High flow nasal cannula

[paramedicmike]

One of my former employers is now mandating high flow nasal cannula (15lpm) as oxygenation prior to, and during, intubation attempts. Seems they've started this, in part, based on this study. While I'm not privy to the numbers my former coworkers tell me that using this has not resulted in a single desat during intubation no matter how sick the patient.

Anybody else doing this yet? I'm finding it pretty fascinating.

[RomeViking09]

Real question is why is the patient having a desat... Is it the intubation attempt or the patho of why the patient is getting the tube? Not many stable patients get a pre-hospital tube. (Personal note: on "elective" intubations (i.e. Not in arrest or apnea) I place the patient on a NRB while I set up if there is no need to bag them and then intubate once ready. Has worked well so far (also look for a sat > 90% at all times while attempting to tube)

[scubanurse]

Using a regular NC or an oximizer? Our RT's throw people on oximizers with capno prior to trach changes.

[paramedicmike]

Regular NC.

[BushyFromOz]

One of my former employers is now mandating high flow nasal cannula (15lpm) as oxygenation prior to, and during, intubation attempts. Seems they've started this, in part, based on this study. While I'm not privy to the numbers my former coworkers tell me that using this has not resulted in a single desat during intubation no matter how sick the patient.

Anybody else doing this yet? I'm finding it pretty fascinating.

Here's some non sensicle annecdotal evidence form someone who does not intubate, though i do work with people who have that skill set and assist with the procedure from time to time.

A lot of guys here incorporated this into their practie when Weingart put that on his podcast and from my many conversations with them they have had very very few desaturations and when they do they desaturate a lot slower than pre-oxygenation with BVM alone. I dunno what its work but from what I've seen I'm pretty much sold on it for the future.

[croaker260]

This is an excellant overview of the science and theory. http://www.epmonthly.com/archives/features/no-desat-/

I personally have had it save my ass on at least on occasion and prevent a difficulty airway . It was a adult male in status SZ for about 60-90 minutes prior to 911 call, how had been trached int he past. His family finally called us after they shoved a plastic toddler spoon in his mouth and caused further trauma.

Anyway, multiple Bezo's at max doses had failed to break the SZ, and the patients SPO2 was dropping (was abotu 65-70% on NRB) . He was also hyperthermic from fever and/or muscle activity. Airway positioning and suctioning was poor due to trismus.

We were literally facing a crash airway, but with his prior trachs and anatomy, RSI/MAI was the last thing I wanted to do. Remembering this tool in the tool box, I dropped the NC at 15 LPM as we prepared for the inevitable RSI. Immediatley (under 2 minutes) his SPO2 came up to 97-99%.

Being very happy with this, we continued transport, and he was subsequently intubated after three attempts with a glide-a-scope by the anesthesiologist (we had called ahead and they were waiting). Looking over the docs shoulder during the attempt, I was really glad we didnt have to try in the field.

Edited April 4, 2014 by croaker260

[rock_shoes]

Here's some non sensicle annecdotal evidence form someone who does not intubate, though i do work with people who have that skill set and assist with the procedure from time to time.

A lot of guys here incorporated this into their practie when Weingart put that on his podcast and from my many conversations with them they have had very very few desaturations and when they do they desaturate a lot slower than pre-oxygenation with BVM alone. I dunno what its work but from what I've seen I'm pretty much sold on it for the future.

I'm right there with your co-workers Bushy. This is something I have incorporated into my airway management practice and I've noticed marked improvement with respect to de-saturation rates.

The practice came to my attention as part of this CME course I participated in last year.

AIME: Airway Intervention and Management in Emergencies http://caep.ca/cpdcme/roadshows-current-cme/aime

The primary text for the course was Airway Management in Emergencies

http://www.amazon.com/Airway-Management-Emergencies-2nd-ED/dp/1607951045

AIME was hands down the best CME course I have ever attended. The information presented was first rate and directly applicable to paramedic practice in the field. BC Ambulance has chosen it as one of our "pillars" for continuing education with the most up to date version of it available to us every three years.

[celticcare]

During my post grad papers it was discussed and has been utilised by some staff I know for cardiac arrest management if running a solo code (unfortunately still single crewed vehicles here in some places) and will chat to med director see if it being recommended as standard practice.

[mikeymedic1984]

Seems reasonable --- but I am not sure it is entirely necessary. I have always said (no I didnt make it up, I stole it from somewhere); patients do not die because medics do not intubate them, they die because medics do not VENTILATE them.

I can't tell you how many times I have watched medics, especially helicopter medics, dig around in somebody's throat for far too long, trying to get them tubed. A good reminder is to always hold your own breath from the minute you remove supplemental oxygen or BVM and begin your intubation attempt until you are successful or fail. When you need to take a deep breath, chances are the patient needed two or three.

[HellsBells]

This is standard practice where I work now, I think the main advantage is that it provides an oxygen source during the intubation attempt.