Pulse oximeters and asthma

Just now I have been peer reviewing a study for the Cochrane Collaboration as part of the Cochrane Airways Groups. It has been fascinating doing this as it is the first time I am part of something from the early stages to now where the study has been carried out and dissemination will occur. Im not sure I can say much about the paper at all but this is not the reason for the post. While reading the paper I kept coming up with questions, thoughts, my own opinions and opinions shared by many who suffer from asthma. The paper was broadly about the use of pulse oximeters in asthma.

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What got me thinking reading this was how often either people will post about how they have low oxygen saturations yet will fail to get and seek medical help or those who have got help but don’t understand the Dr’s lack of urgency when they feel rubbish but have relatively good oxygen saturations.

Having had a tricky time with my asthma for a while now I have seen and felt a lot of different oxygen saturations and the effects it can have on your body. About 10 years ago the Sister of the respiratory ward I used to attend took time and explained all about oxygen saturations, asthma and young people.

I go by numbers- or at least try to. I find if I can see a number and see that it is ok then I am ok and I can relax a little. If I see a bad number I find it almost makes me worse because I know things are not good. However I learned that in asthma particularly in young people a high oxygen saturation for a prolonged time can be a sign of worse to come. I never realised younger people had a bigger oxygen reserve and could have an asthma attack but maintain good oxygenation for a longer period of time. As good as having a reserve is many nurses will worry. I remember this so well, my nurse was in a little panic. I was quite happy as I was in a side room however had said my chest was feeling tight and the effort of breathing getting harder but I knew my jobs were ok as just had them done. I thought I would have a nebuliser and hat would be that. I was shocked when the nurse rushed out and got her colleague and they moved me straight away to the high care bay. The reason being the nurse recognised that I was using up my reserve and she was right. It was not long before my oxygen saturations dropped and I was taken to ICU and put on a non invasive ventilator. Thank goodness for her experience and recognising the signs and a bad situation was averted.

This is what so many people don’t understand with asthma though and probably why the statistics of hospital admissions for exacerbations of asthma and asthma deaths are so bad. Most consultants or GPs will not advocate for their patients to have a portable pulse oximeter at home because by the time oxygen saturations drop in an asthma attack you should be seeking medical help. The first sign of a severe asthma attack is a drop in peak flow but also a slight drop in carbon dioxide level on an ABG. When struggling to breathe your first instinct is to gasp and breathe more causing this initial drop in CO2 but as your airways become tighter and tighter your struggle to get rid of the air you breathe in and your CO2 will start to rise and oxygen will drop. Therefore if you are waiting at home till your oxygen levels drop your taking your life in your hands and risking serious consequences.

The other problem with pulse oximeters is that they are highly unreliable and can be effected by so many external factors. When in hospital you will always have your oxygen levels measured with a pulse ox however they will also be  confirmed by having an arterial blood gas which will give your true oxygen levels in your blood. An ABG can also tell medical staff about how unwell you are and how hard you are having to work with your breathing.

I can totally understand why many people will delay going into hospital despite feeling awful and really struggling to breathe. My feeling is that many Drs and Nurses will take a set of observations and will show the patient the machine and comment that their oxygen levels are good so they are doing ok. They may have good oxygen sats but you can still feel terrible. This comment about having good sats can often make many feel that maybe they shouldn’t be in A and E because the staff have said they are ok. The staff will be saying this to reassure the patient and not suggesting that they shouldn’t be there but it will often feel like that to a patient. This highlights how simple phrases can be taken in so many different ways and different interpretations made from them.

I guess the point of this post is that I want to highlight just how bad asthma can get and how not to rely on a pulse oximeter at home and get help once your oxygen levels start dropping. Even if you hate hospital (as practically everyone does) or are fed up going it is better to go often and get a small amount of treatment to regain control of your asthma than wait till your really ill and in grave danger which requires a huge amount of medication and interventions from Drs and Nurses to get you back to feeling well. It would probably turn out that if you add the hours up that you spend going to hospital or a Dr to treat a mild to moderate asthma attack may very well still equal less hours spent in the hospital than you would if you waited till you were really un well.

Having said all this I must confess I do have a pulse oximeter of my own at home. A previous consultant gave me one but I now use it to monitor my heart rate which seems to go from anything around 110 to 180 when it feels like. Most of the time I have no idea where my pulse ox is and don’t use it very often at all.

If anyone takes anything away from this post it is to get help early for your asthma attacks. Don’t wait until you think a Dr might take you more seriously because your oxygen levels are bad. They would prefer you to come early and get treatment and get home (the cynical side in me would say that this makes Drs lives easier and they don’t need to do so much work this way too!!!).

Facing Fears.

Part of this post is one of the hardest things I will ever write. It will be reliving the most terrifying asthma attack I have ever had and the experience of the whole admission.

Before I go to that I want to explain why I am doing this.

As a coping strategy I block out my asthma attacks. I don’t remember them wether it is a conscious or subconscious thing I am not sure. But I do record every time I am admitted into hospital, what ward I was admitted to and I keep my admission/ discharge letters which have a small description of events that happened. I want to try and learn from these admissions and make admissions more positive as they can often be very hard.

Moving to the hard bit.

6 years ago in June I had the worst hospital admission/ asthma attack I have ever experienced. I am not sure if it was the worst asthma attack but it was the hardest one to fight and one that didn’t really respond well to treatment.

The attack itself started as normal. I had some nebs and called 999 as it wasn’t getting any better. The paramedics arrived very quickly and I knew by their speed at getting me into the ambulance and over the the hospital that I was not particularly well. We went by blue lights across the city. It was a strange experience. I recall the shutter being open in the ambulance so I could see out the window as we travelled at speed across town. Going through red lights. I also thought it really odd that they cannulated me and put me on high flow oxygen rather than the usual nebulisers. They were giving me a lot of stuff through my IV but I am not sure what. For being so ill I felt not that ill. I think it was probably something to do with being very hypoxic. I almost act drunk when I am hypoxic. (When I was living down south the nurses laughed at me when I tried to squeeze between the cot sides to get out of bed- funny now but not at the time). Drs were waiting outside of A and E for me and I was wheeled into resus where they worked on me and got me stabilised a bit. I was not there long. I was moved to intensive care. The journey there I just remember seeing the ITU Dr with the intubation kit in the red backpack on their back and also a trolley with other stuff. there was a machine on my trolley which just beeped all the way.

I got to intensive care and recall wanting to get myself off the trolley into bed but not being allowed to. There were nurses and Drs everywhere. I didnt know who was who as they were all in blue scrubs. For some reason something I always remember is a bandage being cut to hold a ET tube should I be intubated. I don’t know why that is so clear. Everything becomes a bit hazy for a while after that. I think from that I perhaps ran out of adrenaline or knew I was in a safe environment and was going to be looked after and would be ok.

I was there for a few days. Before being moved to the respiratory ward I do clearly remember having a bed bath from a few nurses. I had a lot of lines, drips, catheters, oxygen so was not able to do things for myself. I was also totally exhausted. But this one nurse told me Michael Jackson had died. I thought he was joking. It seemed like such a strange thing to say. I didnt believe him until I was moved to the ward and saw a newspaper. It was true. It was odd to  not believe what someone had said. I think the whole experience in intensive care was surreal and I didnt want to believe it had happened but it had. The rest of the hospital admission was uneventful and I was discharged a few weeks later. The main thing was that for being so ill I didnt feel that unwell and have felt a lot more unwell when I have not been so unwell.

I reread my discharge letter. I know why I was sent to ITU.

My SpO2 was 89%, my HR was 134. My ABG was shocking. My PO2 was 4.8 and PCO2 was 5.3 and lactate was 11 so not a great ABG. My blood glucose was also high and put onto a sliding scale of insulin to bring it back down.

It haunts me this admission. What made it worse was that my parents were all away. It was the one time my mum, dad, step mum and step dad were all away. My uncle came in to see me and as grateful as I was for this it is not the same as your parents.

Getting through that hospital admission shows that I can get through hard hospital admissions but it does not make them any less scary or hard to deal with.

Im glad I can write about it. It has taken a while and other than posts where I remember people like Dawn, Rusty or others who have died it is one of the few times I have cried remembering what happened and crying while writing a post. I am glad I have done it. I hope by doing it that I won’t be haunted by the memories anymore.

I am sure there will be more difficult admissions which will challenge my strength and coping ability but will take it one at a time.