NRB & COPD your input please

Specialties Emergency

Published

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

I`m an EMT/LPN worked over 5 years in a 911 ambulance. Our protocol was to give high flow, at least 15LPM via NRBM for everybody with respiratory distress, regardless COPD. You give 4 LPM via NC, and might be fired. Now I work in a nursing home as LPN. I had a COPD pt yesterday with resp. failure and 60% O2 sat, and put her on mask waiting for the ambulance. Other nurses came, and took her off, put her on NC with 4 LPM. I`m new in the facility, and tried to explain it to them, the low flow is for extended use, continuous o2 use, but when resp failure have to give high flow. Of course they did not think I was right. Whatever.... if I ever have to go to court for something like this, I`m covered. There is a BIG difference between long term care, and emergency care, and would be great if those nurses would realize that.

A common error; however, for a device to be considered high flow, it must meet or exceed the patient's inspiratory flow demand. A NRM at 15 litres per minute typically does not fall in the high flow category.

in EMS that considered high flow, you can look it up in any EMS protocol.

Wikipedia:

High flow oxygen delivery

In cases where the patient requires a flow of up to 100% oxygen, a number of devices are available, with the most common being the non-rebreather mask (or reservoir mask), which is similar to the partial rebreathing mask except it has a series of one-way valves preventing exhaled air from returning to the bag. There should be a minimum flow of 10 L/min. The delivered FIO2 of this system is 60-80%, depending on the oxygen flow and breathing pattern.[9][10] High flows of warmed and humidified air/oxygen blends can also be delivered via a nasal cannula, allowing the patient to continue to talk, eat and drink while still receiving the therapy.[11]

in ems that considered high flow, you can look it up in any ems protocol.

wikipedia:

high flow oxygen delivery

in cases where the patient requires a flow of up to 100% oxygen, a number of devices are available, with the most common being the non-rebreather mask (or reservoir mask), which is similar to the partial rebreathing mask except it has a series of one-way valves preventing exhaled air from returning to the bag. there should be a minimum flow of 10 l/min. the delivered fio2 of this system is 60-80%, depending on the oxygen flow and breathing pattern.[9][10] high flows of warmed and humidified air/oxygen blends can also be delivered via a nasal cannula, allowing the patient to continue to talk, eat and drink while still receiving the therapy.[11]

wikipedia?

i must agree with gilarrt about a non-rebreathing mask being a low flow device. in the hospital we utilize many other devices that are considered flow by the true defiinition by delivery of inspiratory flow demand.

there is also confusion between high flow and high fio2. a high flow device can deliver 24% oxygen at a high flow rate to meet demand.

here are more reliable references:

administration of oxygen

oxygen delivery devices

Specializes in ER/Trauma.

I too am not too fond of the "he's COPDer - can't give him O2!"

Too often people forget the whole "treat the patient not the numbers/history" aspect of it.

I agree - NRB is NOT high flow.

I'm also a huge fan of the vneturi mask and BiPAP. God I love BiPAP!

I'd stat page RT, and a doc, and put on the NRB. If he loses conciousness and respiratory drive I can still bag him.
One question I like asking is: what should you be more worried about - ventilation or perfusion?

cheers,

Specializes in PICU, NICU, L&D, Public Health, Hospice.

COPD patients should be on a palliative medicine service.

They will die from their disease unless some co-morbidity or similar kills them in an acute incident.

When they have acute failure they often have other other symptoms which exacerbate their distress, like anxiety and nausea.

I know that not all COPDers are hospice patients but they all deserve quality of life and good symptom management until they are hospice patients.

My mother and grandfather died from COPD and my sister in law is in the midst of it now. All of them were/are in the well practiced habit of trading their comfort today for some mysterious "need" tomorrow and this was/is encouraged by the primary care team. Sometimes COPDers "suffer" for extended periods of time before they die because of this. All of them need to have advanced directive discussions with their MDs before they are terminal, intubated, and in the ICU. Sadly, too few of them actually do have these discussions...

Specializes in Spinal Cord injuries, Emergency+EMS.
COPD patients should be on a palliative medicine service.

They will die from their disease unless some co-morbidity or similar kills them in an acute incident.

When they have acute failure they often have other other symptoms which exacerbate their distress, like anxiety and nausea.

I know that not all COPDers are hospice patients but they all deserve quality of life and good symptom management until they are hospice patients.

My mother and grandfather died from COPD and my sister in law is in the midst of it now. All of them were/are in the well practiced habit of trading their comfort today for some mysterious "need" tomorrow and this was/is encouraged by the primary care team. Sometimes COPDers "suffer" for extended periods of time before they die because of this. All of them need to have advanced directive discussions with their MDs before they are terminal, intubated, and in the ICU. Sadly, too few of them actually do have these discussions...

the question is why intubate someone who it is futile to intubate because you know you will not be able to wean them ...

forget 'death panels' and the other male bovine excrement talked by the reds under the hospital beds types - this is why it is extremely rare to intubate someone for an exacerbation of COPD in the UK ... type II respiratory failure responds very well to BiPAP .... good community management of people with advanced COPD is also essential - it;s one of the main target groups for Community matrons in the UK as COPD patients who cannot or will not control their disease process are one of if not the main cause of 'frequent flyers' into many EDS and on to many Acute Assessment units ...

Specializes in ER, telemetry.

I would place the patient on a NRB at 15L/min, page doctor, respiratory for bipap, call critical alert (which gets lab, xray and extra hands to the room), and get someone to bring crash cart with intubation supplies to have nearby, just in case.

The ABG would probably be done after the patient was hooked up to bipap.

the question is why intubate someone who it is futile to intubate because you know you will not be able to wean them ...

forget 'death panels' and the other male bovine excrement talked by the reds under the hospital beds types - this is why it is extremely rare to intubate someone for an exacerbation of COPD in the UK ... type II respiratory failure responds very well to BiPAP .... good community management of people with advanced COPD is also essential - it;s one of the main target groups for Community matrons in the UK as COPD patients who cannot or will not control their disease process are one of if not the main cause of 'frequent flyers' into many EDS and on to many Acute Assessment units ...

The ethics of medicine can become quite involved with many factors to consider. Do we always know that a COPD patient will not wean from a ventilator if they are intubated for an exacerbation with an underlying that might be easily treated or if the required surgery for an unrelated injury or illnes?. Much of their ability to wean will depend greatly on the skill and agressiveness of the practitioners managing their care including RN, RRTs, PTs and physcians.

Even before they get to the hospital it may depend on the Paramedics and right now CPAP is still not readily available on the ambulances in the US.

The other factors concerning maintenance is lack of insurance or inadequate insurance. Maintenance inhalers are expenive. In the US there is no longer a generic Albuterol inhaler available which could be given out at the community clinic for a couple of dollars. The brand names available for HFA standards can cost up to $65. The LABA and combo inhalers cost between $100 - $300 each and some require at least 2 inhalers of each per month. Combine that with the usual meds which accompany long term illnesses such as HTN and Diabetes, you have a very expensive plate of meds. My own hospital insurance plan does not cover the latest and greatest medications. The Physician can order whatever he or she wants but the insurance will make substitutions. Since insurance would be an issue, very few would get to see a Pulmonologist. They would be dependent on the luck of draw for the expertise of the physician at the clinic or ED. Most will just offer something for a quick fix or what happens to be on the ED formulary without any maintenance plan. An ED physician is in no way the best provider for the care of any long term illness. But, the uninsured may have limited options and with the community based clinics closing, there are very few options.

These patients are also still incontrol of their own decisions regardless of advanced directives and those who know extreme shortness of breath will also have a difficult time believing they can be made comfortable to have a peaceful end. Unfortunately in some situations they are correct and unless there are excellent pallative care programs and practitioners available, the COPD patient will die a slow and brutal death in a hospital especially if there is a lack of education about medication administration for comfort. This is where we also find that oxygen does not always just knock out the respiratory drive since a NRB mask at 15 liters would be an ideal way to calm or kill (as some believe) a patient by CO2 narcosis instead of using pain and sedative medications for comfort. Very often some will crank up the O2 instead of the pharmacology which in terminal cases will be futile in offering the relief they need. Again it comes down to understanding hypoxia regardless of the amount of oxygen being administered. Some hospitals will also put these patients through several painful ABGs just to see how short of breath this patient is they have determined to be futile really is. Maybe for some it is still ignorance about the process of death or our reluctance to accept death as health care providers. Again that includes doctors, nurses, RRTs and EMS or any other practitioner who is present at the bedside.

Specializes in Pediatrics, ER.

CO2 is elevated but not HORRIBLE for a COPDer. I think BiPAP would have most appropriate. Oxygenate and blow off that CO2, ease his work of breathing without intubating. It doesn't matter if they are a retainer or not, he was clearly demonstrating signs of hypoxia above and beyond the norm for someone with COPD.

CO2 is elevated but not HORRIBLE for a COPDer. I think BiPAP would have most appropriate. Oxygenate and blow off that CO2, ease his work of breathing without intubating. It doesn't matter if they are a retainer or not, he was clearly demonstrating signs of hypoxia above and beyond the norm for someone with COPD.

Looking at the ABG in a vacuum, I might disagree. The HCO3- is elevated indicating a rather chronic patient. However, in chronic patients who are well compensated, the pH will generally be in a normal or near normal range. This patient's pH was quite acidic indicating that metabolic compensation has failed and the current PaCO2 regardless of the number is much too high and something acutely "bad" is occurring. BiPAP ™ is a consideration; however, we do not know how "lethargic" this patient is. If the patient is beyond being able to cooperate and or tolerate non-invasive ventilation, then it may in fact not work.

Let me just throw this question out to see how people are thinking: Everybody appears to have a BiPAPA ™ bias, assuming a patient is a good candidate for NIV, why would you choose BiPAP ™ over CPAP and visa versa?

Specializes in Pediatrics, ER.

Hi, I was responding just to the CO2 comment from earlier. I've seen the CO2 in the 100s with a pH in the 7.1s and the patient was lethargic but able to speak in short sentences!

We use BiPAP over CPAP when the patient's PaO2 is through the roof, and also when CPAP just wouldn't be enough and we're trying to avoid intubation. BiPAP is usually enough to blow off CO2 and increase the pH enough to do so.

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