Preoxygenation for floor/ICU intubation

[deleted875186]

Curious how others do preoxygenation for floor intubations. If emergency, I usually keep whatever mask is on them, or even better non rebreather, then start bagging them about 10 seconds after pushing drugs. If non emergent, do you guys ask for a non rebreather or just crank up their NC or regular facemask? Do others even bother to mask or just go right to intubation when apnic? Curious how others do it.

While I’m on it, what is everyone’s favorite induction regimen for the typical septic ICU patient?

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[POW16]

Curious how others do preoxygenation for floor intubations. If emergency, I usually keep whatever mask is on them, or even better non rebreather, then start bagging them about 10 seconds after pushing drugs. If non emergent, do you guys ask for a non rebreather or just crank up their NC or regular facemask? Do others even bother to mask or just go right to intubation when apnic? Curious how others do it.

While I’m on it, what is everyone’s favorite induction regimen for the typical septic ICU patient?

I definitely preoxygenate everyone as those patients often have very little reserve. I typically switch to an ambu bag unless they're on HFNC. I don't bag unless first look is unsuccessful. I don't have a specific cocktail as it depends on how sick/awake the patient is but typically at a minimum 2 of midaz for sedation. For paralytic 100 of roc.

 

[NOsaintsfan]

Etomidate --> Roc/nimbex--> tube

The floor nurses freak if we ask for propofol here. If it's truly emergent (vs controlled) as it usually is by the time they page us we just go with whatever facemask ECT. they currently have. We often dont preoxygenate beyond that. Heck by the time we get there the medicine intern has usually tried 5+ times, the airway is bloody and the sats are in the 80's or worse.

 

[jeesapeesa]

Curious how others do preoxygenation for floor intubations. If emergency, I usually keep whatever mask is on them, or even better non rebreather, then start bagging them about 10 seconds after pushing drugs. If non emergent, do you guys ask for a non rebreather or just crank up their NC or regular facemask? Do others even bother to mask or just go right to intubation when apnic? Curious how others do it.

While I’m on it, what is everyone’s favorite induction regimen for the typical septic ICU patient?

keep their own mask/nonrebreather. or just bag with what they have. if they are doing compressions i just intubate with no drugs.

 

[anbuitachi]

Curious how others do preoxygenation for floor intubations. If emergency, I usually keep whatever mask is on them, or even better non rebreather, then start bagging them about 10 seconds after pushing drugs. If non emergent, do you guys ask for a non rebreather or just crank up their NC or regular facemask? Do others even bother to mask or just go right to intubation when apnic? Curious how others do it.

While I’m on it, what is everyone’s favorite induction regimen for the typical septic ICU patient?

so many ways to do it but most common way here is etomidate sux tube.

 

[coffeebythelake]

Would be ok with some high fio2 system like NRB, otherwise the ambubag comes out preinduction. You're in an environment where if **** hits the fan you would be screwed hard. Why make it even harder for yourself with inadequate preoxygenation?

 

[deleted875186]

Would be ok with some high fio2 system like NRB, otherwise the ambubag comes out preinduction. You're in an environment where if **** hits the fan you would be screwed hard. Why make it even harder for yourself with inadequate preoxygenation?

I have found no way to effectively use an ambu bag with someone who is still spontaneously breathing. If they’re really sick you can just take over their breathing. But people who are still with it will freak out.

 

[caligas]

Years ago I had several RTs tell me that patients can not breath spontaneously with an ambu bag. I suspected this was wrong and tried it myself with a clean ambu. Fake news, as anticipated.

 

[HLxDrummer]

ED resident here. NRB should be in most code carts/rooms. Will use this with NC cranked all the way up if available.

BVM will not provide oxygen unless adequate seal and spontaneously breathing or you are bagging. If bad seal or not breathing, the valve is shut and nothing comes out.

 

[anbuitachi]

ED resident here. NRB should be in most code carts/rooms. Will use this with NC cranked all the way up if available.

BVM will not provide oxygen unless adequate seal and spontaneously breathing or you are bagging. If bad seal or not breathing, the valve is shut and nothing comes out.

Yea even though NRB only delivers 60-80% Fio2 i still usually just do NRB since most ppl there can't get an adequate seal with BVM, and i'm busy drawing up my drugs

 

[deleted171991]

Another NRB mask user here. I ask the patient to take deep breaths for at least 30-60 seconds (longer if their breathing is shallow), the same way I do it in the OR. I have never regretted "wasting" time on preoxygenation, regardless of the artistic impression.

I am not a big believer in the ambubag in an awake patient. It's not as easy to support spontaneous breathing as with a collapsible bag. The chance of dyssynchrony is much higher.

 

[Psai]

No need for preoxygenation when you have 100% success with grade 1 views every time. prop roc tube

 

[facted]

Years ago I had several RTs tell me that patients can not breath spontaneously with an ambu bag. I suspected this was wrong and tried it myself with a clean ambu. Fake news, as anticipated.

Actually, this is not fake news.

This happened to me once with a spontaneously breathing pt who I kept intubated to PACU via AMBU. You think you're giving 100% FiO2 but you're not.

From medscape: Some bags have one-way expiratory valves to prevent the entry of room air; these allow for delivery of more than 90% oxygen to ventilated and spontaneously breathing patients. Bags lacking this feature deliver a high concentration of oxygen during positive-pressure ventilation (PPV) but deliver only 30% oxygen during spontaneous breaths. [8]

 

[deleted162650]

Ok, so I just tried it (you know you’ve been in the OR too long when . . .). You can in fact breathe spontaneously through an Ambu bag quite easily.

 

[anbuitachi]

Ok, so I just tried it (you know you’ve been in the OR too long when . . .). You can in fact breathe spontaneously through an Ambu bag quite easily.

Question is what is the fiO2 you are breathing in

 

[deleted162650]

Question is what is the fiO2 you are breathing in

I’m pretty sure it was 21%.

 

[facted]

Ok, so I just tried it (you know you’ve been in the OR too long when . . .). You can in fact breathe spontaneously through an Ambu bag quite easily.

Depending on the maker of the bag, FiO2 concentration can vary widely when spontaneously breathing because of varying valve mechanisms each bag has (down to as little as 50% fio2 I found in one study). Some of the bags can give you Fio2 of 90%+ while spontaneously breathing but do not assume that the kind you are using can unlesss you're sure of it. You are better off strapping a 100% NRB on a patient for pre-oxygenation than using a BVM unless you're assisting the patient manually.

 

[facted]

I’m pretty sure it was 21%.

The question is not whether you can spontaneously breathe through an BVM mask (answer is clearly yes). It's just that you may not be anywhere close to 100% FIO2.

 

[MoMoGesiologist]

Jackson Reese all the way! (For spontaneously breathing patients)

 

[osumd]

Jackson Reese all the way! (For spontaneously breathing patients)

I do this often. It’s in all of the ICU airway carts & in our airway bag (don’t start ). If they’re wearing CPAP/BiPAP, I just make sure it’s on 100% and leave it until drugs have gone in.

 

[jwk]

Ok, so I just tried it (you know you’ve been in the OR too long when . . .). You can in fact breathe spontaneously through an Ambu bag quite easily.

Of course you can.

 

[jwk]

I have found no way to effectively use an ambu bag with someone who is still spontaneously breathing. If they’re really sick you can just take over their breathing. But people who are still with it will freak out.

I'm sorry - just not true. An Ambu bag with mask in the hands of just about anyone besides anesthesia folks is marginal at best. I doubt you'd even see an EtCO2 reading because of all the leaks. But in the hands of someone who routinely uses masks for ventilation in the OR, for the most part, this shouldn't be a big deal.

 

[deleted875186]

I'm sorry - just not true. An Ambu bag with mask in the hands of just about anyone besides anesthesia folks is marginal at best. I doubt you'd even see an EtCO2 reading because of all the leaks. But in the hands of someone who routinely uses masks for ventilation in the OR, for the most part, this shouldn't be a big deal.

I have no problem bagging apnic people with it. But I’ve never been able to “assist” a spontaneously breathing patient with it. Maybe I just need to practice more?

 

[vector2]

I have no problem bagging apnic people with it. But I’ve never been able to “assist” a spontaneously breathing patient with it. Maybe I just need to practice more?

These opportunities can sometimes be hard to come by depending on the number of people in the ICU or OR who actually need this kind of assist, but a good way to practice is start doing more deep extubations and assist the pt as he's breathing off gas. After the ETT is out, hold a good seal with the mask, close the popoff to 5-10, and feel the deflation of the bag as the patient generates negative inspiratory pressure. If the inspiratory rate is semiregular, look at the patient's neck, chest, and belly, and while feeling the bag try to anticipate when the next breath is coming and then synchronize with your squeeze. When using the ambu, hold some tension on the bag to keep the valve open as you make a seal, and then squeeze as the patient is about to breathe. If you're doing it correctly, the resistance when you squeeze will be noticeably lower than when you try to breathe against an exhalation and you'll get good chest rise. I've also noticed that when the pt isn't totally gorked, he'll actually realize what's happening (his inspiratory effort is becoming easier at some regular interval) and will actually synchronize with you to some degree.

 

[deleted697535]

Just to clarify the floor you speak of is ICU or some similar high dependency unit?

Ambu is fine