iPhoneIcon_BigApnoeic oxygenation in anaesthesia is the concept of providing oxygenation without ventilation. The idea is that even without lung expansion, oxygen will passively be dragged into the alveoli along the oxygen gradient caused by alveolar oxygen being transported away by the bloodstream. Hope that makes sense. If not, theres a better explanation at LITFL.  In theory, and in experimental conditions, the apnoeic patient will remain oxygenated indefinitely, given that the FiO2 in the pharynx is high enough and given that the airway is perfectly patent. The problem is rather hypercapnia and acidosis building up.

Since a few years, apnoeic oxygenation has been incorporated into  emergency anaesthesia and intubations. If we could provide apnoeic oxygenation during laryngoscopy, then we would have all the time in the world to intubate as the patient won’t deoxygenate. Most systems I am aware of have applied nasal cannula with high flow O2. I was concerned about that. Can we really achieve an high enough FiO2 in the pharynx with just nasal cannulae? Also, many of the patients I intubate have facial and nasal bleeds or injury which should restrict oxygen flow.

So I was a bit intrigued by a solution that was recently posted on youtube.  It´s the (Royal, Imperial???) Hungarian HEMS demonstrating their RSI protocol. Note how they pre-oxygenate with a non-rebreather mask and two nasal airways. Then, at 1:00, after relaxation, instead of using nasal cannulae for apnoeic oxygenation, they cut the oxygen tubing and shove it way down the nasal airway. This way, they provide high O2 flow, and apnoeic oxygenation, directly at the oropharynx. At least, I think that is what is going on. I don´t understand a word of what they’re saying.

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  1. James DuCanto says:

    Ok, great, awesome use of minimal resources!!
    Note that as medic places tubing into nasal airway, he jaw thrusts and occluded the mouth, thus placing a positive pressure breath into the patient (which would be enhanced if he occluded the other nostril as well). Good stuff, a symphony of simplicity.
    On another similar topic, a nasal cannula on high flow would do this well ESPECIALLY IF YOU PUT A BIOOCLUSIVE DRESSING over the whole cannula and nose. Turns it into a CPAP mask. No kidding (been there, done it). Thanks Thomas! Hopefully see you at SMACC.

    • Otis says:

      Nice technique very slick… The original studies on apneic oxygenation were actually done using placement of the oxygen tubing into oro-pharynx

  2. Matthieu Komorowski says:

    Thanks for your post! I find nasal oxygenation particularly useful and quite efficient during intubation of obese patients, in conjonction with CPAP preoxygenation. See for example.

  3. Ervin says:

    They are basically giving induction meds, the last being sux, then start counting every 5 seconds and following the patient’s active respiratory movements, which seize around 35 seconds, after fasciculations, at which point they intubate. They don’t mention anything about the apneic oxygenation, which is just the title of their video.

    By the way, Hungary is a republic, so nothing Royal or Imperial there. 🙂

  4. Aaron M. says:

    Neat stuff for sure and quite handy if you have limited resources and plenty of time as noted, but the hyper focus on pre-oxygenation and oxygenation seems a little distracting. All the nifty tricks to keep that blue number as close to 100% are just that. Intubation shouldn’t take all day for the majority of patients. If all the extras mentioned above are necessary or needed often perhaps folks need to brush up on their BVM use, their A&P, their clinical intubation skills or their crash airway decision making process.

    I’m all for style points but whatever the SpO2 is when the decision to intubate has been made – the sooner one performs direct laryngoscopy, visualizes the damn vocal chords, passes the tube, checks/confirms placement, secures the tube and effectively ventilates – the better.

  5. Magnus Byröd says:

    There is a short discussion on the EmCrit G+ site:

    According to Minh Le Cong:
    “few case reports out there of complications of nasal catheter oxygen

  6. Thomas D says:

    If you don’t have your nasopharyngeal silicone tubes in place, the oxygen tube might be too stiff to want to shove it through the delicate (and well circulated/easily bleeding) mucosa of the nose. Then a good trick can be to use a suction catheter through the nose and into the nasopharynx. The oxygen tubing easily attaches to the suction catheter. Read more on that here:

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