If you believe apneic oxygenation increases safe apnea time during intubation, and accept the NODESAT methodology, you’ve probably found yourself in an RSI conundrum.
Three devices are needed to effectively preoxgyenate and safely intubate a patient: 1) O2 Mask (NRB), 2) Nasal Cannula (NC), and 3) BVM. But with a maximum of two oxygen outlets in a typical hospital or transport berth it’s impossible to supply all three at once. You might already be doing some version of the following if you have two connections:
- During preoxygenation, place the mask and NC (+/- nasal trumpet/s) on the patient, both at maximum FiO2. After 3 minutes of O2 Sat > 95%, or 8 vital capacity (maximal inhalation-exhalation) breaths, medicate.
- Once apnea kicks in remove the mask, disconnect it from the wall, and hook up the BVM at maximum flow (leaving the NC on and running).
- Proceed with laryngoscopy, etc.
The problem: In the mess of lines filling the narrow space above a patient’s head tangled tubing confuses assistants, stuff drops to the ground, etc… As a result, RSI is no longer “rapid”, nasal cannulae get disconnected, and patients can end up off of oxygen for some time.
Getting out of the mess: Make Step 2 smoother and safer by taping together the ends of the mask and BVM oxygen lines while you’re setting up (photo above). Plug in the NC and NRB (taped to BVM line) to two separate connections. Once sedative and paralytic kick-in, simply ask an assistant to switch between the two taped lines (on right, below) as you’re removing the mask from the patient’s face. This way, the lines are clearly marked, there is no need to touch the NC, and nasal oxygen supply to the patient continues uninterrupted.
Bonus point: Tape the lines in advance, while both devices are mostly in their packaging (though you may need to discard them at some point, check local rules). For safety mark the BVM line with tape and the letters “BVM”.
References:
1) Weingart, S., Levitan, R. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. Volume 59, Issue 3 , Pages 165-175.e1, March 2012. <;;a href=”http://www.annemergmed.com/article/S0196-0644(11)01667-2/fulltext
2) Levitan, R. NO DESAT! Emergency Physicians Monthly. December 2010.
3) Herbert, M. Apneic Oxygenation. EM:RAP
4) Apneic Oxygenation – for further reading see citations in Ref #1 (above)
Another tip. Avoid swapping lines in the middle of the procedure by hooking up two to wall oxygen, and the last one to a tank of oxygen. Most modern beds have a slot underneath for a tank to allow oxygen delivery during transport.
An excellent quick fix also. Best to do whatever is most available and most reliable in your shop. Thanks for the comment!