You know that I obsess over the physiologically difficult airway–well there turns out to be an ED Crit Care doc who is equally as obsessive–Jarrod Mosier. Today, we talk about the hypoxemic physiologically difficult airway and many things preox!
Jarrod Mosier, MD FCCM
Associate Professor, Emergency Medicine
Associate Professor, Medicine
Associate Program Director, Critical Care Fellowship
Medical Director, Adult ECMO (Extracorporeal Membrane Oxygenation) Service
University of Arizona College of Medicine
We Discuss…
Preox Strategies
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Low to Moderate Risk of Desaturation
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Moderate to High Risk of Desaturation
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High to Refractory Risk of Hypoxemia
Pendelluft Phenomenon
Moody Teenager Lung
Rough Notes
#### Mosier JM Br J Anaesth 2020;125(1):e1 far right of the bell curve of risk of desaturation - Need a reasonable FRC - full oxygenation of that FRC - That volume connected to the alveolar vessels -to be transmitted to the bloodstream Tanoubi et al. estimation of safe apnea time formula Why doesn't apox work it is shunt fraction and its syngergistic partner low SvO2 Need a lot more PEEP when transitioning from NPV to PPV PEEP is maint. in addition to recruitment Pendelluft Phenomena movement of gas from recruited lung to non-recruited causing lung injury he also postulates an abrupt increase in r sided heart pressures made even worse by bagging Does 100% precipitate absorption atelectasis--no! put in the article from crashing patient #### Mosier et al. WestJem 2015;16(7):1109 added R sided failure to the HOP killers nebulized milrinone #### Mosier et al. Intens Care Med 2017;43:226 in the lungs PaO2 creates the sat in the blood, the sat creates the PaO2
Dr. Mosier's Relevant Publications
- Kornas, Rebecca L., Clark G. Owyang, John C. Sakles, Lorraine J. Foley, and Jarrod M. Mosier. “Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management.” Anesthesia & Analgesia Publish Ahead of Print (October 14, 2020). https://doi.org/10.1213/ANE.0000000000005233.
- Mosier, Jarrod, Raj Joshi, Cameron Hypes, Garrett Pacheco, Terence Valenzuela, and John Sakles. “The Physiologically Difficult Airway.” Western Journal of Emergency Medicine 16, no. 7 (December 17, 2015): 1109–17. https://doi.org/10.5811/westjem.2015.8.27467.
- Mosier, Jarrod M. “Physiologically Difficult Airway in Critically Ill Patients: Winning the Race between Haemoglobin Desaturation and Tracheal Intubation.” British Journal of Anaesthesia 125, no. 1 (July 2020): e1–4. https://doi.org/10.1016/j.bja.2019.12.001.
- Mosier, Jarrod M., and Cameron D. Hypes. “Mechanical Ventilation Strategies for the Patient with Severe Obstructive Lung Disease.” Emergency Medicine Clinics of North America 37, no. 3 (August 2019): 445–58. https://doi.org/10.1016/j.emc.2019.04.003.
- Mosier, Jarrod M., Cameron D. Hypes, and John C. Sakles. “Understanding Preoxygenation and Apneic Oxygenation during Intubation in the Critically Ill.” Intensive Care Medicine 43, no. 2 (February 2017): 226–28. https://doi.org/10.1007/s00134-016-4426-0.
- Sakles, John, Cassidy Augustinovich, Asad Patanwala, Garrett Pacheco, and Jarrod Mosier. “Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program.” Western Journal of Emergency Medicine 20, no. 4 (June 3, 2019): 610–18. https://doi.org/10.5811/westjem.2019.4.42343.
Additional New Information
More on EMCrit
- EMCrit Podcast 206 – ApOx, ENDAO, & PreOx Update
- EMCrit Wee – Should a Nasal Cannula be Part of Denitrogenation / Preoxygenation
- EMCrit Wee – Preoxygenation Update 2015
- Podcast 173 – LaMW – Oxygenation Kills Part I
- Podcast 174 – LaMW – Oxygenation Kills Part II
Additional Resources
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Now on to the Podcast
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Wow what a great episode.
Do you have any tips on bad saturation post intubation?
Patients in the „worst“ category sometimes like to sit at mid 80s even after intubation while having a good MAP.
What we usually do in those cases is give them a lot of PEEP and if that doesn’t help we prone them. Sadly we don’t have access to inodilators or iNO.
What do you do in these cases and what do you think is the main physiological cause of it (atelectasis from apnea, shunt or lack of negative pressure ventilation)?
Greetings from Germany
APRV purely for temporary recruitment is the thing I add in this situations. I have at times done the traditional recruitment maneuvers if things have really gone down the toilet, but I really try to avoid them when possible.
Great episode. For the patients who are refractory hypoxemic, and you are planning on doing an awake intubation, how are you maintaining their oxygen saturations during the awake intubation. I assume you have them on high flow NC maxed out. Obviously can’t do an awake intubation with a CPAP/BPAP mask on. My experience is that HFNC has difficulty maintaining sats if patients needed CPAP/BPAP to maintain their sats in the first place. Are you willing to tolerate a sat in the 70-80s on HFNC during an awake intubation given that you know it shouldn’t fall lower than that because there… Read more »
will answer in the next Q&A in a couple of weeks
Thanks!
I might have missed your answer to this question but I can’t seem to find it on emcrit. Can you point me to the answer. Many thanks.