We've spoken a ton on EMCrit on Apneic Oxygenation and Preoxygenation, well here is some more. Nick Caputo and his Lincoln Airway Group did an amazing trial of ApOx in the ED. Rory recently wrote about it and there have been some amazing posts around the FOAM world as well (see Rory's post). Now I weigh in with my take and a discussion of my new thoughts on PreOx.
Three Items to Read
Also See
Should we use Nasal Cannula?
I think yes, because:
- ApOx will still probably benefit some patients (probably those without sig. physiological shunt or those whom you have recruited)
- Makes BVM mask leaks better
- Allows apneic CPAP with the devices below
Why Doesn't It Work in this RCT?
- Great Preox
- Not Enough Potential for Sig. Desat due to rapidity and ease of intubation
- THRIVE NC is Different than Standard
- Physiologic Shunt-Shunt Fraction would be a great thing to know to interpret these studies
What Should be on the Patient's Face just prior to Induction
choose one:
- Vent as Bag with BVM Mask
- Oxylator with BVM Mask
- BiPAP Machine with BVM Mask
- Ultimate BVM with PEEP Valve, Pressure Gauge
All of the above should have a NC @ >15 lpm and ETCO2 capnography
Why not the Mapleson C (or similar)? I'd like a pressure gauge on that badboy to track each breath
Update
Ivan Pavlov updated the tables from our MA (Am J Emerg Med. 2017 Aug;35(8):1184-1189) to include the Caputo trial:
Additional Articles of Interest
- Narrative review of ApOx in Anesthesia realm (PMID 28050802)
Update
Peter Young Sent me this interesting poster on THRIVE and Pressure
Additional New Information
More on EMCrit
- Preoxygenation, Reoxygenation and Deoxygenation(Opens in a new browser tab)
- EMCrit – When it comes to Preintubation Terminology we stink like POO(Opens in a new browser tab)
- Wee – What the heck is a Mapleson B Circuit and Why You Probably Shouldn't Care(Opens in a new browser tab)
- Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Oxylators can backfire easily in severely dyspneic/anxious patients who breath at much more than the max flow rate of 30L/min that the device allows. In Québec, they are widely used in prehospital setting in lieu of a CPAP. In our ED, the first step to treat resp. failure is to take off the Oxylator. Around 1/3 of patients get better immediately even while breathing room air. BVM + PEEP valve (+/- standard NC) is the way to go in those situations. Although Optiflow cannulae allow higher flow rates, they make it rather difficult to get a good seal, so overall,… Read more »
Ivan, oxylator is going on as patient is being induced so no problem with tachypnea. Oxylator is a shitty replacement for CPAP, not sure what they are thinking. I am sure they do not have PEEP adaptors or PEEP valves with them, so they are treating things like APE with pressure support=fail. Major point in the podcast is that I’m not sure that optiflow does allow higher flow rates, they did same rates with standard. ? is do thrive devices allow less turbulent flow. I have your redo of death rates with Caputo added, do you have one for the… Read more »
Sure, once induced, Oxylator is OK. I was taking about pre-ox’ing a unmedicated tachypneic patient — very bad idea. From self-experimenting with a standard NC, and Optiflow cannula, the large-bore Optilow *does* allow for less turbulent flow. A medium Optiflow cannula is very confortable at 60L/min, I barely felt a nice breeze in my throat. With a small Optiflow cannula, there was some discomfort, but nothing unbearable still. What’s interesting, is that the 60L/min max flow is probably ~ the maximum laminar flow that the cannula allows for. I’ve tried a large cannula at 120L/min, and I couldn’t stand it… Read more »
Interesting podcast Scott and I appreciate your volume of work on this topic. I do worry that this whole issue is now being over-complicated, and thus the solutions over-engineered. My preference is a high flow Mapleson circuit with adjustable pressure limit valve and a tight facemask to de-nitrogenate. Like you I am strongly in favour of using gentle ventilations throughout the drug-induced apnea. I suspect that as acceptance of this technique grows, the relevance/utility of nasal ApOx will diminish further. The study hints at this – if critical care intubations are done properly and by experts, nasal ApOx adds nothing.… Read more »
Mapleson is nice, high-flow CPAP built-in. What was described is no more complicated in action–it just fits EDs better as often the practitioners can’t wait at the top of the bed during the denitrogenation. If you can, then just put a NC and use BVM with PEEP valve. Mapleson is probably giving apox, even without squeezing, though nobody has looked at this AFAIK.
Hello, uterus nerd here, not an intensive tuber! Interested to know if you think nasal cannulae preox is of value in obstetric patients given their predisposition to desaturate at intubation, or if firing a dry hurricane through their more delicate nasal membranes is just going to cause bleeding that reduces the benefit?
Well if you are looking for ApOx benefit, my guess is no ins tandard form b/c these folks are shunt city. However, in my opinion, no group benefits more from CPAP Preox (with good evidence) and Apneic CPAP (no evidence) and therefore I would def. want a NC there if using a BVM.
Here is the Skeptics’ Guide to Emergency Medicine critical review of the ApOx paper for RSI published in AEM. The review was done with EM Nerd Rory Spiegel.
http://thesgem.com/2017/09/sgem186-apneic-and-the-o-o-o2-for-rapid-sequence-intubation/