Um, question on hyperventilation for ya

[bunkie]

Went to the ER tonight because I thought I had H1N1, still do.. flu swab was negative but they gave me treatment for it anyway. Got there in respiratory distress, they took me back when I was in failure. I had my book bag with me and this nurse guy (says he's a paramedic) asks me if they were my books. I said they were, my goal was so study in the ER waiting room expecting a long wait. I was back there in 5 minutes flat by passing dozens of angry looking people. So then he starts quizzing me! And ok, cool, can appreciate that, but not while I feel like crap and I'm completely unable to breathe. Anyway.. besides the point here. :glare: He asked me how you treat a hyperventilating pt. I gave him a blank look and he said put a NRB on them without O2.
Thats not what we're learning. So I was curious if he was right, and if any of you do this/have seen it done.

EDIT: Sorry, this was supposed to be in BLS! I blame my sickness.

 

[Shishkabob]

I doubt you were in respiratory failure... you wouldn't be holding a conversation about EMT school if you were



It's stupid to put someone on an NRB without air flowing, period. Good way to cause them to become hypercapnic. Eventually all they will be breathing is pure recycled CO2, screwing up their metabolism. Now, a simple face mask or a partial-rebreather (IE a NRB with atleast 1 valve removed) with atleast 2lpm O2 is a different story... but you'll still have people on both sides of the fence on it, same as with "breathing into a paper bag".




Best thing to do with someone that is strictly hyperventilating without any other underlying cause is to hook them up to capnography. Coach them on their breathing, and try to have them bring the capnography into normal range (35-45ish). Have them match your breathing. All else fails, they'll eventually pass out and return to normal breathing.

 

[medichopeful]

All else fails, they'll eventually pass out and return to normal breathing.

I think you want to avoid this at all costs h34r:

Anyways, yes, I was taught that you could put on a NRB with no oxygen, but only for a moment. But be VERY careful.

 

[medichopeful]

I doubt you were in respiratory failure... you wouldn't be holding a conversation about EMT school if you were

That reminds me. How would you do CPR on somebody with a sucking chest wound?

 

[Achromatic]

That reminds me. How would you do CPR on somebody with a sucking chest wound?

Very gently/carefully? (Tongue firmly in cheek)

Aside to Bunkie - are you guys getting H1N1 shots? Thurston is planning to roll them out over the next couple of months, I believe. We're not required to get them (nor regular flu vaccinations), but "strongly advised".

On the original question: we were taught that you most definitely do not use paper bags or unconnected NRMs. "Remove from source of anxiety, instruct patient to consciously slow rate of breathing and tidal volume, perhaps to keep mouth closed." Also, be aware that some MIs and pulmonary embolisms can present as hyperventilation.

Don't withhold O2, but consider the effect of oxygenation volumes and rates when determining flow.

 

[Akulahawk]

How do you treat hyperventilation? It depends on the cause...

I had a patient that intentionally hyperventilated herself... and once she'd blown off enough CO2, she got to the point where she started feeling paresthesias... and that freaked her out... and she kept hyperventilating... right into having carpal-pedal spasms.

Knowing how this episode developed... treatment was hideously easy. I coached her breathing. I made her count for 5 seconds before taking another breath. She forced herself to go from 40+/min to 12... and it worked.

 

[bunkie]

I wasn't talking to him, I was barely able to understand him and kept dazing off. They kept shaking me and b*tching at me to keep my eyes open and answer their questions with nods and hand gestures. So you're prob right, but I wasn't talking. Anything I "said" was with weak nods.

 

[bunkie]

Very gently/carefully? (Tongue firmly in cheek)

Aside to Bunkie - are you guys getting H1N1 shots? Thurston is planning to roll them out over the next couple of months, I believe. We're not required to get them (nor regular flu vaccinations), but "strongly advised".

On the original question: we were taught that you most definitely do not use paper bags or unconnected NRMs. "Remove from source of anxiety, instruct patient to consciously slow rate of breathing and tidal volume, perhaps to keep mouth closed." Also, be aware that some MIs and pulmonary embolisms can present as hyperventilation.

Don't withhold O2, but consider the effect of oxygenation volumes and rates when determining flow.

I dont know. I'm a military dependent so thats a whole other animal. Right now the military hospital is only giving them to the soldiers and their health care staff. I dont know if my county is doing them for civilians yet. I'm not an official "HCP" yet and the school sure isn't doing them.

 

[MSDeltaFlt]

Went to the ER tonight because I thought I had H1N1, still do.. flu swab was negative but they gave me treatment for it anyway. Got there in respiratory distress, they took me back when I was in failure. I had my book bag with me and this nurse guy (says he's a paramedic) asks me if they were my books. I said they were, my goal was so study in the ER waiting room expecting a long wait. I was back there in 5 minutes flat by passing dozens of angry looking people. So then he starts quizzing me! And ok, cool, can appreciate that, but not while I feel like crap and I'm completely unable to breathe. Anyway.. besides the point here. :glare: He asked me how you treat a hyperventilating pt. I gave him a blank look and he said put a NRB on them without O2.
Thats not what we're learning. So I was curious if he was right, and if any of you do this/have seen it done.

EDIT: Sorry, this was supposed to be in BLS! I blame my sickness.

Hyperventilation Syndrome is purely psychological. Enhancing calm and letting it pass is all that is needed.

 

[VentMedic]

Hyperventilation Syndrome is purely psychological. Enhancing calm and letting it pass is all that is needed.

Unlesss there is a physiological reason. There is a chronic disorder of HVS which may require medication.

Remember all tachypnea does NOT mean hyperventilation. In fact, quite the opposite is true. Pts with real medical illness can appear anxious. A thorough assessment must be done. And, for some patients, further testing might need to be done for HVS which may need to be done in a sleep lab. A trancutaneous monitor along with the sidestream ETCO2 is placed after a baseline ABG is obtained. Pt with chronic HVS may even hyperventilate in their sleep. Our lab logs at least a couple of these patients each month and often they are confirmed. It is a weird syndrome to witness as they are no more able to control it when sleeping than when they are awake.

BTW: No RN or Physician will ever place a patient's face into a NRBM without O2 or into a paper bag in our EDs without answering to the Chiefs of Medicine for whatever unit.

 

[Scout]

Anyone use compressed CO2?


The NRM would be an extension of the paper bag/cupped hand idea. All our NRB's have at least one valve flaper missing.

 

[VentMedic]

Anyone use compressed CO2?


The NRM would be an extension of the paper bag/cupped hand idea. All our NRB's have at least one valve flaper missing.

Do you carry an iSTAT to confirm an ABG and hyperventilation?

What if the patient has an undiagnosed head trauma or AV malformation or whatever neuro event? Do you know what increasing their CO2 level will do? If they are lucky it will only be permanent impairment. Not so lucky-death.

Paper and plastic bags over the face got thrashed in the 80s after way too may adverse side effects.

 

[mycrofft]

Once you have evaluated the pt...

...get them talking. Get them emotionally engaged and they will use that breath to talk, which is a wimpy valsalva (air against vocal cords) and spaces inhalations.
Another is to have them pull up the front of thier t shirt and breath throgh it. Other than being a distraction, it supplies them with lowered (not without) oxygen in warmed and somewhat moistened air. If they lose it, the shirt removes itself. But this is as or after you are evaluating.

Done this dozens of times and no ill effects.

 

[Scout]

I dotn carry anything. It was a question as i'm aware of some areas trialing CO2, We only advocate cupped hands and coaching.

We used to have hypovent bags but they are now gone.

 

[VentMedic]

I dotn carry anything. It was a question as i'm aware of some areas trialing CO2, We only advocate cupped hands and coaching.

We used to have hypovent bags but they are now gone.

The thing with using CO2 is that you would have to confirm "hyperventilation". Tachypnea does not always equal hyperventilation. In fact, it is a late sign for impending respiratory failure. If it is hyperventilation there are many, many medical reasons that must be ruled out such as lactate level, fever, neuro injuries or diseases, GI disturbances, DKA, etc.

Once the decision to administer CO2 is made, a buffering agent may need to be hung such as Tham or NaHCO3 and PaCO2 monitoring will have to be done frequently. Electrolytes should be done to check the anion gap and the Na as well as the glucose.

CO2 is nothing new but for "hyperventilation", by the time the evaluation/assessment is done, if it is an emotional cause, that usually has passed and you have not done the patient further harm by sticking their head in a paper or plastic bag if there is a true medical cause. People who are medically ill and/or feel they can not breathe can be very emotional. Also, an emotional event can trigger a neuro or cardiac even. Often women, the elderly or those with some neuropathy such as diabetics or HIV positive will not experience the classic symptoms but their body may still react as the pump is failing.

Now can you see why the paper bag went away as a method of treatment?

We do use CO2 for some neonatal cardiac patients and it was used over 30 years ago before modern/sophisticated ventilators for a few different reasons.

 

[Scout]

^^Thanks