thanks mate for a great podcast so soon after article publication. Kudos to the investigators for questioning the role of ApoX in emergent RSI in their ICU setting. I think you have hit the nail on the head in that BVM was used in about half of each trial arm, in other words totallly diluting the effect of Apox. We know ApOx works as the physiology has been well described for decades. I think the FELLOW trial demonstrates that you can do other things that are just a good as ApOx adjunct in your RSI practice i.e good preox, adjunctive… Read more »

Great discussion, my hat is off to Matt and colleagues for completing such an interesting study. I agree with your comments Scott. If a patient is hypoxic at the beginning, then I think CPAP/BiPAP should be used for preox, and continued post-induction (or BVM used) – exactly as ‘Weingart and Levitan’ originally described in AnnEmergMed. I think ApOx with nasal prongs alone is only an option in patients who are not hypoxic from the start and not using CPAP/BIPAP/BVM. It wasn’t clear to me from reading the study that BVM was performed, or if the BVM was simply being used… Read more »

Did I hear that right in the PC? Did he say it took roughly 2-3 minutes to pass the tube in the majority of the PTs from the time of pushing the induction meds?

Also at my FD ApOx is a must for all RSI PTs. The NC goes on immediately when we see we have a critical PT, a respiratory distress PT or a PT who may be a candidate for airway management and it doesn’t come off until after intubation. We don’t consider ApOx an extra step since it literally take 5 seconds to place the cannula on the PT and does not get in the way. We also have no compromise in mask seal with PTs on a BVM or CPAP ever since we use foam masks on all our PTs.… Read more »

I think this article will help clarify a few points on pre-oxygenation techniques. It may be, when airway management is performed using some of the techniques for pre-oxygenation that they used it may substantially negate the benefits of using a nasal cannula. I don’t think most emergency medicine providers utilize B-PAP for pre-oxygenation and even though I believe that BVM ventilation is common prior to intubation it is my belief that this practice should be avoided in our setting. I have unpublished data from prehospital RSI’s (a data set of about 260 patients) showing an 12.5% reduction in SpO2 dropping… Read more »

I’ll continue using apneic oxygenation in the patients I don’t want to ventilate with a bag valve mask (bowel obstruction etc). As an anesthesiologist I’m confident in hand ventilating most patients. If they desaturate I just use the BVM.
But, in the patients I absolutely don’t want to ventilate, buying some time with apneic oxygenation is golden.

Scott,
FELLOW Trial summary and review by The Bottom Line coming very soon.
Blame Paul Young @DogICUma for the delay. 2 major trials in one week?!
Fantastic podcast. Thanks for doing all the hard work for us
BWs
Steve

Once again this trial shows that difficulties of using data obtained in one setting…say the ED or the OR or ICU…and trying to show effectiveness of and intervention or lack of. I applaud anybody who does research since nowadays it is hard to even get the most simple study approved by IRB process. I was happy to get to hear the dialogue you had Scott. I am of the mindset, similar to some above, that it is just such a simple step to add and I cant think of anyway it can cause harm…unless of course you get your blade… Read more »

Forget the studies. Anecdotally the nasal cannula in my experience definitely buys you precious time for laryngoscopy during a true RSI – and I find this time is particularly useful when training residents. Once patients start to desat, the situations always get more dicey. I don’t like desats during emergency intubations in my trauma bay or ICU, period. Even if you don’t believe it works for the apneic period – everyone believes in pre-induction denitrogentation/oxygenation. The cannula increases the efficiency and time to do this….. So taking it off would be an extra step which just isn’t necessary. Leave it… Read more »

Pasting my comment from emlitofnote: My question about the PPV isn’t that it’s not usual care; rather, it’s a different, very sick population that required that much PPV (only 77% in control arm, 70% in intervention arm). So not only is this a small study to begin with, but only 40 patients weren’t getting active ventilation in during the (non)apneic period. One takeaway I’ve had from using nasal ox during laryngoscopy is that it really seems to separate out the truly hypoxic patients, versus the healthy ones that I just let the intern do DL a little too long on….… Read more »

Scott, Awesome job getting Matt on so shortly after news of this trial go out. My thoughts: I mentally break this down (similarly to Matt) into 3 PHASES: 1) Pre-Oxygenation prior to apnea 2) Apnea to Laryngoscopy 3) Laryngoscopy to intubation ApOx only comes into play during PHASE 2 & PHASE 3 If we implement BVM/NIPPV during PHASE 2, we chop out a huge chunk of potential benefit from ApOx, and this essentially becomes a trial of: PHASE 3 ApOx vs PHASE 3 No ApOx {Patients with significant shunt physiology aside}.. Even in patients W/OUT significant shunt physiology, if we… Read more »

Great interview on an insightful study. It seems to me the evolving discussion here is about the relative safety of bagging or Bipaping sick, hypoxic pts after RSI meds are given vs. avoiding PPV due to aspiration risk

For me this underlines (with exclamation mark) that any provider involved in invasive airway management, must have a very clear understanding of respiratory physiology and pathophysiology. (Urgh, getting chills when thinking back to my time spent with West. Well worth it in the end).

As to not have a false sense of security when using any adjunctive method to guard against hypoxemia. In this case ApoX alone is not going to help much.

Very insightful research and discussion.

Dwayne
Specialist Anaesthesiologist
South Africa

Good analysis and good points. The first thing this study proves is that NODESAT is safe, that is, it is not worse than the other therapies. Obviously, this study proves that NODESAT is not substantially better than the other approaches, but….and here is the catch….I don’t think the study’s hypothesis can be proved with a simple pulse oximeter. So what kind of monitoring can prove the hypothesis? That is the important question. Here is a potential list: 1. Sidestream gas analysis monitor (the thing anesthesiologists use in the operating room for capnographry) (1) Analyze the pre-induction End-Tidal O2 with the… Read more »