Starting Point: We do a bad job at preoxygenation
There are better alternatives to bag-mask ventilation but they’re logistically problematic
Nasal Cannula for Preoxygenation & Apneic Oxygenation: How to do it
- Apply a regular nasal cannula to the patient.
- If time allows, tape the cannula to the patient's cheeks with the prongs well seated in the nostrils. You don’t want it coming out in the heat of battle. This also discourages people from removing the cannula when you're about to intubate (1).
- Crank the oxygen flow to 15 liters per minute. Then keep turning up the oxygen flow rate until the resuscitation room starts sounding like a wind tunnel. This should get you to about 30-45 liters/minute flow.
- The patient should be preoxygenated within about five minutes.
- Leave the cannula on throughout the entire intubation. After the patient has been paralyzed, decrease the flow rate to 15 liters/minute; this will provide apneic oxygenation (4).
Why it works
Disadvantages and Risks
Other uses of nasal cannula oxygen at 6-45 liters/min flow
Expert Commentary from Scott Weingart
Safety of high-flow nasal cannula
Efficacy of high-flow nasal cannula oxygen for preoxygneation
Image credits: https://upload.wikimedia.org/wikipedia/commons/f/ff/Nasal_cannula.png
- IBCC chapter:Guide to APRV for COVID-19 - April 8, 2020
- PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0) - April 2, 2020
- PulmCrit wee – Why the SCCM/AARC/ASA/APSF/AACN/CHEST joint statement on split ventilators is wrong. - March 29, 2020