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

[canoehead, BSN, RN]

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.

I have been waiting for a consult with a COPD pt and found he would get less responsive when I put the O2 on needed to keep sats above 90%, but he started having runs of vtach when I allowed the sats to go any lower. That was a long 15 minutes.

[GreyGull]

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 am going to elaborate a little more on this.

One of the few and probably the ONLY time you ever need a room air ABG is when you are qualifying someone for home oxygen near the end of their hospital stay after all other acute problems are resolved and that is only if the insurance insists that an SpO2 is not adequate. If a physician can not tell whether a patient is in distress by an assessment or by the A-a gradient from an ABG drawn after some type of treatment is done to alleviate the patient's distress......the rest of what I have to say is not suitable for print on a public forum. If the physician sees the patient is in distress, why the heck would he/she want to cause them more distress by removing the patient from O2 and doing a painful arterial sick?

Patients have great coping mechanisms...until they tire and crash. ABGs do not take into consideration the patient's appearance and if the patient's ABG came back normal, what was the physician going to do? Discharge him or declare he needs no O2 or assisted breathing? I've seen physicians delay treatment because of a "good ABG" only to have the patient code 10 minutes later and the sad thing with each situation was that the patient's initial presentation screamed "code". I've also heard "good ABG" results called to the physician without stressing the physical appearance. It is too bad this RT's time had to be spent inflicting more pain and increasing O2 demand on an already distressed cardiovascular system instead of providing relief to the patient by way of more O2 and/or BiPAP.

Besides home O2 qualification, another time which might call for a room air ABG would be for a shunt study done on some high risk surgical patient pre-op. But, the patients are not in acute respiratory distress when this is done since it is a lengthy process which requires full non distracted cooperation from the patient. Other situations might be for acid-base problems but the breathing part should be taken care of also. One more exception might be on a borderline 1 or 2 L NC to get a baseline CYA ABG in the ED for a discision to discharge but the patient is not struggling to breathe.

I wish nursing schools would stop teaching the "limit O2 with COPDers" crap. It really muddies up their emergency care.

A couple of the newer textbooks are now careful in their wording about this and do mention that just "2 L NC" is not always enough for emergent situations.

[WonderRN]

I know many have already weighed in on this issue, but I'll give my 2 cents....

NRB for all hypoxic patients regardless of history. They need oxygen first and foremost, you can fix the acidosis later. Many COPDers live at PaCO2 of 60 anyways.

I would have called for the BiPap stat and had intubation equipment readily available.

I agree that the whole NC only for COPDers is a VERY dangerous thing they are teaching. It does not apply to emergent situations.

No need to take the patient off of 02 for an ABG. NEVER have I seen this done.

Also would have like to know what the Pa02 was. I'm sure it was extremely low considering the Sp02 was in the toilet already.

[ZippyGBR, BSN, RN]

i will attempt to explain this. i am sure someone else can do better than me. someppl with copd retain co2. their drive to breathe is hypoxaemia whereasnormal drive to breathe is reduced blood ph from dissolved co2.

if you create an oxygen problemthrough poor monitoring and injudicious oxygen adminstration 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. :)

i've fixed some of the dangerous statements

the fact is that if someone's po2 is dangerously low they need oxygen hypoxaemia will kill before hypercapnia

someone in this much respiratory distress is going to be closely monitored and may well end up needing bipap or if clinically suitable intubation

also interpreting the blood gas also depends on base excess etc

you also need to consider how effectively the patient is breathing from an actual mechanical gas flow point of view and thinking aobut the psychological approaches to improving ventilation as well ( coaching, temperature, 'breeze' )

i'd also agree that the room air abg is only really relative in determining whether some one should have long term o2 therapy. in an emergency situation it makes very little difference and may well increase hypoxaemia.

[Lunah, MSN, RN]

No need to take the patient off of 02 for an ABG. NEVER have I seen this done.

Yep ... on the form we send to the lab with the ABG, we note what kind of O2 we have them on (NRB, NC, BiPAP, Vent + settings, etc.), and they adjust accordingly.

[GreyGull]

Yep ... on the form we send to the lab with the ABG, we note what kind of O2 we have them on (NRB, NC, BiPAP, Vent + settings, etc.), and they adjust accordingly.

If you work around intense pulmonary patients such as in the ED or ICU, you should be able to do a few simple pulmonary calculations yourself or at least understand what they mean. The only thing the lab will do, maybe, is print the A-a gradient, O2 content and hopefully give a measured rather than calculated SaO2. But, you should be familiar with what each means, an understanding of the Alveolar Air Equation and associate the A-a to V/Q mismatching.

If you understand the responses concerning V/Q mismatching, deadspace ventilation, pulmonary vasoconstriction and the Haldane Effect on profoundly hypoxic COPD patients, you won't be taken by surprise and will have more of an explanation why a patient's PaCO2 did rise from a physiological standpoint. The hypoxic drive is still valid but rarely is the situation with the COPD patient in acute respiratory failure because they ARE hypoxic. A NRB mask may give a quick change in the above mentioned factors other than the hypoxic drive and yes, a rise in PaCO2 may be expected. But, to just blame the hypoxic drive shows you are missing the big picture. The PaO2 may also not rise as quickly as the PaCO2. After a patient is placed on a ventilator, the first ABG may show a surprise by having a higher PaCO2 then even the pre-intubation ABG. Did the RT or Physician screw up on the ventilator settings? Probably not. That again goes back to an understanding of all the factors I mentioned in the first sentence of this paragraph.

Some hospitals have started using masks (OxyMask) that can be categorized as high flow and can be titrated from 1 liter up to 30 liters. These are ideal for walking up the patient's SpO2 according to patient AND health care provider's comfort level. They can also stay in place while NT suctioning or NGT placement is being done as well as drinking or taking meds and temp by mouth. You can even give a mouth piece neb with the mask left in place.

I also recommend quality CEUs to update yourself on the latest concepts that the textbooks did not provide a good foundation on or just gave a general "hypoxic drive" explanation.

One excellent seminar is from PESI.

Patient Crisis: Identify the Signs and Symptoms Before the Patient Crashes with Educator Carol Whiteside, MSN, PhD.

I also recommend taking an advanced ABG class. The very simplified course of "look at the pH" left out some very important components that must be considered.

This website gives you an idea about what I mean there is more to the story of ABGs.

http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php

A little side note: this formula is known as Winter's and is used to calculate normal PaCO2 for a patient so the ventilator settings don't take the PaCO2 down too low. If the PaCO2 is taken down to low and the body no longer compensates for the higher PaCO2, when the patient is extubated the PaCO2 rises quickly, pH falls and the extubation is written off as a "failure" when it may not be the patient who failed but rather those managing the ventilator.

PaCO2 = (1.5 x [HCO3-]) +8

[mmutk, BSN, RN, EMT-I]

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

Your patient needed Bipap! and then Intubation if that failed.

Because of the chronic elevation of PaCO2 the central chemoreceptors that normally

act as the primary stimulus for breathing no longer act that way and the peripheral chemoreceptors

take over. The peripheral chemoreceptors are sensitive to PaO2 instead of PaCO2 so an over

abundance of O2 will shut them down next. There are no more chemoreceptors after them!

So you have no drive to breathe.

[GilaRRT]

Your patient needed Bipap! and then Intubation if that failed.

Because of the chronic elevation of PaCO2 the central chemoreceptors that normally

act as the primary stimulus for breathing no longer act that way and the peripheral chemoreceptors

take over. The peripheral chemoreceptors are sensitive to PaO2 instead of PaCO2 so an over

abundance of O2 will shut them down next. There are no more chemoreceptors after them!

So you have no drive to breathe.

Your description of the "hypoxic drive" is just the thing many of us are discussing. As I stated, the hypoxic drive is overblown to the point that it's a scarecrow. The description of the hypoxic drive you stated is a brilliant work of physiological assumption and one I believed for some years. Unfortunately, it does not really happen.

Remember, the drive to breath (Central Chemoreceptors) is not based on PaCO2 per se. The drive to breath is based on Ph changes. While, elevated PaCO2 will decrease the Ph and typically cause increased minute ventilation, in chronic patients, the metabolic system kicks in and increases the bicarbonate to compensate for the low Ph. So, you have a patient with an elevated CO2, but he/she has a relatively normal Ph. This is most likely the best way to look at chronic patients. If you do not believe my Ph story and drive to breath, you need only consider a patient in DKA. Their CO2 is typically very low; however, they will continue to hyperventilate because of the decreased Ph.

Regarding BiPAP. It is a good consideration; however, the lethargy is of some concern. For non-invasive ventilation modalities to be effective in these patients, you need somebody who is awake and aware enough to co-operate and tolerate the therapy.

In any case, if a patient needs oxygen, give it to them.

[mmutk, BSN, RN, EMT-I]

Well I appreciate your response, I was just answering the original poster's question about explaining the hypoxic drive theory. I didn't read further down the posts before posting.

I agree that if a patient needs oxygen give it too them, but I am still not in favor of a NRB in COPD patients, it's useless with these patients, being as when you take it off after getting the sats up they will just fall again. Non-invasive Positive Pressure Ventilation is what this patient needed(most likely with a rate) and Intubation if he could not handle the Bipap even with a rate.

[mmutk, BSN, RN, EMT-I]

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.

Ohh MDs are falling for this as well.

[Tonjia]

a short time on a NRB is not going to hurt this patient. It sounds to me like he needed a continuous neb and/or a bipap anyway

[DixieJeanne]

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!

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.

I would have called for the BiPap stat and had intubation equipment readily available.

Yes - exactly.

Regarding BiPAP. It is a good consideration; however, the lethargy is of some concern. For non-invasive ventilation modalities to be effective in these patients, you need somebody who is awake and aware enough to co-operate and tolerate the therapy.

In any case, if a patient needs oxygen, give it to them.

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.