Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

High Flow Nasal Oxygen During Intubation

High flow oxygen by nasal cannula to improve intubation outcomes?

Crazy or intelligent and aggressive.

During pre-oxygenation, applying nasal oxygen in addition to a non-re-breather face mask can significantly boost the effective inspired oxygen. After apnea created by RSI the same high flow nasal cannula will help maintain, or even increase, oxygen saturation during efforts securing the tube (oral intubation). The use of nasal oxygen during pre-oxygenation and continued during apnea can prevent hypoxia before and during intubation, even in extreme clinical cases.[1]

Yes. High flow oxygen by nasal cannula.

15 LPM (Liters Per Minute) oxygen by nasal cannula.

Nasal oxygen doesn’t affect the choice of oral intubation technique (direct or video laryngoscopy). The short time use of non-humidified oxygen has minimal risk of bleeding or irritation. Decreasing respiratory drive in patients with chronic hypercarbia is irrelevant after the decision to intubate. There is no risk of barotrauma, even at combined face and nasal oxygen flow rates exceeding 30 lpm. Air can leak out of a face-mask through the exhalation ports (rubber flaps) or from the pressure release valves built into a bag-mask resuscitator. The only challenge to the routine use of nasal oxygen is the availability of a second oxygen source.[1]

We should have a spare oxygen regulator on every ambulance.

Small changes in FiO2 create dramatic changes in the availability of oxygen at the alveolus, and these increases result in marked expansion of the oxygen reservoir in the lungs prior to the induction of apnea.[1]

What he does not state is that the reverse should also be true. We tend to be cavalier with oxygen, up until the point where we panic and decide to intubate. If we are more aggressive with patients who desaturate quickly before they desaturate, maybe we will not even feel the need to intubate some of these patients.

The net result is that during apnea, oxygen insufflated into the upper airway will be “drawn” down the trachea and into the alveolus. Oxygenation can be maintained in non-breathing humans for 100 minutes through apneic diffusion, even as carbon dioxide builds up in the blood.[1]

Oxygenation can be maintained in non-breathing humans for 100 minutes

Perhaps this is a part of the reason some patients survive unrecognized esophageal intubations.

If oxygen is being aggressively delivered to the patient’s stomach, some of that high concentration atmosphere will progress from the stomach to fill the airway, then expand down the trachea, and diffuse into the alveoli.

Dr. Levitan is one of the more creative airway management people around. Go read the whole article.


Emergency Physicians Monthly
by Rich Levitan, MD on December 9, 2010



  1. Even better than keeping those pesky regulators around, we’ve gone to built in regulators on our D and E cylinders at one of the services I work for. Built in DISS ports as well! Too bad we can’t carry CPAP (only credentialed EMT-B there), but if we did it’d be no problem switching tanks.

  2. Awesome article, I can’t believe I didn’t come across this idea sooner. I’m definitely going to run this idea by some of our ER docs and see if any bite.


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