So I've been giving this talk for Grand Rounds for a decade now. I've kept it off the podcast so I would have something unheard to discuss when I come to visit a program. I don't do many grand rounds any more–so the time has come, here is:
Laryngoscope as a Murder Weapon: Oxygenation Kills
There are two other LaMW talks:
Most of the things discussed are elaborated upon on the EMCrit Preox Page.
This will be a two-parter. The things we will cover over the course of these two segments are:
- PreOx (Including VaPoX)
- Preventing Deox with ApOx and Apenic CPAP
- ReOx
See Part II
Additional New Information
More on EMCrit
EMCrit 216 – The Hemodynamically Neutral Intubation [LaMW](Opens in a new browser tab)
Additional Resources
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- EMCrit 393 – CV-EMCrit – Inotrope Basics Part 1 - January 25, 2025
In my ED we use a Water’s circuit with a PEEP valve for both spontaneously breathing and apnoeic patients. It is standard practice and we very rarely use the other BVM when this is available. Do you ever use this device?
Steve Young
EM/anaesthetics trainee
Morriston Hospital
Wales
UK
search the website, have extensive discussion of the pros and cons
Hi Scott, I am aware of your papers and all your podcasts about this topic and I love them all. Unfortunately where I work almost everyone is quite dogmatic to do everything as they have always done, and unfortunately physicians here (Austria) rarely think with logic about those things – but I am trying to get them to. Theres one thing though that I want to ask. You mentioned “the 15l/min are more than enough flow to provide PAP”: I tried the setup with BVM and NC + PEEP myselfe and hooked it up to a mannometer, not because I… Read more »
not at all. The neg insp pressure of the pt’s breaths is actually a huge recruitment augmenter, not a derecruiter. The only time you need to worry about collapse is during exhalation/between breaths
Your right, that totally makes sense.
What about in the case of shunt due to for instance edema or pneumonia or something else inhibiting properly ventilated alveoli,
would you say the PAP in the inspiratory phase is also then not very crucial and its only the expiratory phase that matters? Because then real high flow cpap really should not hold any advantage in f.i. CHF exacerb over BVM+NC+PEEP valve or over other cheap CPAP devices that also use 15l/m flow as driving source.
I don’t use PSV on NIPPV machines, so no–no benefit of machine over BVM-NC-PEEP valve
ok, but the question is if you think that using a ventilator (as you use in your VAPOX technique) who can match a patients inspiratory flow by providing respective flow to keep the CPAP pressure in the inspiratory phase, is superior to the BVM-NC-PEEP where there is no CPAP in inspiration if the patient breaths with enough inspiratory flow — in the case of shunt physiology where the CPAP is as you always mention the way to go for preox..?
Thanks for your thoughts
Hey Scott, Great episode – you touched on some specific aspects of PreOx which are super important. With regard to the use of NRB Mask for PreOx/Denitrogenation in the non-physiologically shunted patient: These patients by our definition should have an SaO2>95%. So our aim is to optimally increase FIO2%, in order to optimally increase ETO2 (ETO2 being a good marker of Denitrogenation). ApOx completely aside, just wanted to discuss solely & specifically the use of NRB @ 15 lpm + NC @15 lpm for PreOx/Denitro You mentioned the recent studies looking at this stuff. I agree it’s important to read… Read more »
Hi Scott,
Another great podcast. Just a quick question for our RSI check list. I understand that we should titrate O2 above 93% before we begin the procedure. At one point do you stop your attempt and re-oxygenate your patient; at 90%?
Wait for Monday’s part II
Dear Scott Weingart,
I just wanted to drop the following line:
Your Website is awesome!!!!
best regards
c.
Hey scott,
I am a paramedic, and am wondering what you think the best course of action is to BVM a VSA pt in pre-hospital care??
Thanks for a great podcast. I’ve just have one comment.
In this podcast you mentioned five causes of hypoxemia.
I disagree than V/Q mismatch/dead space ventilation gives hypoxemia.
Your example is “not enough cardiac flow to match their ventilation…”
Low cardiac output gives you problems with oxygen delivery, but the blood coming back to the left ventricle is fully oxygenated so there is not hypoxemia. It’s just to little blood….
Kind regards
M.D. Henrik S Hytten
Resident anesthesiology and intensive care
Drammen hospital
Norway
Henrik,
Your mentors in either anesthesiology or EM should be able to explain this to you. Or just crack one of the Anesthesiology textbooks, they all have a chapter on the physiology of oxygenation.
Thanks for answer but I still disagree that dead space ventilation per definition leads to hypoxemia and her is my explanation: Diffusion happens in the alveoli. Air that enters the airways, but never comes in contact with the blood, will never contribute to diffusion. The amount of air that is present in a tidal volume, but doesn’t reach the alveoli formes the anatomical dead space. That is, mouth, throat, trachea and bronchi. About 30% of a tidal volume forms the anatomical dead space. Alveolar dead space means ventilated alveoli that are not perfused. The sum of anatomical and alveolar dead… Read more »
Henrik,
Your mentors in either anesthesiology or EM should be able to explain this to you. Or just crack one of the Anesthesiology textbooks, they all have a chapter on the physiology of oxygenation.
Hello. I have used DSI in COVID 19 patients with great results. They came with saturation in the 50’s even in non-rebreather and once I push an intermediate/high dose of ketamine, they start to climb to the 80’s quickly. Once i have them between 80-90% sat, i push my paralitic and tube them with VL. This strategy also allows me to prepare everything and do it calmly. Sometimes i put them in NIV but some times i can’t because there are no more masks so i just use non-rebreather or BVM with a filter (and PPE for all my staff,… Read more »