101 The Efficacy of Current Preoxygenation Strategies During Rapid Sequence Intubation in the Emergency Department

Abstract

Rapid sequence intubation (RSI) in the emergency department (ED) is high risk and is associated with a high prevalence of oxygen desaturation. Preoxygenation is a vital step to ensure that the patients have an adequate reservoir on oxygen to prevent the development of hypoxemia during intubation. It is unknown how efficacious preoxygenation is in the ED setting. The aim of this study is to determine how efficacious current preoxygenation methods in the ED are by measuring end-tidal O2 (ETO2) during RSI. Current recommendations suggest a goal of ETO2 ≥ 85% for airway management in critically ill patients. This study was carried out in 2 academic centers in Sydney, Australia and New York City. Waiver of informed consent was granted by the institutional review boards. All patients undergoing RSI in these EDs were included in the study. A gas analyzer was used to measure ETO2 and FiO2 throughout intubation and a pulse oximeter was used to measure O2 saturations. Emergency physicians were blinded to the ETO2 and FiO2 measurements that observers were collecting. One-hundred patients were enrolled in the study over a 6-month period. The mean ETO2 achieved after preoxygenation and immediately before intubation attempt was 74% (95% CI 70%-78%). The highest ETO2 achieved was in the group in which a non-rebreather (NRB) mask at flush rate was used (ETO2 84%, 95% CI 78% to 90%) and the group in which a bag-valve mask (BVM) was used at flush rate (ETO2 81%, 95% CI 74% to 88%). See Graph 1 for more details on each subgroup. Bag valve mask and non-rebreather mask at flush rates demonstrated the greatest ability to reach the goal of FeO2 of 90 (see graph 1). These results demonstrate that there is considerable variability in the quality of preoxygenation during RSI in the ED. Use of a NRB at flush rate or BVM at flush rate resulted in the best preoxygenation. Further study is warranted to determine if gas analyzers in the ED capable of measuring ETO2 would be helpful to emergency physicians to optimize preoxygenation before RSI.