# OPA Use



## Supermannnnnnn (Nov 3, 2014)

Quick question.  Would it be appropriate to use a OPA on an unresponsive patient but not place them on any supplemental oxygen if they were breathing adequately and had good sats?  What are your guys thoughts?


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## OnceAnEMT (Nov 3, 2014)

I may be wrong, but I've never heard of someone breathing on their own with an OPA on board. That said, NRB at minimum if an OPA is indicated, and I've got the BVM sitting at the ear.


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## gotbeerz001 (Nov 3, 2014)

SpO2 is not sufficient for the unconscious pt in my mind. I have simply placed an OPA on an unconscious pt (OD, ETOH etc) and monitored ventilatory performance based on ETCO2 and SPO2. 

If airway can be maintained with positioning and a simple adjunct and pt has adequate ventilatory performance, then we are good.


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## Supermannnnnnn (Nov 5, 2014)

Thanks for the replies.  Thinking about it now if a patient is ventilating and oxygenating appropriately they probably don't need an opa.  A NPA and recovery position would probably do just fine.


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## gnosis (Nov 7, 2014)

For a nonresponsive pt, I would have no problem placing an OPA in case their airway deteriorated. If they don't need ventilations, don't ventilate. Airway and breathing interventions don't have to come together.


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## Tigger (Nov 7, 2014)

Alternatively you might stimulate their gag and cause them to vomit unnecessarily...


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## EpiEMS (Nov 7, 2014)

NPA? Sure, probably not going to cause a problem. OPA? Probably not.


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## gnosis (Nov 7, 2014)

Which is why we only put OPAs in unresponsive patients.


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## Tigger (Nov 8, 2014)

Errr unresponsive patients still have the ability to gag and/or vomit.


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## Nightmare (Nov 8, 2014)

I believe standard practice is to use the least invasive airway possible if the patient is able to ventilate on their own (if they are snoring or breathing normally but are unresponsive) so if an NPA secures the airway properly for you then that is what you use, now if they aren't breathing, you need an open airway that you can force air down...OPA or intubation. Also keep in mind the average human breathes primarily through their nose...so an NPA might better serve you when securing the airway.


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## NomadicMedic (Nov 8, 2014)

Nightmare said:


> I believe standard practice is to use the least invasive airway possible if the patient is able to ventilate on their own (if they are snoring or breathing normally but are unresponsive) so if an NPA secures the airway properly for you then that is what you use, now if they aren't breathing, you need an open airway that you can force air down...OPA or intubation. Also keep in mind the average human breathes primarily through their nose...so an NPA might better serve you when securing the airway.




Use the airway that allows you to provide effective ventilation. The choice is also easier with some experience. After you use a few, you'll know which to grab.  I tend to only use an OPA in a cardiac arrest, simply because those folks have zero gag. If you're providing BVM ventilation, you're going to want all the help you can get, so use an OPA and a couple of NPAs. Bagging an opiate OD? Use an NPA until the Narcan works, then pull it. 

Also, the idea that an NPA is a better choice because "adults primarily breathe through their nose" is false. Infants are obligate nose breathers, but ventilating any human via the oropharynx is effective and acceptable. (Unless, of course, it's impossible due to trauma or obstruction... But in that case, you've got other, more pressing problems.)


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## grind time medic (Nov 17, 2014)

yes, you can place an OPA and if tolerated (not gagging or vomiting) not give o2. The OPA is establishing the way for the ambient o2 a path to be brought into the lungs by the muscilature of the chest. The debate about NPA and OPA in a unresponsive patient is more about preference (how the patient is cared for) than principle (what is true for all patients to see improvement or survive).


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## Tigger (Nov 17, 2014)

Err there are definitely times when certain airway adjuncts are more preferable than others, and it's not a matter of a preference. If you anticipate that someone is going to regain their gag, you should not be placing an OPA.

Not to mention that it's rather rare for someone to be unconscious enough to not be able to maintain their airway and require an adjunct but not ventilation. Sure it couldhappen, but that is not a likely event.


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## gronch (Nov 17, 2014)

Leaving the O2 part out of the equation, is there research on whether 2 NPAs and 1 OPA improves respiration?


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## jwk (Nov 17, 2014)

gronch said:


> Leaving the O2 part out of the equation, is there research on whether 2 NPAs and 1 OPA improves respiration?


Using 2 NPA's and an OPA is pointless.


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## cprted (Nov 17, 2014)

And as a reminder, OPAs and NPAs are airway adjuncts, they help us manage the airway, they don't do it for us.  In many cases, even with an OPA or NPA in place, you still have to maintain a jaw thrust or head-tilt/chin lift to keep the airway open.  There are some good CT images of airway use and the difference in various techniques, I'll see if I can find them.


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## Tigger (Nov 17, 2014)

jwk said:


> Using 2 NPA's and an OPA is pointless.


That is our new passive oxygenation protocol, though I cannot find any research to support using three adjuncts.


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## EpiEMS (Nov 17, 2014)

Tigger said:


> That is our new passive oxygenation protocol, though I cannot find any research to support using three adjuncts.



If one is good, two is better, and three fills up all the holes?

In all seriousness, if I'm running a BLS arrest with enough personnel, and there's good ventilation with BVM + OPAwith supplemental O2, good CPR in progress, and an AED attached, I don't see why *not* to stick in an extra NPA...

If it's respiratory distress, but the patient is conscious and being BVM'ed, why not double up on the NPAs, assuming they're tolerated? (I realize "why not" isn't necessarily evidence based -- on the other hand, I can't imagine that any harm would occur...)


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## Clare (Nov 18, 2014)

jwk said:


> Using 2 NPA's and an OPA is pointless.



I've seen a patient with two NPAs and an OPA in situ - it's called the hedgehog look! 

Also, whatever adjunct you have won't improve _respiration; _it will (hopefully!) improve _oxygenation.  _In the short term sub optimal _ventilation_ can be tolerated provided that the _oxygenation _is satisfactory.  And as a timely remind, oxygenation and ventilation are *not* the same thing.


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## gotbeerz001 (Nov 18, 2014)

Clare said:


> I've seen a patient with two NPAs and an OPA in situ - it's called the hedgehog look!
> 
> Also, whatever adjunct you have won't improve _respiration; _it will (hopefully!) improve _oxygenation.  _In the short term sub optimal _ventilation_ can be tolerated provided that the _oxygenation _is satisfactory.  And as a timely remind, oxygenation and ventilation are *not* the same thing.


Which is why ETCO2 waveform capnography is so beneficial. It can show whether pt is adequately ventilating or needs intervention.


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## Tigger (Nov 18, 2014)

EpiEMS said:


> If one is good, two is better, and three fills up all the holes?
> 
> In all seriousness, if I'm running a BLS arrest with enough personnel, and there's good ventilation with BVM + OPAwith supplemental O2, good CPR in progress, and an AED attached, I don't see why *not* to stick in an extra NPA...
> 
> If it's respiratory distress, but the patient is conscious and being BVM'ed, why not double up on the NPAs, assuming they're tolerated? (I realize "why not" isn't necessarily evidence based -- on the other hand, I can't imagine that any harm would occur...)


I understand the logic with passive oxygenation since no one is actively managing the airway, but I still wonder how effective three adjuncts actually are. As said, it's not like any of them negate the need to open airway with proper positioning when you're actively ventilating someone.


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## jwk (Nov 18, 2014)

If you're using multiple airways, you're simply trying to make up for the fact that your BVM technique is poor.  It simply isn't necessary.  If you have an unconscious patient, and can't ventilate with just the BVM, stick an oral airway in and ventilate.  Still can't ventilate?  Why not?  You have an oral airway in - you should be ventilating - sooooo...either your mask seal is poor or your oral airway has pushed the tongue in the back of the pharynx because you've placed it incorrectly or it's the wrong size.  Fix the problem - adding an additional "airway" is not the solution.

Similarly - an appropriately sized nasal airway is plenty big all by itself.  The 7.0 ETT's I place every day are smaller than a lot of nasal airways.  I don't place two ETT's to get better ventilation, and you shouldn't need two nasal airways.  Why are you not ventilating adequately with a nasal airway?  Too small a diameter or not long enough to get in the posterior pharynx?  Or crappy BVM technique?  Fix the problem.

OAW's are probably better for unconscious patients because you know (if you use the correct size) that the tongue is out of the way.  I simply don't place nasal airways in my unconscious patients for that reason.


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## ERDoc (Nov 18, 2014)

I have to agree with jwk, if you are doing it right, there is no need for multiple airways.  Putting in nasals when you have a good oral airway is not going to add anything.


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## Tigger (Nov 18, 2014)

This is for passive oxygenation with a non-rebreather during the early stages of presumed non-respiratory arrests...


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## OnceAnEMT (Nov 18, 2014)

Is there a negative to inserting 2 NPAs and an OPA, as long as other tasks aren't being delayed? There are often too many people on the scene of a code, and any EMR+ can drop an adjunct. The way Evidence Based Medicine works is you can do it until proven otherwise as long as it doesn't have a negative effect on the patient.


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## EpiEMS (Nov 18, 2014)

Tigger said:


> I understand the logic with passive oxygenation since no one is actively managing the airway, but I still wonder how effective three adjuncts actually are. As said, it's not like any of them negate the need to open airway with proper positioning when you're actively ventilating someone.



I don't disagree at all, I would totally question if there's incremental improvement, as well. That being said, it is plausible that there could be a benefit, no?


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## Tigger (Nov 18, 2014)

For sure, and I will continue to do as my medical direction wishes, which is two NPAs and an OPA along with an NRB until the patient is intubated.


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## Gurby (Nov 18, 2014)

jwk said:


> If you're using multiple airways, you're simply trying to make up for the fact that your BVM technique is poor.  It simply isn't necessary.  If you have an unconscious patient, and can't ventilate with just the BVM, stick an oral airway in and ventilate.  Still can't ventilate?  Why not?  You have an oral airway in - you should be ventilating - sooooo...either your mask seal is poor or your oral airway has pushed the tongue in the back of the pharynx because you've placed it incorrectly or it's the wrong size.  Fix the problem - adding an additional "airway" is not the solution.
> 
> Similarly - an appropriately sized nasal airway is plenty big all by itself.  The 7.0 ETT's I place every day are smaller than a lot of nasal airways.  I don't place two ETT's to get better ventilation, and you shouldn't need two nasal airways.  Why are you not ventilating adequately with a nasal airway?  Too small a diameter or not long enough to get in the posterior pharynx?  Or crappy BVM technique?  Fix the problem.
> 
> OAW's are probably better for unconscious patients because you know (if you use the correct size) that the tongue is out of the way.  I simply don't place nasal airways in my unconscious patients for that reason.





ERDoc said:


> I have to agree with jwk, if you are doing it right, there is no need for multiple airways.  Putting in nasals when you have a good oral airway is not going to add anything.



I really appreciate you both sharing your time and experience with us - thanks!


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## gotbeerz001 (Nov 18, 2014)

ERDoc said:


> I have to agree with jwk, if you are doing it right, there is no need for multiple airways.  Putting in nasals when you have a good oral airway is not going to add anything.


The OP question did not include assisted ventilations; it was simply whether or not an adjunct and SpO2 alone was sufficient for an unresponsive pt with (seemingly) adequate ventilations.


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## ERDoc (Nov 18, 2014)

Sorry about that.  I was just trying go through some posts while at work and didn't have a chance to go back to the OP.


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## gotbeerz001 (Nov 18, 2014)

ERDoc said:


> Sorry about that.  I was just trying go through some posts while at work and didn't have a chance to go back to the OP.


Your information is great, just wanted to make sure we're on the same page.


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## ERDoc (Nov 19, 2014)

Obviously one of us was on the wrong page (that would be me). To actually address to OPs question, a pt that needs/tolerates doesn't necessarily need supplemental oxygen.  An OPA doesn't improve oxygenation/ventilation, it improves your ability to oxygenate/ventilate.  If you place an OPA and the pt can oxygenate/ventilate adequately then oxygen isn't going to add anything (unless you want to argue that it will provide preoxygenation in case you need to RSI) but in the short term, it won't hurt either.


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## jwk (Nov 20, 2014)

Grimes said:


> Is there a negative to inserting 2 NPAs and an OPA, as long as other tasks aren't being delayed? There are often too many people on the scene of a code, and any EMR+ can drop an adjunct. The way Evidence Based Medicine works is you can do it until proven otherwise as long as it doesn't have a negative effect on the patient.


That is NOT the definition of evidence-based medicine.


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## jwk (Nov 20, 2014)

Tigger said:


> For sure, and I will continue to do as my medical direction wishes, which is two NPAs and an OPA along with an NRB until the patient is intubated.


Please let your medical director know I don't think he knows what he's talking about.


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## TransportJockey (Nov 20, 2014)

jwk said:


> Please let your medical director know I don't think he knows what he's talking about.


actually passive oxygenation is an idea that is gaining traction in the anesthesia field
And heres a study showing a possible increase of benefit in ohca for witnessed arrests
http://www.resuscitationjournal.com...cle/S0300-9572(12)00792-7/fulltext?mobileUi=1


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## triemal04 (Nov 20, 2014)

TransportJockey said:


> actually passive oxygenation is an idea that is gaining traction in the anesthesia field
> And heres a study showing a possible increase of benefit in ohca for witnessed arrests
> http://www.resuscitationjournal.com/article/S0300-9572(12)00792-7/abstract#/article/S0300-9572(12)00792-7/fulltext?mobileUi=1


It's not that passive oxygenation (or apneic oxygenation in a different situation) doesn't work, but do you really need all those different adjuncts for it to work?  Excluding some specific situations, probably not.  Proper positioning along with either an OPA or NPA should usually be all that is required.  

Did you read the full text of that link?


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## TransportJockey (Nov 20, 2014)

triemal04 said:


> It's not that passive oxygenation (or apneic oxygenation in a different situation) doesn't work, but do you really need all those different adjuncts for it to work?  Excluding some specific situations, probably not.  Proper positioning along with either an OPA or NPA should usually be all that is required.
> 
> Did you read the full text of that link?


Yea I just must-read the thread. I thought that the poster was taking about the nrb not the adjuncts


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## jwk (Nov 20, 2014)

TransportJockey said:


> Yea I just must-read the thread. I thought that the poster was taking about the nrb not the adjuncts


That article was basically worthless.  Pure speculation.  Sorry.


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## OnceAnEMT (Nov 20, 2014)

jwk said:


> That is NOT the definition of evidence-based medicine.



I never said it was the definition of EBM. I said it was an aspect of it. For example, in sports medicine the use of cryotherapy as a treatment modality for acute injuries is considered "inconclusive" by the NATA because of lack of sufficient evidence supporting the therapeutic and physiological effects. However, because it is not shown to have negative effect in those who lack specific cold-related conditions, we still do it anyway. All. The. Time.

I won't say for certain because I haven't been through pharmacology nor done additional research, but I believe I have seen on this forum the argument of epinephrine perhaps not being the most efficient vasopressor in cardiac arrest. We still push it though.

Another analogy. Spine boards require a bear minimum of 3 body straps. Let's say an airway requires 1 adjunct. Whats wrong with me placing 4, 5, 6 straps? What about a 2nd and 3rd adjunct? At no point in either case am I going out of my scope, voiding manufacturer instructions, or committing a tort. If anything, it will improve patient outcome. 

I don't think anyone is necessarily arguing that having all 3 adjuncts on board instead of 1 is more effective, but it certainly won't be a negative thing, so why not?


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## Tigger (Nov 21, 2014)

triemal04 said:


> It's not that passive oxygenation (or apneic oxygenation in a different situation) doesn't work, but do you really need all those different adjuncts for it to work?  Excluding some specific situations, probably not.  Proper positioning along with either an OPA or NPA should usually be all that is required.
> 
> Did you read the full text of that link?


I have no idea if the adjuncts help or not. I am not sure they do anything considering that no one is assigned to properly position the airway during an arrest under the current protocol. Inserting OPA =/= airway positioning, as I'm sure most are aware. I am not sure if the thought behind the three adjuncts is that this will somehow alleviate positioning issues. I think sometimes people give themselves too much credit and draw inappropriate conclusions from the research at hand.


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## jwk (Nov 21, 2014)

Grimes said:


> I never said it was the definition of EBM. I said it was an aspect of it. For example, in sports medicine the use of cryotherapy as a treatment modality for acute injuries is considered "inconclusive" by the NATA because of lack of sufficient evidence supporting the therapeutic and physiological effects. However, because it is not shown to have negative effect in those who lack specific cold-related conditions, we still do it anyway. All. The. Time.
> 
> I won't say for certain because I haven't been through pharmacology nor done additional research, but I believe I have seen on this forum the argument of epinephrine perhaps not being the most efficient vasopressor in cardiac arrest. We still push it though.
> 
> ...



So one is good, two must be better, three even better, since you don't think there's a reason not to do it?  That's your idea of "evidence based medicine"?


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## Carlos Danger (Nov 21, 2014)

Grimes said:


> For example, in sports medicine the use of cryotherapy as a treatment modality for acute injuries is considered "inconclusive" by the NATA because of lack of sufficient evidence supporting the therapeutic and physiological effects. However, because it is not shown to have negative effect in those who lack specific cold-related conditions, we still do it anyway. All. The. Time.
> 
> I won't say for certain because I haven't been through pharmacology nor done additional research, but I believe I have seen on this forum the argument of epinephrine perhaps not being the most efficient vasopressor in cardiac arrest. We still push it though.
> 
> Another analogy. Spine boards require a bear minimum of 3 body straps. Let's say an airway requires 1 adjunct. Whats wrong with me placing 4, 5, 6 straps? What about a 2nd and 3rd adjunct? At no point in either case am I going out of my scope, voiding manufacturer instructions, or committing a tort. If anything, it will improve patient outcome.



First of all, I don't think pointing to other evidence-less practices is a good strategy for justifying a given evidence-less practice.

Secondly, you have to understand that there is no such thing as a risk-free medical intervention. 

Do you always place 2 IV's in every patient? 3 IV's? a 12-lead? Why not? 

Placing an airway adjunct is not a benign procedure. Do you know for sure that patient you want to put a second NPA in has no coagulopathy? That they aren't on anticoagulants? Is there really no chance at all that the OPA will stimulate a vagal response, or vomiting? 

Airway trumps all. If for some reason you NEED 2 or 3 adjuncts to ventilate, so be it.

But if you are ventilating just fine on just an OPA, or on just 1 NPA, then you really should leave it alone.


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## Tigger (Nov 22, 2014)

I guess my current question is how much do adjuncts help if you are not actively ventilating someone but rather slapping a mask on them and leaving them alone?


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## Carlos Danger (Nov 22, 2014)

Tigger said:


> I guess my current question is how much do adjuncts help if you are not actively ventilating someone but rather slapping a mask on them and leaving them alone?



Potentially a lot, it just depends on the patient and how obtunded they are. Many people suffer some degree of airway obstruction when relaxed, in some cases a very high degree of obstruction. Usually good head positioning will alleviate it, but that requires constant maintenance.....and even in that case an adjunct will often make it easier.

Chest wall movement in a breathing patient doesn't necessarily mean they are exchanging air well....can you see fogging inside the 02 mask? Can you feel air movement if you place your hand an inch or so from their mouth and nose? Do you have an Etc02 waveform? If yes to all of those, you probably don't need an adjunct. But personally I think a good rule of thumb whenever you are concerned about your patient's ventilatory status is to always use an OPA or NPA if they will tolerate it.


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## triemal04 (Nov 22, 2014)

jwk said:


> So one is good, two must be better, three even better, since you don't think there's a reason not to do it?  That's your idea of "evidence based medicine"?


For a lot of people that's probably not far off.  It's a lot easier to do something because "it won't be a negative thing, so why not" rather than consider why you are doing something and what effect, if any, it will have, both immedietly, and down the road.


Tigger said:


> I guess my current question is how much do adjuncts help if you are not actively ventilating someone but rather slapping a mask on them and leaving them alone?


Probably helps a bit; if this is during a CPR (or CCR I suppose) an OPA would ensure that the tongue doesn't block anything, but then I don't know how much it would matter with the passive flow of O2.  I think using 3 is overkill and I can't imagine there would be any benefit over just using an OPA; add in someone adjusting the head and really don't think it'd help.


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## Carlos Danger (Nov 22, 2014)

triemal04 said:


> For a lot of people that's probably not far off.  It's a lot easier to do something because "it won't be a negative thing, so why not" rather than consider why you are doing something and what effect, if any, it will have, both immedietly, and down the road.
> 
> Probably helps a bit; if this is during a CPR (or CCR I suppose) an OPA would ensure that the tongue doesn't block anything, *but then I don't know how much it would matter with the passive flow of O2.*  I think using 3 is overkill and I can't imagine there would be any benefit over just using an OPA; add in someone adjusting the head and really don't think it'd help.



In passive oxygenation, relief of obstruction matters just as much as with positive pressure ventilation, possibly more.


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