EBQ:ED Preoxygenation: Difference between revisions
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Reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation. | Reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation. | ||
==Major Points== | ==Major Points== | ||
[[File:Preox table.png|thumbnail]] | |||
*Prior to intubation, physicians should aim to achieve an 02 saturation of 100% | |||
*Increasing oxygen storage requires denitrogenation of the residual capacity of the lungs | |||
*Preoxygenation can extend the duration of time until a patient reaches O<sub>2</sub> saturation of 88-90%. This is know as the “safe apnea” period. | |||
*Desaturation after Paralysis with succinylcholine in adults (<90% O<sub>2</sub> saturation)<ref>1. Benumof JL, Dagg R, Benumof R. Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine. Anesthesiology. 1997;87(4):979.</ref> | |||
**8.7 min in healthy patient (70kg) | |||
**5.5 minutes in moderately ill patient | |||
**3.7 minutes in healthy child (10kg) | |||
**3.1minutes in obese patient. (127kg) | |||
==Design== | ==Design== | ||
This was a review of methods and approaches to preparing for intubation of patients with varying levels of risk of hypoxia from critical care, emergency medicine, and anesthesia literature. | |||
==Conclusion== | |||
*Preoxygenation and apneic oxygenation are crucial in emergency airway management especially prior to rapid sequence intubation in order to prevent desaturation and prolong the time to desaturation, known as the safe apenic period. | |||
*Since standard BVMs cannot deliver PEEP, in patients with shunt physiology (i.e. pneumonia, pulmonary edema) a PEEP valve attached to the BVM or non-invavisve positive pressure ventilation (i.e. CPAP,BIPAP) should be utilized | |||
====Preoxygenation Times:==== | |||
#3 minutes of tidal volume breathing with a high FiO2 source (15L nasal cannula + 100% non rebreather on patient at the same time) | |||
OR | |||
#8 vital capacity breaths (maximal inhalation and maximal exhalation) with a high FiO2 source | |||
====Oxygen Sources for Preoxygenation:==== | |||
#Standard nonrebreather at 15L/minute will deliver 60 – 70% FiO2 | |||
#The FiO<sub>2</sub> can be increased to ≥90% with flow rates > 30L/min | |||
OR | |||
#Consider adding a nasal cannula increased >10L/min or as tolerated by patient along with nonrebreather mask | |||
*Positive pressure ventilation should be given to patients unable to achieve oxygen saturations of >93 – 95% with 3 minutes of high FiO<sub>2</sub> | |||
*Positive pressure ventilation should be given to patients already apneic due to respiratory failure | |||
====Patient Positioning | |||
==Review Questions== | ==Review Questions== | ||
<quiz display=simple> | <quiz display=simple> | ||
Revision as of 21:21, 5 April 2014
Under Review Journal Club Article
Weingart, S. et al. "Preoxygenation and Prevention of Desaturation During Emergency Airway Management". Annals of Emergency Medicine. 2012. 59(=3):165-75.
PubMed PDF
PubMed PDF
Clinical Question
Reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation.
Major Points
- Prior to intubation, physicians should aim to achieve an 02 saturation of 100%
- Increasing oxygen storage requires denitrogenation of the residual capacity of the lungs
- Preoxygenation can extend the duration of time until a patient reaches O2 saturation of 88-90%. This is know as the “safe apnea” period.
- Desaturation after Paralysis with succinylcholine in adults (<90% O2 saturation)[1]
- 8.7 min in healthy patient (70kg)
- 5.5 minutes in moderately ill patient
- 3.7 minutes in healthy child (10kg)
- 3.1minutes in obese patient. (127kg)
Design
This was a review of methods and approaches to preparing for intubation of patients with varying levels of risk of hypoxia from critical care, emergency medicine, and anesthesia literature.
Conclusion
- Preoxygenation and apneic oxygenation are crucial in emergency airway management especially prior to rapid sequence intubation in order to prevent desaturation and prolong the time to desaturation, known as the safe apenic period.
- Since standard BVMs cannot deliver PEEP, in patients with shunt physiology (i.e. pneumonia, pulmonary edema) a PEEP valve attached to the BVM or non-invavisve positive pressure ventilation (i.e. CPAP,BIPAP) should be utilized
Preoxygenation Times:
- 3 minutes of tidal volume breathing with a high FiO2 source (15L nasal cannula + 100% non rebreather on patient at the same time)
OR
- 8 vital capacity breaths (maximal inhalation and maximal exhalation) with a high FiO2 source
Oxygen Sources for Preoxygenation:
- Standard nonrebreather at 15L/minute will deliver 60 – 70% FiO2
- The FiO2 can be increased to ≥90% with flow rates > 30L/min
OR
- Consider adding a nasal cannula increased >10L/min or as tolerated by patient along with nonrebreather mask
- Positive pressure ventilation should be given to patients unable to achieve oxygen saturations of >93 – 95% with 3 minutes of high FiO2
- Positive pressure ventilation should be given to patients already apneic due to respiratory failure
====Patient Positioning
Review Questions
Sources
- ↑ 1. Benumof JL, Dagg R, Benumof R. Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine. Anesthesiology. 1997;87(4):979.