Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do?

Nurses General Nursing

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  1. Chronic COPD'er, 1 lung, 02 @ 6L, What would you do?

    • 222
      I think the Paramedic was right to increase the 02 to 6L. I am a Nurse.
    • 16
      I think the Paramedic was right to increase the 02 to 6L. I am a Paramedic or EMT.
    • 180
      I think ultimately the patients wished should have been honored. I am a Nurse.
    • 6
      I think ultimately the patients wishes should have been honored. I am a Paramedic or EMT.
    • 122
      I think the Paramedic should be reported to her agency for ignoring everyone. I am a Nurse.
    • 8
      I think the Paramedic should be reported to her agency for ignoring everyone. Paramedic/EMT.
    • 79
      I think this was a true emergency situation. I am a Nurse.
    • 9
      I think this was a true emergency situation. I am a Paramedic or EMT
    • 13
      I don't know, it's all too confusing
    • 7
      Leave me out of it. I don't want to participate.

148 members have participated

I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they felt it should be coming up after breathing treatments and wanted to call before it got too late in the evening.

She/he is a chronic COPD'er, who has only one lung, who functions well with 02 sats in the low 80's. She/he has 02 BNC @ 2.5L/min. When I got there she/he was sitting up talking to me. She/he said she/he didn't feel in the least SOB, 02 sat was 73%, Temp 102 and her/his one lung was full of wheezes. I felt as though she/he should go to the hospital but that it was not an emergency situation. The family fully agreed. They said she/he preferred to go by ambulance so she/he wouldn't have to sit in the ER. I agreed. We called 911.

An EMT got there and asked what was going on. I told him. A few minutes later the ambulance got there and a paramedic came in. She saw me but asked the EMT what was going on. "Oh my God a sat of 73% crank her up to 6L/min. I said no. I explained why. She said "well we have to get her 02 sat up because she's not perfusing 02 to her brain. I said she's talking to you. Please do not turn her up to 6L/min you'll do more harm. She did it anyway. The daughter said "the last time you guys did this she/he ended up with a CO2 of 134 and ended up on a ventilator". The patient said please don't do this to me. The paramedic ignored everyone. The EMT turned it back down to 2L/min the paramedic saw it and turned it back up to 6L/min. She told the patient she would put her/him on a non-rebreather once they got her/him in the ambulance!

I was told that once the paramedics arrive they are in charge and what they do is their responsibility but how ignorant to not listen to the nurse, the family and the patient?

I will make sure this paramedic gets reported. I wonder what you guys thoughts are?

Specializes in OB, M/S, HH, Medical Imaging RN.
i hope u documented well!!! by the way, how did the pt come out of this in the end?amomanurse

Unfortnately the patient passed away. The cause of death was acute pancreatitis.

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Someone please explain this to me!!! As an BSN/RN student I know very well a COPDer is operating only on a secondary hypoxic drive and that high flow oxygen can knockout their respiratory drive. I also know that oxygen absorption and carbon dioxide release by the blood while related are independent mechanisms. I also have been told that no matter the protocols or doctors orders if they are wrong and I follow them I can expect to be sued/found at fault as well. How can anyone defend the use of high flow oxygen on a known COPD patient????

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Specializes in Nurse Scientist-Research.
If the last 2 posters took time to read the entire thread they would realize that

*I have agreed that the paramedic was correct to follow her protocol.

*The 6L of 02 did not kill the patient.

*The patient should have gone by car but the family refused.

*Once the ambulance arrived the patients care is out of the nurses hands.

*Home Health nurses are competent.

*Many of us learned a valuable lesson or two!

Not nice...

I have followed this thread since it's beginning. Is it frustrating to others like it is to myself that the recent posters haven't bothered to read the whole thing; or even say the last few posts?

DutchGirl; I quoted you above simply to help update some of those who haven't kept up. There are many complex issues addressed in this thread; a lot of information can be gathered and so much can be learned; from Home Health nurses, acute care nurses, ED nurses, students, EMT's & Paramedics, and others. Even though this thread is very lengthy I encourage all those who feel like posting to first read at least the first 4-5 pages of comments first; at least to the point where the OP posts the patient's final outcome. It is good stuff.

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I have followed the thread since the beginning. Lets see sats in the 70's COPD bad but not unknown. Alert and oriented but lethargic. High flow oxygen and knock out respiratory drive or live with what you have seems simple to me!!!

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Specializes in Nurse Scientist-Research.
it is different for pre-hospital textbooks.

this is right out of a paramedic textbook, page 303...

"delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

how to prepare for the emt paramedic exam (paperback)

by [color=#003399]mark marchetta (author)

also, straight out of my nursing textbook,

"the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."

medical-surgical nursing, ignatavicius and workman, pg 491

the italics are the actual italics in the wording of the textbook, not my own.

also a link to an article regarding hypoxic drive in copd patients:

http://cmbi.bjmu.edu.cn/uptodate/critical%20care/other/the%20use%20of%20oxygen%20in%20patients%20with%20hypercapnia.htm

a link to an rt student's personal research with several links to professional articles on hypoxic drive in copd patients.

http://home.pacbell.net/whitnack/why_the_hypoxic_drive_theory_sucks_wind.htm.6306

i pulled all these links and information directly from earlier in this thread.

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Specializes in ER.
Someone please explain this to me!!! As an BSN/RN student I know very well a COPDer is operating only on a secondary hypoxic drive and that high flow oxygen can knockout their respiratory drive. I also know that oxygen absorption and carbon dioxide release by the blood while related are independent mechanisms. I also have been told that no matter the protocols or doctors orders if they are wrong and I follow them I can expect to be sued/found at fault as well. How can anyone defend the use of high flow oxygen on a known COPD patient????

Not every COPD patient (in fact it is a small minority - in the 5-10% range) are actually using hypoxic drive. I wrote earlier why the actual problem isn't the 6 lpm via nc, but the ventilator that is the real problem.

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Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.

It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.:nono:

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Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.

I have to agree with Dutchgirl....

Protocols are good, because the thinking is that everyone will follow the protocols and care will be more standardized. The downside is that protocols are not bendable....people are basically taught to follow the protocol and ignore common sense....ie, we aren't supposed to THINK anymore....we are supposed to just follow the written recipe....

The only thing is, not all patients fit into the protocol box....not all people are the same...not all situations are the same....

While this patient was probably working on a pneumonia....it is clear that high levels of 02 in most situations with a COPD patient will knock their respiratory drive completely out....

Before the paramedics arrived, he was not labored...he was just satting in the 70's....I say, don't correct the sat....because he was tolerating that...I would say correct the underlying cause of the sat...ie the pneumonia, with med nebs....steroids....antibiotics....and fluid resuscitation and GENTLE oxygen support....he probably wouldn't have ended up on a vent....just my opinion....

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It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.:nono:

Jill,

We're both shocked at the level of misunderstanding regarding COPD and hypoxic drive, but we're shocked on opposite ends of the argument. The hypoxic drive theory has been progressively taking a well-documented beating in the literature over at least the last ten years. We know it doesn't affect very many COPD pts. When it does, it generally takes hours - far longer than the typical EMS transport. See the 'Prehospital Care' section of the link below for one example of a well-reasoned argument in favor of not withholding O2.

http://www.emedicine.com/emerg/topic99.htm

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Specializes in Emergency.
It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.:nono:

Let's give the EMT's some credit here! They are our eyes and ears in the field and have so much responsibility with a fraction of the training we as nurses receive. They have to deal with hysterical family members while performing CPR on the patient in the middle of the living room, go into homes infested with cockroaches, pull people out of the snow, and at times deal with violent situations. So let's give them a break and thank them for all that they do for our patients and for us. Take the opportunity to help and TEACH our EMT's, don't blame them.

Also, a couple of minutes on high oxygen isn't going to "knock" out a COPD patient's respiratory drive. In the "typical" patient with respiratory distress, low oxygen sats causes the body to work harder to take in more oxygen, inversely causing increased oxygen consumption and furthering the body's oxygen deficit. So, at times higher amounts of oxygen are warranted. The only thing that would truly confirm the patient's ability to oxygenate themselves would be to draw ABG's once at the hospital.

FYI: Hypoxia kills quicker then hypercapnia

Kudos to EricEnfermero for a well-stated post.

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Specializes in ER.
It never ceases to amaze me that so many medical people (nurses,emt's,etc.) are oblivious to the fact that you cannot turn the O2 up on a COPD patient. I would have told the emt's to get out of the patient's room and don't touch his O2, or anything else for that matter. I would tell them I'm not comfortable letting you take my patient. Then I would have reported the emt to his/her employer, and whatever board governs them.:nono:

It never ceases to amaze me how many nurses are oblivious to the fact that less than 5 percent (some studies put it at about 0.5%) of patients with COPD are actually on hypoxic drive.

Is it better to kill off brain cells through hypoxia?

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Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.
Jill,

We're both shocked at the level of misunderstanding regarding COPD and hypoxic drive, but we're shocked on opposite ends of the argument. The hypoxic drive theory has been progressively taking a well-documented beating in the literature over at least the last ten years. We know it doesn't affect very many COPD pts. When it does, it generally takes hours - far longer than the typical EMS transport. See the 'Prehospital Care' section of the link below for one example of a well-reasoned argument in favor of not withholding O2.

http://www.emedicine.com/emerg/topic99.htm

Dear Eric, thank you so much for the article. It was a real eye-opener and I have now seen that all is not black and white. :blushkiss

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