Comments on: COPD and the Myth of the “Hypoxic Drive Mediated Sudden Hyperoxic Death Oh My!” http://www.northeastems.org/blog/2009/02/copd-and-the-myth-of-hypoxic-drive-mediated-sudden-hyperoxic-death-oh-my/ Medical Director - Northeastern Maine EMS (Region 4) Wed, 08 Sep 2010 01:08:39 +0000 http://wordpress.org/?v=2.6.5 By: Stefan Fedusiv, RRT-NPS http://www.northeastems.org/blog/2009/02/copd-and-the-myth-of-hypoxic-drive-mediated-sudden-hyperoxic-death-oh-my/#comment-136 Stefan Fedusiv, RRT-NPS Fri, 03 Jul 2009 01:30:56 +0000 http://www.northeastems.org/blog/?p=16#comment-136 Dr Busko, As a respiratory therapist with 14 years clinical experience, I read your essay with great interest and found myself laughing more than once at the clever ways you successfully made your point time and again. Surprisingly, I think I have something worthwhile to add which could help ease the friction while helping the hypoxic patient at the same time: Explain to the nurse that it's not the FiO2 that even matters; rather, it would be the PaO2. Many times I have been in the exact same situation as Steve, the paramedic in B.C. Canada has: placing a decompensating COPD patient on a non-rebreather or other high flow oxygen device, only to be challenged by a well-intentioned, albeit misinformed, nurse. Fact is, even IF the patient was being stimulated to breathe by hypoxia, chemoreceptors have no idea what FiO2 is being delivered. Give enough O2 to reach the target SpO2, and then begin backing down on the FiO2. This way, the patient is happy (oxygen needs are being more adequately met) and the nurse is happy (the patient is no longer receiving a 'lethal' dose of O2). Stefan, Great point. I also think it's worth considering that oxygen is like any other drug we use in the prehospital setting. There are indications for its use and there are lots of different doses that are used for different reasons. In the patient without respiratory distress or hypoxia, there is no indication for high FiO2 oxygen so don't give it. Conversely, I like to think about COPD patients in moderate to severe respiratory distress / insufficiency as being similar to a patient I'm about to paralyze and intubate. Both of them have impending respiratory failure and I'd much rather have them stop breathing with their entire lung volume full of oxygen (which wil continue to drive oxygen in to the blood stream for quite some time based on the concentration gradient) than to have them stop breathing with a lung full of room air. Its the underlying principle of right drug, right time, right indication, and use your judgment. Thanks for the great comment. JMB Dr Busko,
As a respiratory therapist with 14 years clinical experience, I read your essay with great interest and found myself laughing more than once at the clever ways you successfully made your point time and again. Surprisingly, I think I have something worthwhile to add which could help ease the friction while helping the hypoxic patient at the same time: Explain to the nurse that it’s not the FiO2 that even matters; rather, it would be the PaO2. Many times I have been in the exact same situation as Steve, the paramedic in B.C. Canada has: placing a decompensating COPD patient on a non-rebreather or other high flow oxygen device, only to be challenged by a well-intentioned, albeit misinformed, nurse. Fact is, even IF the patient was being stimulated to breathe by hypoxia, chemoreceptors have no idea what FiO2 is being delivered. Give enough O2 to reach the target SpO2, and then begin backing down on the FiO2. This way, the patient is happy (oxygen needs are being more adequately met) and the nurse is happy (the patient is no longer receiving a ‘lethal’ dose of O2).

Stefan,
Great point. I also think it’s worth considering that oxygen is like any other drug we use in the prehospital setting. There are indications for its use and there are lots of different doses that are used for different reasons. In the patient without respiratory distress or hypoxia, there is no indication for high FiO2 oxygen so don’t give it. Conversely, I like to think about COPD patients in moderate to severe respiratory distress / insufficiency as being similar to a patient I’m about to paralyze and intubate. Both of them have impending respiratory failure and I’d much rather have them stop breathing with their entire lung volume full of oxygen (which wil continue to drive oxygen in to the blood stream for quite some time based on the concentration gradient) than to have them stop breathing with a lung full of room air. Its the underlying principle of right drug, right time, right indication, and use your judgment. Thanks for the great comment.

JMB

]]>