02 in COPD Patients?

[Timmy]

I recently had a patient will the following:

-59 Year old Male

-AMI

-ST elevation/Tacy Sinus

-SOB

-cyanosed around the lips

-hx of pleural mesothelioma

-?? Thoracic METS

-COPD (C02 Retainer)

-Emphysema (smoking)

-Hypertensive

- 02 stats sitting on 72% @ 3Lt 02 nasal cannula

-Using accessory muscles.

-Chest sounds clear + +

-GSC 15

Basically, his screwed in the long term but was managing at home with ADLS and spending time with his family. His on an 02 concentrator at around 3Lt via nasal 27/7.

Is quiet short of breath most of the time but he needs to use accessory muscles on excretion.

My question: because his a COPD 02 retainer does he get more 02 than 3 Lts? There’s a lot of debate about this and I cant really find a clear answer.

[WolfmanHarris]

He's complaining of SOB right? Therefore his current concentration of oxygen isn't enough, so increase it. I'd be switching him to NRB and considering ventilation depending on the condition. Hypoxic drive is a concern, but not on the short term of patient contact EMS usually has.

Our provincial protocol is if the COPD patient has decreased LOC or AMS, severe respiratory distress or major/multiple trauma they get high concentration O2 and we are watching carefully for respiratory arrest.

If the patient is alert and anxious, in mild to moderate respiratory distress, can speak with minimal difficulty and is no more cyanosed than usual they get 24-28% O2 via nasal or 1-2lpm above usual home O2 levels. (if no improvement increase to high concentration)

If unsure, high concentration.

My text says that most COPD patients other than those with severe end stage disease can receive high concentration for up to 30min without adverse effects.

[rock_shoes]

Never deny O2 to a patient with clear signs of inadequate perfusion. This patients poor perfusion and SOB is of much greater concern than the outside chance that the high flow will cause respiratory depression. Low flow O2 for COPD patients is for those who are able to maintain adequate perfusion on low flow.

[Arizonaffcep]

My question: because his a COPD 02 retainer does he get more 02 than 3 Lts? There’s a lot of debate about this and I cant really find a clear answer.

To shut down the hypoxic drive takes a fairly long time, and really isn't a concern for prehospital providers. Can it happen? Yes...but unless your transport times are an hour+, you really shouldn't be running into this issue. Even if you do...intubate and bag.

[Timmy]

Thanks guys. We did end up bumping him to 8lts after much debate between the RNs, NP and LMO. The hospital I work at is very small hence he was bumped over to the RTC about 40mins away.

Since his trip in ED I’ve seen him on community nursing a few times as a hospital in the home palliative care patient. The AMI knocked him around a bit, his deteriorated some what, we think the METS are advancing but he has a LOMTO and doesn’t want to be diagnosed. It’s just a waiting game at the moment, pain control, symptom management and spending time with family and freinds.

[CBEMT]

02 in COPD Patients?

Yes. Next question?

Look, the worst COPDer I ever had was gray and damn near unconscious when we found her. Why? Her discharge paperwork from the hospital listen oxygen as an ALLERGY. The MD note stated that the reason she'd been sent in in the first place (unresponsiveness) was most likely due to be being left on O2 all night. So therefore the nursing home was heretofore ordered to not administer oxygen unless the patient could be monitored (common room etc).

SNF RN: "Her orders are for no oxygen."

Partner: "Yeah... that ends right now."

We started her out on 5lpm, partner had her weaned to 1lpm by the end of the 10-minute transport. By the time I pulled the stretcher out she was smiling and waving at me.

ED RN: "Any allergies?"

Me/partner: "Oxygen!"

ED RN: *priceless facial expression*

Me: "Don't look at me, your doctor wrote it!"

[Arizonaffcep]

Yes. Next question?

Look, the worst COPDer I ever had was gray and damn near unconscious when we found her. Why? Her discharge paperwork from the hospital listen oxygen as an ALLERGY.

Wow...that's better than the order I saw the other day for "CPR PRN."

[WolfmanHarris]

Wow that's like a reverse DNR.

[CAPMEDIC-EMWFR]

Wow, lol-ing at the O2 allergy. Now as far as the risk of respiratory depression with elevated O2 levels and hypoxic drive, what is the reason it can take 1 or more hours for that to take effect? Does it take that long for the ABGs to shift, is hypoxic drive slower to react to a change in ABGs (I personally think that is less likely, as it wouldn't be much of a respiratory drive without the ability to compensate for minute by minute changes like that), or is it something else? Or is it something very basic that I am going to slap myself in the face for not thinking about?

[VentMedic]

his family. His on an 02 concentrator at around 3Lt via nasal 27/7.

Is quiet short of breath most of the time but he needs to use accessory muscles on excretion.

My question: because his a COPD 02 retainer does he get more 02 than 3 Lts? There’s a lot of debate about this and I cant really find a clear answer.

An O2 concentrator, depending on make, model and maintenance, may not deliver anywhere near what a flow meter from an O2 tank delivers.

People get hung up on memorizing numbers for O2 delivered for "2 L/min NC" as it to be 28%. That number all depends on the minute volume of the patient. The number 28% is derived from a normal Joe Public breathing at a text book normal rate with a normal tidal volume in no respiratory distress. That is why I find the arguments of "2 or 4 L/min?" so ridiculous in that it shows little understanding of respiratory basics 101 and the equipment.

If a person says they can't breathe...give O2.

If they are blue, give O2.

If the SpO2 is low and you have every reason to believe it is in the ball park give O2.

If they are symptomatic with any signs of increased work of breathing, give O2.

If they are talking to you, they are still ventilating.

The BVM is your friend because if you "knock out their drive" with an extra liter of O2 in the few minutes you are with them, they were going down anyway.

You must take into consideration V/Q mismatching and shunting along with all of the disease processes that are causing a low SpO2 and difficulty breathing. The dx of COPD always skew some from doing an adequate assessment to treat the real problem(s).

A dx of COPD does not mean they are even a CO2 retainer. Less than 5% are. I see that everyday. I may draw 20 ABGs on 20 different "COPD" pts on any given day and see only one that fits the criteria of being a CO2 retainer.

They hypoxic drive has been debated for almost 30 years. Do a literature search or check out the name Jeff Whitnack who has done the search for you on his website.

The only patient for which O2 is used with extreme caution or not used at all (16% may even be used instead) is on an infant with a ductal dependent cardiac anomaly or CHD.