NRB & COPD your input please

[crb613, BSN, RN]

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

[nursing6207]

I 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. :)

[crb613, BSN, RN]

I agree to keep sats 88-92% would probally be normal....but 60%? I may be confused on this but it is my understanding that not all people with copd are retainers.....and no he was not intubated BIPAP was working when I left. Thanks for your reply.

[GilaRRT]

Sorry 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.

[highlandlass1592, BSN, RN]

That'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.

[GreyGull]

There 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.

The reasoning behind this is that the NRB is not a high flow device. It is actually a low flow device because it limits the amount of flow a patient can receive. To be clasisified as a high flow device it must be able to meet both the patient's inspiratory flow demand and total minute volume. Patients in respiratory distress can require a minute volume of over 20 liters. The NRB mask is a device that is limiting with a set flow. A venturi device which is probably what the high flow system you are descibing is based, will enable a total flow of over 40 liters/minute and probably more. You may have seen some RTs rig up two aerosol flow devices in attempt to gain more flow and a consistent FiO2. If the patient can acheive and adequate flow for a stable FiO2, the FiO2 might be lowered.

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.

BiPAP for sleep apnea and that for an acute situation are two different things. Even if the patient has a documented sleep study, when something acute arises, this patient needs more monitoring. The setting for their home sleep machine was designed for a normal night's sleep and not treating unknown situations. It is lucky your RTs have specifically spelled out their protocols because some places don't and then the RNs end up with a very hgh acuity patient.

[meandragonbrett]

There is a difference between a COPDer and COPDer who is in resp. distress. If they are hypoxic and in distress give them oxygen.

We tend to place our COPDers on a venti/venturi instead of a NRB.

[SummitRN, BSN, RN]

Removing 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!

[GreyGull]

It should never stop you from giving high flow O2 to an acutely hypoxic patient in order to stabilize them!

Or 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.

[crb613, BSN, RN]

Thanks to all....that is the way I was thinking. As to the rest of the ABG I dont remember...those were the numbers that stuck in my head, and he did have CHF. Thanks again!

[casi, ASN, RN]

I'd say slap the NRB on him until RT can set up the bi-pap. Letting someone hang out with O2Sats of 70 probably isn't that helpful for the patient.

[FlyingScot, RN]

There is a big difference between chronic CO2 retainers and COPDers with respiratory failure. When I looked at the ABG I saw respiratory acidosis and hypercarbia which indicates respiratory failure not chronic CO2 retention. Patients with chronic CO2 retention are usually not so severely acidotic. They may have slightly lower pH's and slightly increased HC03 (compensatory) but not down to 7.2. In addition they are not usually in severe respiratory distress. IMO an NRB would be an acceptable stopgap measure while equipment is being set up for more intense respiratory support. If I had a venti handy I would probably grab that first but only if I had it really handy. I wish nursing schools would stop teaching the "limit O2 with COPDers" crap. It really muddies up their emergency care.