Monday, February 19, 2018

Near Perfection in Airway Management is now Possible #4

Nasal Oxygen Delivery- Profound Discovery.

The world is slowly awakening to the importance of the Nasal Ventilation and Oxygenation and its many merits. Like all great changes recognition begins and spreads from the early adopters, to the early majority and then becomes fully incorporated in Airway Culture. To the impatient observer this is painfully slow as all changes prove to be. To be featured on the ASA Algorithm , wide recognition must be achieved.  

The superiority of Nasal Route of ventilation has been recognized and promoted by basic scientists who have surely documented the advantage of positive pressure delivered via nasal route. The mechanics are such that the pressure from an oral mask which normally presses the tongue backward to occlude the pharynx becomes a force that pushes the tongue forward and greatly improves the passage way for Oxygen and air.

Flush Nasal Oxygen with Nasal Prongs

The routine use of nasal prongs in the pre-induction state is a widely appreciated method of delivering oxygen. The use of high flows , 15L/min or more, can provide some apneic ventilation at times but must be monitored for effectiveness as the results are variable without CPAP. This strategy has been promoted for an extended period by Scott Weingart and Dr. Richard Levitan and reviewed in their excellent paper.
Preoxygenation and prevention of desaturation during emergency airway management.
 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3.

Modified Pediatric Nasal Mask

James Tse- Legendary work demonstrating Rescue with Nasal Tse PAP (Use of a modified Pediatric facemask) allows positive pressure ventilation via nasal route, intubation with GlideScope (highly angled feature is important) , without removal of the nasal mask. Thus a high oxygen environment and flexibility is maintained while the enhanced nasal route pressure CPAP tends to keep the tongue and pharynx open. Dr. Tse has presented multiple times at ASA and SAM winning the anesthesia safety foundation award. This strategy is very economical with oxygen use.

Thrive- A Great Australian Contribution

The Thrive device is extraordinary as it is used to deliver up to 70 L of humidified oxygen flow during extended periods of apnea lasting over 30 minutes at times. This allows Dr. Patel to work for an extended time on his specialty Tracheal stenosis cases. The Thrive device uses a large amount of oxygen in use , and  therefore is not suited to austere environments. The lifesaving potential of this equipment during airway emergencies cannot be overstated. It is imperative that emergence airway managers be aware of the huge advantage of this equipment. The ED and ICU Airway Lead should make the equipment fully available for severe problems but it is not suited to routine airway management when high flow nasal prongs or Nasal CPAP could do the job much more economically.

Anaesthesia 2015, 70, 323–329 Patel and Nouraei | THRIVE oxygenation in difficult intubation. urethral control device for male urinary incontinence. -

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