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I'm not sure if this was ever discussed....
Does any of your protocols advise against giving oxygen to COPD PT's? I have heard a lot of rumors about it causing the pt's to go into resp arrest and other say give o2 to anyone with difficulty breathing.
I was always taught to "Never withhold oxygen from anyone who needs it."
What's your take on this?
Paramedic503
10-31-2003, 02:59
Rob,
I have lost count how many times I've been jumped for having a COPD patient on a Non-rebreather, the ER staff goes totally insane. :roll:
I was taught the same as you, do not withold oxygen to a patient that needs it, period.
With that said, it is an understanding that a COPD that gets placed on a non-rebreather will not suffer any effects from the oxygen due to the short transport times we generally have in ems. Normally it takes 2-3 hours of the patient being on the non-rebreather (for instance) for their hypoxic drive to be kicked out. As a Paramedic, I treat each COPD patient aggressively to try to prevent them from buying a tube. COPD patients are extremely difficult to wean off a ventilator....
Our medical director once told me, "If they get excited about your high flow oxygen and start screaming about it, tell the staff to produce the research contraindicating it, because alot of us would like to see it."
Just my 2 cents... :)
Yeah, that's why I posted...We had a COPD pt and put a NRB on her. Once in the ER, the RN's where all over us. I'm just wondering if the RN's are taught different from EMT's in the COPD + o2 setting. Like you, we have very short transport times so us giving o2 won't hurt anything. But we still never hear the end of it.
But I will still practice the way I was trained. It may be ignorant but it's better than sitting in a court room explaining why I withheld o2 from a pt. :x
As Mike said, COPD'ers have to be on High-Flow oxygen for long periods of time before their system goes so far out of whack they go into Respiratory Failure. The 15 minutes we spend with them is not going to do anything with these patients.
A little Hx of COPD for those that are not sure what it is. COPD is Chronic Obstructive Pulmonary Disease. Then COPD acronym is given to a group of people who suffer from airflow blockages and breathing related problems. COPD is more commonly known as "The Smoker's Disease". However, COPD can include emphysema, chronic bronchitis, and in some cases asthma. People with COPD often have "barrel chests" and are on home oxygen 24/7 and usually have numerous inhalers. Most "normal" people run on an oxygen-rich body system. The body is use to having the oxygen in the body. However, with the COPD system, the patient's body has been deprived of oxygen for so long, the body has kind of adapted to their acidic pH balances. Their acidic, because there is fluid and "gunk" caught between the capillaries and the aveolar sacs in the lung tissue...In healthy people the capillaries and aveolar sacs are right next to each other to allow for free O2 and CO2 exchange through the Aveolar membrane. In patient with Resp. Diseases, the capillaries are pushed away from the aveolar membrane by fluids and "gunk". So, the 02 and CO2 have to travel farther to get the exchange, but much of the exchange in lost in the interrestial (sp??) space where the fluid and "gunk" are now. This happens in Pneumonia and CHF too, the Pulm. Edema pushes the capillaries away from the aveolar sacs, which does not allow the "normal" exchanges of O2 and CO2, so that is why they are always oxygen deprived. Because the normal gas exchange is not happening, so the hemoglobin in the RBC's are not attached to the full amounts oxygen that they normally are.
So, the moral of the story. Give the patients high-flow oxygen if you think they need it. If you get yelled at by the hospital staff, just smile and walk out of the hospital knowing that you know a little more about prehospital care for the COPD'er than that overpaid vomit catcher.
msharpe1047
10-31-2003, 11:18
Rob,
As the others have said don't with hold the O2 from patients that need it. I think the nurses are looking at the long term effects of O2 on COPD patients. Remember that we usually only see pts for a short time and that the hospital is looking at long term care. They are very different settings and most nurses have no clue as to what goes on outside the hospitals that they work in. :?
hageremtp
10-31-2003, 11:50
One thing to point out that I think needs to be said, watch your patient! If it looks like their respirations are decreasing, then turn down or off the O2. I was once told by a doctor that if you have a long transport time and you need to give a COPDer O2, do it. If they start to lose their drive to breathe, then have 'em breath into a sack (brown paper one) to retain some CO2 and get that respiratory drive back in there. I have never done this, so I dont know what to say about it!!!
Romeo7111
10-31-2003, 15:31
If they're on a NRB, just cut the 02 supply - it will work just like a paper bag to increase the C02. (Works real well for the hyperventilating pt, too. They think they're having trouble breathing - tell 'em your giving them 02 to help, but only turn it to 1 or 2 lpm... everyone is happy)
We've been down the same road with COPD.. I've been told that if they need 02, you give it to them. What alternative is there?
Jim
OARMedic
10-31-2003, 16:33
Our protocols said to give O2 in whatever manner, to maintain SpO2 levels in the normal range of 95-99%, OR what is "normal" for that patient. This gives up leeway to use whatever will work. If they stop breathing, bag 'em.
mcaldwell
10-31-2003, 20:08
Our protocols also include providing o2 at reduced rates (1-2 lpm), unless there is trauma involved, then 10 lpm. If the patient on low flow o2 continues to show signs of Dyspnea or deteriorates, we can increase the flow by 1 lpm every minute to a max of 5 lpm.
If Carbon Dioxide Narcosis develops, we are not supposed to stop o2 therapy completely either, but slowly scale it back and prepare to bag them if necessary.
I have only had to treat 1 elderly lady who had been recently diagnosed with COPD. She hadn't bothered to get any o2 gear before her trip, and when she got to the mountains, she found she needed some daily therapy for the week she was here (higher altitude). After checking with our MD, we gave her a bottle and nasal canula to use while she was here, and I had to visit her each day for a simple exam.
She was fine for the week with 10-20 minutes of self administered low flow o2 a few times each day as she needed it.
emmit233
11-01-2003, 01:42
While sitting around staring at each other last night I brought this topic up to my ER cohorts. We all agreed to do as most EMS'ers are taught, give the O2. Our resp. therapist said to just keep an eye out for decreased resp.s and the ween the pt. down or turn the O2 off but keep the NRB in place for a little bit. It seems that most of us are in agreement here.
The only disagreement from our resp. therapist... she said that some COPD pt.s drive does go more quickly than others and even a short transport with high flow O2 will knock them out. She also said that once we knock out their drive and tube them it is hard as heck to gt a COPD pt. off of the vent. She still said to give the O2 and watch for the side effects very closely.
Since I am both a Paramedic and Respiratory Therapist I love to hear the mythology surrounding COPD. There is a lot of disinformation that both EMS and hospital staff (especially RN's) have regarding this chronic disease.
Firstly, only 10% of this patient population functions on hypoxic drive (therefore 90% of the COPD population will not be affected by supplemental oxygen therapy). Of the 10% of COPD patients that function on hypoxic drive approximately 1% will have a significant sensitivity of their drive that allows respiratory failure in a short time course.
ABMedic
Certainly a concern can be raised regarding inappropriate oxygen therapy in the very small fraction of COPD patient's with equisitive hypoxic drive.
Guidelines that have been published (ASRT) and others dictate that maintaining a SpO2 of 90 - 92% is adequate for COPD patients that are not in extremis; whereas in COPD patients that are in extremis (aka respiratory failure, requiring manual or mechanical ventilation that a SpO2 > 95% should be targeted in the immediate resuscitation phase.
Oxygen therapy like other drug therapy should be targeted at the appropriate dose and route of administration. Clinical evaluation and consideration of their clinical presentation, in conjunction with their SpO2 should guide therapy. In the event that a COPD patient experienced a medical misadventure (commonly referred to as an iatrogenic cause) for their respiratory failure/arrest (and not due to an underlying acute exacerbation of their COPD) - then weaning in the short term is not problematic. We can often extubate in the first few hours without the complications associated with more prolonged ventilation.
Avoidance is still desired, since manual or mechanical ventilation can induce barotrauma.
ABMedic
Don't you hate getting toned out in a middle of a post!
As for withholding oxygen therapy for COPD patients - the answer has to be a rationale one - specifically if they are experiencing an acute exacerbation of their chronic failure then they require supplementary oxygen therapy - the key question is the degree of their distress?
For patients with min to moderate increase in their respiratory distress or associated symptoms, chest pain, etc - then titrating their oxygen flowrate to meet their oxygen demands might mean only increasing their nasal cannula flowrates a couple of liters, and then re-evaluate their condition. Concurrent with this intervention, is treating the underlying cause of their distress - ie bronchodilators in the prehospital environment.
For patients with severe distress, a NRBM at highflow rates perhaps is the interventional step of choice. In severe cases where acute respiratory failure/arrest is imminent, then use of BiBAP/CPAP and or intubation with manual/mechanical ventilation may be the intervention of reluctant choice. Ultimately the patients presenting symptomology decides the degree of intervention.
I don't agree that every patient requires high flow oxygen therapy with a NRBM, unfortunately some individuals clinical practice is not tailored to the individual patient but rather to a shotgun approach, where everyone gets the same treatment or intervention without appreciation for the potential benefits versus risk. Although the risk of problematic weaning and subsequent extubation is not a significant risk in the short term, the risk of barotrauma (blowing a bleb and causing a pneumothorax), aspiration, and the effects of medications that might subsequently be used to capture the airway are real, and should be avoided if possible.
ABMedic
Don't you hate getting toned out in a middle of a post!
Oh sure, AB, you just wanted to get your post #'s up there....hehe :wink: :lol:
mcaldwell
11-02-2003, 02:23
Don't you hate getting toned out in a middle of a post!
Oh sure, AB, you just wanted to get your post #'s up there....hehe :wink: :lol:
C'mon, everybody gets to pad the first few to lose that horrible "Probie" banner. :wink: :lol:
You all make pretty good points. I agree that on long transport times o2 should be cut and no short tp's, it wont hurt anything.
Thanks for all of the feedback! :D
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