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EMCrit Wee – Preoxygenation Update 2015

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Here is a bit of follow-up on prior EMCrit discussions and some new stuff for Janu-Airway

For all of the shownotes, come to the EMCrit Preox Page

Now on to the Wee…

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Scott Weingart

An ED Intensivist from NY.

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Cite this post as:

Scott Weingart. EMCrit Wee – Preoxygenation Update 2015. EMCrit Blog. Published on January 22, 2015. Accessed on September 20th 2017. Available at [https://emcrit.org/emcrit/preoxygenation-update/ ].

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Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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9 Comments on "EMCrit Wee – Preoxygenation Update 2015"

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Leon Boudourakis
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Leon Boudourakis
Two issues. 1) the problem you should be aware of with high flow is that while it works great for apneic oxygenation, it physically gets in the way of bag valve mask ventilation (or I should say any mask ventilation) because you can’t create a good seal with the high flow tubing in the way. With a normal nasal cannula, a seal with the mask is no problem. With high flow, the tubing is bigger/harder – so you can’t seal (and thus if you want to give more peep with a mask u can’t for example). 2) is more of a comment/question. I’m a huge peep fan….. Which is why I like the idea of using a machine and not a bvm with a peep valve. But no matter what you set the peep valve to…. Once the bvm deflates all the way, you lose your peep. So you are basically only getting peep during the expiration phase of the bvm and then ultimately losing it in the time you are waiting for the next breath. On the one hand, slow controlled bvm is important so you don’t inadvertently go to a higher pressure with your excitement and blow up… Read more »
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2 years 7 months ago
Scott Weingart
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Scott Weingart

NC @ 15 will fully pressurize the PEEP valve regardless of pt ventilations. No need to squeeze. Thought I taught you that before you left. Vent manages pressure, but not flow–need the NC even with the vent. Always NC! Some of the high-flow systems make BVM tough, some do not. I mentioned this in the podcast.

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2 years 7 months ago
Leon
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Leon

Cannula even with vent for sure…. Always…..That’s obvious. That’s not a question. I just wasn’t aware that a bvm with peep valve hooked up to O2 nc maintained your set peep (say up to 15). Really? I must have missed that very importent point! I’m not quite understanding the physics though how the cannula maintains the pressure in the peep valve with a bvm though…..

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2 years 7 months ago
Scott Weingart
Author
Scott Weingart

NC @ 15lpm is actually a lot of pressure. If there is a mask-seal you have pressurized the airway to the extent of the release set by the peep valve.

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2 years 7 months ago
trackback
LITFL Review 166 - LITFL

[…] Weingart has an update on techniques and physiology of preoxygenation for us in a new Emcrit wee. […]

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2 years 7 months ago
Mike
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Mike

Dr. Weingart,

After following your podcasts, I do use apneic oxygenation routinely in RSI and really believe in it. We have considered protocolizing it and the following questions have come up:

I often have patients with shunt hypoxia on CPAP already. They are holding on but it becomes clear we will perform a controlled RSI for a deteriorating state. Perhaps the patient is 92% on CPAP of 12 and 100% fiO2. In these patients, would you temporarily take off the CPAP mask to place the nasal cannula to use for apneic oxygenation, risking desaturation? Is the nasal cannula still useful in severely shunted patients?

Thank you for the amazing education you provide that has elevated so many clinicians and helped so many patients!

I am a hospitalist who works in an ICU with the assistance of a telemedicine ICU.

Mike

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2 years 7 months ago
Frédéric Lemaire
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Frédéric Lemaire

Wow ! It makes a lot of sense. I was expecting a 2 lines answer to my case, not a 20min Wee and 2 videos of rat lungs 😉 Thank you for that
If i remembered the peep on my patient was 10 cm H20, i’ll reach for 15cm H20 next time.

Fred

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2 years 7 months ago
Stacy Turner
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Stacy Turner

Hi Scott,
Great post.
In your reply to Josh Farkas on his webiste, you quote an RCT using standard (non-high flow) nasal cannulae. I’m struggling to find this. Can you point me in the right direction?
Thanks,
Stacy Turner

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2 years 7 months ago
trackback
More on preoxygenation | FOAM links

[…] http://emcrit.org/wee/preoxygenation-update […]

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1 year 10 months ago
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Scott Weingart, MDHi, my name is Scott Weingart.
I am an ED Intensivist from New York. Along with my friends, we are attempting to provide and teach Maximally Aggressive Care, Everywhere! From the field to the ICU, EMCrit is about optimal critical care and resuscitation.

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