12/11/2019 SAFE APNOEA TIME — The Vortex Approach

V O R TEX L I F ELINES G R E EN ZONE C I C O RESCU E

S A F E APNOE A T I M E P L A NNING T R A INING

A I R WAY CAR T D O W NLOAD S P U B LICATIO N S

C O N TACT

SAFE APNOEA
TIME
P R E O X

R E O X

A P O X

C O N O X


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PREOX REOX APOX CONOX

THE OXYGENATION CONTINUUM

The primary goal of airway management is to maintain tissue oxygenation so as to
prevent patients from suffering hypoxic injury. While techniques exist which allow
airway management without the occurrence of apnoea/airway obstruction, these may
not always be successful or clinically appropriate. Additionally, these techniques are
usually only implemented when a challenging airway is anticipated, and as such, have
limited utility in the management of the unanticipated challenging airway. Thus the risk
of an interruption to alveolar oxygen delivery and subsequent hypoxic harm, is
inherently involved with the process of airway management in both the elective and
emergency situation.

When apnoea/obstruction occurs, oxygen delivery to the alveoli must be restored

before critical desaturation occurs in order to avoid the risk of hypoxic injury. Two
complementary strategies are available to preserve tissue oxygenation and reduce the
risk of patients suffering hypoxic injury:

1. Establishing alveolar oxygen delivery: is the definitive strategy to preserve

tissue oxygenation. A sustained interruption to alveolar oxygen delivery will
eventually inevitably lead to decreases in blood oxygen content (“blood
oxygenation”) and delivery of oxygen to the tissues (“tissue oxygenation”).
Interruptions to tissue oxygenation which are sufficiently prolonged or severe will
result in hypoxic injury to the patient. Establishment of alveolar oxygen delivery is
represented in the Vortex Approach by entry into the Green Zone.

2. Extending the safe apnoea time: is a supplementary strategy that can prolong
the time until blood and tissue oxygenation decreases in the event that alveolar
oxygen delivery by ventilation/insufflation is transiently interrupted (safe apnoea
time). If alveolar oxygen delivery is not restored, however, the patient will still
eventually falls in blood and tissue oxygenation to dangerous levels. Extending

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the safe apnoea time merely delays critical desaturation and provides time to
implement the definitive strategy that will ultimately prevent/reverse desaturation.
It is thus an adjunct, not an alternative, to restoring alveolar oxygen delivery.

Whilst other factors such as gas

exchange, haemoglobin concentration
“Extending the safe
and blood flow may also impact tissue
apnoea time merely
oxygenation, these are not influenced by
the interventions associated with airway delays critical
management. Thus it is important to desaturation and
recognise that maintenance of normal
provides time to
oxygen saturations is not synonymous
implement the
with entry into the Green Zone. Normal
oxygen saturations may be maintained definitive airway
within the safe apnoea time despite the strategy that will
absence of ongoing alveolar oxygen
ultimately
delivery. Conversely factors influencing
prevent/reverse
gas exchange or cardiac output may lead
to compromise of oxygen saturations desaturation. It is thus
despite the presence of alveolar oxygen an adjunct, not an
delivery. Note that the term "alveolar
alternative, to restoring
oxygenation" has been avoided due to
alveolar oxygen
ambiguity over whether it refers to
delivery of fresh oxygen to the alveoli delivery.”
(alveolar oxygen delivery) or
maintenance of high alveolar
concentrations (which may occur due to effective preoxygenation despite airway
obstruction and an interruption to alveolar oxygen delivery).

The concept of the oxygenation continuum provides a visual representation describing

the relationship between techniques to establish alveolar oxygen delivery and
techniques to prolong the safe apnoea time in minimising the risk of exposing patients
to hypoxic injury.

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Under routine circumstances the time taken to establish entry into the Green Zone is
shorter than the time for critical desaturation, providing a margin of safety for airway
management during which the oxygenation continuum is maintained, avoiding exposing
the patient to critical hypoxia. The actual time available until critical desaturation occurs
if alveolar oxygen delivery is interrupted is only known retrospectively but there are a
number of patient factors which might influence it including:

Body habitus: obesity, pregnancy and other factors which decrease the size of
the functional residual capacity may limit the safe apnoea time.
Increased oxygen consumption: e.g. sepsis, pregnancy, paediatrics may decrease
the safe apnoea time
Impaired gas exchange: respiratory disease may decrease safe apnoea time
Decreased blood oxygen carrying capacity: anaemia may decrease safe apnoea
time
Decreased cardiac output: may lead to increased oxygen extraction, lower mixed
venous oxygen content, increased alveolar oxygen uptake and a lower oxygen
content of any shunted blood - all of which will tend to depress the arterial
oxygen saturations.
Techniques to increase the safe apnoea time: preoxygenation, reoxygenation,
apnoeic oxygenation, conserving oxygenation

Similarly the time taken to establish alveolar oxygen delivery is unknown prospectively
but may be influenced by a number of patient, situational or clinician factors. These are
outlined in relation to airway assessment.

If the safe apnoea time is shortened &/or the time to entry into the Green Zone
prolonged, the margin of safety is reduced. If this occurs to a sufficient extent the
oxygenation continuum may be interrupted, exposing the patient to critical hypoxia.

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Minimising the risk of exposing the patient to prolonged hypoxia necessitates

maximising the safe apnoea time and minimising the time to enter the Green Zone so
as to optimise the margin of safety and decrease the chance of interruption to the
oxygenation continuum.

The Vortex Approach is directed at minimising the time to gain entry into the
Green Zone by establishing alveolar oxygen delivery as efficiently as possible.
Techniques to prolong the safe apnoea time maximise the time to critical
desaturation. These techniques are not part of the Vortex Approach but are
valuable complementary strategies that should be utilised with it in an integrated
fashion. The information outlined below in relation to these techniques is based
predominantly on the work or Scott Weingart, Richard Levitan, Anil Patel and
Andrew Heard.

Delaying desaturation by extending the

safe apnoea time not only reduces the
“Extending the safe
risk of exposing the patient to hypoxia
apnoea time thus
while airway interventions are performed
but also makes an important makes contributions to
psychological contribution, decreasing both technical and
clinician stress and thereby potentially
human factors
improving both cognitive and motor
considerations that can
function during airway
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management. These improvements act decrease the risk of

synergistically with the principles of the
patient hypoxia during
Vortex Approach to augment the quality
of any interventions by improving both airway management”
decision making and technical skills and
thus the likelihood of success at
establishing alveolar oxygen delivery by either the upper airway lifelines or CICO
Rescue. Extending the safe apnoea time thus makes contributions to both technical and
human factors considerations that can decrease the risk of patient hypoxia during
airway management.

PREOXYGENATION
P R E O X

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PRINICPLES OF PREOXYGENATION
Preoxygenation is a safe, simple and effective technique to increase the safe apnoea
time. Optimal preoxygenation requires attention to three key elements:

1. Maximising the oxygen concentration in the lung functional residual capacity

(FRC).
2. Maximising the volume of the lung FRC
3. Optimising gas exchange from the oxygenated alveoli

The first two elements increase the oxygen content in the FRC which can be used to
sustain blood oxygenation in the event that alveolar oxygen delivery is interrupted. The
third element improves uptake of alveolar oxygen into the blood and decreases shunt
in order to maximise the blood oxygenation that can be achieved from these alveolar
oxygen stores.

ALVEOLAR OXYGEN CONCENTRATION

Effective preoxygenation with 100% oxygen increases the oxygen content of gas in the
patient’s FRC from 21% towards 100% which should theoretically produce a
proportionate increase in the safe apnoea time. Whilst in practice achieving alveolar
oxygen concentrations of 100% is not possible, increasing the end-tidal oxygen
concentration to levels of 80-90% is usually readily achievable. The requirements for
maximising alveolar oxygen concentration are as follows:

1. High Oxygen Concentration Device: despite being connected to a wall outlet or

cylinder which provides a source of 100% oxygen, not all oxygen delivery devices are
able to supply this 100% oxygen to the patient undiluted.

Oxygen delivery devices such as an anaesthetic circuit (circle, Mapleson, etc) or

some bag-valve-mask devices, are capable of providing close to 100% oxygen
due to the presence of a reservoir bag and valves as well as a mask which can
create a tight seal on the face. Together these factors prevent
rebreathing/entrainment of room air allowing the device to deliver undiluted 100%
oxygen to the patient.
Whilst it is typically well appreciated that oxygen delivery devices such as non-
rebreather masks, Hudson masks and nasal prongs are unable to deliver a high

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oxygen concentration to the patient, there is less awareness that even some
designs of bag-valve-mask (BVM) device (those without an expiratory port valve),
are able to deliver an oxygen concentrations of only 60% during spontaneous
ventilation due to dilution of the 100% oxygen source by room air. During positive
pressure ventilation BVM's will deliver 100% irrespective of whether they have an
expiratory port valve. Thus BVM's without an expiratory port valve are suitable for
reoxygenation of an apnoeic patient (positive pressure ventilation) but not
preoxygenation (spontaneous ventilation).
Even BVM's with an expiratory port valve may entrain room air if minute ventilation
is high enough to exceed the flow of 100% oxygen supplying the device. This can
lead to a dramatic fall in inspired oxygen concentration and occurs independently
of whether the device is being used during spontaneous or positive pressure
ventilation.
Use of supplementary oxygen sources can compensate for the inability of some
oxygen delivery devices to provide a closed system and increase the FiO2
provided by them towards acceptable levels for preoxygenation.

This video
Performance
explains the
of Oxygen De‐
reasons for the livery
10:06 Devices
variability in the
oxygen
concentration
provided by an
array of devices
and demonstrates
the FiO2
achieved with
them under a
variety of
conditions. These
results are
summarised in
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the
accompanying
table.

2. Firm Seal/High Flows: devices

capable of delivering an FiO2 of 100%
will only realise this potential if the face
mask is correctly sized to fit the patient’s
face and applied firmly so that there are
no leaks which allow dilution of the
inspired oxygen with room air. Prevention
of leaks is dependent on mask design,
operator technique and patient factors
(e.g. more difficult with beard,
edentulous). Even small leaks such as
that depicted opposite can lead to a
dramatic decrease in FiO2 due to
entrainment of room air. In the
demonstration depicted opposite this
small leak resulted in end tidal oxygen
concentrations of only 40% following 3
mins of preoxygenation with 100%
oxygen supplied at 15L/min via an
anaesthetic circle circuit. Thus
preoxygenation holding the face mask
above the patient’s face without any seal
(as is sometimes observed in elective
anaesthetic practice) allows entrainment
of large volumes of room air and
significantly decreases the effective
inspired oxygen concentration,
diminishing the effectiveness of pre-
oxygenation and the safe apnoea time.
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This issue is exaggerated when pre-

oxygenation is being performed via a
bag-valve-mask device with a one way
valve at the patient end to prevent
rebreathing (see photo opposite), as
limited oxygen will flow from the mask
unless a pressure differential exists
which opens the valve. This means that if
the bag is held away from the patient’s
face, such that a negative pressure
cannot be generated by patient
inspiration to open the valve, only low
oxygen flows will be delivered and the
patient will receive predominantly room
air.

With some equipment it is possible to

supply 100% O2 despite the absence of
an occlusive seal if the 100% O2 source
is supplied at a flow rate that exceeds
maximal inspiratory flow rates and thus
circumvents the entrainment of room air.

3. Adequate alveolar ventilation: washout of nitrogen and its replacement with high
concentrations of oxygen being inspired during pre-oxygenation is a function of both
the rate of alveolar ventilation and the duration of pre-oxygenation. Adequate pre-
oxygenation is achieved with 3 mins of normal tidal ventilation. Similar degrees of pre-
oxygenation can be achieved by 8 vital capacity breaths within 60 secs. The time to
effective pre-oxygenation can be further reduced by encouraging cooperative patients
to exhale to residual volume prior to commencing pre-oxygenation.

VOLUME OF FUNCTIONAL RESIDUAL CAPACITY

In addition to the above techniques to improve the oxygen concentration in the FRC,
optimal preoxygenation should involve consideration of additional strategies to

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increase the volume of the FRC such as PEEP/CPAP and 20 degrees head up tilt.
These strategies maximise the volume of the reservoir which can be filled with high
concentration oxygen and is available in the event that an interruption to alveolar
oxygen delivery occurs. By limiting atelectasis and shunting of pulmonary blood these
techniques also improve gas exchange, maximising the impact of both preoxygenation,
reoxygenation and apnoeic oxygenation techniques.

BARRIERS TO PREOXYGENATION
Absorption Atelectasis:

Some clinicians have raised concerns that inspired oxygen concentrations of 100% may
cause harm by causing absorption atelectasis and have advocated using an inspired
oxygen concentrations of 80% or less for pre-oxygenation. Whilst preoxygenation with
100% vs 80% oxygen has been demonstrated to produce an increased degree of
atelectasis on CT studies, no causal link has been demonstrated between this
radiological finding and increased pulmonary complications. In any case any airway
closure resulting from use of 100% oxygen for preoxygenation is readily reversed by
use of a recruitment manoeuvre (>40cm H2O for >15 sec) once a definitive airway has
been established. Conversely preoxygenation with 80% oxygen results in a clinically
significant decrease in the safe apnoea time. As such concerns regarding absorption
atelectasis should not represent a deterrent and preoxygenation with 100% oxygen is
advocated to maximise patient safety, particularly in situations where the possibility of a
delay in restoring alveolar oxygen delivery &/or a more rapid desaturation with
interruption to the oxygenation continuum, are anticipated.

Patient Discomfort:

Some clinicians are reluctant to perform

preoxygenation due to concerns that a
“it should be very rare
tight fitting mask will cause discomfort to
that full
patients. Most patients tolerate
preoxygenation well but a small preoxygenation is not
proportion do experience significant possible due to patient
distress from application of a tight fitting
discomfort”
mask. A number of techniques are
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available which still allow fulll

preoxygenation in these patients without
causing distress:

Nasal preoxygenation: application of a paediatric

face mask only to the nose of the patient with a
tight seal may be better tolerated than a mask
placed over the nose and mouth. Provided the An Entonox mouthpiece attached

patient is instructed to breathe in and out only to a circle, Mapleson or BVM (with
patient breathing only through
through their nose this technique allows full their mouth) can be used to
preoxygention with 100% oxygen in the same provide 100% oxygen for
preoxygenation in patients who
manner as a face mask.
will not tolerate an occlusive face
Mouthpiece preoxygenation: connection of a mask.

mouthpiece (see image) or cut off endotracheal

tube to the anaesthetic circuit or BVM which can
be held between the lips (creating a seal) allows
full preoxygenation with 100% oxygen and may be
better tolerated in patient's who find an occlusive
mask seal claustraphobic. It is important that the
A cut off ETT can also be used as
patient breaths only through their mouth when a makeshift mouthpiece to allow

using this technique and asking the patient to hold preoxygenation in patients who
will not tolerate a face mask.
their nose is recommended to prevent entrainment
of room air.
Non-rebreather mask: use of some designs of non-rebreather mask in
combination with 15L/min supplementary oxygen via nasal prongs to compensate
for the lack of a seal around the mask, can provide adequate preoxygenation and
may be better tolerated by patients who are distressed by application of a tight
fitting mask with an occlusive seal. The inspired oxygen concentration provided
by this method may vary with different designs of non-rebreather mask so this
should be confirmed with the particular devices used before using this technique.
High Flow Humidified Nasal Oxygen (HFHNO): this technique utilises very high
flow (up to 70L/min) humidified nasal oxygen. Since these flows exceed the
inspiratory flow rate they allow for full preoxygenation without the entrainment of
room air, despite the absence of an occlusive face mask, provided the patient

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does not speak and keeps their mouth closed. If patient speaks or breathes
through their mouth during PreOx with HFHNO an FiO2 of 100% is not reliably
achieved.

Using the above variations to the standard technique where necessary, it should be
very rare that full preoxygenation is not possible due to patient discomfort.

Patient Cooperation:

Full preoxygenation may be difficult in patients who are uncooperative with having
oxygen delivery devices applied for the required time. In these patients light sedation
can be useful to assist with them tolerating a face mask. As patients who are acutely
distressed and uncooperative also tend to unfasted, the risk of sedation and the
attendant potential for impaired airway protection and pulmonary aspiration, must be
weighed against the risk of interruption to the oxygenation continuum without
preoxygenation. Small, titrated doses of ketamine tend to produce less risk of
impairment of airway protective reflexes than other sedatives but ketamine sedation
should not be considered to be without risk in this regard. The emergency medicine
literature has formalised this process in terms of the technique of 'Delayed Sequence
Intubation' (DSI). This technique conceptualises DSI as a form of procedural sedation in
which the procedure is preoxygenation.

Time:

It is difficult to conceive of many circumstances in which there is inadequate time

available to perform preoxygenation prior to advanced airway management, particularly
when using the 8 vital capacity breaths technique. Time pressure should not generally
be regarded as an impediment to performing preoxygenation which typically can be
undertaken in parallel with other preparations for airway management.

USE OF CAPNOGRAPHY DURING PREOXYGENATION

Preoxygenation should ideally be

performed with capnography attached.
Whilst this is usual practice in an
operating room setting using an
anaesthetic machine, it may be
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overlooked in other settings such as the post-anaesthesia care unit (PACU), emergency
department (ED) or intensive care unit (ICU) when a bag-valve-mask device or
Mapleson circuit is being used. Preoxygenation with ETCO2 monitoring attached
provides the following ancillary benefits:

Confirmation of functioning capnography: having capnography attached during

preoxygenation provides an opportunity to check that the capnograph is
available, ready & functioning prior to induction. This avoids confusion about
whether subsequent absence of an ETCO2 trace, using any of the upper airway
lifelines, is due to a measurement error or an interruption to alveolar oxygen
delivery.
Confirmation of correctly fitting mask: where a waveform capnograph trace is
present, inability to achieve a good square waveform may indicate a leak around
the mask. This is significant on two fronts:
1. Impaired preoxygenation: entrainment of room air through this leak during
preoxygenation will diminish the effectiveness of denitrogenation of the
alveoli and diminish safe apnoea time if there is an interruption to alveolar
oxygen delivery
2. Compromised mask ventilation: if an effective seal cannot be achieved with
the mask during preoxyenation it is likely that this same leak will impair the
ability to apply positive pressure for the purposes of mask ventilation post
induction, increasing the likelihood of an interruption to alveolar oxygen
delivery.
Confirmation of effective facemask ventilation: capnography is important not
just for confirming correct placement of an endotracheal tube, but also for
confirming whether ventilation (& thus alveolar oxygen delivery) is occurring when
other lifelines are used. Even if the primary intention is placement of an
endotracheal tube, a face mask is likely to be used as the primary rescue
techniques if intubation is initially unsuccessful. Having capnography already
attached to the face mask allows immediate assessment of whether the Green
Zone has been entered as failure to obtain an ETCO2 trace when ventilating via a
facemask suggests that alveolar oxygen delivery is not occurring.

ENDPOINTS TO PREOXYGENATION

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Completion of effective pre oxygenation is typically determined one of the following

criteria:

End-Tidal Oxygen Concentration: ideally oxygen analysers capable of

measuring end-tidal oxygen concentrations should be available in all settings in
which advanced airway management takes place as this represents the most
reliable way of assessing the adequacy of preoxygenation. Generally an end-tidal
O2 (ETO2) concentration > 80% can be considered to represent full
preoxygenation – but the highest achievable ETO2 should always be aimed for.
While ETO2 monitoring is standard in an operating theatre environment it may not
be available routinely in other settings such as PACU, ED or ICU.
Time: where end-tidal O2 analysis is not available, preoxygenation is usually
considered to be complete after 3 minutes (assuming normal tidal ventilation and
a good seal) as described above.
Number of Breaths: as described above, 8 vital capacity breaths will usually
achieve full PreO2 when gas analysis is not available.

Note that oxygen saturations are not

included amongst the list of criteria to
“a static saturation
assess the adequacy of preoxygenation.
reading is in fact
A static saturation reading is in fact
irrelevant to determining whether a irrelevant to
patient is adequately preoxgenated. determining whether a
Since most healthy individuals have an
patient is adequately
SpO2 close to 100% when breathing 21%
preoxygenated”
oxygen, a high SpO2 cannot be used to
infer that the FRC contains gas with an
oxygen concentration approaching 100%.
Similarly, very unwell patients may have poor gas exchange and thus poor oxygen
saturations despite full preoxygenation. Only a dynamic SpO2 reading is relevant to
determining whether the patient is adequately preoxygenated: if the SpO2 is
continuing to rise during PreO2, then the oxygen content of the blood is rising and it is
reasonable to assume that the alveolar oxygen concentration is also still rising, and to
continue preoxygenation until the SaO2 plateaus, even if the 3 minute time period for
PreO2 has already elapsed.
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References:

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During

Emergency Airway Management. Annals of Emergency Medicine 2012; 59(3): 165-175

Sirian R, Wills J. Apnoea and the benefits of preoxygenation. Contin Educ Anaesth Crit
Care Pain 2009; 9 (4): 105-108

Just a little oxygen to breathe as you go off to sleep…is it always a good idea? Br J
Anaesth 2007; 99(6): 769-771

Hedenstierna G. Oxygen and anaesthesia: what lung do we deliver to the post-

operative ward? Acta Anaesthesiol Scand 2012; 56 675-685

Chrimes N. Not all bag-valve-mask devices are created equal: beware a possible
lower FiO2 during spontaneous ventilation. Anaesth Intensive Care 2014; 42(2) 276

Driver BE, Prekker ME, Kornas RL, Cales EK, Reardon RF. Flush Rate Oxygen for
Emergency Airway Preoxygenation. Ann Emerg Med 2017; 69(1) 1-6

REOXYGENATION
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R E O X

BENEFITS OF REOXYGENATION

The opportunity to reoxygenate the

patient arises any time the Green Zone is
entered. Reoxygenation via positive
pressure ventilation during airway
management provides exactly the same
benefits as those described using
preoxygenation during spontaneous
ventilation prior to airway management.
Thus reoxygenation is not just an
opportunity to return low oxygen
saturations to normal levels but to
replenish oxygen stores in the functional
residual capacity (FRC) of the lung and
restore the safe apnoea time in case
there is a further interruption to alveolar
oxygen delivery.

An ancillary benefit is that successful face mask ventilation following induction, while
waiting for muscle relaxants to take effect, also provides the team with confirmation of
being in the Green Zone which can decrease stress and allow airway subsequent
airway management to be approached in a more controlled way. Conversely

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recognition of the inability to mask ventilate provides the opportunity to make the most
efficient use of the safe apnoea time via early commencement of optimisation
interventions according to the Vortex Approach and gives the team increased
situational awareness of the significance of the inability to enter the Green Zone via
other lifelines during subsequent attempts.

FACE MASK VENTILATION DURING RAPID SEQUENCE

INDUCTION
Even during a rapid sequence induction (RSI), gentle face mask ventilation with
inspiratory pressures <15cmH2O whilst waiting for the onset of muscle paralysis is
acceptable and should not cause gastric insufflation or increase the risk of
regurgitation of gastric contents. Maintaining ventilation pressures below this limit is
more reliably achieved in an operating theatre setting where circuits with soft bags (that
provide good tactile feedback about airway pressures), adjustable pressure limiting
valves and airway manometry provide some safeguards against excessive ventilation
pressures. It may be reasonable to exercise greater caution during RSI in other
environments where the lack of tactile feedback about ventilation pressures from the
more rigid self inflating bag of a BVM device and the absence of airway manometry
place clinicians at increased risk of causing gastric insufflation with the potential to
provoke regurgitation and aspiration.

APNOEIC
OXYGENATION
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A P O X

PHYSIOLOGY OF APNOEIC OXYGENATION

The process of apnoeic oxygenation (ApOx) relies on the discrepancy between the rate
at which oxygen is normally removed from the alveoli compared with that at which
carbon dioxide (CO2) is delivered to them. Predominantly due to differences in their
respective solubilities in the blood, it is estimated that during apnoea CO2 enters the
alveoli at a rate of only approximately 10ml/min whilst oxygen is removed at a rate of
approximately 250ml/min. This 240ml/min net removal of gas volume from the alveoli
during periods of apnoea results in a reduction in barometric pressure in the alveoli.
The sub-atmospheric pressure which develops serves as the driving force for gas to
move from the upper airway to the alveoli by the process of apnoeic mass movement,
provided the airway is patent. The mechanism for apnoeic mass movement is thus bulk
flow down a pressure gradient, not molecular diffusion, yet is able to occur during
periods of apnoea as it does not depend upon the generation of positive pressure in
the upper airway nor on respiratory effort by the patient. This process has been
recognised for over fifty years but has only recently started being used as a routine
adjunctive technique to deliberately prolong the safe apnoea time in susceptible
patients.

The requirements for effective apnoeic oxygenation are as thus as follows:

High Oxygen Concentration: apnoeic oxygenation can only be effectively

performed following preoxygenation to ensure high oxygen concentrations
thoughout the respiratory tree. This is required to ensure that the a sufficient
volume of gas is taken up from the alveoli and that this is replenished with gas

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from the upper airway that contains sufficient oxygen to maintain adequate
oxygenation of pulmonary capillary blood and allow the process to continue. It
should be noted that for these reasons apnoeic oxygenation is not effective in
restoring the oxygen saturations of patients that have already desaturated - as
during airway management desaturation usually indicates that a low oxygen
concentration has developed in the alveoli.

Oxygen source: insufflation of high flow oxygen into the upper airway via the
nasal or buccal routes prevents entrainment of room air so that further high
concentration oxygen is available to move down the trachea to the alveoli and
replace that being consumed.

Patent Airway: oxygen delivered to the upper airway can only move towards the
lungs in response to the subatmospheric alveolar pressure if the airway is patent.
A nasopharyngeal airway may be useful to assist nasal oxygen passing from the
nasopharynx into the hypopharynx.

LIMITATIONS OF APNOEIC OXYGENATION

Although apnoeic oxygenation has been shown to prolong the safe apnoea time
significantly this is not guaranteed and some patients may still rapidly desaturate
despite these techniques. Apart from airway obstruction another factor limiting the
efficacy of apnoeic oxygenation is alveolar collapse. Rather than draw further gas into
the alveolus, the negative pressure generated there can potentially lead to loss of
volume and ultimately collapse of the alveolus (aborption atelectasis). This can result in
a pulmonary shunt and depression of the oxygen saturations. Patients with pre-existing
shunt physiology and those pre-disposed to developing it during periods of apnoea are
therefore less likely to benefit from apnoeic oxygenation techniques. The likelihood of
developing absorption atelectasis in depends in part on the balance of expansive and
retractive forces acting on the alveoli and the resistance to gas flow in the respiratory
tree. Unfortunately morbidly obese patients in whom prolongation of the safe apnoea
time might be most desirable are are more susceptible to developing shunt physiology
during apnoea and may have the least benefit. Still, prolonged periods of sustained
blood oxygenation have been demonstrated in obese patients using apnoeic
oxygenation. Even obese patients, who desaturate more rapidly due to shunt, may still
be demonstrating significant prolongation of their safe apnoea time relative to what it

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might have been in the absence of apnoeic oxygenation. This is supported by animal
models where even though a higher shunt fraction has been associated with a more
precipitous initial fall in SpO2 at the onset of apnoea (even with use of apnoeic
oxygenation), the value at which the falling SpO2 has plateaued has been higher when
apnoeic oxygenation has been implemented suggesting that a benefit is still being
derived. Once shunt becomes sufficiently severe, however, the plateau SpO2 level will
not longer be sufficiently high to qualify as 'safe'. A high shunt may be responsible for
the inability to demonstrate a benefit from apnoeic oxygenation during airway
management in critically ill patients.

Minimising atelectasis via application of CPAP and head up tilt should reduce shunt and
maximise the impact of apnoeic oxygenation techniques.

The important point is to be aware that apnoeic oxygenation is a important adjunctive

tool to extend the safe apnoea time but that it cannot be relied upon or used as an
alternative to the definitive strategy of restoring alveolar oxygen delivery via one of the
upper airway lifelines or CICO Rescue. Apnoeic oxygenation should be used to extend
the time available to efficiently make attempts to restore alveolar oxygen delivery by
these techniques without desaturation occurring but the maintenance of high
saturations it provides should not influence decision making about the need to move
on to alternative strategies where best efforts at one or more of the upper airway
lifelines have not secured entry into the Green Zone.

"CONFIRMED" ALVEOLAR OXYGEN DELIVERY

Effective decision making during airway

management requires the ability to
“apnoeic mechanisms
rapidly confirm whether alveolar oxygen
to deliver oxygen to the
delivery has been achieved by a
particular strategy. This allows an alveoli do not provide
immediate judgement to be made about the information
the need to perform optimisation
required to make
manoeuvres or move on to an alternate
timely decisions about
technique. The inability to promptly
identify that a technique to achieve whether this goal is

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alveolar oxygen delivery has been being achieved and

unsuccessful wastes valuable ‘safe
the need to optimise or
apnoea time’ during which rescue
strategies could have be implemented move on to an
and increases the risk of exposing the alternate technique
patient to sustained hypoxia. Apnoeic during airway
oxygenation techniques do do not allow
management”
a prospective assessment to be made of
whether they are achieving alveolar
oxygen delivery or how long existing
oxygen saturations are likely to be maintained before desaturation occurs. Since
apnoeic methods for oxygen delivery do not typically produce a rise in existing oxygen
saturations, their success or failure can only be identified in hindsight by observing
when oxygen saturations begin to decline. Thus from a practical perspective, apnoeic
mechanisms to deliver oxygen to the alveoli do not provide the information required to
make timely decisions about whether this goal is being achieved and the need to
optimise or move on to an alternate technique during airway management. As such the
Vortex Approach restricts the meaning of the term "alveolar oxygen delivery" to refer
only to the concept of confirmed alveolar oxygen delivery. Since alveolar oxygen
delivery cannot be directly measured, real-time assessment of whether it is occurring
must be inferred from other clearly definable endpoints. Real-time confirmation of
alveolar oxygen delivery can thus only be achieved by confirming ventilation with
oxygen or direct tracheal insufflation of oxygen via a neck airway. In most
circumstances this involves obtaining a capnography trace and/or evidence of an
upward trend in oxygen saturations (as opposed to sustained high saturations). The
ability to confirm alveolar oxygen delivery is thus restricted to those techniques which
involve cyclical inflation/deflation of the lungs as the mechanism to deliver oxygen –
ventilation via the upper airway lifelines or ventilation/intermittent insufflation via neck
airways. Techniques involving apnoeic mechanisms for delivering oxygen
(“unconfirmed” alveolar oxygen delivery) are better considered as techniques to
prolong the safe apnoea time.

As such while apnoeic oxygenation, when successful, does technically achieve

"alveolar oxygen delivery" the Vortex Approach emphasises the need to achieve

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‘confirmed’ alveolar oxygen delivery and uses the term "alveolar oxygen delivery" in
this way.

TECHNIQUES FOR APNOEIC OXYGENATION

NO DESAT (Nasal Oxygen During Efforts Securing A Tube)

While, if the airway is patent, apnoeic oxygenation occurs in any preoxygenated patient
while a face mask is applied, the NO DESAT technique allows the benefits of apnoeic
oxygenation to be yielded even during attempts at laryngoscopy. This enables apnoeic
oxygenation to be achieved even in many patients in whom airway patency cannot be
established via the three lifelines of face mask, supraglottic airway and endotracheal
tube. This is possible because even when a patent airway cannot be achieved via one
of the three lifelines, in the absence of laryngeal pathology or a foreign body, it is likely
that during attempts at laryngoscopy the upper airway will still be patent and able to
allow delivery of oxygen to the alveoli via apnoeic mass movement – even though a
view of the larynx may not be able to be achieved or an endotracheal tube passed.
Thus whilst the patent airway achieved with a laryngoscope in place does not allow for
positive pressure ventilation, if a reservoir of high concentration oxygen can be created
in the nasopharynx it can be drawn towards the alveoli by apnoeic mass movement.

Nasal cannulae alone provide only low

inspired oxygen concentrations in
spontaneously ventilating patients. This
occurs because even during quiet
breathing the inspiratory flow rate (in
contrast to the minute ventilation which is
the averaged flow rate over time derived
from intermittent inspiration/expiration) of
gas in and out of the lung is much higher
(upto 30Lt/min) than the oxygen flow rate
delivered by the cannulae. The result is that significant volumes of room air must also
be entrained during inspiration to make up this difference. This low oxygen
concentration gas mixes with the 100% oxygen entering the nasopharynx via the nasal
prongs (as well as with low oxygen concentration gas present in the anatomical dead

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space at the end of the previous expiration), diluting the concentration of oxygen in the
gas that is drawn into the alveoli with inspiration down to around only 30% .

The effect of oxygen delivery via nasal cannulae in the apnoeic patient is quite
different, however. In the absence of ventilation, no room air or expired gas with a low
oxygen concentration enters the nasopharynx to dilute the 100% oxygen insufflated by
the nasal prongs. The result is that if nasal cannulae are applied with flows of 15Lt/min
during preoxygenation, then once apnoea occurs they provide a reservoir of near 100%
oxygen in the nasopharynx which is available to be drawn down the trachea into the
alveoli by apnoeic mass movement. A second oxygen oxygen source, in addition to
that being used to supply the mask being used, is required to provide oxygen flow for
the nasal cannula.

Using nasal cannulae at 15L/min, apnoeic oxygenation has been demonstrated to

extend the duration of apnoea without desaturation to beyond 10mins in some cases.

THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange)

THRIVE employs very high flow (upto

70L/min) humidified nasal oxygen and Interview with D…
D…
has resulted in extension of the safe
apnoea time by a mean of 14 mins and
upto an hour in some patients. In
addition to apnoeic oxygenation, THRIVE
has the following benefits in relation to
Dr Anil Patel discusses the possibilities
extending the safe apnoea time:
and limitations of THRIVE at the ANZCA
Apnoeic Ventilation: limiting the rise ASM 2016
in arterial CO2 levels during the
apnoeic period (although high
CO2's and respiratory acidosis are typically well tolerated in otherwise well
patients). This has potential benefits when used in contexts of prolonged (> 15min)
apnoea, such as some ENT surgery, but probably does not provide a significant
advantage during emergency airway management when restoration of ventilation
by other means would typically have been achieved well within this timeframe.

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Continuous positive airways pressure (CPAP): which can reduce atelectasis and
shunting thereby assisting with maintenance of oxygen saturations. In addition
this could assist with splinting open of the upper airway and maintenance of
airway patency without use of an occlusive face mask.
Increased FiO2 during PreOx: as the flow rates using THRIVE are able to exceed
inspiratory flow rates, it can also be used for preoxygenation, without the need for
an occlusive face mask, while avoiding the discomfort that occurs when these
high flows are delivered using non-humidified oxygen sources (see below).

Unrelated to its impact on safe apnoea time, the warm humidified gas used in THRIVE
has adjuvant benefits in decreasing discomfort (when used in awake patients) as well
as limiting mucosal injury and impairment of ciliary function, with the potential to
decrease the incidence of subsequent respiratory infections (compared with use of
cold, dry gas).

The equipment for nasal oxygen delivery during THRIVE involves bulky corrugated
tubing which prevents being able to achieve a seal with a face mask while it is in place.
As such THRIVE must be removed and replaced before and after each attempt at face
mask ventilation which increases the complexity associated with its use during
management of a challenging airway. THRIVE also requires dedicated equipment which
is more expensive in comparison to that required for NODESAT or buccal ApOx (which
utilise cheap, generic airway equipment). As such it is logical to limit use of THRIVE to
the circumstances in which it offers particular advantages: prolonged apnoea, high risk
of atelectasis and maintenance of a high FiO2/CPAP in situations where use of an
occlusive face mask is undesirable.

Buccal Oxygen Delivery

This technique provides supplementary oxygen flow via the oral route using an
adapted RAE endotracheal tube secured in the left buccal space. Like NODESAT this
technique allows the benefits of ApOx to be obtained during attempts at laryngoscopy
and does not interfere with the ability to face mask ventilate between these attempts
(unlike THRIVE - see above). It is also simpler to apply than

It has been postulated that buccal oxygen delivery may be superior to NODESAT and
THRIVE because it offers additional protection from the theoretical risk of pulmonary or
gastric barotrauma with these techniques (see below), since the position of the oxygen
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source in the oral cavity ensures that any rise in pharyngeal pressure will be vented via
the mouth. In contrast it is theoretically possible for airway pressures to rise during
NODESAT if the oral cavity becomes obstructed by the tongue/soft palate. Additionally
it has been suggested that the efficacy of NODESAT may be limited by the occurrence
of retropalatal obstruction when obese patients are induced for airway management.
Supplementary oral oxygen is not impacted by obstruction of passage between the
naso- & oropharynx by the soft palate, and effective ApOx using this technique requires
only that airway patency between the oro- & laryngopharyx is able to be maintained by
performance of sustained laryngoscopy. Buccal oxygen supplementation is also
advantageous when performing ApOx in patients in whom nasal instrumentation is
contraindicated.

In obese patients, ApOx using a buccal oxygen source at 10L/min has been
demonstrated to significantly reduce the risk of desaturation during apnoeic episodes
in excess of 12 minutes. This flow rate (which is less than that used with
NODESAT) provides a high pharyngeal oxygen concentration during apnoea, allowing
ApOx to occur, but probably provides negligible CPAP and does not produce the
apnoeic ventilation phenomenon of THRIVE.

CONCERNS WITH NASAL OXYGEN INSUFFLATION

Interference with Face Mask Seal: one concern with use of the NODESAT technique
is the possibility that the nasal cannula oxygen tubing might interfere with getting a
good seal for face mask ventilation – though in practice this is not usually an issue, and
nasal cannulae could be easily removed if this were the case. The large diameter
corrugated tubing used for THRIVE does prevent a face mask seal but the THRIVE
nasal cannulae can be easily removed to allow face mask ventilation and replaced
again during attempts at laryngoscopy. This does provide an extra task during
management of a challenging airway and it is forseeable that replacing the THRIVE
cannula during laryngoscopy could be overlooked resulting in a termination of apnoeic
oxygenation.

Barotrauma: the pressure generated from insufflation of gas into the upper airway is a
function of the rate of gas flow and the resistance flow of this gas back to the
atmosphere via the upper airway. If none of the insufflated gas were able to be vented
to the atmosphere it would rapidly accumulate in the stomach or lungs leading to a rise

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in volume/pressure and the potential for serious complications. Gastric rupture has
been reported with insufflation of relatively low flows (4L/min) of oxygen via long
nasal/nasopharyngeal catheters during procedural sedation but remains a only
theoretical concern with use of NO DESAT & THRIVE which utilise shorter intranasal
cannulae but at much higher flow rates. THRIVE has been shown to produce elevation
of pulmonary pressures equivalent to only 5cmH2O but this limit is dependent on the
upper airway remaining unobstructed to allow venting of insufflated gas.
Supplementary oxygen via the buccal route has been postulated to be safer a safer
technique for ApOx by providing a reliable, low resistance route for egress of
insufflated oxygen and avoiding this theoretical risk.

ANCILLIARY BENEFITS OF SUPPLEMENTARY OXYGEN

INSUFFLATION
In addition to allowing apnoeic oxygenation there are a number of potential ancillary
benefits from using supplementary insufflation of oxygen during preoxygenation and
airway management.

Increased FiO2: the supplementary oxygen flow can compensate for room air
entrainment which would otherwise prevent some oxygen delivery devices (e.g. a
non-rebreather mask) providing sufficient inspired oxygen concentrations to allow
for preoxygenation in spontaneously ventilating patient. Utilising supplementary
nasal or buccal oxygen for this indication requires a clear understanding of the
oxygen delivery capabilities of the specific devices when used in this way as the
achievement of an adequate FiO2 for preoxygention is not guaranteed. Use of
non-humidified gas at high flow rates during these techniques may also cause
significant discomfort to fully conscious patients. Utilising an anaesthetic circuit
(circle or Mapleson) or a Bag-Valve-Mask device with an expiratory port valve that
provides the ability to achieve a face mask seal is preferred wherever feasible.
Leak Compensation: supplementary oxygen flow via nasal or buccal routes may
compensate for the loss of gas via small face mask leaks and improve the ability
to achieve effective positive pressure ventilation via face mask in these
circumstances.
PEEP/CPAP: supplementary oxygen flow using nasal cannulae for NODESAT can
assist in generating CPAP/PEEP thereby limiting atelectasis, reducing
intrapulmonary shunting and optimising oxygenation of pulmonary capillary blood.
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In addition PEEP/CPAP increases the volume of the functional residual capacity

and thus the volume of the oxygen reservoir generated during preoxygenation.
Splinting of upper airway: based on anecdotal observation it is possible that
nasal (but not buccal) oxygen flow could act to splint open the upper airway in
effect creating a "pneumatic nasopharyngeal airway" that improves the ease of
face mask ventilation by holding the soft palate open. This has not been
confirmed in clinical trials. Conversely, as mentioned above, persistent obstruction
of the nasopharynx by the soft palate, preventing nasally insufflated oxygen
reaching the respiratory tree, has also been proposed as one of the factors
potentially limiting the effectiveness of supplementary nasal oxygen in prolonging
the safe apnoea time in obese patients (and thus an advantage of buccal oxygen
supplementation).

References:

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During

Emergency Airway Management. Annals of Emergency Medicine 2012; 59(3): 165-175

Levitan RM. NO DESAT! Nasal oxygen during efforts securing a tube. Emergency
Physicians Monthly. December 9, 2010. www.epmonthly.com/?features/?current-
features/?no-desat-/?. Accessed August 3, 2016.

Frumin MJ, Epstein RM, Cohen G. Apneic Oxygenation in Man. Anesthesiology 1959;
20(6): 789-98

Teller LE, Alexander CM, Frumin MJ, Gross JB. Pharyngeal Insufflation of Oxygen
Prevents Arterial Desaturation during Apnea. Anesthesiology 1988; 69: 980-82

Rudolf B, Hohenhorst W. Use of Apneic Oxygenation for the Performance of Pan-

Endoscopy. Otolaryngol Head Neck Surgery 2013; 149(2): 235-239

Fraioli RL, Sheffer LA, Steffenson JL. Pulmonary and Cardiovascular Effects of Apneic
Oxygenation in Man. Anesthesiology 1973; 39(6): 588-96

Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange

(THRIVE): a physiological method of increasing apnoea time in patients with difficult

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airways. Anaesthesia 2015; 70: 323–329

Yao HH, Tuck MV, McNally C, Smith M, Usatoff V. Gastric rupture following
nasopharyngeal catheter oxygen delivery-a report of two cases. Anaesth Intensive
Care 2015; 43(2):244-8

Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a

Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med 2016;
68(2): 174-80

Groombridge C, Chin CW, Hanrahan B, Holdgate A. Assessment of Common

Preoxygenation Strategies Outside of the Operating Room Environment. Academ
Emerg Med 2016; 23(3):342-6

Patel A, Nouraei SAR. Nasal Ventilation: Oxygenation, NO DESAT, and THRIVE.

Anesthesiology News. August 8th 2016. Available from
http://www.anesthesiologynews.com/Review-Articles/Article/08-16/Nasal-Ventilation-
Oxygenation-NO-DESAT-and-THRIVE/37294. Accessed August 16th, 2016

Heard A, Toner AJ, Evans JR, Palacios AMA, Lauer S. Apneic Oxygenation During
Prolonged Laryngoscopy in Obese Patients: A Randomised, Controlled Trial of Buccal
RAE Tube Oxygen Administration. Anaesth Analg. DOI:
10.1213/ANE.0000000000001564

CONSERVE
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OXYGENATION
C O N O X

DECREASING OXYGEN CONSUMPTION

Techniques which decrease oxygen consumption allow more effective use to be made
of the oxygen reserves during periods of apnoea thereby conserving oxygenation. In
particular, skeletal muscle fasciculations caused by suxamethonium have been shown
to result in an increase in oxygen consumption of nearly 10% in animal models.
Minimising or avoiding these fasciculations can prolong the time to critical desaturation.
This can be achieved by the following techniques:

Use of adjuvants to attenuate fasciculations: use of fentanyl & lignocaine during

intubation has been shown to decrease both the intensity of fasciculations seen
with suxamethonium use and cause a significant increase in the safe apnoea
time. These drugs also cause a decrease in the mean arterial pressure and heart
rate seen during intubation compared with use of suxamethonium alone, which
could also potentially contribute to a decrease in whole body oxygen
consumption.
Use of rocuronium instead of suxamethonium: provides a small additional
prolongation of the safe apnoea time compared with use of suxamethonium and
adjuvant drugs by avoiding the occurrence of fasciculations entirely.

References:

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Sirian R, Wills J. Apnoea and the benefits of preoxygenation. Contin Educ Anaesth Crit
Care Pain 2009; 9 (4): 105-108

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During

Emergency Airway Management. Annals of Emergency Medicine 2012; 59(3): 165-175

Tang L, Li S, Huang S, Ma H, Wang Z. Desaturation following rapid sequence induction

using succinylholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand
2011; 55: 203-208

Taha SK, El-Kathib MF, Baraka AS, Haidar YA, Abdallah FW, Zbeidy RA, Siddik-Sayyid
SM. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during
apnoea following rapid sequence induction. Anaesthesia 2010; 65: 358-361

TOP

NEWS + RESOURCES

Dr Nicholas Dr Peter Fritz

Chrimes MBBS FACEM
MBBS(Hons) Emergency
FANZCA Physician and

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Consultant
Follow @NicholasChrimes Retrieval
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Anaesthesiologis specialist
t
Principal
Creator of the consultant during
Vortex Approach. development of
Author of all the Vortex
Vortex related Approach. Co-
materials. author of selected
Vortex materials
(as indicated).

Neither Nicholas Chrimes nor Peter Fritz have any financial interest in the Vortex
Approach

© Copyright Nicholas Chrimes 2013, 2016. All materials on this site are distributed
under the terms of the Creative Commons Attribution Non-Commercial No
Derivatives License which permits use without alteration for non-commercial clinical
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