OXYGEN

• Minimum: Standard nasal canula at 15L/min. Head of the bed elevated if not contraindicated.  
• Better: Standard reservoir face mask with flow rate as high as possible.
• Best: If adequate respirations, standard reservoir face mask set with flow rate as high as possible augmented with nasal cannula at 15L/min oxygen in preparation for apneic oxygenation, leave in situ throughout procedure. If inadequate respirations Bag-Valve-Mask (BVM) with positive end-expiratory pressure (PEEP) valve and flow rate as high as possible.

Preoxygenation prolongs tolerance of the apneic period.  The goal is 3 minutes of tidal volume breathing at 90% Fraction of Inspired Oxygen (FiO2).  For those with inadequate respirations BVM ventilation may be necessary.  Though it appears to be relatively simple, the procedure requires preparation, training and skill to perform correctly.  Care should be taken to ensure proper volume and rate of bag-delivered breath.  One hand should provide moderate pressure to the bag for no more than 50% of the volume of an adult bag or just enough to see the chest begin to rise at a rate of 12-16 breaths per minute (one breath every 4-5 seconds) initially. The resuscitation bag should be no larger than 1000ml (For reference, the pocket BVM is 1600ml, 50% is 800 ml TV). It is important to avoid hyperventilation through large or rapid breaths. If able, use a two-handed technique to ensure a proper mask seal, with assistant squeezing the bag along with use of oropharyngeal or nasopharyngeal airway. See Appendix C: Bag-Valve-Mask Technique for a detailed description.