How to maximize oxygenation during intubation in a patient with pulmonary edema?

From the Guidelines

To maximize oxygenation during intubation when pulmonary edema is present, preoxygenate with 100% oxygen using non-invasive positive pressure ventilation (NIPPV) or high-flow nasal cannula (HFNC) at 50-60 L/min, as recommended by recent guidelines 1. When managing a patient with pulmonary edema, it is crucial to prioritize interventions that improve oxygenation and reduce the risk of complications.

• Preoxygenation with NIPPV or HFNC can help increase oxygen reserves and reduce the risk of hypoxia during intubation 1.
• Positioning the patient in a 20-30 degree head-up position can help reduce hydrostatic pressure and improve functional residual capacity.
• Administering diuretics such as furosemide 40-80 mg IV can help reduce fluid overload, and nitroglycerin 0.5-1 mcg/kg/min IV can help reduce preload if hypertension is present.
• During the procedure, using rapid sequence intubation with agents less likely to cause hemodynamic compromise, such as etomidate (0.2-0.3 mg/kg) or ketamine (1-2 mg/kg), can help minimize the risk of cardiovascular complications.
• Applying positive end-expiratory pressure (PEEP) of 5-10 cmH2O immediately after tube placement, as recommended by recent guidelines 1, can help recruit alveoli and improve oxygenation.
• Using apneic oxygenation during intubation attempts by maintaining nasal cannula oxygen at 15 L/min can help maintain oxygen saturation.
• Keeping intubation attempts brief (under 30 seconds) and having backup airway devices readily available can help minimize the risk of complications.

The use of non-invasive ventilation in acute respiratory failure, including pulmonary edema, has been studied in several trials 1, but the most recent and highest quality study recommends the use of NIPPV or HFNC for pre-oxygenation in ICU patients 1.

• The study by Masip et al 1 showed a more rapid clinical improvement when NIV was compared with oxygen therapy in acute cardiogenic pulmonary oedema, but the most recent guidelines recommend a more comprehensive approach to intubation, including pre-oxygenation, rapid sequence intubation, and post-intubation recruitment manoeuvre 1.
• The guidelines also recommend the use of a protocol for intubation, including a respiratory component, to decrease respiratory complications 1.

From the Research

Maximizing Oxygenation during Intubation with Pulmonary Edema

To maximize oxygenation during intubation when pulmonary edema is present, several strategies can be employed based on existing research:

• Non-invasive positive pressure ventilation (NIPPV): Studies have shown that NIPPV, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP), can reduce the need for invasive mechanical ventilation and improve oxygenation in patients with acute cardiogenic pulmonary edema 2, 3, 4, 5.
• Selection between CPAP and BiPAP: While both CPAP and BiPAP are effective, the choice between them may depend on specific patient conditions. Research suggests that CPAP can be associated with a lower mortality rate compared to standard therapy 3, and both CPAP and BiPAP can reduce the need for mechanical ventilation 3, 5.
• Early Intervention: Early use of non-invasive ventilation in the prehospital setting can significantly reduce intubation rates and complications associated with endotracheal intubation 5.
• Monitoring and Adjustment: Continuous monitoring of the patient's condition and adjustment of the ventilation strategy as needed can help in maximizing oxygenation and improving outcomes 2, 6.

Key Considerations

• Patient Selection: The decision to use NIPPV should be based on careful patient selection, considering factors such as the severity of pulmonary edema, the patient's ability to tolerate the mask, and the presence of any contraindications to NIPPV.
• Technique and Settings: The technique and settings used for NIPPV, such as the level of pressure support and the use of positive end-expiratory pressure (PEEP), can significantly impact the effectiveness of the treatment and should be adjusted based on the patient's response 2, 6.
• Clinical Outcomes: While NIPPV can improve oxygenation and reduce the need for intubation, its impact on other clinical outcomes, such as hospital length of stay and mortality, may vary depending on the patient population and the specific context in which it is used 2, 3, 6.