NRB & COPD your input please
- 0I 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
- 1Nov 3, '10 by nursing6207I will attempt to explain this. I am sure someone else can do better than me. Ppl with COPD retain CO2. Their drive to breathe is oxygen whereas our drive to breathe is CO2. If you fix the oxygen problem then they will not have a drive to breathe anymore. That's why ppl with COPD, usually the MD writes to keep O2 sats 88-92%. That is usually normal for the pt.
Now to add to your question. If you put more oxygen on him just to get O2 sats 88-92% and no higher. Would that have been ok? Did this pt end up intubated?
Hope this helps a little until someone can explain it a little better.
- 17Nov 3, '10 by GilaRRTSorry all, this hypoxic drive theory is a scarecrow that nursing instructors use to frighten their students. If somebody needs oxygen, give them oxygen. With the ABG stated, this patient is in failure and will most likely require intubation.
- 4Nov 3, '10 by highlandlass1592That's correct, not all COPD'ers are retainers. You didn't state what the PO2 on the ABG was, but CO2 was very high and he was retaining. This might be the kind of patient you allow to have a higher CO2 level, which may be in the say 50's. Using Bipap is like using a recruitment manuever for an inutbated patient, opens the alveoli to get a better oxygen exchanged. (Positive pressure)
Now I don't know a NRB would be the way to go. Honestly, we have special flow meters at our facility where we can use what's called a "high flow" mask and I've found it works MUCH better than a NRB. This set up uses humidified oxygen with this special flow meter and mask; it actually delivers a higher oxygen concentration than a NRB...and as the oxygen is moist, can help a patient mobilize secretions. However, if a NRB is what you have, it's what you use. I definitely would NOT have left him on 4L via NC, could have tried a venti-mask if the Bipap wasn't an option.
What would have also been important would have been to figure out what was causing the lungs to sound "like crap". Fluid overload due to heart failure? Pneumonia? The hypoxia is the symptom, if possible you wanted to try to find the cause of the problem. On our telemetery floor, we can't initiate Bipap..per RT protocol, they have to go to ICU if no documented sleep study. The great thing in the ICU is they can do Bipap off the vent...same set-up as when someone's intubated, just has the Bipap mask attached instead of hooking up to an ET tube. That way, if the Bipap doesn't work, they just tube them and use the same vent. Gotta love these newer vents, so many more options!
So anyway, I hope this gives you some more ideas of options out that. As to your point that "were you supposed to wait for this guy to code?", absolutely you treat this pt. And honestly, if you did have to intubate this pt due to him not improving with other interventions, this is probably the type of pt who would code as soon as he was tubed...I've seen it happen a lot. You get the oxygen problem fixed, they are still acidotic as heck and then lose a pressure promptly followed by a pulse. So, I have a tendency to have the crash cart nearby. You're usually gonna need it. Hope some of this helps.
- 3Nov 3, '10 by GreyGullThere is a lot more to the ABG then just a few numbers. What was the PaO2 and A-a gradient? What was the base deficit? Lactate? Anion gap? Those will give a clue about the events leading up to the present situation.
Most patients that fall into the category of "COPD" are not retainers. Either way, you treat hypoxia especially when a patient is this symptomatic. The hypoxic drive has been disputed for over 30 years and it is now thought to be the pulmonary vasoconstriction response to high FiO2 that causes the rise in PaCO2. If it is significant enough to cause an immediate need for intubation, then the patient was heading that way already. Long term use of a higher FiO2 can influence the patient's PaCO2 retention but in the ED, this will probably not be an issue.
BiPAP splints the airways and also promotes fluid redistribution for patient who may have a CHF component or for cor pulmonale. Cor Pulmonale itself is an interesting factor.
Now I don't know a NRB would be the way to go. Honestly, we have special flow meters at our facility where we can use what's called a "high flow" mask and I've found it works MUCH better than a NRB.
Fluid overload due to heart failure? Pneumonia? The hypoxia is the symptom, if possible you wanted to try to find the cause of the problem. On our telemetery floor, we can't initiate Bipap..per RT protocol, they have to go to ICU if no documented sleep study.Last edit by GreyGull on Nov 3, '10
- 5Nov 3, '10 by SummitRNRemoving the hypoxic drive in a COPD pt by delivering high ppO2 is something that occurs CHRONICALLY in some COPD pts. It should never stop you from giving high flow O2 to an acutely hypoxic patient in order to stabilize them!
- 1Nov 3, '10 by GreyGullQuote from SummitAPOr at least a NRB mask or increasing the flow of the NC or whatever other low flow device you might be using if a high flow device is not available.It should never stop you from giving high flow O2 to an acutely hypoxic patient in order to stabilize them!