Episode 2: Keep Calm and Ventilate with Ryan McAfee

Listen here or download on iTunes, Podcast Addicts, or Podcast Republic. 



  • Tongue is the most likely source of obstruction
  • Adjuncts used to control the tongue:
    • OPA- used in patients with no gag-reflex
    • NPA- for the patient that is still semi-responsive or clenched
  • Supraglottic airways in current prehospital setting:
    • King LT, Combitube, LMA, and iGel
  • As ALS providers, sometimes we are too quick to jump to advanced airway placement and forget and that the combination of a BVM/Adjunct (OPA/NPA), and suction can function as a PATENT airway
  • There is hesitance to “bag” a patient that is in distress prior to ALS procedures. WHY?!?!?!? Positive-pressure ventilation save lives!
  • Our main goal is to prevent hypoxia at all costs


  • Patients will position themselves to optimize oxygenation; i.e. “tripoding to increase tidal volume
  • By placing patients in an upright position, you allow gravity to work with you; allows for better lung expansion and less diaphragmatic resistance
  • It’s something we all should have learned in EMT class… FOR THE LOVE OF GOD, SIT THESE PEOPLE UPRIGHT!!



  • These patients generate their own PEEP, so why “bag” one of these patients, or put them on CPAP?
  • THEY ARE TIRED! The respiratory structures are exhausted and need help.
  • Give them help before they go into respiratory failure or arrest!
  • Early intervention typically prevents advanced airway placement
  • They need high flow O2 because CO2 builds up


  • These patients don’t need help ventilating, they need help oxygenating
  • They have shunt physiology
  • Use PEEP early!
  • Titrate to effect between 5-10cmH2O


  • Positioning
    • Head of the bed needs to be at least 20° high
    • Prevents atelectasis in posterior lung fields
    • Increases tidal volume improving oxygenation
    • Main goal is to denitrogenate the lungs and increase oxygen reservoir for advanced airway placement
  • Oxygenation
    • By improving the oxygen supply, you are increasing the amount of time a patient can be apneic without significant desaturation
    • >85% is the goal, preferably in the >93% range
  • Oxygenation Techniques:
    • Semi-responsive patient that has a patent airway, but is going to be intubated due to the length of procedures or expected digression:
    • NRB @15lpm and supplemental NC @15lpm as well
    • Yes… A nasal cannula can go up to 15lpm
  • For the patient that cannot maintain their own airway:
    • BVM @15lpm and supplemental NC@15lpm
    • Adjunct preferable, but not a prerequisite for success; deliberate manual positioning works!
    • Remember… Apneic preoxygenation with a NC does not necessarily show marked benefit in a patient with shunt physiology


  • SGA placement by an ALS provider does not signify failure!
    • Several studies are showing that SGA placement yield better results
    • Before all of you go up in arms, we are not advocating for an all BLS airway system…
    • We will eventually be doing a podcast covering the difference between BLS/ALS airways and the pros/cons of each.
  • Don’t kill someone by being overly eager to rush to ALS and forgetting the importance of BLS airway maintenance and preoxygenation.


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