Delayed Sequence Intubation and/or Bipap before Induction and Paralysis

Delayed Sequence Intubation and/or Bipap before Induction and Paralysis

So, you have probably heard about or even done both of the the above.

Where you might have heard it from
a) Intubating a patient with severe acidosis
http://emcrit.org/podcasts/tube-severe-acidosis/

b) Delayed Sequence Intubation
http://emcrit.org/podcasts/dsi/

We recently had a FMC Sim session where it was quite clear that getting this actually done was something I should review. So I thought I could put together a quick email with some photos and a video you can check out and comment on if you are interested as well.

1) To “BIPAP” a patient we are basically talking about providing a patient with an amount of pressure support when they inspire and an amount of PEEP when they exhale.  We almost always ask the RT’s to bring a “BIPAP” machine to the bedside as we don’t seem to use the actual ventilator to do this.  Why is this???  Mainly because these machines do BIPAP really well, the are simple to use and they are also portable, meaning they can be hooked up to an bottle of oxygen and the patient can be transported while being BIPAP’ed where as this can’t be done with the large ventilators.  The downside is that they are really large and take up a lot of real-estate in the trauma bays and such.
Image

FMC BIPAP MACHINE

2) You may not know that you need to use a special mask with the BIPAP machine!  I don’t mean that it is special in the fact that it is nice and soft and needs to be on the patient really tightly, but there are actually two different masks for non-invasive ventilation.

BIPAP MACHINE: As you can see there is only one tube going to the patient providing air, but no return circuit.  As such, where does the patient exhale?  You MUST use a make with exhalation holes in it with this mask or the patient really can’t exhale at all other than leaking around the mask.  The photo below shows the mask the RT’s will put on the patient which has these holes or vents.

3) You most definitely can do non-invasive ventilation with the regular ventilators we have in the department.  However, you need to use a special NON-VENTED mask as the ventilator DOES have a exhalation tube that returns to the machine.  As you can see, the NON-VENTED mask has the blue nose looking thing and no holes in it.

IMG_2812

 

4) I have decided that bringing in a BIPAP machine into a code room when I have every intention to intubate them in the very near future makes not sense.  The RT’s agree with me.  As such, I have done some playing with the vent and figured out ONE of the ways of doing this.  I am sure some of you will have lots of comments on other ways of doing this as well.

5) Find a ventilator and let the RT know what you are thinking.  “I want to non-invasively ventilate this patient until I am ready to pass the ETT”.  Perhaps you are doing this for a patient with an ASA overdose or a severe DKA patient and you are really worried that if the patient becomes any more hypercarbic they really aren’t going to do well.  Or, maybe they are wild and crazy and have a severe pneumonia and you feel that they need some sedation and pre oxygenation prior to intubation.

6) Here is what the ventilators look like in standby mode.

IMG_2790

 

6) You can attache the ventilator hosing to the the NON-VENTED BIPAP mask if you wish.  Notice I have also hooked up the end-tidal CO2 to this set up which would be helpful as well.  Using the wrong mask in this setting.  Meaning if you can’t find the non-vented mask you could use the vented one, but there is just going to be a big “leak” out the holes.  It wouldn’t be dangerous, whereas doing the opposite (using a non-vented mask on the BIPAP machine would be).

IMG_2796

 

7) I also like this set up as it totally removes any concern of using a special mask and would solve the same problem, but just require someone to maintain a good seal with the patient.  I suspect to do this well you would have to have a obtunded or very cooperative patient.  This is where some Ketamine/Haldol might go a long way.

IMG_2795

8) I suggest you listen to the podcast on incubating the acidotic patient and see the video I made below.

Agree/disagree?  I look forward to your comments.

Safe Travels,

DL

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