own the oxygen
DESCRIPTION
An overview of the recent review of oxygenation during rapid sequence intubation by Weingart and LevitanTRANSCRIPT
Chris Nickson Emergency Registrar
SCGH, November 2011
Preoxygenation and apneic oxygenation during emergency intubation
OWN THE OXYGEN!
A talk that pays homage tothe brilliant work of
Richard Levitan and Scott Weingart
http://lifeinthefastlane.com/2011/11/rr-in-the-fastlane-001/
3 Steps to Own the Oxygen!
①Preoxygenation• Why, how, and for how long?
②Apneic oxygenation• Why and how?• Positioning, ventilations and maneuvers• Paralytic agents
③Putting it into practice• Risk stratification and logistics
Why preoxygenate before you intubate?
Preoxygenation extends safe apnea time
during intubation
From Weingart and Levitan 2011
Goals of preoxygenation
①SaO2 100%
②Denitrogenate the lungs (big O2 reservoir)
③Oxygenate the blood (less important)
What is the best source of high FiO2 for preoxygenation?
Use a face mask with a reservoir and oxygen flow as high as possible
e.g. NRB mask with 15+ L/min
How long should you preoxygenate for before intubation?
If adequate respiratory drive:
3 minutesor
8 breaths with maximal inspiration and expiration
Is there a role for positive pressure in preoxygenation?
Yes!
Use CPAP or NIV or BVM with PEEP valve in patients with baseline SpO2 95% or less
How should you position the patient during preoxygenation?
Whenever possible, elevate the head
How long will it take a preoxygenated patient to desaturate?
Somewhere between 8 minutes and immediately!
From Walls RM, Murphy MF. Manual of Emergency Airway Management (2008), 3rd edition
What is the role of apneic oxygenation?
15 L/min via nasal cannulae extends the safe apnea time
Are ventilations during the apneic period an option?
Yes… if benefits > risks
consider if SpO2 90-95%
‘essential’ if SpO2 <90%
How should the patient be positioned,
and what maneuvers should be used,
during the apneic period?
Ear-to-sternal notch positioning
Consider nasal airway
Jaw thrust when apneic
(Forget cricoid!)
Position is everything!
Ear hole at the same height as the neck hole!
(aka sternal notch)
Scott Weingart - http://emcrit.org/
How does choice of paralytic agent affect oxygenation?
Suxamethonium leads to
shorter safe apnea times than rocuronium
http://lifeinthefastlane.com/2011/05/ruling-the-resus-room-004/
In Summary…
Oxygenate according to risk
Know the logistics…
Preoxygenation period
• Head up positioning• Ear-to-sternal notch position• Place nasal cannula• High flow oxygen: 15 L/min via NRB• Preoxygenate for 3 minutes with tidal breaths, or
8 maximal inspirations/ expirations• If hypoxic, consider:– CPAP (e.g. 5-15 cmH20 to achieve SO2 >98%)– BVM with PEEP valve
Apneic period
• Push sedative and roc• Commence 15 L/min oxygen via nasal cannula• Remove face mask• Maintain airway with jaw thrust• If hypoxic, consider:– CPAP– BVM (6 breaths/ min) with PEEP valve
Intubation period
• Leave the nasal cannula on at 15 L/min while you….
OWN THE AIRWAY!
Low risk
High risk
Hypoxic
http://lifeinthefastlane.com/2011/02/own-the-airway/
Remember to check out:http://emcrit.org/preoxygenation/
THE END