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Airway Notes A review of the Literature Weingart, Levitan Annals of EM Mar 2012 Weingart et al Annals of EM Apr 2015 July 14, 2017 1 Goals of Preoxygenation • • • • SpO2 of 100% Denitrogenate lungs and blood Delay desaturation as long as possible Note: Does nothing for hypercapnea though July 14, 2017 2 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 July 14, 2017 3 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. July 14, 2017 4 Preoxygenation • Consider PEEP valve on BVM or CPAP/BiPAP if SpO2<93-95% during preoxygenation • Elevate HOB 25 -30˚ or reverse trendelenburg and look at “ear to sternal notch” alignment July 14, 2017 5 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 July 14, 2017 6 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 July 14, 2017 7 Choice of Paralytic • Rocuronium associated with delayed time to desaturation vs. Succinylcholine – Hypothesis – increased oxygen usage due to fasciculation July 14, 2017 8 Bottom Line • Preoxygenation is key to prevent hypoxic complications during RSI • Consider techniques and recommendations discussed July 14, 2017 9 Delayed Sequence Intubation DSI • 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 July 14, 2017 10 Delayed Sequence Intubation DSI • 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 July 14, 2017 11 Delayed Sequence Intubation DSI • Multiple conditions for intubation • Pt’s with SpO2<93% were able to increase their SpO2 to >93% with DSI – All but one required NIPPV July 14, 2017 12 Delayed Sequence Intubation DSI • Possible complications – Apnea pre paralysis – Vomiting – Cardiac arrest/death – None of these occurred in this study July 14, 2017 13 Delayed Sequence Intubation DSI • 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 July 14, 2017 14 Delayed Sequence Intubation DSI • Conclusion – DSI seems safe and effective as long as provider/team are experienced in sedation and airway. July 14, 2017 15