
Oops. I Knew <35 was alkalotic. My bad mixing them up. ..... *sheepish grin*
 

E tank

Caution: Paralyzing Agent
820
630
93
ETCO2 from a bipap set up wouldn't be as reliable as an ETT tube, so I wouldn't be too surprised at your readings. That said, she's in respiratory failure which in part means she isn't eliminating her CO2 where it would be detected by your monitor.

There could be a diffusion barrier defect caused by fluid or her pneumonia (atelectasis, bronchospasm, mucous plugs, etc) that is preventing her CO2 from leaving her blood and entering her lungs to be exhaled. Probably a contributor to your low ETCO2 as well.

So you're right, I'd expect that someone like this would have a respiratory acidosis with her attendant tachypnea...a rising PaCO2 with a low ETC02.


...all this assuming her blood pressure isn't in the tank....
 
Last edited:

VFlutter

Flight Nurse
3,550
1,063
113
Or done something differently to try to lower her resp rate and hopefully her acidotic nature? Or would increasing the cpap rate of even DONE anything except possibly tank her bp? guess im just looking for some reassurance. Lol.
How did you get an ETC02? Probe between the mask and tubing or a ETC02 NC under the mask? I have found the latter to be more reliable depending on vented vs non-vented mask and leak.

Would lowering her RR be helpful for her acidosis?

Unfortunately only so much you can do with a pneumatic CPAP. A transport Ventilator with Bi-Level would have probably been ideal.

Rate of CPAP? Did you have a baseline respiratory rate on? What would maxing out PEEP have done for her ETC02 and RR?
 
OP
M

mrhunt

Forum Crew Member
88
11
8
So i just used the Intubation style ETC02 monitor which fits nicely into our type of cpap and doesnt interfere with the mask seal at all. We dont have ventilators on our units so thats not an option. Also her bp was perfectly fine the whole transport. Lowest it got was 110 systolic and was typically in 130's.
 
OP
M

mrhunt

Forum Crew Member
88
11
8
Cpap was at around 7 to 8 mm/h20 which was what the sending facility had it at as well. She maintained fine on that and i didnt want to max it out and risk dumping her pressure or something just to have a 99% Sp02 or something dumb.

She had nearly every resp issue there was without throwing in asthma or copd as well....So there was alot working against her.
 

VFlutter

Flight Nurse
3,550
1,063
113
When talking about NPPV it is important to be specific. The first sentence says in the ER the patient was placed on BiPAP at 7, which is probably the EPAP. Were they on CPAP the whole time or started on BiPAP in the ER then transported on CPAP?

Did they get an ABG?

There is a lot working against her but also a lot of potential interventions to improve the situation if you have the right treatment path
 
OP
M

mrhunt

Forum Crew Member
88
11
8
They were on bipap in sending hospital. Im honestly Not sure what Epap is.

Sending facility didnt specify an Abg. Receiving hospital did one but i dont have info on that result.
 

DesertMedic66

Forum Troll
10,408
2,742
113
They were on bipap in sending hospital. Im honestly Not sure what Epap is.

Sending facility didnt specify an Abg. Receiving hospital did one but i dont have info on that result.
BiPAP is made up of 2 components, IPAP and EPAP. IPAP is the inspiratory pressure the patient receives when they take a breath in. EPAP is the continuous pressure the patient gets, which is PEEP.
 

Remi

Forum Deputy Chief
Premium Member
3,920
2,560
113
learn something everyday! I know PEEP, Just never heard it called EPAP....
The two really aren't synonymous. At least they never used to be, but folks are starting to use them interchangeably.

EPAP was originally a proprietary term used to described the airway pressure during the expiratory phase of "Bi-Level Ventilation", which was a proprietary mode found on specific ventilators made by a specific company (can't recall at the moment which one - the Maquet Servo-i? Not sure).

Since then, bi-level ventilatory modes have become much more common and some people refer to expiratory pressure as EPAP.
 

Akulahawk

EMT-P/ED RN
Community Leader
4,378
847
113
she maintained find at the rate of cpap she was on and checked her frequently, all vitals maintained and she has no complaints. Even though she's tachypnic theres no accessory muscle use and she even starts sleeping near end of transport.
I'd expect that someone like this would have a respiratory acidosis with her attendant tachypnea...a rising PaCO2 with a low ETC02.
When I read the initial post, I saw something that made me think of a rising PaCO2... This patient is on CPAP during transport. As stated above, it improves oxygenation but doesn't help as much as BiPAP does with ventilation. I'm sure her SpO2 was just fine during transport but I suspect her CO2 level was climbing and was probably starting to make her somnolent. If getting her back on BiPAP upon arrival at the destination didn't turn her back around...
 

hometownmedic5

Forum Asst. Chief
717
570
93
Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.
 

DesertMedic66

Forum Troll
10,408
2,742
113
Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.
Pulmodyne offers CPAPs that have a treaded fitting that connects to threaded ports on portable tanks and ambulance regulators.
 

VFlutter

Flight Nurse
3,550
1,063
113


You do the best with what you have however I think this patient would have been better served being transferred with an actual ventilator.
 
Top