HFNC vs. BVM for Pre-oxygenation prior to intubation

A sentinel event is one where, amongst other different outcomes, leads to death. In critical care, anesthesia, and emergency medicine, we often deal with emergent airways on patients who are on the brink of death unless we intervene expediently. Despite having performed many intubations in my young career, I have the utmost respect for every airway. Any one of them can become at catastrophe at any time. If you're not prepared and thinking two steps ahead, you're honestly not adequately trained. If you haven't been burned before, you have not performed sufficient procedures to truly be proficient. Please don't take offense by that, it's just the name of the game. In residency I made sure to hunt down every single airway possible. In med school I hung out with the anesthesiologists to attempt to intubate their patients prior to surgery. Some of the ED attendings during residency had my number and would page/text me to perform the procedure to provide me with more experience. In fellowship I would love to tag along with the anesthesia residents on the "airway team" and go intubate patients throughout the hospital.

A way to mitigate the risk of patient demise is to attempt to pre-oxygenate your patients as much as possible prior to intubation. There are many strategies to do this, a NRB, BVM, NIV, and HFNC which will all deliver 100% FiO2. A regular nasal cannula won't really cut it on the sick patients. Remember, one needs to be prepared for catastrophe to occur on EVERY AIRWAY. This RCT from 2015 which is completely free compared in 40 pts the strategy of pre-oxygenating the patients with either HFNC of BVM prior to intubation. There were largely no significant differences between the two groups in their outcomes, but they did find one significant difference that really caught my eye. The SpO2 dropped significantly in the one minute of apnea after induction in the group that was preoxygenated with the BVM (p=0.001). Sure, that didn't change the outcomes overall in these 40 patients which is admittedly a small sample size, but it only takes one airway to become a true disaster where the patient develops anoxic brain injury or even dies during the intubation due to hypoxia. That would be a sentinel event that will keep you up at night. I do not wish that on anyone. Please be careful with your airway out there. The most important skill is knowing how to bag your patient. You should also be trained in how to cut the neck so that when it does happen, and I wish you never have to go through this yourself, you don't freeze.

-EJ



Link to Article

FREE FULL PDF

Simon M, Wachs C, Braune S, Heer G de, Frings D, Kluge S. High-flow nasal cannula versus bag-valve-mask for preoxygenation before intubation in subjects with hypoxemic respiratory failure. Respiratory Care 2016;61:1160–7.

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Enteral Nutrition: When should we start in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 

A 🎩 tip to the authors! 

- EJ

Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54. 

Can high-flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta-analysis

Link to Abstract

Link to PDF

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How to position your patient prior to intubation: ramped vs. sniffing

We still don’t know what’s the best way to position our patients to intubate them; ramped position (torso and head elevated) which has had some theoretical OR benefits vs. sniffing position (torso supine, neck flexed forward, and head extended). Patients did worse with the ramped position. An important takeaway is listed below. I do recommend that you add the Cormack-Lehane Grade views to your airway notes. This, combined with what medications you used, what size glidescope or blade you used definitely helps with future intubations. You should learn to look for prior intubation notes to prepare for difficult airways. All it takes is one bad one and your confidence will be shattered. Don’t let it happen to you. A hat tip to the investigators. 

A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Semler, Matthew W.Janz, David R. et al.

http://journal.chestnet.org/article/S0012-3692(17)30881-4/fulltext

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Pre-intubation Checklist

This was essentially a negative trial but I do feel the checklist they used is very helpful for house-staff; especially those who take call without direct supervision (as I did just a few short years ago). A hat tip to the investigators. Article linked below.

A multicenter, randomized trial of a checklist for endotracheal intubation of critically ill adults. Janz DR1, Semler MW2, Joffe AM3, Casey JD2, Lentz RJ2, deBoisblanc BP4, Khan YA4, Santanilla JI5, Bentov I3, Rice TW2; Check-UP Investigators; Pragmatic Critical Care Research Group.
Chest. 2017 Sep 13. pii: S0012-3692(17)32685-5. doi: 10.1016/j.chest.2017.08.1163.
http://journal.chestnet.org/article/S0012-3692(17)32685-5/pdf

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.