In patients requiring emergency rapid sequence intubation (RSI), 100% oxygen is often delivered for preoxygenation to replace alveolar nitrogen with oxygen. Sometimes, however, preoxygenation devices are prematurely removed from the patient prior to the onset of apnea, which can lead to rapid loss of preoxygenation.
We sought to determine the elapsed time, on average, between removing the oxygen source and the loss of preoxygenation among non–critically ill patients in the emergency department (ED).
We conducted a prospective, crossover study of non–critically ill patients in the ED. Each patient received two identical preoxygenation trials for 4 min using a non–rebreather mask with oxygen flow at flush rate and a nasal cannula with oxygen flow at 10 L/min. After each preoxygenation trial, patients underwent two trials in random order while continuing spontaneous breathing: 1) removal of both oxygen sources and 2) removal of non–rebreather mask with nasal cannula left in place. We defined loss of preoxygenation as an end-tidal oxygen (exhaled oxygen percentage; EtO2) value < 70%. We measured EtO2 breath by breath until loss of preoxygenation occurred.
We enrolled 42 patients, median age was 43 years (interquartile range [IQR] 30 to 54 years) and 72% were male. Median time to loss of preoxygenation was 20 s (IQR 17–25 s, 4.5 breaths) when all oxygen devices were removed, and 39 s (IQR 21–56 s, 8 breaths) when the nasal cannula was left in place.
In this population of non–critically ill ED patients, most had loss of preoxygenation after 5 breaths if all oxygen devices were removed, and after 8 breaths if a nasal cannula was left in place. These data suggest that during ED RSI, preoxygenation devices should be left in place until the patient is completely apneic.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of Emergency Medicine
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Preoxygenation and prevention of desaturation during emergency airway management.Ann Emerg Med. 2012; 59: 165-165.e1
- Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation.Br J Anaesth. 2020; 125: e1-e4
- Comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure (PEEP) ramp procedure in an experimental model of acute respiratory distress syndrome.Crit Care. 2008; 12: R91
- Understanding preoxygenation and apneic oxygenation during intubation in the critically ill.Intensive Care Med. 2017; 43: 226-228
- Optimizing preoxygenation in adults.Can J Anesth. 2009; 56: 449-466
- Preoxygenation with flush rate oxygen: comparing the nonrebreather mask with the bag-valve mask.Ann Emerg Med. 2018; 71: 381-386
- Flush rate oxygen for emergency airway preoxygenation.Ann Emerg Med. 2017; 69: 1-6
- Assessment of common preoxygenation strategies outside of the operating room environment.Acad Emerg Med. 2016; 23: 342-346
- Preoxygenation by spontaneous breathing or noninvasive positive pressure ventilation with and without positive end-expiratory pressure: a randomised controlled trial.Eur J Anaesthesiol. 2015; 32: 881-887
- Preoxygenation in critically ill patients requiring emergency tracheal intubation.Crit Care Med. 2005; 33: 2672-2675
- Efficacy of nasal cannula oxygen as a preoxygenation adjunct in emergency airway management.Ann Emerg Med. 2016; 68: 174-180
- Principles of preparatory oxygenation.in: Brown III, C.A. Sakles J.C. Mick N.W. The Walls Manual of Emergency Airway Management. Wolters Kluwer, South Holland, Netherlands2018: 49-60
- Tracheal intubation in the critically ill: where we came from and where we should go.Am J Respir Crit Care Med. 2020; 201: 775-788
- Risk factors for and prediction of hypoxemia during tracheal intubation of critically ill adults.Ann Am Thorac Soc. 2018; 15: 1320-1327
- Predictors of arterial desaturation during intubation: a nested case-control study of airway management-part I.J Thorac Dis. 2017; 9: 3996-4005
- Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: a multicenter cohort study.Crit Care Med. 2018; 46: 532-539
- Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352
- Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications.Intern Emerg Med. 2017; 12: 1235-1243
- The importance of first pass success when performing orotracheal intubation in the emergency department.Acad Emerg Med. 2013; 20: 71-78
- Bag-mask ventilation during tracheal intubation of critically ill adults.N Engl J Med. 2019; 380: 811-821
Published online: August 05, 2020
Accepted: June 20, 2020
Received in revised form: June 4, 2020
Received: May 4, 2020
This article was accepted for presentation at the Annual Meeting for the Society of Academic Emergency Medicine, Denver, CO, May 2020.
© 2020 Elsevier Inc. All rights reserved.