1. A review of the Literature
Airway Notes
A review of the Literature
Weingart, Levitan
Annals of EM Mar 2012
Weingart et al
Annals of EM Apr 2015
April 11, 2018

2. Goals of Preoxygenation
SpO2 of 100%
Denitrogenate lungs and blood
Delay desaturation as long as possible
Note: Does nothing for hypercapnea though
April 11, 2018

3. Preoxygenation
Steep portion of deoxygenation curve happens at SpO2 of 88 – 90%
Desaturation occurs at 45 – 60 secs, for pt on RA after RSI.
Standard “non breather” at 15 L/min only gives FiO2 60 – 70%
With BVM get best seal with 2 hands
April 11, 2018

4. Preoxygenation
Maximal tidal volume (8 full inhale/exhale) or 3 mins with normally breathing cooperative pt
NIPPV can delay deoxygenation in critical patients who are shunting.
April 11, 2018

5. Preoxygenation
Consider PEEP valve on BVM or CPAP/BiPAP if SpO2<93-95% during preoxygenation
Elevate HOB ˚ or reverse trendelenburg and look at “ear to sternal notch” alignment
April 11, 2018

6. Preoxygenation
Critically ill/injured pt’s will desaturate more quickly – due to R to L shunting
Shunt = oxygen poor blood returning from lung to heart
NODESAT=Nasal Oxygen During Efforts at Securing a Tube
Apneic Oxygenation
15L/min – adult
10L/min – child
5L/min – infant
April 11, 2018

7. Preoxygenation
Positive press ventilation: if SpO2<91-95% with preoxygenation
Caution: use low volume, low rate &PEEP valve recommended
Benefits/Risks: full stomach - ? Vomit or aspirate
April 11, 2018

8. Choice of Paralytic
Rocuronium associated with delayed time to desaturation vs. Succinylcholine
Hypothesis – increased oxygen usage due to fasciculation
April 11, 2018

9. Bottom Line
Preoxygenation is key to prevent hypoxic complications during RSI
Consider techniques and recommendations discussed
April 11, 2018

10. Delayed Sequence Intubation DSI
Prospective study of pt’s who had altered mental status and/or could not be preoxygenated
Poor O2 reserves leads to faster desaturation
Need to preoxygenate with respiratory effort preserved
April 11, 2018

11. Delayed Sequence Intubation DSI
Ketamine – 1mg/kg followed by 0.5mg/kg if needed
(Give Ketamine over 30 to 45 secs)
Preoxygenate with HOB at 30˚
NRB mask or CPAP if needed
Then high flow nasal cannula for apneic oxygenation
April 11, 2018

12. Delayed Sequence Intubation DSI
Multiple conditions for intubation
Pt’s with SpO2<93% were able to increase their SpO2 to >93% with DSI
All but one required NIPPV
April 11, 2018

13. Delayed Sequence Intubation DSI
Possible complications
Apnea pre paralysis
Vomiting
Cardiac arrest/death
None of these occurred in this study
April 11, 2018

14. Delayed Sequence Intubation DSI
Discussion
Authors feel safe to use Ketamine and NIPPV to aid in preoxygenation, as it is a bridge/temporary to intubation
No other sedatives considered due to apnea concerns
April 11, 2018

15. Delayed Sequence Intubation DSI
Conclusion
DSI seems safe and effective as long as provider/team are experienced in sedation and airway.
April 11, 2018