OPA Use

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...)
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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.
 
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.
 
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.
 
This is for passive oxygenation with a non-rebreather during the early stages of presumed non-respiratory arrests...
 
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.
 
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.
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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?
 
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.
 
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.
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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.
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I really appreciate you both sharing your time and experience with us - thanks!
 
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.
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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.
 
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.
 
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.
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Your information is great, just wanted to make sure we're on the same page.
 
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.
 
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.
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That is NOT the definition of evidence-based medicine.
 
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.
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Please let your medical director know I don't think he knows what he's talking about. ;)
 
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
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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?
 
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?
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Yea I just must-read the thread. I thought that the poster was taking about the nrb not the adjuncts
 
jwk said:
That is NOT the definition of evidence-based medicine.
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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?
 
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?
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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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