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Airway Notes

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  1. Airway Notes A review of the Literature Weingart, Levitan Annals of EM Mar 2012 Weingart et al Annals of EM Apr 2015

  2. Goals of Preoxygenation • SpO2 of 100% • Denitrogenate lungs and blood • Delay desaturation as long as possible • Note: Does nothing for hypercapnea though

  3. Preoxygenation • Steep portion of deoxygenation curve happens at SpO2 of 88 – 90% • Desaturation occurs at 45 – 60 secs, for pt on RA after RSI. • Standard “non breather” at 15 L/min only gives FiO2 60 – 70% • With BVM get best seal with 2 hands

  4. Preoxygenation • Maximal tidal volume (8 full inhale/exhale) or 3 mins with normally breathing cooperative pt • NIPPV can delay deoxygenation in critical patients who are shunting.

  5. Preoxygenation • Consider PEEP valve on BVM or CPAP/BiPAP if SpO2<93-95% during preoxygenation • Elevate HOB 25 -30˚ or reversetrendelenburgand look at “ear to sternal notch” alignment

  6. Preoxygenation • Critically ill/injured pt’s will desaturate more quickly – due to R to L shunting • Shunt = oxygen poor blood returning from lung to heart • NODESAT=Nasal Oxygen During Efforts at Securing a Tube • Apneic Oxygenation • 15L/min – adult • 10L/min – child • 5L/min – infant

  7. Preoxygenation • Positive press ventilation: if SpO2<91-95% with preoxygenation • Caution: use low volume, low rate &PEEP valve recommended • Benefits/Risks: full stomach - ? Vomit or aspirate

  8. Choice of Paralytic • Rocuronium associated with delayed time to desaturation vs. Succinylcholine • Hypothesis – increased oxygen usage due to fasciculation

  9. Bottom Line • Preoxygenation is key to prevent hypoxic complications during RSI • Consider techniques and recommendations discussed

  10. Delayed Sequence IntubationDSI • Prospective study of pt’s who had altered mental status and/or could not be preoxygenated • Poor O2 reserves leads to faster desaturation • Need to preoxygenate with respiratory effort preserved

  11. Delayed Sequence IntubationDSI • Ketamine – 1mg/kg followed by 0.5mg/kg if needed • (Give Ketamine over 30 to 45 secs) • Preoxygenate with HOB at 30˚ • NRB mask or CPAP if needed • Then high flow nasal cannula for apneic oxygenation

  12. Delayed Sequence IntubationDSI • Multiple conditions for intubation • Pt’s with SpO2<93% were able to increase their SpO2 to >93% with DSI • All but one required NIPPV

  13. Delayed Sequence IntubationDSI • Possible complications • Apnea pre paralysis • Vomiting • Cardiac arrest/death • None of these occurred in this study

  14. Delayed Sequence IntubationDSI • Discussion • Authors feel safe to use Ketamine and NIPPV to aid in preoxygenation, as it is a bridge/temporary to intubation • No other sedatives considered due to apnea concerns

  15. Delayed Sequence IntubationDSI • Conclusion • DSI seems safe and effective as long as provider/team are experienced in sedation and airway.

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