Nasal intubation and no ventilatory assistance????

[AMESEMT]

I wouldn't do just an NRB, bag them. If the person was able to protect their own airway stay basic. I ran a dude that was very intoxicated and was unconscious and unresponsive. Gag reflex we assumed intact. He was on the line of possibly needing to be intubated, but we did a NPA which worked. The only time I have seen anything even remotely like just doing the NRB on the tube was in the OR. They kept the person on the vent, but allowed them to spontaneously breath on their own without any mechanical help. This was after the surgery was finished and were waiting for the person to be conscious enough to protect their own airway.

[DwayneEMTP]

I ran a dude that was very intoxicated and was unconscious and unresponsive. Gag reflex we assumed intact. He was on the line of possibly needing to be intubated...

Not sniping man, but what would cause you to believe a completely obtunded person's gag reflex was intact? Unless this was a 90 y/o alchoholic, what did he gain by not being intubated? What was your motivation for not intubating?

...but we did a NPA which worked.

Worked how? The two tools serve almost completely different perposes. The trumpet aleviates the need to breath past the tongue. The tube protects the patient from aspiration. I'm not clear how you believe doing the former was a replacement for the latter? See what I mean?

What an awsome discussion this has turned into! When it started I was ok with the tube alone if they were breathing comfortably and not fighting it. What a presumptive bonehead I can be sometimes.....

Dwayne

[akroeze]

I'm not overly familiar with transport vents. Are any EMS geared vents capable of pressure support? Is it common?

[akroeze]

Also, any recommended websites to further my knowledge of vents and their settings?

[VentMedic]

Comparison of 15 Transport ventilators

http://www.rcjournal.com/contents/06.07/06.07.0740.pdf

Some of the ATVs and simplistic vents seen in EMS and unfortunately some CCT/Flight programs

http://www.lifemedicalsupplier.com/resusci...=0&sort=20a

Great source for reading Respiratory reviews and research (The journal for RTs)

http://www.rcjournal.com/

Good overview of oxygen and ventilators as well as other critcal care items of interest.

http://www.ccmtutorials.com/rs/index.htm

[fireflymedic]

This statement is extremely concerning to me on a variety of levels. The first being that did we ever stop to consider that even a nasal tube can become dislodged? There is no way to monitor this if you dont have ETCO2 going as well ! Also, you have just placed a straw essentially into the patient's trachea - if they are unable to protect their airway to the point of needing intubation, well then they are needing to have PPV. As previously stated, if breathing, breathe with them. There is no reason to act this irresponsibly as a medic, and I am hoping this was addressed with the medic and if no satisfactory result, your employer. I wouldnt want them working on me ! I understand the need to protect the airway, that's fine. I'm okay with aggressive airway management, however, using just a NRB over the nasal tube, not cool. I dont know how many pt's you've seen nasally tubed, but putting blood in the airway (even if you use neosyn spray prior) as you are introducing something foreign and potentially causing trauma. I've seen many a patient have issues with bleeding and it's impossible to adequately suction with a NRB on. Period, end of story. Sounds like a recipe for disaster here.

[JPINFV]

Mind the bump:

I'm in favor of doing this for a pediatric DKA patient who is kussmaul breathing but requires airway protection. You don't want to paralyze these patients or sedate them too much for ventilation.

Quick question then. At what point (especially geared for EMT-Bs who are taught to essentially bag everything over 28 breaths/min :roll:) do you decide to take override a patient's breathing since tachnypea can decrease gas exchange causing hypoxia, but the Kussmauls is trying to counteract the acidosis that can kill the patient just as easily?

[chbare]

Good question when you look at this from a BLS standpoint. Provided the patients airway is patent, their not in obvious respiratory distress, and adequately ventilating and oxygenating, I would let them be. Even with the tachypnea, I would simply support and watch for any problems. Kussmauls respirations are typically rapid and deep allowing for gas exchange versus other patterns that are so shallow the patient is essentially exchanging dead space. Obviously, shallow rapid respirations (low minute volume), airway compromise, or an exhausted patient may require more aggressive interventions.

This is going to be a judgment call; however, I would steer away from taking over a DKA patients respirations.

I think Doc was looking at this from the point of having to intubate a DKA patient due to some type of airway compromise. In that case, we will need to be very careful about how we manage these patients. The RT's are going to play a critical role in managing the intubated DKA patient. As they can set the ventilator up to support and assist these patients with their breathing pattern. Because we are talking about a compensatory respiratory pattern, we must understand that "wiping out" the said pattern can be met with disastrous consequences.

I am sure more than a few well meaning providers have tubed a DKA patient and thought they were doing the right thing when they corrected the patient's end tidal Co2 to a "normal' number, while in reality, they destroyed the patients ability to effectively compensate for the metabolic acidosis.

Take care,

chbare.

[fireflymedic]

first off, just a thought here people, nasal intubation is only useful if they ARE breathing - if they aren't breathing, it's not an option, so give it up ! If they are breathing at a reasonable rate, then bag with them, if not bag with them and supplement along ! Do your job people, don't expect someone else to do it for you !

[Camulos]

Funny things nasal intubations. In my experience with these I believe the complication rate far exceeds the benefits. Have seen them used when oral intubation was not possible secondary to trismus – and no option for RSI. Whether this particular pt required intubation or not is open to debate and is probably worthy of another topic. So considering the tube was already placed let’s take it from there.

I agree with vent medics earlier sentiments that the insertion of the tube increases airway resistance. This does have the potential to cause the pt harm if their spontaneous respiratory effort is not strong enough to overcome this resistance. Placing a NRB over the top of the ETT is quite unusual. I have never seen any established protocols to support this practice. In spontaneously breathing pts you can connect the BVM to the ETT without providing the manual positive pressure ventilations. However you still have the problem of the resistance of the tube becoming an issue, particularly if a small tube was used, and have to be aware of that when adopting this practice. When doing this I always have a low threshold for providing some positive pressure support. Mind you, providing manual PPV to a spontaneously breathing pt is not without its dangers. You have to be careful not to over expand the lungs and cause barotrauma – particularly in small adults and children. That’s why it is always advantageous to use a BVM with an airway release valve.

Unfortuantely these are not always available.

Interested to hear others comments on this.

Stay safe,

Curse :evil: