Episode 6: Oxygenation

Oxygenation

To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful!

 

Some of the stuff we talked about:

Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here.Screen Shot 2016-03-17 at 09.28.46

But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible.

Screen Shot 2016-03-17 at 10.09.34Taken from: http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices

A water’s circuit looks like this:

Labelled waters circuit

This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart & Levitan 2012.Screen Shot 2016-03-17 at 10.14.50

Here are some other great resources which demonstrate some of the principles we have discussed:

Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation:

http://www.heftemcast.co.uk/apnoeic-oxygenation/

There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here:

http://emcrit.org/preoxygenation

A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team:

http://lifeinthefastlane.com/ccc/bag-mask/

This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation.

References

Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376.

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175.

Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355.

Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010;

Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72.

Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67.

Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial)

How to cite this podcast:

Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

2 thoughts on “Episode 6: Oxygenation

  1. I absolutely love PHEMCAST. I found this episode really useful and informative as it is very relevant to my dissertation subject so thank you so much for this. The interview around apnoeic oxygenation was brilliant and the study done by Yash Wimalasena is something I have already looked at and am including within my evidence. I would have really loved some further discussion and opinion around paramedics within ambulance trusts who intubate for example in a cardiac arrest and if the use of apnoeic oxygenation could and should also be incorporated for better outcome of these patients as was seen in those who received RSI.
    Again many thanks and hope you all have a wonderful Christmas and New year

    Like

    • Thanks for your feedback. I’m glad you enjoy the podcast.
      I have been thinking about whether there is a place for apnoeic oxygenation when intubating in cardiac arrest, and I think the lack of circulation would make the technique less effective as there would be no/minimal circulation to remove the oxygen from the alveoli which is what theoretically creates the concentration gradient to draw the oxygen down passively from the oropharynx.
      So I suspect apnoeic oxygenation is not worth doing in cardiac arrest patients, and the focus should be on prompt airway management by whichever means will achieve ventilation and oxygenation most rapidly, including using a supraglottic device.

      Happy New Year to you too!

      Like

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