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Post by katevaughn on Apr 27, 2017 12:33:49 GMT -5
This month's journal club is presented by Vania. She chose a great article concerning apneic oxygenation and ways to help facilitate a safer prolonged apnea time. "It addresses the validity and usefulness of apneic oxygenation prior to induction/intubation attempts, especially in the pediatric population and in cases of anticipated difficult airways." I believe you all will learn great tips that you can use in your daily practice to help better care for our patients. Enjoy! Here is a link to the article. Questions to encompass within your responses: 1. Have you ever seen or used apneic oxygenation in your practice? If so, do you think it was helpful in delaying the onset of hypoxemia? If you haven't seen or used it, do you feel it would be helpful, and if so, in what population that you care for? 2. Which delivery method, if any, do you feel would be the most feasible, easy to use and cost effective?
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Post by Kels on Apr 27, 2017 13:50:30 GMT -5
I have seen apneic oxygenation. I gave a 15 min break to a coworker in the ENT/airway room . During this break the surgeons were working away in the airway while oxygen was being delivered though a nasal trumpet. The Pt was not breathing spontaneously and was not on the ventilator, breaths were being held. The time to the first fall in saturation definitely took longer than usual. A great thing !
I did like this method and may use it in the future. With the nasal airway it can always be kept in place once the surgery is finished in prep for emergence .
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Post by Ben Waldbaum on Apr 27, 2017 16:58:02 GMT -5
I have used apneic oxygenation many times and in different ways depending on the scenario. It definitely works. For a difficult FOI I'll put a nasal trumpet it, connected it to a 7.0 ETT adapter, then to a circuit and set it to 10L/min. I've seen 20 mins with greater than 95% sat the entire time. I've also done rigid bronchoscopy and used this same technique many times for more than 45 mins. I've never had a problem. A few times a blood gas was indicated and not a single time was the patient acidotic.
The delivery method I described above is cost effective as it uses supplies we regularly have.
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Post by faresha on Apr 30, 2017 15:18:45 GMT -5
Great information!
I have used apneic oxygenation on two occasions. One request by an ENT surgeon and other by MDA. It was unbelievable how long the patient sustained adequate oxygenation in the high 90s. I was standing next to the patient prepared to tell the surgeon that I must ventilate but it never happened because the patient saturation was 100-98% after 10-15 minutes with no signs of decompensating any time soon.
First time was nasal trumphet with ett connector to circuit- my favorite- because it allows the highest flows. Second time was in Endoscopy due to a possible difficult intubation so my Attending wanted nasal cannula on during induction and remained on until ETT confirmation. Not sure the effectiveness of this method because the patient was an easy intubation thus quickly performed.
The ideal patient population is obese and/or potential difficult airways. Again my favorite is nasal trumphet w/ett connector to circuit however, I have much reservation w/ using nasal trumphets due to nasal bleeding.
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kty67
New Member
Posts: 22
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Post by kty67 on May 1, 2017 9:47:27 GMT -5
1. We all use AO in every day work, for example for Wilmer blocks we use nasal cannula O2 flow, in endoscopy when patients have apneic episodes, I frequently use nasal airway with O2 flow through it as Ben described using a ETT adapter or just 6-10 l/m O2 flow with nasal cannula, chin lift. 2. The method I choose for the patient usually depends on a patient. I like to use nasal airway, if there is no contraindication, with nasal cannula or with ETT connector.
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Post by Rouchon on May 3, 2017 7:48:15 GMT -5
A very good article indeed. I have used this technique for "difficult to sedate" patients, BMI 40+ with PMH to include OSA, excessive submandibular tissue, short neck and HTN in endoscopy for EGD. We preoxygenated via face mask with anesthesia circuit 10L flow x 2 min. began slow induction 20mg propofol to placed well lubricated nasal trumpet atraumatically, connect ETT 6.0 adaptor to nasal trumpet opening, then the anesthesia circuit to the ETT adaptor. It allowed induction for EGD scope entry by a training endoscopist without much drop in SpO2 from a propofol bolus. It also helped maintain oxygentation during the procedure. Ultimately the nasal prongs were not used.
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Post by jhadley on May 5, 2017 16:47:00 GMT -5
1. I use apneic oxygenation very frequently in the airway room for tracheal stenosis cases. We induce the patient and demonstrate that we can bag/mask ventilate, then place a nasal trumpet with an ETT adapter to the anesthesia circuit with high flow 02. This works extremely well in healthy patients who are not obese. I have seen patients maintain there SP02 for 30min or longer without desaturating. In patients with lung disease or who are obese apneic oxygenation still prolongs their time to desaturation significantly, however inevitably we do have to ventilate these patients after a few minutes by placing an ETT.
2. I feel the nasal trumpet with ETT adapter method works great for apneic oxygenation.
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Post by LMEGINNIS on May 10, 2017 11:05:19 GMT -5
I have also used apneic oxygenation. Works best with healthy patients. The last rigid bronch I participated in (ASA 3) I had to periodically mask ventilate due to desaturations. I also use the nasal trumpet with the ETT adapter.
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Post by Wai-Ling Lo on May 10, 2017 16:43:41 GMT -5
1. Yes, I've used AO before. I used it mainly in endo with obese pts to delay or even eliminate desaturation from propofol. I use the nasal airway and connect it to the circuit through ETT connector. Usually it works really well.
2. Dr. Schiavi loves to leave pts on nasal prong for continuous O2 insufflation during intubation to delay desaturation. However, it doesn't work too well in obese pts because of all the redundant tissues in posterior pharnygeal area blocking the flow. I personally prefer using nasal airway if pts have no contraindication.
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Post by emedina1 on May 26, 2017 19:40:57 GMT -5
I have used this technique before mostly in ophthalmology obese pt. before i sedate them for the retrobulbar block or subtenon block , i put the o2 nasal cannula next to applying the pulse oximeter.nAnd most of the time the desaturation doesn't happen. I am pleased to know that such technique had been studied and now I can say that some of my practices are really current. Beth Medina CRNA from Johns Hopkins
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Post by Soo-Ok Kim on May 29, 2017 20:39:17 GMT -5
Yes, I used it before. But, mostly with spontaneous breathing, but anesthetized pediatric patient for SML/rigid bronchoscopy, so it is not technically AO. We place ETT in the oral cavity with high flow oxygen during rigid bronch. : definately delays desaturation. Occasionally, connect auxillary O2 flow meter with suction tubing to rigid bronch side port works as well to deliver high flow O2. I have used nasal trumphet with ETT adapter for high flow O2 during difficult airway situation. I think it will work best with ASA 1-2 patients, but it would delay desaturation for other pipulation as well, not as well as heathy patient group.
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Post by krechti1 on May 30, 2017 7:53:30 GMT -5
I have used apneic oxygenation. One instance is for airway cases when the surgeon is taking the tube in and out, and while the tube is out, AO is used to passively oxygenate the patient. The time to desaturation is dramatically longer than without the use of AO. Also, as discussed above, during deep sedation cases, when pt is apneic and high flow NC is used, this keeps O2 sat up for a longer period of time. Also, as mentioned in the article, preoxygenation makes a big difference in the time to desaturation during a difficult intubation, or during a deep sedation case where the patient is apneic after the initial propofol dose for a short period of time. Those times when I did not preoxygenate really demonstrate the importance of this, and shows how much of a difference preoxygenation makes. Healthy ASA 1-2 patients have the most dramatic effect from this technique, but I think it is helpful with all patients, and in fact, those ASA 3-4 with pulmonary disease may benefit the most since they cannot tolerate drops in O2 sat as well as healthy patients.
I agree with the above that the best method to deliver AO is through a nasal trumpet with ETT adapter connected to circuit. This delivers the highest concentration of O2 without getting diluted with room air, and goes directly as close to the trachea as possible.
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Post by BrittneyKeating on May 31, 2017 7:56:20 GMT -5
This is a great article to highlight the utility of apneic oxygenation, especially in high-risk patient’s, and review of physiologic mechanisms important to our everyday practice. The effectiveness of this technique is highlighted by all of the clinical research findings presented in this article, including that which states apneic oxygenation provides saturations greater than 95% for 45 minutes in the non-obese adult patient. Reviewing this article now has me thinking that we underutilize this technique in our everyday practice.
I actually used this technique yesterday in endoscopy to sedate a 161kg patient with OSA. I had my doubts as to whether the technique would work for this patient, but the oxygen saturation remained >97% throughout the case. Maybe just luck! But, I will definitely use this technique more often. The delivery method that seams most feasible and effective is the use of a nasal trumpet with appropriate size endotracheal tube attachment piece connected to the ventilator circuit at 10L/min O2. I have just joined the otolaryngology cohort, so I will definitely keep this practice in mind for this patient population, as well.
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Post by abenson on May 31, 2017 11:40:00 GMT -5
Vania, this was a great article choice. Thanks for submitting it. I do use the AO technique and realized that I could use it in additional capacities that I haven't previously. As others have mentioned, we use it all the time whether we realize it or not, in endo, wilmer and any sedation case that we need to have the patient deep initially. I am not in the ENT cohort but this technique would prove to be beneficial and useful in those cases.
The nasal trumpet attached to the circuit seems to be the best method that most of us use. I not only learned from reading the article but also from the posts from the CRNAs.
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nanci
Junior Member
Posts: 57
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Post by nanci on May 31, 2017 13:30:38 GMT -5
1) This article really does a good review of physiology of apneic oxygenation. I do use the AO technique often, especially in the remote areas with sedation cases. I've just started using the nasal trumpet with ETT connector more in Endoscopy (Dr. Al-Grain showed me on morbidly obese patients) and it works so very well. Definitely helps to delay hypoxemia.
2) Delivery method we have is the nasal trumpet with ETT connector or the nasal cannulas. I do not know how much the trumpet and connector would cost and if obtaining the Nasal-Flo (Nasopharyngeal Airway Device) would be more cost effective or not. We have the standard Nasal cannulas and also have the ETCO2 nasal cannulas readily available too- so we have the supplies. Not sure which way would be most cost effective.
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