NRB & COPD your input please

[crb613]

I had a pt come in the other night severe resp. distress. We had little hx on the pt at the time except COPDer, and he could not talk (working to breathe). He was diaphoretic, rr 30+ guppy breathing, tachy,lethargic. Sats with good wave form 70%. Lungs sounded like crap. EMS had him on 4l nc.

RT was there took him off oxygen to get room air ABG, then back on 4l. During this sats dropping rapidly down to 60% and they were not coming up....rr increasing along with hr.

I wanted to put him on a NRB, another nurse said no he's a retainer.....waht are you thinking??? I was a little upset with this.....my response was so we let him code & then do something? My thinking if you need oxygen you need oxygen.... treat what you see in front of you. His ABG ph 7.2, PCO2 60, HCO3 30.

Just wondering how you all would respond to a pt like this?

btw...I posted this in pulmonary also to gain more feedback

[GreyGull]

We use BiPap on a lot of our COPDers. It's a great tool. We don't need RT to initiate it though. We have the freedom to do so as long as an MD assesses pt soon after initiation.

What BiPAP machine are you using?

We use the Respironics (Philips) Vision or V60 if there is a good chance the patient won't be intubated. If there is doubt, BiPAP is done with a regular ICU type ventilator. All require a bit of time for training and experience to master which not all ED managers are eager to budget for inservicing all the RNs.

We have the freedom to do so as long as an MD assesses pt soon after initiation.

Depending on the machine you are using, it might be wiser to have a physician assess before a nurse initiates BiPAP. Just like some of the complications we are seeing from just the field devices, a hospital machine can cause a lot of damage in a short time. Unfortunately some may have to learn the hard way before they realize the warnings presented in a good BiPAP lecture/training session can become a reality.

I would agree that in extreme lethargy it MAY not be wise to use it, but I've seen BiPap work wonder in lethargic COPD pts. In fact, enough to raise their LOC.

Yes it can but tying up an RN and/or RRT to do 1:1 may not always be practical. If we do attempt this, the patient is moved very quickly to ICU with an RRT or RN always close by the patient. We also don't wait too long to see if the patient will wake up before a secure airway is established.

[DixieJeanne]

I guess I should clarify that I work in a rural facility at the moment so our docs are not always available immediately (one doc covers the entire hospital). Therefore we have to initiate this without them assessing first frequently. We also are ER/ICU/Everything nurses so we do it all, therefore training happens because it has to and worrying about staffing isn't an issue because we do it all (unfortunately..... or fortunately, depending on how you look at it I guess).

We use a Respironics also.

But like I said in another thread.....rural nurses are jacks of all trades and masters of none....... so it is what it is at this facility anyway.

I do agree with all your points though. And yes, we would never leave them on a BiPap for an extended period of time waiting for them to wake up. It can be a great rapid fix though in some patients, and if it's not working then progress to an advanced airway rapidly.

[badphish]

In 28 yrs of dealing with COPD in ems the ER. Etc. I've seen maybe three people that lost their drive on oxygen.

Me I'm thinking bipap or cpap. Worst case he gets intubated.

[badphish]

On another thought. Medics brought him in on NC. With sats in 70s. *** ???

At the least I would have them on CPAP. Old days. Bagging them.

[GreyGull]

On another thought. Medics brought him in on NC. With sats in 70s. *** ???

Since 4 L NC is the usual EMS treatment regardless of SpO2 or the patient's symptoms, I didn't give that part much thought. I did however find fault with an RT, who should know better, pulling the patient off O2 to do a "RA ABG".

Apparently there is an article circulating around EMS that O2 is bad. But, they don't take into consideration most studies were done in the ICUs after 24 - 48 hours of high FiO2 and high PaO2 or that every patient situation can be different. I found this out one night when a couple of Paramedics went totally bonkers in the ED when the patient was switched from their 4 L NC, which must be a magic number, to a 15 liter Oxymask until he could be taken to the ICU because the lactate was 7 mmol/l with bilateral pulmonary infiltrates, was febrile and his BP was being supported by pressors.

[GilaRRT]

Since 4 L NC is the usual EMS treatment regardless of SpO2 or the patient's symptoms, I didn't give that part much thought.

You have good literature that says this is the usual EMS treatment regardless of pulse oximetry or symptoms or is this anecdotal?

[GreyGull]

You have good literature that says this is the usual EMS treatment regardless of pulse oximetry or symptoms or is this anecdotal?

I could probably get you some local EMS protocols that call for 4 L NC or the NRBM if that is what you want.

I work and have worked in EDs across the country. These O2 situations and EMS have been from my experience especially recently. Now it seems like they believe the patient needs no O2 at all or very little regardless of the SpO2 or how hard the patient is breathing because some article stated it was harmful. I'll ask some of the Paramedics later if they have a copy of this article or know where to look for it.

Do not take any of my remarks as supporting no O2 on a patient who needs it regardless of what the SpO2 says. I did not state that I agreed with EMS and the way they choose to transport their patients which may be totally based on their protocols that they must follow. I just never gave it much thought in the original post. It is what happened after arrival to the hospital that I was commenting on. But, if a patient is breathing rapidly to maintain an acceptable SpO2, they probably need oxygen. I believe O2 is appropriate for many situations especially in the short term and with holding oxygen can be just as dangerous in the short term as too much oxygen is in the long term.

[GilaRRT]

You made a rather bold statement that appeared to generalise EMS. If this is becoming a general trend and is being reported in the literature, I would love to see the references. This has not been my experience (n=1) where I live, but I can not comment on the country as a whole.

[GreyGull]

you made a rather bold statement that appeared to generalise ems. if this is becoming a general trend and is being reported in the literature, i would love to see the references. this has not been my experience (n=1) where i live, but i can not comment on the country as a whole.

i don't believe that was a bold statement. i stated two paramedics went bonkers. two paramedics do not represent a whole country.

do you work in the ed? has it been recent experience? i just noticed this over the past couple of months when o2 must have been the hot discussion in ems. how much oxygen do the emts and paramedics bring the patients in on? are you aware ambulances do not even have pulse oximeters?

jems seems to be one source of information with blogs and forums that discuss articles on the dangers of oxygen.

there appears to be some strong titles in that magazine and forum about oxygen.

http://www.jems.com/

is oxygen hurting the patients we intubate?

change in how paramedics use oxygen could reduce deaths in copd patients

myocardial infarction and oxygen administration: a bad practice?

in the hospital setting we are able to evaluate a patient with many different diagnostic tools and it is understood that ems does not have the same luxury. my point is that not all patients fall into the same category just because of a couple of articles. there is so much more factors that must be considered which is not always possible in the field.

i want to emphasize again i do not advocate with holding oxygen from patients who need it for various reasons and i don't know if that is what your reason is for wanting more information pro no oxygen. i just don't believe it is a wise idea in the prehospital phase of patient care to with hold oxygen from a patient who may need it until other treatment is initiated. please offer your reasons if you believe otherwise.

you could also talk to the paramedics in your area and see if they are familiar with any of the articles or if they have had this discussion in recent (within the past two months) acls classes to see if the use of oxygen is falling out of favor or that the use of nrbm is being scrutinized. as i stated before in my post that you took very critically, 4 l nc is a common o2 setting since the nrbm may be too much but in the situation i mentioned about the two paramedics, a higher fio2 was needed but not understood by the two paramedics who thought the ed staff was stupid for putting the patient on that much o2 because of some article that said it was harmful. however, i will say again two paramedics do not make up an entire country but others have also mentioned articles about o2 being harmful. this is also discussed with the articles, forums or whatever you want to call jems. it may or may not be the best source for information but apparently it is still well known.

[GilaRRT]

No you stated 4LPM is the usual EMS treatment, nothing was written about a specific or isolated case involving two paramedics. "Since 4 L NC is the usual EMS treatment regardless of SpO2 or the patient's symptoms, I didn't give that part much thought." The statement was pretty general IMHO. My experience is recent, both within and outside of the hospital. The EMS services in my area of the sand box have pulse oximetry as a part of their standard load out. I cannot generalise this case, but it is certainly the case where I live and work.

I do not think you have ever advocated with holding oxygen. In fact, I agree with your points.

[GreyGull]

No you stated 4LPM is the usual EMS treatment, nothing was written about a specific or isolated case involving two paramedics. "Since 4 L NC is the usual EMS treatment regardless of SpO2 or the patient's symptoms, I didn't give that part much thought." The statement was pretty general IMHO.

It could be taken at a very general statement but there are Paramedics who feel they must put the patient on 4 L NC just to have some oxygen on but some are now reluctant to go with a NRBM even though it might be warranted. EMT-Bs usually will go with a NRBM especially since many of them do not have pulse oximeters. The one thing you should know about EMS is that it varies all over the country with many different titles and protocol differences. A lot of areas do not even have ALS, some have inbetween services which are a little more than an EMT or not quite a Paramedic and some Paramedics have very strict protocols they must follow.

But, if you also look at some of the different ACS protocols in the hospital, 4 L NC also seems to be fairly common.

So I do not give much thought to seeing 4 L NC by EMS in a post which is why I didn't bother to comment on it. I do find fault with an RT who takes a patient with an extremely low SpO2 off oxygen and the RN or RNs go along with it.

[GilaRRT]

I do find fault with an RT who takes a patient with an extremely low SpO2 off oxygen and the RN or RNs go along with it.

Agree. It is not particularly difficult to calculate the PAO2 and appreciate a large A-a with a patient on oxygen and/or do a PF ratio. Clearly, if somebody has a significant shunt, getting a room air gas will not somehow make it easier to find as it should be fairly obvious and depriving oxygen when needed is akin to negligence IMHO.