Elsevier

Air Medical Journal

Volume 34, Issue 2, March–April 2015, Pages 82-85
Air Medical Journal

Original Research
Preoxygenation Reduces Desaturation Events and Improves Intubation Success

https://doi.org/10.1016/j.amj.2014.12.007Get rights and content

Abstract

Objective

Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and is associated with increased morbidity and mortality. Preoxygenation with positive pressure ventilation by bag valve mask may delay the onset of desaturation. The purpose of this study was to evaluate implementation of a targeted preoxygenation protocol including the use of positive pressure ventilation on desaturation events and intubation success during air medical RSI.

Methods

The RSI air medical program airway training model was modified to target an oxygen saturation as measured by pulse oximetry value of ≥ 93% before initial laryngoscopy. A review of oxygen saturation as measured by pulse oximetry tracings was performed for 2 years before and 2 years after implementation of this protocol. The incidence of desaturation events and overall intubation success rates were compared before and after the intervention.

Results

One hundred fifty-five RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the 2 years before algorithm changes to 28% in the first year and 14% in the second year after implementation (P < .01). Intubation success rates increased from 89% to 98% (P < .01). There were no self-reports of aspiration events during the study period.

Conclusion

A preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success without an increase in the number of reported aspiration events.

Section snippets

Design

This was a prospective, before and after study conducted from 2005 to 2008. A wavier of informed consent was granted by our investigational review board.

Setting

Mercy Air Medical Services includes 8 bases throughout Southern California. Flight crews routinely perform RSI for specific indications, including coma from any cause as well as severe respiratory distress. The protocol during the study period included routine administration of etomidate and succinylcholine before intubation attempts, with

Results

A total of 155 RSI procedures were included in this analysis (81 preintervention and 74 postintervention). Desaturation events decreased from 58% (2005-2006) in the years before the algorithm changes to 28% (2007) in the first year and 14% (2008) in the second year after implementation (P < .01) (Fig. 1). Overall intubation success rates increased from 89% in the years before introduction of the algorithm changes to 94% the year after its introduction and 98% the second year after

Discussion

Although advanced airway management represents a cornerstone of out-of-hospital resuscitative care, the high potential for desaturations and possibility of failure underscore the importance of an optimal approach emphasizing preoxygenation and aggressive training. In a prior study, we documented a high rate of desaturations during RSI with SpO2 values below 93% with initial laryngoscopy.5 In response, we modified our advanced airway management protocols to emphasize preoxygenation strategies,

Conclusions

In this brief report, the implementation of a preoxygenation bundle using PPV via BVM to achieve SpO2 ≥ 93% before RSI was associated with a significant decrease in desaturation events as well as improved ETI success rates, without a concomitant increase in aspiration events. Although further research is needed to fully evaluate the downstream effects of adoption this protocol, the results of this study in combination with the lack of evidence supporting a clear association between PPV during

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