Critical care
Rapid sequence intubation
Casey and colleagues recently published a study (N Engl J Med. 2019;380[9]:811) that challenges the long-held view that rapid sequence intubation (RSI) should not include ventilation attempts between induction and laryngoscopy. Airway management purists will say that true RSI is pre-oxygenate, give a sedation agent followed immediately by a paralytic agent, and immediate laryngoscopy as soon as the patient is paralyzed. However, RSI has come to mean the use of a sedation agent and a paralytic agent without specific timing of when to give the paralytic.
Purists would also say RSI is done for patients who are at a high risk for aspiration. In this study, the amount of subjectively reported aspiration was actually lower in the YES BVM group: 2.5% vs 4.0%. The presence of a new opacity on chest radiograph within 48 hours was 16% vs 15%, suggesting that there is no significant difference in the incidence of aspiration.
In this study, 40% in the NO BVM group and 30% in the YES BVM group had O2 desaturations below 90%. These statistics highlight the fact that it is imperative to pre-oxygenate all patients who will undergo intubation. Critically ill patients have little reserve. These patients are on the steep portion of the oxygen dissociation curve. The saturations will drop quickly. It is better to avoid any desaturation if possible.
Dr. John Gaillard
This study demonstrates that bag-mask ventilation between induction and laryngoscopy can help prevent severe desaturation with a number needed to treat to prevent one severe hypoxic event is nine.
John Gaillard, MD, FCCP
Steering Committee Member
Home-based mechanical ventilation and neuromuscular disease
Pressures of competitive bidding process
Advancements in invasive and noninvasive ventilator technology have allowed patients with neuromuscular conditions and severe COPD to transition from institutional care to living at home. Ventilator support is reserved for severe or progressive respiratory impairment where interruption would lead to serious negative consequences. Access to this technology does entail significant cost, as monthly rental fees range from $660 to $1,352 and yearly ventilator claims for chronic respiratory failure have increased from 29% in 2009 to 85% in 2015 (US Dept HHS, OIG Data brief 2016). There is a current proposal to include home mechanical ventilators with oxygen and other services in competitive bidding programs (CBP). Since oxygen was included in CBP, access to liquid oxygen systems and payments for oxygen have decreased significantly. Of patients using home oxygen since July 1, 2016, 59% reported difficulties with access to oxygen-related equipment and services (American Association for Respiratory Care Comment on Federal policies, aarc.org).
Dr. Jeannette Brown
Ventilator-dependent patients should not be subjected to the pressures of CBP when trying to obtain the equipment, supplies, and access to experienced medical providers that are necessary to remain in their homes. Beyond denying ventilatory support to some, CBP may also result in other unintended consequences, including the increased use of otherwise avoidable tracheostomies to ensure coverage for appropriate services. CHEST, including the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork and other patient groups, has advocated that home mechanical ventilators should be permanently excluded from the CBP to protect these fragile and vulnerable patients.
Jeanette Brown, MD, PhD
Steering Committee Member