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> COPD and Oxygen therapy, Oxygen use in chronic chest conditions
sgarth
  Posted: Apr 22 2005, 11:51 AM
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Hi,

I would like to know your thoughts on the use of oxygen during medical emergencies (not just cardiac arrest) in people with Chronic Obstructive Pulmonary Disease.

The concern is around the hypercapnic respiratory drive being affected by a high level of oxygen supply.

What I teach is;

During cardiac or respiratory arrest give as much oxygen as you can.
During sudden medical emergencies give as much oxygen as you can.
Don't be overly concerned as the casualty will be in an emergency unit soon.

My theory being that in hospital you will be able to very soon get blood gases pulse oximetry and the like to moderate the oxygen supply to an adequate level, but until the blood gases are available, more is better than less. Also I believe the problems of hypocapnia in these casualties don't manifest that quickly.

Pre-hospital the above is still true, although an ambulance will take the casualty to accident and emergency where blood gases etc are available. Also pulse oximetry is available in the ambulance.

I have phoned a few colleagues who basically agree with me. However, the views of the forum would be welcome.

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nuscw
Posted: Apr 22 2005, 01:56 PM
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Hi Steve,

I think you've just about covered everything. We used to leave a pregnant pause in lectures after stating 'Everyone gets 100% 02 in an emergency', because this would always come up. Nowadays I'm sure you'll agree, with ILS and ALERT, not many people even mention it. Everyone I get to see these days has a non-rebreathe mask clamped to their face, (not always turned on, but hey...)

The only thing I can add is regarding pulse oximetry. If your COPD patient is reliant on their hypoxic drive as opposed to hypercapnic, as the severe ones are, then as you've said there is a theoretical risk that if you give them supplemental 02 you will remove the stimulus to breathe. The problem this gives us is an initial hypercapnia, (as the resp rate falls), with the accompanying CNS depression etc, etc. But because you've stuck 100% 02 on them, it will take quite some time for hypoxia to become a problem - even if their resp rate is as low as 5 or 6/min. So although monitoring with Sa02 is important, on it's own it's somewhat falsely reassuring in that it will only show a problem in the very late stages, around about the time your patient has a GCS of 3 and looks pretty ropey.

In hospital it is quite easy to check serial ABG's, and a patient this ill is never unattended (allegedly), so this issue is almost of no consequence in practice. Out of hospital, without ABG's it's a little trickier. I guess it's up to the assessment and evaluation skills of paramedics, if their already struggling COPD patient acutely deteriorates with high Fi02's, then turn it down or maybe give them a little help with a BVM and 2 or 3 litres 02.

The bottom line anyway you look at it is; hypoxia kills quicker than hypercapnia so everyone gets 100% 02 in an emergency. But it would be interesting to hear from others to see if this is a policy in practice throughout the EU.

Stuart.

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rormonde
Posted: May 6 2005, 11:57 AM
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I agree with Steve
Any patient that ill SHOULD be observed at all times and transered to a suitable place for treatment and further observation e.g. ED or HDU.

Lack of oxygen will kill everyone.
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Posted: May 21 2005, 06:18 PM
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Agree with all of the above, Unfortunately I still have to leave the pregnant pause stewart mentioned as I still get the same old argument( it is getting better though) However as in line with everyone else's practice I advise give oxygen whilst help is on the way/ being transfered to an ED HDU etc. and then reassess with ABG's
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sgarth
Posted: May 23 2005, 08:24 PM
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Thanks for your responses, and it is good to see we all agree. I also leave the pregannt pause, it really is about time we delivered this baby.
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marijakopljar1
Posted: Sep 5 2005, 07:10 AM
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Hallo,Steve!
I got the infromation that CONSIOUS PATIENT with the o2 saturation of 83% gets the oxigen rate 4L/min ,Venturi mask.(28% 02)

COSCIOUS PT WITH COBD,NOT CR AREST!!!
( that is another q!)

Do U probably have the rule what 02 concentraions in oximeter go with which 02 concentration in such patienst?


Thanks a lot!
M
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sgarth
Posted: Sep 5 2005, 11:39 AM
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I am sorry but I disagree.

Assuming you are on about the suddenly ill casualty with COPD, an oxygen level of 83 is far too low in my book.

I would give this patient high concentration. I would be bold enough to say that 28% would be useless in this case.

I am aware that some COPD have a normal saturation of 80-85%, but if the casualty is suddenly ill, I would like to attempt to get it up to 90% in the emeregency situation.

As for other casualties, you need to judge whether they require oxygen at all. In my book all serious sudden illnesses, (MI, PE, CVA, Head injury, chest injury, moderate shock, abdominal emergency, respiratory distress, unexpected sudden collapse, etc.) would get high concentration until told otherwise by oximetry or ABG.

I don't know of any actual rule, but I work at getting everyone 90% or over.
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anthonyhoswell1
Posted: Sep 8 2005, 12:21 AM
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Hi all

found this site while looking for info. on pre-hospital O2 therapy. I am a Paramedic and I personally do not believe non-rebreather masks are appropriately used in the majority of patients with COPD. I believe we should be calling non-rebreathers "trauma masks" and using them as such. The only COPD patients to benefit are the severely hypoxic , the crucial point is recognising them, which is obviously more difficult in COPD patient's due to their "normally" low O2 sats. As a completely unresearched and anecdotal comment I would say that the majority of breathless COPD patients I have seen maintained sats of >90% on 60% 02 or less.

Anyway I have found a good article which I would like to share with you:

http://emj.bmjjournals.com/cgi/content/full/18/6/421

For what it's worth, the majority of my colleagues use non-rebreathers on COPD patients and adverse incidents are rare but the problem is when the attendant does not notice the patient deterioration and delivers a hypercapnic respiratory depressed patient to A&E, generally making us all out to be idiots!

Thanks for your time
Ant
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Posted: Oct 8 2005, 09:44 AM
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All patients should have as little oxygen as they need, Unfortunately in the immediate phase of a medical emergency or resus event we don't know how little they need, so we give them 100% to ensure they all get as little as they need.
The problem is the lack of observations when doing so. Co2 exceretion is not a problem as long as the patients minute volume is maintained.

Interestingly some patients who run on hypoxic drive require high levels of oxygen during their medical emergency, which may not be respiratory.

Monitor your patient properly and there should be no problems until someone can find out how little oxygen they need.
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marijakopljar1
Posted: Oct 21 2005, 04:07 PM
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Hi,Stewe!
First of all, than U for the answer again!
Look, sorry to bother with details, but the main reason to ask this quiestion was nothing less then job interview. A s all of this sort, it was in some case important to me. The employer asked the that q (pt with COBP) had 02 saturation 83%.
I told first to give 2 L/min nasal cannula./ that was how we were told before)
He said it was wrong.
Then i said to give 100% 02 for the BEGINNING and then watch the patient and monitor his s02 and according to it and he said it ws wrong too.
Then he told me he woudl give 28 % 02.
Look, it is surely his private office and his right it to employ whoever he wants.
To be honest, i appreciate anobodies opnions and am completely sure he did nto want to harm the patient. Maybe he just found some other rules in some medical journals or sth. On the other hand, his natural right is to eliminate anyone if he wants so.
I live in poor country and all the chances to advance in he medical fiels are strictly limited.
I just wanted to get any further with my education.
It all made me confused and demoralised.
My aim is not to stuck with the local authorities opinions but to widen my horizonts and make a person of me pepole wil trust one day.

I hope U undestand why i asked that.
THANK U ALL A LOT ONES AGAIN!
m
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Sonjamaria
Posted: Nov 28 2005, 04:20 AM
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Hello All,
Just thought I would add to the topic . I don't neccessarily agree with flooding the patient initally with oxygen on a high flow NRB. Whilst I do agree that there are situations that warrants this, it has been shown that quite often we over oxygenate our COPD patient. In fact, research has shown that this also increases their hospital stays as their blood gases are blown out from our aggresive therapies.


I would suggest that if initally a high flow is used that this should be very carfully watched and then adjusted downward as far as possible, or alternatively start low and work your way up. It may sound terrible and perhaps even inappropriate but these patients live with constant hypoxia, the likelyhood of resp arrest in our care is quite small, but the incidence of increased hospital stay and difficulty in ongoing management in ED is far greater.

Sonja
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marijakopljar1
Posted: Dec 8 2005, 07:19 PM
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Hallo Sonjamaria!
I falied the exam cause i told i would prehosptally apply 100% o2 to the pt with copd saturation 02 86%.
The examider said i shoudl apply 28% o2.
after that i tried hardly to find the soursce of this data.
foudn only one site onthe net saying the oxigenation level we aim in such pts is 90%,this is optimal for them
hcanu help me with searchign the data?
seems intersting
Thanks
M
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marijakopljar1
Posted: Jan 20 2006, 02:40 PM
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Dear all! ph34r.gif
The topic is really interesting!
But what about this:
THE HIGH O2 CONCENTRATION CAN MAKE PT STOP BREATHING!!!
SO WHAT!!!
ARE WE PROFESSIONALS OR NOT?
IS IT RISKY TO RISK THE PT STOP BREATHING AND HOW MUCH RISKY AND WHAT ARE WE SUPPOSED TO DO?
I ask for official law data, as usual!
Regards
M

rendezvouz_with_rama@yahoo.com
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sgarth
Posted: Jan 20 2006, 04:40 PM
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I agree with sonjamaria and what I teach my out of hospital staff is in the acute medical emergency give 100% and the ambulancement will modifythat whe nthey arrive. As previously said, we cannot tell how much oxygen the COPD needs until we are able to fully assess the casualty.

Marija, yes we should be able to deal with a COPD who has stopped breathing. However we should not be content with that. That is like saying let him drink the poison because we have the antidote!

Our aim is to do no harm, or at least minimise harm. It would be wrong to place all COPD patients at risk simply because we can deal with the consequences. Sometimes we cannot get them breathing again as many have multiple problems. We would increase their stay in ICU on a ventilator, which can cause other problems, we increase their hospital stay which has more problems again.

This discussion, I believe, is around how much oxygen we give a COPD casualty in the medical emergency. I think the answer is a risk assessment between surviving the initital medical emergencyperiod, and surviving the post event period during which the casualty has to survive the cause of the medical emergency AND the screwed up blood gases affecting their ability to breath.
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Sonjamaria
Posted: Jan 24 2006, 06:44 AM
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Hi Marija,
In regards to the email you sent me. Do you require information regarding flow rates for COPD with acute on chronic presentations...? Is that it? Or information regarding extended hospital stays?

I probably have both of these floating around if you are interested. My field is in prehospital ambulance care in Australia/New Zealand. Would this be of any help to you?
regards
Sonja

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