It costs you nothing, but gains everything for your patient!

It costs you nothing, but gains everything for your patient!

Attend the entire presentation Complete and submit the evaluation This session is approved for: ANCC hours CECBEMS hours No partial credit will be awarded

Air Evac EMS Inc. believes that part of being a good corporate citizen is supporting the needs of the local communities in which it operates by providing outreach education as a general service. We do not discriminate against attendees all are welcome to attend. The fees we charge are to cover our cost, not to make money, so please accept this service and the information provided in the spirit intended. We have taken care to confirm the accuracy of the information presented, to describe how our company operates (including drug selection and dosage) and to describe generally accepted practices, as we know them. However, in view of ongoing research, changes in government regulation, the constant flow of information in the medical field and simple honest mistakes, the information we present may contain errors, problems or other limitations. Because providing this type of information is not our business, we cannot be responsible for errors or omissions or for any consequences from application of the information presented, and make no warranty, expressed or implied, with respect to the currency, completeness or accuracy of the information. Our presentations are for general information and education purposes, not medical or protocol advice. Application of information we provide in a particular situation remains the professional responsibility of the practitioner, and you should follow local standing orders and protocols established by your medical director and professional governing agency.

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The learner will be able to describe Apneic Oxygenation (AO) and its implications in Airway Management The learner will be able to demonstrate proper application of AO techniques in a simulated environment The learner will be able to describe the benefits of AO

The goal of any airway management episode is to maintain saturation of all available hemoglobin with oxygen to prevent a hypoxemic event. Secondary goals for the intubator is to prevent critical hypoxia and aspiration. The challenge in the emergency environment is to do this rapidly, without harm to the patient.

This short program will review and discuss the techniques associated with the preoxygenation and peri-intubation oxygenation phases of airway management.

Pre-oxygenation offers the patient a safe condition during airway management. It extends the duration of safe apnea during peri-intubation.

In the Emergency Environment, there are 3 goals of pre-oxygenation: 1. Increase the SPO2 to as close to 100% as possible 2. Denitrogenate the lungs which maximizes the patient s natural reservoir 3. Denitrogenate and maximally oxygenate the bloodstream Weingart and Levitan, 2012

95 91 >90

Frumin et al demonstrated in a 1958 research paper that man can sustain safe apnea times of 15-55 minutes with adequate preoxygenation in the anesthesia environment. Not an anesthesia environment, but you get the point! Frumin, et. al. 1958

The challenge is not the time period for preoxygenation. Osborn, 2009; Mort, et. al. 2009

The challenge is to deliver a high FiO2 to your patient, to prevent hypoxia

Earl, 2003

Some practitioners opt to utilize a selfinflating bag-valve-mask device to preoxygenate patients.

2 person technique is preferred Downside to BVM use- gastric insufflation which increases the risk of vomiting and aspiration. Upside to BVM use- useful for the apneic patient who requires assistance.

Scenario - Let s assume that your patient has no respiratory disease or shunting. This may be the isolated head injury who is unable to protect their airway, but is spontaneously breathing. How do we manage apneic oxygenation for this patient?

The typical approach to apneic oxygenation is to apply a nasal cannula at 6 L/min, then a non-rebreather mask at 15 L/min.

Allow the patient to breath spontaneously for 3 minutes or 8 maximal vital breaths. Once apnea has been achieved and prior to intubation: 1. increase the nasal cannula flow to at least 15 L/min (near 100% FiO2) NO DESAT! 2. remove mask, but leave nasal cannula in place 3. allow for paralysis to take place then intubate and confirm 4. remove cannula once oxygen therapy has been initiated via airway device

Why leave the cannula in place for an apneic patient? Levitan, 2013

What if the patient is unable to be preoxygenated above 93%? Suspect some type of shunt physiology Examples: Obesity Pneumonia Pulmonary Edema

One of the first maneuvers is to augment the pressure at the alveolar level. Can easily be done by adding a disposable PEEP valve to your BVM for the patient that requires assistance.

For the patient who is still breathing but requires PEEP during the preoxygenation phase due to shunting: Non-invasive positive pressure can be applied Note- in critically ill adults with high degrees of shunting, apneic oxygenation may not be helpful without using PEEP and/or positive pressure ventilation.

Supine positioning is not ideal: Difficulty in maximizing ventilations Posterior aspect of lung becomes prone to atelectatic collapse Leads to a reduction in safe apnea time Positioning may be difficult in trauma patients with spinal protection in place. Lane, et. al (2005); Altermatt, et. al. (2005)

Unless contraindicated, all patients require the head of the bed to be elevated for preoxygenation to at least 20 degrees. Lane, et. al (2005); Ramkumar, et al. (2011)

What about the trauma patient that can t have the HOB raised? Reverse Trendelenburg at 30 degrees is effective for the preoxygenation phase.

One requirement for proper positioning EAR to STERNAL NOTCH positioning Sniffing position Maintain patency of the airway Improves the mechanics of ventilation Lengthens the apneic time period to critical hypoxia Improves direct laryngoscope views

Leaving the patient flat is not an option! A proper ramping includes loads of linens and plenty of help to elevate the patient. Best to position the patient before laryngoscope attempts. Airwaycam.com

What is the primary benefit of Apneic Oxygenation? The creation of a reservoir of oxygen in the alveoli. Why are we concerned about the time to desaturate? ONE episode of hypoxia increases their mortality rate.

Benumof, 1999

Downside: Poor perfusion status leads to erroneous waveforms Practitioner ability to interpret Lag time-30-60 seconds Only measures the amount of a gas bound to hemoglobin, it does not tell you which gas it is Useful Device Often called the 5 th Vital Sign Reliable when cardiac output is adequate

LOW RISK SPO2 96-100% Preoxygenation Period Nonrebreather at 15 L/min Onset of Muscle Relaxant Nonrebreather mask and nasal cannula at 15 L/min Apneic period-no DESAT at 15 L/min Weingart and Levitan, 2012

HIGH RISK SPO2 91%-95% Preoxygenation Period-Nonrebreather mask, CPAP or bag-valve-mask device with PEEP. Onset of Muscle Relaxant-Nonrebreather mask, CPAP or bag-valve-mask with PEEP, and NO DESAT at 15 L/min. Apneic Period- NO DESAT at 15 L/min. Weingart and Levitan, 2012

HYPOXEMIC SPO2 90% or Less Preoxygenation Period-CPAP or bag-valve-mask device with PEEP. Onset of Muscle Relaxant-CPAP or bag-valve-mask with PEEP, and NO DESAT at 15 L/min. Apneic Period- NO DESAT at 15 L/min. Weingart and Levitan, 2012

Preoxygenation Period Weingart and Levitan, 2012

Apneic period Weingart and Levitan, 2012

Intubation Period Weingart and Levitan, 2012

Apneic Oxygenation is not new. Requires little equipment. Preoxygenation can take place in 3-4 min. Ramp all patients to proper position. Leave the cannula on during intubation- NO DESAT! You must recognize and compensate for shunting. The Benefits of AO outweigh any Risk!

Altermatt, F. R., Munoz, H. R., Delfine, A. E., et. al. (2005) Br J Anaesth. Pre-oxygenation in the obese patient: Effects of position on tolerance of apnoea. 95: 706-709 Earl, J.W. (2003) The Science Journal of the American Association for Respiratory Care. Delivery of High FIO2. Abstract Frumin, M.J., et. al. (Nov-Dec 1959) Anesthesiology. Apneic Oxygenation in Man. pp. 789-798 Lane, S, Saunder, D., Shofield A, et. al. (2005) Anaesthesia. A prospective, randomized controlled trial comparing the efficacy of preoxygenation in the 20 degrees head-up vs. supine position. 60:1064-1067 Levitan, R. M. (2010) Emergency Physicians Monthly. NO DESAT!. Retrieved from http://www.epmonthly.com/archives/features/no-desat-/ on 7/15/2014 Mort, T.C., et. al. (2009) Crit Care Med. Extending the preoxygenation period from 4 to 8 mins in critically ill patients undergoing emergency intubation. Retrieved from http://ncbi.nlm.nih.gov/pubmed/19050620?access_num=19050620&link_type=med&dopt=abstr act on 7/14/2014 Osborn, T. M. (2009) Emergency Medicine. Preoxygenation for Emergency intubation: Longer is not better. Retrieved from http://jwatch.org/em200901300000001/2009/01/30/preoxygenationemergency-intubation-longer-not on 7/14/2014 Ramkumar, V., et. al. (2011) J Anesth. Preoxygenation with 20 head up tilt provides a longer duration of non-hypoxic apnea than conventional pre-oxygenation in non-obese healthy adults. 25:189-194 Weingart, S. D. & Levitan, R. M. (2012) Annals of Emergency Medicine. Preoxygenation and prevention of desaturation during emergency airway management. 59:3 pp. 165-175

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