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Airway Notes

This review explores the goals and techniques of preoxygenation in airway management, including the use of nasal oxygen, positive pressure ventilation, and delayed sequence intubation. It highlights the importance of preoxygenation in preventing hypoxic complications during rapid sequence intubation.

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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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