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1 It s not just about the tube, its the VAPORS & Resuscitation Sequence Intubation What are our lives except a vapor that appears for a little while and vanishes and passes away? James 4:14 Ventilation Acidosis Pressures Oxygenation Regurgitation Shock airwaycam.com

2 @airwaycam airwaycam.com

3 - Pre-ox, ap ox > expanding safe apnea time - Ventilate during onset of muscle relaxants? Are we responsible for the Difficult Airway? Why is cutting the neck the ultimate response to Cannot Intubate, Cannot Oxygenate?

4 What lessons should we take away from the Elaine Bromiley case? Elaine Bromiley Case 2005 Clinical Human Factors Group, UK cannot intubate, ventilate in FLAT position via MOUTH

5 Jones, DH & Cohle, SD Anesth Analg. 1993; 77: Are we responsible for the difficult airway?

6 Two year old in cardiac arrest.bagged en route supine positioning gravity causes airway collapse midline head position tongue obstruction heart collapses posterior lung segments anterior lung collapses posterior alveoli face-mask seal created by pushing down Ergonomics of ventilation from above Gas into shared aero-digestive tract Insufflation pressure > stomach distention Stomach distention > decreased lung excursion Breath stacking decreases cardiac return Stomach and head same level > regurgitation

7 Hypoxia, Hypotension, Aspiration No difference between experts vs non-experts Experts provided cricoid pressure significantly less often (56 vs. 81%), and did less attempts

8 Incidence and factors associated with cardiac arrest complicating emergency airway management. Heffner AC, et. al. Resuscitation Nov;84(11): pa(ents; CA occurred in 17/410 (4.2%), median 6 min post intuba(on. Pulseless electrical ac(vity was the ini(al rhythm in the majority of cases. CA associated with increased odds of hospital death (OR 14.8; 95% CI: ). CA more common w pre intuba(on hypotension (12% vs 3%; p<0.002). Pre RSI shock index (SI) and weight were independently associated with CA. CONCLUSIONS: In this series, 1 in 25 emergency intuba(ons was associated with the complica(on of CA.

9 Extremes of Ventilation: Pressures & Acidosis

10 Auto-PEEP & stacking breaths: COPD, asthma 6 breaths / 500 cc start 3 lpm MV, fast flow in Monitor plateau pressures <30 cm H20 Ketamine drip, permissive hypoventilation, bicarb? Deleganis AV, AJR 2000; 174: pre-intubation MV 9L hypotension MV 6L

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13 Cannot Oxygenate Face Flat In Neutral

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15 I can t breathe with this Oxygenation: Are we listening?

16 Fig. 4. Mean SD for pharyngeal fraction of inspired oxygen (F IO2 ) at selected liter flows while breathing at a resting level with the mouth closed (lower data line) and open (upper data line).

17 O s Up the Nose Upright Nose: Fire door of airway mouth wrong orifice flat wrong position upright best for alveoli, diaphragm, fluids the passively patent airway is the nose - not the mouth

18 shoulder dislocation OOPS

19 OOPS Oxygen On Pull mandible Sit patient up Tongue Base Soft palate Epiglottis Cords O s Up the Nose Pull mandible forward Sit patient up Where does upper airway obstruction happen?

20 Mean Apnea Time 14 minutes No desaturation <90% Opti-Flow 70 lpm

21 4 Requirements of Apneic Diffusion Oxygenation - Open alveoli (no diffusion if collapsed or fluid filled) POSITIONING - Oxygen gradient allowing diffusion from alveolus into plasma (leave O2 on ) - Red cells to bind oxygen to hemoglobin - Forward blood flow, so RBCs reach alveolus 4 binding sites 92 A- 94 A Binding of one O2 molecule changes shape of molecule for more binding

22 Pre-oxygenation: How it works Optimizing preoxygenation in adults Issam Tanoubi, et al. Can J Anesth/J Can Anesth (2009) 56: Oxygen reserves in a normal healthy adult when breathing room air (left), after breathing 100% oxygen (right), at onset of apnea, and when reaching an oxygen saturation (SpO2) of 90%. In this example, a subject with an oxygen consumption of 250 ml per min could sustain a period of apnea of 228/250 =0.9 min after breathing air and 2267/250 = 9 min after breathing oxygen Oxygen Reserves (ml) Lungs Hemoglobin Plasma Air SpO2 = 90% Oxygen SpO2 = 90%

23 Apneic Oxygenation in Man Frumin MJ, Epstein RM, Cohen G. Anesthesiology, Nov-Dec 1959, pp minutes without any ventilation Saturation O2 98%-100% Gas absorption CONTINUES without ventilation

24 Pharyngeal Insufflation of Oxygen Prevents Arterial Desaturation During Apnea Teller LE, et al. Anesthesiology 1988; 69: n=20, nasal airway s/p induction (36 Fr) 8 Fr Catheter inserted just beyond nasal trumpet, 3 liters per minute Sux, sedation, apnea until pulse ox 92% or, 10 minutes had elapsed Each patient served as their own control (with and w/o 3 lpm)

25 Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Taha SK, et al., Anaesthesia, 2006, 61, pages Preoxygenation 4 deep breath technique within 30 s, 30 ASA I or II patients - Study group (n = 15), pre-oxygenation and insufflation O2 5 liter per min via a nasopharyngeal catheter commenced at the onset of apnoea. - In the control group, pre-oxygenation was not followed by nasopharyngeal oxygen insufflation (n = 15). - In the control group, SpO2 fell to 95% within a mean (SD) apnoea time of 3.65 (1.15) min, - in the study group, SpO2 was maintained in all patients at 100% throughout the 6 min of apnoea - Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique can delay the onset of haemoglobin desaturation for a significant period of time during the subsequent apnoea.

26 Boyce JR et al., Obes Surg Feb;13(1):4-9. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. 26 patients, BMI ~56 Reverse Trendelenburg (RT, 30 degrees tilt), Flat, Back Up Fowlers Time SaO2 to drop 100% to 92%: Safe Apnea Period (SAP)

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28 1. Incrementalized Approach to Hypoxia

29 2. Incrementalized Approach to Hypoxia

30 PEEP valves on every BVM BVM & nasal cannula. Upright 3. Incrementalized Approach to Hypoxia

31 Nasal cannula & BVM with PEEP; O s up the Nose during intubation Courtesy George Kovacs, MD - AIME -

32 Add PEEP valves to every BMV unit in ED

33 initial pulse ox 55% - visibly blue intubated w/o desaturation first attempt

34 4-6 liters pre-oxygenation not sick Severe hypoxemia 15 lpm pre-oxygenation NO DESAT NO DESAT Apneic oxygenation needs only 1/4 lpm 15 lpm opens airway > flow into trachea Mouth opened by oral device High FiO2 in pharynx O2 drawn passively into trachea APNEIC oxygenation via nasal cannula during oral intubation NO DESAT: Nasal Oxygen During Efforts Securing A Tube

35 Oxygenation and Ventilation Strategy Based on Pulse Oximetry Weingart S, Levitan RM Preoxygenation and Weingart Prevention S, Levitan of Desaturation RM. During Emergency Text Airway Ann Emerg Management, Med Ann Mar;59(3): Emerg Med, in press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

36 with onset of muscle relaxa3on? NG first, remove on induc3on Closed loop communica3on RSI meds - 60 seconds Head elevated posi3oning; ear-sternal notch EpigloCoscopy - slow bright light cri3cal 2 suc3on set-up; don t immerse video in pool Back up in extreme instances > cut the neck [mask, LMA, King LT, ap ox > all will do poorly]

37 Peri-intubation hypotension due to insufficient venous return VR P ms (mean systemic) P ra (right atrial) Caution w sedatives, +Fluids, Push Dose Pressors (epi, phenyl) Sepsis: Fluids & pressor drip first? Shock Index > 1.0 (HR/SBP) Estimate minute ventilation prior to intubation and approximate same volume, watching peak pressures, BP, oxygenation HCO3 drip to deal with acidosis if permissive hypoventilation Tachypnea is biggest risk of breath stacking (6 per minute) TV of 6-8 ml/kg to start, square waveform, 60 lpm (up to 100) Keep plateau pressures cm H20 PEEP critical in markedly hypoxic, lower TVs, increase rate

38 Initial pulse ox 60% - CHF, fibrosis, COPD, pneumonia NO desaturation during intubation

39 Address the VAPORS & Resucitation Sequence Intubation Ventilation Acidosis Pressures Oxygenation Regurgitation Shock index Bottom line: Extremes of ventilation > match peri and post-intubation Oxygenate: positioning, Os up nose/mask/peep/kai-dsi Decompress the bowel obstructed, major upper GI bleeds first SI- Good IV access, fill the tank, resuscitate > intubate, pressors first