Today's post is about an airway management work around (apneic oxygenation) during the COVID-19 pandemic. This was shared on the ISEN listserv by Brian Espinoza of Arizona, and was written by an anesthesiologist he works with. The idea is to avoid bagging the patient, so as not to spread secretions and virus particles
Obviously this will not work on everyone, but it works on the majority as we've seen.
After placement of ASA monitors, high flow nasal cannula oxygen is administered for several minutes, with the patient coached immediately prior to induction to ventilate deeply via the nose several times. Immediately upon induction, the oxygen is increased from 6 or 8 l/minute to 10, and the nares are pinched shut while pushing the cannula up against the nasal septum. This forces oxygen through the airway. I typically use my right hand to do that while using my left to chin lift. My objective is to maintain an open airway, allowing the flow of oxygen access to the trachea regardless of patient ventilation.
As oxygen uptake by the body is passive, all that is required for maintenance of oxygenation is the presence of oxygen in the lungs; ventilation is not required. Of course, ventilation is required to eliminate CO2 from the body, but the 4 or 5 minutes it usually takes a patient to start ventilating won't cause much of a CO2 issue. It is actually helpful in that increased CO2 will increase their drive to breath.
In addition, the chest wall compliance is high enough in at least half of the patients we have such that I actually get chest wall excursion just from pinching the cares around the cannula while maintaining a chin lift. In these cases, the patient is ventilating without the use of the ambu-bag.
Overall I would say this is successful 85 to 90% of the time. Oxygen levels are typically high 80's or low 90's. Whether or not they require manual ventilation will depend on their oxygenation levels as well as if their ability to ventilate has recovered sufficiently.
Regards,
Gerald Peiser, DO
Diplomate American Board of Anesthesiology.
In normal times, preoxygenation followed by vigorous hyperventilation until adequate seizure length has been obtained is standard for most patients. Apneic oxygenation may not provide a fully optimized seizure, but seems a prudent option to consider in some patients for infection safety during the pandemic.
As I noted previously, there have been many suggested variations in airway management and appropriate infection control for ECT during the pandemic; a collaborative working relationship with anesthesiology and infection control experts will guide exactly what each ECT service chooses to implement.
There is also some literature about this technique, from before the COVID era, including this study:
Zhu Y, Kang Y, Wei J, Hu J, Wang C, Wang S.
Eur J Anaesthesiol. 2019 Apr;36(4):309-310. doi: 10.1097/EJA.0000000000000944. No abstract available.
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