21 Aug 2017

August 21, 2017

Written by REBEL EM
Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest.  The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU.  What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy.  Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting.  Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice.
Medical Categories: Resuscitation
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17 Jul 2017

July 17, 2017

Written by REBEL EM
Background: Apneic oxygenation (ApOx) is the passive flow of oxygen into the alveoli during apnea.  This passive movement occurs due to the differential rate between alveolar oxygen absorption and carbon dioxide excretion producing a mass flow of gas from the upper respiratory tract into the lungs.  Another important component of this maneuver is maintaining a patent airway so that supplemental oxygen administered through the nares is able to be delivered to the alveoli.  This practice has been a game changer in emergency airway management for many providers.  However, there are still some naysayers that believe in the sickest patients ApOx may not be so beneficial. This post is a review of two recent systematic reviews/meta-analyses published in the critical care and ED/retrieval settings on the use of ApOx.
Medical Categories: Resuscitation
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17 Jul 2017

July 17, 2017

Written by REBEL EM
Background: Apneic oxygenation (ApOx) is the passive flow of oxygen into the alveoli during apnea.  This passive movement occurs due to the differential rate between alveolar oxygen absorption and carbon dioxide excretion producing a mass flow of gas from the upper respiratory tract into the lungs.  Another important component of this maneuver is maintaining a patent airway so that supplemental oxygen administered through the nares is able to be delivered to the alveoli.  This practice has been a game changer in emergency airway management for many providers.  However, there are still some naysayers that believe in the sickest patients ApOx may not be so beneficial. This post is a review of two recent systematic reviews/meta-analyses published in the critical care and ED/retrieval settings on the use of ApOx.
Medical Categories: Resuscitation
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4 Apr 2016

April 4, 2016

Written by REBEL Cast
Welcome back to the April 2016 edition of REBELCast. For this episode I was lucky enough to get Scott Weingart on the show to talk to us about all things Apneic Oxygenation (ApOx). ApOx is a concept that has been around for some time in the operating room literature, but only recently been gaining acceptance in the ED, especially after the publication of this concept by Scott and Richard Levitan in the Annals of Emergency Medicine in 2011 [1]. Many nay sayers will argue that the OR studies were in controlled settings with elective surgical patients who were not in critical condition. The believers would argue that ApOx makes sense, its low cost,  and low complexity.  To date there has been no randomized controlled trials (RCTs) on ApOx in the ED.  There has been one ICU Trial (i.e. The FELLOW Trial) [2] and an even more recent observational trial in the ED [3] that have been published on the topic of ApOx. So the question remains: Is Apneic Oxygenation Overhyped?
Medical Categories: Resuscitation
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8 Feb 2016

February 8, 2016

Written by REBEL Crit
Background: Tracheal intubation is a procedure that is often performed in the ED on patients in critical condition. Because of this, there is the potential for complications such as hypoxemia, hypotension, dysrhythmias, aspiration, and cardiac arrest. Apneic Oxygenation (ApOx) is a concept first explored decades ago in the anesthesia literature and more recently, has gained acceptance in the ED. Studies in the operating room (OR) show that delivery of oxygen through the use of nasal cannula during periods of apnea significantly delays the onset of oxygen desaturation. These studies however, were in controlled settings with elective surgical patients who were not in critical condition. Physiologically, ApOx makes sense, its low cost, and low complexity and could improve the safety of RSI in the ED, by extending the safe apnea time. To date there have been no RCTs on ApOx in the ED. The recently published Fellow Trial questioned the use of ApOx in critically ill patients, but had some significant issues with 2/3 of the usual care arm not being apneic (i.e. Bag Valve Mask Ventilation or Non-Invasive Ventilation) prior to intubation.
Medical Categories: Resuscitation
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