* Replace Cannulas and Hoses Often

People are put on oxygen for many different reasons but the most common are for COPD, heart disease, and congestive heart failure.
Don’t depend on your oxygen supply company for general maintenance of your oxygen equipment. Take responsibility for your own health or that of a loved one. Depending on a supply company to keep track of when your oxygen hoses and cannulas need replacing can turn in to a life threatening situation.
Mom might have avoided a whole chain of events that ended up putting her in the hospital if only her oxygen hoses had been replaced.
Oxygen hoses and cannulas can be affected by many different things; dust particles can build up, moisture buildup due to humidity or the oxygen tank humidifier, kinks in the line, small punctures, etc.
Oxygen hoses should be replaced at least every six weeks, more often depending on the weather and environment. Cannulas should be replaced at least once a month. I recommend they be changed every two or three weeks. A cannula goes in your nose. It can be a breeding ground for bacteria. Replace it often. Regularly clean or replace the oxygen tank humidifier cup. It’s also a breeding ground for bacteria that can dislodge directly into your oxygen supply. Be sure to use distilled water so mineral deposits don’t build up and clog hoses and adapters.
It’s the oxygen supply company’s responsibility to provide these items. Don’t let them talk you in to a longer schedule. Also, have the oxygen supply company check the air flow and pressure all the way to the end of the hose. The delivery people usually carry a very small portable test device that effectively tests these functions.
A good way to remember to replace these items is to put a reminder note on your calendar. I added a scheduled event on my computer calendar. Whenever the reminder popped up on my screen I would call Mom to let her know it was time for a replacement. Because this equipment was a trouble area for Mom, I scheduled the hoses to alert me every 4 weeks and the cannulas popped up every 2 weeks. By using the calendar as a reminder tool we no longer had problems with these simple but critical items.
One last bit of advice. When your nose is dry from the constant oxygen flow, be sure to use only the lubricating cream provided by the oxygen supply company. Under no circumstances should you use petroleum based products such as Vaseline or generic petroleum jelly. These products are flammable, a dangerous combination with oxygen. They can also cause a breakdown and deterioration in the plastic material that cannulas are made of.

* Congestive Heart Failure

Written 08/11/2006 – 09/10/2006

Mom checked herself into the hospital again because of extreme weakness and trouble breathing. It turns out her blood oxygen level was dangerously low.

Here I have included updates to my family and friends so that you might understand the roller coaster ride that care givers experience. Hopefully my account will help others to cope and support each other:

Hi All,
Mom was moved to a room on the Physical Therapy floor and started some treatments this afternoon. Basically, they got her on her feet and walking a few steps with a walker, and teaching her how to breath correctly to keep her oxygen level up.
In dealing with all the issues of cancer and COPD, the third disease that she’s had for years has been ignored, that is heart disease. The doctor feels that Mom could be dealing with some heart failure along with everything else. Congestive Heart Failure is not something that I have researched until last night and did not know that it could very well be the cause of her current problems. I thought it strictly affected the heart when in fact it can cause congested lungs, swollen ankles, fatigue, weakness, confusion, a feeling of fullness, loss of appetite, all of which Mom has been experiencing the last few weeks and more so now.
Unless Mom makes some miraculous improvement (she’s surprised us before) the doctor does not anticipate her leaving the hospital without a lot of home care or a nursing home. The doctor has NOT stated this to Mom and neither have I, so DO NOT bring it up in a phone conversation. The doctor does not want to dump too much on her at this stage and just wants to try and get her stronger. I have not talked to the doctor today, but yesterday he was still leaning toward the infection getting her down and only mentioned heart failure as an aside. He feels that if the infection can be cleared up she’ll be able to regain some strength.
So, that’s it for now.
Emily


Hi All,
So, here’s the latest on Mom… Monday afternoon the doctor was talking about possibly moving Mom to a nursing home where he anticipated that she may last a month.
On Tuesday, Mom was then moved to the Physical Therapy floor to see if she could regain some of her strength.
On Wednesday, she seemed to sound stronger and feel a little better, but Emily told me that the nurses wanted to make sure that the family understood the dire condition that Mom was in.
This morning about 10am I talked to the doctor and he was talking about putting Mom back on Hospice, moving her to the hospice floor, and just trying to make her as comfortable as possible. In the course of the conversation he stated that he felt she only had a few days to live. I asked him to clarify his statement since only Monday he had given her a month. He stated that the physical therapists were very concerned that Mom’s oxygen level would drop drastically at the least effort, like just sitting up in a chair. I left work and got to the hospital around 11am. I had just missed the doctor but he had written in her chart to continue physical therapy and a normal diet. To add to the confusion, Mom had both an upper and lower GI done this morning – doesn’t sound like comfort care to me. In addition, Mom devoured her lunch, and looked and sounded better than I’ve seen her in weeks. I got a phone message from the doctor about 1:30pm stating that Mom was eating better, breathing better, feeling better, and moving around better. He said he would talk to me again in a couple of days.
Go figure… Is this Mom doing better just before the end? Possibly. Is this Mom showing us what she’s made of and fighting to get better? Very likely, she has surprised us in the past. Is this a doctor’s hour by hour best guess? Most definitely.
So, now you are as bewildered as I am. Should you come? When should you come? I have no idea. You have to follow your own heart on this one.
Emily


Hi All,
So, it was the doctor’s best guess at the time. I got a message update and then talked to the doctor directly this afternoon. The doctor stated that Mom was doing better yesterday and much better today. He's thinking that she had a very bad day on Wednesday but is now about the same as when she came into the hospital. He is no longer pushing Hospice and morphine, and is back to watching her progress. He said that he might have overreacted yesterday morning since Mom had such a bad day on Wednesday. He plans to leave her were she's at for now and continue the physical therapy to get Mom stronger. She is on an extended stay floor and can be there for 20 days. He does not anticipate her being there that long and is back to his original plan of getting her to where she can go back to her apartment with home help. All good news...
Emily


And then one last email to a friend:

Well, I’ve put this off long enough and I still can’t bring myself to call you, so this will have to do for now.
My Mamma died last Sunday, September 3, 2006. She was in the hospital for two weeks fighting an infection and suffering some heart failure. The doctor “said” that he had both under control. Personally, I think that Mom had been experiencing heart failure for at least a month. Anyway, she went from the hospital into a nursing home for a little over a week but was not gaining any strength back.
My brother had been scheduled to visit Memorial Day weekend and arrived on Saturday morning. My middle sister had been here for about two weeks, and my oldest sister arrived on Thursday before the weekend. So, all of Mom’s kids were here to visit on Saturday. We all had a feeling she was not going to be with us much longer and we each said goodbye in our own way. Sunday morning Mom got out of bed and her heart just gave up. It’s like she said, “I’ve seen you all one more time, now I’m out of here, I’ll see you later”. Official cause of death is Respiratory Failure as a consequence of lung cancer and COPD but I think it was the heart disease that actually took her.

* Morphine and COPD, Deadly Combo

Kaiser also promotes free rein of Morphine administration to their hospice
doctors and nurses:

http://www.kaiserpapers.org/hos.html

* Hospice, Morphine, and COPD

For another perspective on the Mophine / COPD issue, check out what Hospice Patients Alliance has to say:

http://www.hospicepatients.org/no-prn-morphine-copd.html

* Morphine Contraindications

The following is an abbreviated list of Morphine Contraindications. For complete documentation go to:http://www.themediweb.net/pharmacy/Morphine.htm#1

While reading keep in mind that my mom had lung cancer, COPD, heart disease, hypothyroidism, and she was on full time oxygen because of respiratory depression.

Contraindications for use;

Note: Several of the following conditions may be listed under both ‘contraindications for use’ and ‘cautions for use’ as several different products are included under the one heading. Generally the oral preparations have stricter notes on contraindications than the parenteral preparations. The treating physician/surgeon needs to weigh the benefits of treating vulnerable patients with morphine against the risk of harm to the patient caused by using morphine. Morphine can generally be used if extreme caution is employed in tandem with close patient monitoring and dose titration in the patient groups mentioned below.

• Respiratory depression, head injury, chronic obstructive pulmonary disease (COPD), known morphine sensitivity or sensitivity to any of the ingredients of any morphine preparation, acute hepatic disease and concurrent use or use within 2 weeks of discontinuation of a Monoamine Oxidase Inhibitor antidepressant. Oral preparations in general should not be given to patients with paralytic ileus, an acute abdomen or delayed gastric emptying. Sevredol should additionally not be given in pregnancy and to children aged 3 or under. MST should not be used for post-operative pain in children, in lactating mothers or for administration pre-operatively. MXL should not be given in the first day postoperatively and finally sustained release preparations should not be given within 24 hours pre-operatively to patients undergoing a cordotomy or other pain relieving surgery

Cautions for use;

• The dosage should be reduced in the elderly, in those patients with hypothyroidism and in significant renal or hepatic impairment. Continuous infusions are contraindicated in these patients.

• Morphine should also be used with caution in opiate dependant patients, patients with raised intracranial pressure, hypotension with hypovolaemia, pancreatitis, diseases of the biliary tract, inflammatory bowel disorders, prostatic hypertrophy and adrenocorticoid insufficiency, myxoedema, urethral stricture, acute alcoholism or delerium tremens, Addison’s disease, severe kyphoscoliosis or convulsive disorders. Oral sustained release preparations should not be used postoperatively as intestinal motility is affected and should only be used when the physician/surgeon is satisfied that normal bowel motility has been restored.

• Respiratory depression is the chief hazard of all morphine preparations. It occurs more frequently in elderly and debilitated patients and in those suffering from conditions accompanied by hypoxia or hypercapnia when even moderate therapeutic doses may significantly decrease pulmonary ventilation.

• Morphine should be used with extreme caution in patients with COPD or cor pulmonale and in those patients with a substantially decreased respiratory reserve, hypoxia, hypercapnia or pre-existing respiratory depression. In these patients even usual therapeutic doses of morphine may increase airway resistance and decrease respiratory drive to the point of apnoea. Note: Severe pain antagonises the respiratory depressant effects of morphine.

* Morphine and COPD Don't Mix

Written 04/18/2006

Dear Dr. [ ],

FYI pertaining to my Mom:

I believe I’ve identified the very likely cause of my Mom collapsing and ending up in the emergency room for the second time in a week and a half. Here is a record of the chain of events that led up to it.

• Mom came home on Sunday March 19, from an alternative cancer treatment center feeling better than she had in many months, with more energy, and breathing better
• On her way home she had trouble with the altitude in Black Forest but stabilized once she got home to Pueblo.
• Over the week her energy and breathing slowly declined to where on Friday March 24 she checked into the ER and found that her oxygen level was extremely low - in the 50s. Once she was warmed up and on hospital oxygen her level stabilized in the 90s. An X-ray was clear other than expected cancer and COPD – no pneumonia. An EKG came back normal. Once stabilized, she was sent home.
• The oxygen company was called to check out her equipment. The concentrator was checked and calibrated and her oxygen tube was switched to a liquid oxygen tank as a precaution. The tube and canella were not checked or replaced.
• By Saturday April 1 Mom was again feeling a lack of energy and shortness of breath but decided to keep a previously planned shopping trip with a friend. While shopping she was using her portable oxygen unit and started feeling better.
• Sunday morning April 2 Mom was again having a very difficult time breathing and no energy. I had her call the oxygen company and the hospice nurse. The oxygen company said that her tubing was clogged and replaced it along with the canella. The hospice nurse started administering Morphine to help with anxiety and breathing. When I arrived I questioned the Morphine because my Mom was not in pain or had she ever been in pain due to the cancer. I noticed that Mom was breathing through her mouth and repeatedly reminded her to breathe through her nose. After the oxygen company brought a mask at the request of the nurse, Mom’s oxygen level finally stabilized in the 90s. By this time she was pretty well out of it from the Morphine and slept most of the afternoon.
• On Monday April 3 the hospice nurse came by to check on Mom. She administered more Morphine and then left my Mom by herself. My aunt brought dinner for my Mom later and she ate most of it. About 9:30 pm my aunt tried calling Mom and it was busy. Since it is unusual for my Mom to be on the phone at that time of night, my aunt got concerned and went over to her house. She found my Mom collapsed on the floor and only barely conscious. She was taken to the ER where the ER Doctor ordered an X-ray to evaluate her condition but the hospice nurse canceled the order stating that it would not be paid for by Medicare. She was moved to a private room where more Morphine was administered on a regular basis. Albuteral lung treatments were administered, but no tests were ordered to evaluate her true condition.
• Throughout her treatment both at home and at the hospital I continued to question the use of Morphine. On April 5 Mom said that she did not want any more Morphine because of the way it made her feel. At the same time, hospice was discontinued and Dr. Shapiro was called in to take over her care. A Dextrose drip, antibiotics, and a steroid for her breathing were ordered and administered. A blood work and CT scan were also ordered. Mom took a sudden turn for the better.
• Mom was discharged from the hospital on April 8 and has continued to improve on a daily basis.
• On the evening of April 16 we dodged yet another bullet by noticing the oxygen tank was dangerously near empty. The oxygen company was called and the tank was filled.
• Not having any answers as to why Mom collapsed, I began researching all of the medications that Mom was / is taking and found some very disturbing information about Morphine and COPD.

I believe that Mom’s body was already compromised by the two weeks of oxygen level fluctuations and slow oxygen depravation that was then compounded by the Morphine. The night that Mom collapsed it was apparent that she had thrown up due to regurgitated remains of her dinner in the trash can. I feel that the Morphine made her sick and also caused her to pass out and possibly stop breathing for a short time. Continued administration of Morphine in the hospital hindered her recovery progress.

Attached is the information on Morphine that I have based my assumptions on. I know that all this is speculative and behinds us now, but for the future I have advised my Mom to refuse any further administration of Morphine or any of its derivatives.

I ask that you please keep this in mind with other COPD patients so that they do not have to go through the same agonizing experience or worse. I also ask that you make the hospice doctors and nurses aware of this so that they do not just follow standard practice with COPD patients and administer Morphine at the drop of a hat.

Thanks you for your time.