RSI in adult patient - what about ventilation | Alexandre Jeleff at TBS23
•
1 like•176 views
- The document discusses the risks of rapid sequence intubation (RSI) and debates whether positive pressure ventilation should be used during RSI. - While regurgitation during RSI has a very low incidence (0.01%) and mortality (0.002%), severe hypoxia during RSI has a much higher incidence (30-50%) and can result in cardiac arrest in 2% of cases. - A large multicenter trial found that using a bag-mask device with PEEP during the apnea period of RSI reduced the lowest observed oxygen saturation and the risk of severe hypoxemia, without increasing risks of regurgitation or pulmonary aspiration.
Recommended
Recommended
More Related Content
Similar to RSI in adult patient - what about ventilation | Alexandre Jeleff at TBS23
Similar to RSI in adult patient - what about ventilation | Alexandre Jeleff at TBS23 (20)
More from scanFOAM
More from scanFOAM (20)
Recently uploaded
Recently uploaded (20)
RSI in adult patient - what about ventilation | Alexandre Jeleff at TBS23
- 1. RSI IN ADULT PATIENT: WHAT ABOUT VENTILATION? FROM SELLICK TO NEJM Dr Alexandre Jeleff, MD Geneva University Hospital, Switzerland TBS-Zermatt 2023 02.08.2023
- 3. Where does this presentation come from?
- 4. A bit of history
- 5. A bit of history • Mendelson (1946): Inhalation of gastric content
- 6. A bit of history • Mendelson (1946): Inhalation of gastric content • Paton, Scurr, Bourne (1950, 1951, 1952): Succinylcholine
- 7. A bit of history POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 8. A bit of history • Sellick (1961): Cricoid pressure POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 9. A bit of history • Sellick (1961): Cricoid pressure POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 10. A bit of history • Sellick (1961): Cricoid pressure POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 11. A bit of history • Sellick (1961): Cricoid pressure POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 12. A bit of history • Sellick (1961): Cricoid pressure POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 13. A bit of history • Sellick (1961): Cricoid pressure • Wylie (1963): No ventilation during RSI POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 14. A bit of history • Sellick (1961): Cricoid pressure • Wylie (1963): No ventilation during RSI POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 15. A bit of history • Sellick (1961): Cricoid pressure • Wylie (1963): No ventilation during RSI POSITIVE PRESSURE GASTRIC AND OESOPHAGEAL CONTENTS STOP
- 18. But not only…
- 19. •Regurgitation 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION
- 20. •Regurgitation •Pulmonary aspiration •Gastric distension 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION
- 21. •Regurgitation •Pulmonary aspiration •Gastric distension •Difficult intubation •Severe hypoxia 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION
- 22. •Regurgitation •Pulmonary aspiration •Gastric distension •Difficult intubation •Severe hypoxia •Oxygenation vs decarboxylation 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION
- 23. •Regurgitation •Pulmonary aspiration •Gastric distension •Difficult intubation •Severe hypoxia •Oxygenation vs decarboxylation •Emergency call to ENT •Cricothyroidotomy •And … 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION
- 24. Some facts about regurgitation • Incidence of regurgitation: 1/10000 to 1/900 (0.01 to 0.1%) Robinson, BJA Educ 2014 • Sun, Ann Palliat Med 2021 (IF = 2): • Gastric regurgitation with pulmonary aspiration (PA): 1/8325 (0.01%) • Mortality of PA: 1/55497 (0.002%) • Emergency procedures = Risk x 30 • 4 and 14 times Zdravkovic, BJANE 2021
- 25. Some facts about desaturation during RSI • Incidence of Sp02 < 92% during adult anesthesia induction for all procedures and surgeries: 0.86% Lemoto, Anesthesia & Analgesia 2016 • Incidence of SpO2 < 90% during RSI: 30 to 50% Casey, NEJM 2019; Gebremedhn, World J Emerg Med 2014 • Incidence of Cardiac Arrest (CA) due to deep hypoxia during RSI: 2% Mort, J Clin Anesth 2004
- 26. Semantic precisions • Positive pressure respiration = Oxygenation + Ventilation • Oxygenation : FiO2 + PEEP • Ventilation = Decarboxylation : Vt x RR • What are we really looking for while performing RSI? • Oxygenation? • Decarboxylation? • Or both?
- 27. What we are looking for is… • OXYGENATION • As we will see, ventilation is not so important
- 28. Why? • Some patients quickly desaturate during laryngoscopy • While others, not…
- 29. Because of physiological shunt Peterson, ERJ 2014 https://emcrit.org/pulmcrit/pressure-rsi/
- 31. Fight the shunt To fight atelectasis With pressure Pressure Atelectasis
- 32. Ventilation or not? • Rough debate for decades without robust evidence until... IS THAT THE QUESTION???
- 34. Topic of the study • Interest of a positive pressure « ventilation » with bag-mask device • During the apnea phase of RSI • To decrease the risk of severe hypoxemia • Evaluated by SpO2
- 35. Methods • Use of bag-mask device with PEEP valve:
- 36. Outcomes • Primary : • Lowest SpO2 observed • Between induction and 2 minutes after intubation • Secondary : • Incidence of severe hypoxemia SpO2 < 80% • Occurrence of PA • Occurrence of new opacities on the chest radiography in the 2 days
- 42. Highlights • Multicenter pragmatic trial with a large number of patients (400) • Hypoxia during RSI is much more common than regurgitation: • Lowest incidence of hypoxia during RSI = 30% • Highest incidence of regurgitation during RSI = 0.3% •X 100 • Respective mortality rates: • Occurrence of CA following severe hypoxia during RSI = 2% • Mortality of regurgitation in the context of RSI = 0.06% •X 33 Regurgitation Hypoxia
- 43. THE question… • Is not: should we deliver pressure during RSI? • Is: how to best deliver PP while limiting the risks? THAT IS THE QUESTION!!!
- 44. What is important is…
- 45. What is important is… • OXYGENATION
- 46. What about decarboxylation? Gustafsson, BJA 2017
- 47. What about decarboxylation? Gustafsson, BJA 2017
- 48. What about decarboxylation? Gustafsson, BJA 2017 0.25 kPa/min
- 49. What about decarboxylation? Gustafsson, BJA 2017 0.25 kPa/min Only 0.5 kPa
- 50. Tracheobronchial inhalation (TI) • Esophagus ≠ simple pipe connecting the pharynx to the stomach • UES + LES = one-way valves Shaker, Dysphagia 1995 • One-way valves can be deactivated: • By distension of esophagus = reflex peristaltis • Releasing the esophageal contents towards stomach or pharynx • 3 mechanisms of regurgitation: • Transcient increase in gastric pressure • Reduction of LES barrier pressure • Complete relaxation of the LES Dodds, NEJM 1982 THANKS TO UES AND LES!!!
- 51. Gastric gas insufflation = regurgitation? • Leads to : • Relaxation of the gastric wall (a good thing) • Relaxation of UES and LES (not a good thing) Bouvet, Anesthesiology 2014 • Curarization does not affect the LES but does affect the UES • UES barrier pressure = 15 cmH2O with curarization • Risk of gastric insufflation of gas when PP ≥ 15 cmH2O
- 52. Optimal inspiratory pressure during RSI? • No clear answer possible • But the minimal pressure will be the safest • < 15 cmH2O for sure!!! So 10 cmH2O even more • In order to deliver a PEEP • Because it's oxygenation that matters • Not decarboxylation answer
- 53. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 54. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 55. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 56. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 57. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 58. Mean Airway Pressure https://mededucation.stanford.edu/lessons/determinants-of-mean-airway-pressure/
- 62. Anesthetist’s skilled hands strategy = COTBS • Preoxygenation: closing the APL valve to allow a PEEP between 5 and 10 cmH2O • Continuation of oxygenation : • Use the bag • APL valve sets at 10 cmH2O • Minimal Vt • Maintaining a PEEP • 4 hands, in a perfectly positioned patient, with a Guedel's cannula in place
- 64. One thought • Is this evidence sufficient to go ahead and apply PP during RSI? • Complex study to design • We have clinical practice and experience, pathophysiology, secondary evidence on our side… • Should we thoughtlessly apply a precept put forward by Wylie in 1963? • You have to make an informed choice • I did mine!!!
- 65. Take home messages • It is possible to bag-mask during RSI • Major risk of RSI: • Severe hypoxemia>>> Gastric regurgitation • Incidence X 100, Mortality X 33 • NEJM’s study provides robust arguments, but ICU patients • Continuation of oxygenation ≠ ventilation • Know pathophysiology of TI • Practice, practice, practice: • In the OR first • Then on The Big Sick patient…
- 66. 1963 – 2019 Here lies a dead human from severe HYPOXIA and not from REGURGITATION during RSI