Re: Oxygen and COPD

April 5, 2004

In a message dated 4/4/2004 5:39:18 PM Eastern Standard Time,

nurse_tracy@... writes:

> Hi All, I'm a nurse (married to a paramedic) and a few years ago

> when we went to confrence we sat through a seminar about the use of

> oxygen in COPD patients. I'll admit I didn't pay great attention at

> the time and now find myself in a situation were I need the

> information I missed. Does anyone remember that lecture.. or what it

> said about high flow O2 in COPD? Any help would be

> appriciated.

Howdy, :

This is an age-old question in emergency care. I would say there are a

couple of things, to simplify it, to remember when giving oxygen to a COPD-er:

1. Most COPD deaths are from hypoxia. They need O2. In one really cool

study done in the VA hospital system, they found that about 70% of the COPD

deaths were from hypoxia. The REALLY cool thing about that study was that they

also concluded that a significant portion of those where " iatrogenic " .....caused

by the intentional withholding of O2 by the health care personnel. (oops!)

For most COPD-ers, the nasal cannula will be fine. They are VERY comfortable

with the nasal cannula (n.c.)...to the point that they have pet names for

them ( " This is Bubba...my nasal cannula and my friend " ). There is an advantage

to that comfort level that we can all benefit from.

If you can't get their SpO2 up to 90-ish with a n.c., then go to an NRB. If

that doesn't work, use the BVM.

2. COPD patients also suffer from hypercarbia....and can die of that

independent of their oxygenation status. O2 and CO2 are both interrelated and

separate. For example, giving a COPD-er lots of O2 will NOT improve the

hypercarbia. You have to recognize and fix hypercarbia independent of hypoxia.

The only

way to fix high CO2 is through ventilation.....either getting the patient to

breath better (coaching - " take big breaths " ....very intensive and

difficult....but most effective), or by using the BVM (careful about those

pressures,

tho).

3. Lots of oxygen CAN be harmful to a COPD-er. But NOT by " knocking out

their respiratory drive " . There are NO verifiable reports of that EVER actually

happening in the out-of-hospital environment. COPD-ers will occasionally quit

breathing after you start giving them O2, but that ain't " hypoxic

drive " .....it's exhaustion ( & a little bit of trust in you....now that you're at

their

side helping them).

How is O2 bad for them? Well, COPD-ers have a really hard time getting rid

of CO2. Too much CO2 will make them sick and even kill them, all by itself.

And when they are metabolizing O2, guess what they are producing as the

byproduct? Yup...that bad ol' CO2. And if they're using MORE o2, they're

producing

more CO2...that they can't get rid of. So the trick is to get their O2

levels up, while watching for hypercarbia and treating it ( " take big breaths "

and/or using BVM).

Hope that helps.

, BS, LP

Director

Pre-Hospital Services

and White Memorial Hospital

Temple, Texas

April 5, 2004

In a message dated 4/4/2004 5:39:18 PM Eastern Standard Time,

nurse_tracy@... writes:

> Hi All, I'm a nurse (married to a paramedic) and a few years ago

> when we went to confrence we sat through a seminar about the use of

> oxygen in COPD patients. I'll admit I didn't pay great attention at

> the time and now find myself in a situation were I need the

> information I missed. Does anyone remember that lecture.. or what it

> said about high flow O2 in COPD? Any help would be

> appriciated.

Howdy, :

This is an age-old question in emergency care. I would say there are a couple

of things, to simplify it, to remember when giving oxygen to a COPD-er:

1. Most COPD deaths are from hypoxia. They need O2. In one really cool study

done in the VA hospital system, they found that about 70% of the COPD deaths

were from hypoxia. The REALLY cool thing about that study was that they also

concluded that a significant portion of those where " iatrogenic " .....caused by

the intentional withholding of O2 by the health care personnel. (oops!)

For most COPD-ers, the nasal cannula will be fine. If you can't get their SpO2

up to 90-ish with an n.c., then go to an NRB. If that doesn't work, use the

BVM.

2. COPD patients also suffer from hypercarbia....and can die of that

independant of their oxygenation status. O2 and CO2 are both inter-related and

separate. For example, giving a COPD-er lots of O2 will NOT improve the

hypercarbia. You have to recognize and fix hypercarbia independant of hypoxia.

The only way to fix high CO2 is through ventilation.....either getting the

patient to breath better (coaching - " take big breaths " ....very intensive and

difficult....but very effective), or by using the BVM (careful about those

pressures, tho).

3. Lots of oxygen CAN be harmful to a COPD-er. But NOT by " knocking out their

respiratory drive. There are NO verifiable reports of that EVER actually

happening in the out-of-hospital environment. COPD-ers will occassionally quit

breathing after you start giving them O2, but that ain't " hypoxic

drive " .....it's exhaustion( & a little bit of trust in you).

How is O2 bad for them? Well, COPD-ers have a really hard time getting rid of

CO2. Too much CO2 will make them sick and even kill them, all by itself. And

when they are using O2, guess what they are producing as the byproduct? And if

they're using MORE o2, they're producing more CO2...that they can't get rid of.

So the trick is to get their O2 levels up, while watching for hypercarbia and

treating it ( " take big breaths " and/or using BVM)

Hope that helps.

, BS, LP

Director

Pre-Hospital Services

and White Memorial Hospital

Temple, Texas

April 5, 2004

NEVER withhold EMERGENCY O2 from any patient that needs it. EMERGENCY

O2 and THERAPUTIC O2 are different things. In the emergent clinical

setting, O2 is a necessity. Any issues with COPD patients are factors

in the long term theraputic clinical setting, but don't factor into the

short-term EMS outlook. In fact, the FDA clearly differentiates between

CLINICAL and THERAPUTIC Oxygen administration. For example, EMERGENCY

O2 administration is a class we teach to laypersons. It doesn't even

require a prescription.

=Steve , EMT-LP=

Regional Instructor Trainer

American Safety & Health Institute

Brown wrote:

>Hi All, I'm a nurse (married to a paramedic) and a few years ago

>when we went to confrence we sat through a seminar about the use of

>oxygen in COPD patients. I'll admit I didn't pay great attention at

>the time and now find myself in a situation were I need the

>information I missed. Does anyone remember that lecture.. or what it

>said about high flow O2 in COPD? Any help would be appriciated.

>Thanks.

>

April 6, 2004

The short term effects of high flow O2 to COPD'ers has long been an issue

for us in the pre hospital arena, while physicians and nurses alike (certain

present company excluded) deal almost strictly with long term issues, we in

the field tend to deal with 'what do they need right now?'.

Patients who are at risk of repiratory failure secondary to the loss of the

hypoxic drive, are at risk after what could amount to a few hours of high

flow O2, and quite honestly, if it's an emergency, and it takes you longer

than a couple of hours to get to the ER, you should consider flying, or

driving faster....

An O2 sat of 84% for a long term COPD'er, may very well be normal for them.

The benchmarks that you learned in school, no matter the level of

certification, are guidelines to follow, but they are not written in stone.

Not all patients who sat at less than 90% are definitively losing brain

cells. In the case of the patient you present, I am curious as to if the O2

helped the altered LOC any? Could you have increased the oxygen

progessively? Assessing the patient each time? What other history did they

have, yada yada yada.

I certainly won't armchair quarterback your call, but what was the outcome

of it all?

Just remember that not all patients are 'textbook'. what's normal for one,

may be abnormal for the next, and neither will be what you expected...

Reagards,

'Tater Salad' Hatfield

" I had the right to remain silent, but I did not have the ability. "

Don't miss EMStock 2004!!!

May 21-23 in booming Midlothian, Texas!!!!

www.EMStock.com

> Yesterday I responded to a call with a COPD patient presenting with

> and altered LOC. When we put the o2 sat on the pt it read 84%. So we

> placed the pt on high flow o2. Which then increased the pts o2 sat

> to 100%. When we got to the ER the nurse immediatly yanked the NRB

> off the pt. When my partner asked the Dr. about this, she replied

> that a NC on 5 or 6 whould be better for the patient. I have been

> taught that If a pts o2 sat is below 95% they are slightly hypoxic,

> and below 90% they are hypoxic. So as I have been taught an o2 sat of

> 84% brain cells are dying. So I think that high flow o2 is a nessity

> to the patient. Why would the Nurse and Dr. feel this way.

April 6, 2004

Because that's the way they were trained.

You will continue to have this fight as long as you are in EMS, along with

some other ones. Very few ER nurse or doctors realize that you practice

medicine from a different point of view than they do, just as the brand of

medicine they practice is different from Med Surg or ICU. Sometimes, you

just have to put your head down and keep truckin' in spite of the nasty

looks and snide comments. I brought a patient in from an MVA once, in really

bad shape. It was raining cats and dogs, and the car was sideays in a ditch.

It took us 20 minutes to get the car cut open enough to get the pt. out, and

during that time I stuck a 16 g in the one arm I could get to. We drag-assed

into the ER covered in mud and soaked to the bone, and the nurse says

" Christ, can't you people hit anything except an AC? " Different kinds of

medicine. ER nurse do theirs in a different setting, with different

priorities, and the 2 worlds do not always mesh. Thus shall it ever be. Your

protocol says high flow O2, you give high flow O2.

magnetass sends

Oxygen and COPD