Preoxygenation

[EpiEMS]

What's your protocol requirement for preoxygenation and/or apneic oxygenation (if any) prior to and/or during intubation attempts?

What ought it be?

 

[Peak]

We do not have a requirement. Since we have limited resources and extended times before loading in a bus or bird we just bag them up before tubing. We do not have any formal saturation or time requirement, but rather rely on clinician experience.

In the ideal world we would be having a nasal cannula on them at 15 and bag them up first and leave the cannula on during the attempt. I knew of a couple of metro agencies who did this and I never saw their data but it sounded like they had great results.

 

[Carlos Danger]

We do not have a requirement. Since we have limited resources and extended times before loading in a bus or bird we just bag them up before tubing. We do not have any formal saturation or time requirement, but rather rely on clinician experience.

In the ideal world we would be having a nasal cannula on them at 15 and bag them up first and leave the cannula on during the attempt. I knew of a couple of metro agencies who did this and I never saw their data but it sounded like they had great results.

What do you mean by "bag them up"? Are you talking about routinely giving PPV prior to an intubation attempt, or only when sats are low?

 

[Peak]

What do you mean by "bag them up"? Are you talking about routinely giving PPV prior to an intubation attempt, or only when sats are low?

We preoxygenate before any attempt. For us that typically means that one of us is bagging while the other is getting their equipment ready or we are waiting for our RSI drugs to kick in and assisting ventilations in the interim. If they are on a pulse ox and their sats are rising with bagging they we would love to get them into the high 90s before we make an attempt; however often they are not improving with bagging/they have difficult compliance, we are not getting a good pulse ox reading, or we are working a trauma pathway and they are not yet on a pulse ox.

Since we have such a weird combination of very limited resources, pediatrics, significant oncologic disease process, and tend to end up with traumatic injuries it is difficult to have anything resembling a standard policy.

 

[TXmed]

We preoxygenate before any attempt. For us that typically means that one of us is bagging while the other is getting their equipment ready or we are waiting for our RSI drugs to kick in and assisting ventilations in the interim. If they are on a pulse ox and their sats are rising with bagging they we would love to get them into the high 90s before we make an attempt; however often they are not improving with bagging/they have difficult compliance, we are not getting a good pulse ox reading, or we are working a trauma pathway and they are not yet on a pulse ox.

Since we have such a weird combination of very limited resources, pediatrics, significant oncologic disease process, and tend to end up with traumatic injuries it is difficult to have anything resembling a standard policy.

No offense to you sir, but this does not sound like very appropriate preoxygenation procedures. For someone with any kind of respiratory drive NRB+NC for 2-3 minutes is the standard. CPAP for patients with shunt physiology. Or NC +BVM with PEEP valve set at 10-15. If you are consistently bagging patients just for the sake of preox then you're probably increasing risk of aspiration as well as not fully de-nitrogenating. You also make it sound as if pulse ox reading is providers choice.

 

[VFlutter]

NRB @ 15 lpm for patient's with adequate spontaneous respirations then NC @ 10-15 lpm for apneic oxygenation during attempt. If still not adequate then BVM with PEEP after paralyzed. I usually don't do more than a few vital capacity breaths. Terminate attempt when sats drop to 93 or below.

You can also use the BVM w/ PEEP and high flow 02 to mask oxygenate if saturations are low without assisting ventilation.

 

[Peak]

No offense to you sir, but this does not sound like very appropriate preoxygenation procedures. For someone with any kind of respiratory drive NRB+NC for 2-3 minutes is the standard. CPAP for patients with shunt physiology. Or NC +BVM with PEEP valve set at 10-15. If you are consistently bagging patients just for the sake of preox then you're probably increasing risk of aspiration as well as not fully de-nitrogenating. You also make it sound as if pulse ox reading is providers choice.

No offense taken. I didn't say our procedures are ideal, they are a reality of having to pack in supplies in a wilderness environment, and I may have to make the oxygen we carry in last until we can get transport which can be well over an hour. Oxygen is a very limited resource for us.

We have a lot of clinician discretion in our protocols, and if I need to secure a failed airway before putting them on a pulse ox then yes we are supported by our medical directors and protocols.

 

[Tigger]

As a note, I recently learned that most EtCO2 cannulas do not have flow rates higher than 6lpm. Which is unfortunate.

 

[Underoath87]

We’re supposed to preoxygenate with a high flow nasal cannula (the basic cannula, not the capno cannula) and a NRB.

 

[Carlos Danger]

What's your protocol requirement for preoxygenation and/or apneic oxygenation (if any) prior to and/or during intubation attempts?

What ought it be?

In a spontaneously breathing patient, breathing the highest fi02 reasonably possible for at least 3 min prior to the intubation attempt.

I'm not personally sold yet that using NC during the intubation helps in the patients we are most likely to need it to help with, but it may help and isn't going to hurt, so I think it is probably a good practice.

Positive pressure ventilation should always be avoided unless absolutely necessary. That is, in fact, the entire point of RSI.

 

[EpiEMS]

CPAP for patients with shunt physiology

Oh, I like that! I haven't ever seen that, myself.

Positive pressure ventilation should always be avoided unless absolutely necessary. That is, in fact, the entire point of RSI.

Can you explain that a bit further, the RSI bit?

 

[Carlos Danger]

Can you explain that a bit further, the RSI bit?

The RSI technique of facilitating intubation was adapted from other anesthesia induction techniques for the sole purpose of minimizing the risk of aspiration in non-NPO patients, since it was recognized as such a problem. The defining aspects of an RSI vs. a basic IV induction are minimizing the time that the patient's airway is unprotected (hence the "rapid" part), and NOT providing positive pressure ventilation of the unprotected airway unless absolutely necessary, since one of the most reliable ways to cause pulmonary aspiration is to pump air into the stomach when it is full of food when the patient's natural airway reflexes have been abolished.

The technique initially required the patient to be placed in a steep head-down position, so that if the patient did vomit, gravity would not pull the vomitus into the trachea. Before long, that aspect of the technique was abandoned due to both its impracticality and the adoption of Dr. Sellick's namesake maneuver.

 

[EpiEMS]

@Remi, thanks for explaining.

For emergent intubations of (for now) spontaneously breathing patients in the hospital setting, what's your go-to preoxygenation technique? High flow NC + NRB?

 

[CANMAN]

@Remi, thanks for explaining.

For emergent intubations of (for now) spontaneously breathing patients in the hospital setting, what's your go-to preoxygenation technique? High flow NC + NRB?

In my facility it's either NRM plus NC, or BiPAP if patient warrants it.

 

[Carlos Danger]

@Remi, thanks for explaining.

For emergent intubations of (for now) spontaneously breathing patients in the hospital setting, what's your go-to preoxygenation technique? High flow NC + NRB?

In the OR it’s easy, because our anesthesia breathing circuits are circle systems that allow for rebreathing of expired gas, which results in very high Fi02 at low gas flow rates, and we can very easily adjust PEEP.

Outside the OR, it just depends on what is readily available and the needs of the patient. It can be much more difficult than you would think to get a NRB, for instance.

 

[VFlutter]

It can be much more difficult than you would think to get a NRB, for instance.

I bet the majority of providers out there think they have a NRB when in reality it is a partial-rebreather. Especially in the hospital setting.

 

[EpiEMS]

I bet the majority of providers out there think they have a NRB when in reality it is a partial-rebreather. Especially in the hospital setting.

Wait, so they think that the mask with the open holes on the side and no one way valve is a "non-"rebreather?

 

[Carlos Danger]

Wait, so they think that the mask with the open holes on the side and no one way valve is a "non-"rebreather?

In my hospital, anesthesia usually only gets called for intubations that are emergent and/or anticipated to be difficult. Usually it's an obese medical patient who has been slowly decompensating on CPAP for hours, and they aren't going to get any more oxygenated than they already are, so pre-oxygenating is kind of a moot point.

But more to your question……in most (or maybe all) areas of my hospital, only one facemask (a simple FM) and one type of nasal cannula is readily available. If I were to ask for a non-rebreather mask, or ask for a nasal cannula for a patient who is already wearing a mask, my request would be met with utter confusion and there's a good chance I'd be brought something that I didn't ask for.

It's easy to imagine that hospitals are filled with resources and supplies and that scenarios such as unplanned intubations are well-organized and efficient affairs. I'm sure that's the case somewhere, but not at all where I work now, nor in many other places I've seen.

 

[Peak]

It's easy to imagine that hospitals are filled with resources and supplies and that scenarios such as unplanned intubations are well-organized and efficient affairs. I'm sure that's the case somewhere, but not at all where I work now, nor in many other places I've seen.

There are some places that are well equipped, in our ED we keep glidscopes with blades size 0-4, adult and pediatric bronchoscopes, heated/humidified high flow, CPAP/BiPAP, pneumatic transport vents, electronic transport vents, the standard hospital style vents, jet vents, flow inflating green bags, self inflating bags, size 00 through 6 masks, commercial cric kits, OR surgical airway trays, size 00 through 4 miller blades, 3 and 4 mac blades, 2.0-8.5 mm et tubes, 0-6 LMAs, and all of the other accoutrements that go with it.

There are some things that we don't have either by choice or circumstance. We don't stock kings or other bailout airways besides LMAs, but we haven't dropped an LMA in years so I doubt we ever will buy anything else. There has been a push from the 911 EMS side of our system to transition towards igels, I doubt we will buy them for our ED, our neonatal and high risk OB transport teams don't want them (the two EMS/transport teams based our of our hospital) and the bean counters will say the cost isn't justified. I wish we had the oxymasks, I had them in a prior system and they are great for kids but our inpatient side thinks that they do not have an accurate flow rate. If we are going to CPAP or BiPAP anyone smaller than the small adult mask size then we have to hold the anesthesia style masks ourselves until RT can bring down the correct setup from the PICU, but that is usually only 5-10 minutes.

I have been to some EDs and been shocked at how little airway supplies they have available, my field team is better stocked than some EDs from an airway standpoint (and we are pretty sparse). I would pare down our bags of some things if it wasn't for state regulations (I would rather have a set of masks and a 1 liter flow inflating bag than the EMS CPAP setups for example). I think that some EDs and hospitals as a whole think that not having a resource is okay, and that if they used all of the tools available then poor outcomes are just a result of circumstance and not a problem.

 

[Carlos Danger]

There are some places that are well equipped, in our ED we keep glidscopes with blades size 0-4, adult and pediatric bronchoscopes, heated/humidified high flow, CPAP/BiPAP, pneumatic transport vents, electronic transport vents, the standard hospital style vents, jet vents, flow inflating green bags, self inflating bags, size 00 through 6 masks, commercial cric kits, OR surgical airway trays, size 00 through 4 miller blades, 3 and 4 mac blades, 2.0-8.5 mm et tubes, 0-6 LMAs, and all of the other accoutrements that go with it.

Well yeah, that's all basic stuff in any trauma center or tertiary facility ED. Our ED has most of that stuff (minus the bronchoscopes). But on the medical / surgical floor in a rural 30-bed hospital…..not so much.