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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
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Goals of Preoxygenation
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SpO2 of 100%
Denitrogenate lungs and blood
Delay desaturation as long as possible
Note: Does nothing for hypercapnea
though
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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
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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.
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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
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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
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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
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Choice of Paralytic
• Rocuronium associated with delayed time
to desaturation vs. Succinylcholine
– Hypothesis – increased oxygen usage due to
fasciculation
July 14, 2017
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Bottom Line
• Preoxygenation is key to prevent hypoxic
complications during RSI
• Consider techniques and
recommendations discussed
July 14, 2017
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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
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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
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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
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Delayed Sequence Intubation
DSI
• Possible complications
– Apnea pre paralysis
– Vomiting
– Cardiac arrest/death
– None of these occurred in this study
July 14, 2017
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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
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Delayed Sequence Intubation
DSI
• Conclusion
– DSI seems safe and effective as long as
provider/team are experienced in sedation
and airway.
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