You came back for part two! In this episode Dr. Jeff Jarvis and I discuss his system's technique for pre-oxygenation, and why pre-loading your bougie can help increase your first pass success. Tip 3. NODESAT! “Nasal Oxygen During Efforts To Secure a Tube” (NODESAT) is a term coined by Rich Levitan in regards to placing a nasal cannula at high flow on a patient during the pre-ox and intubation process. This allows not only augmentation of FI02 from a NRB or BVM, but also the ability to provide apneic oxygenation during intubation. The idea is during the pre-ox period you place a NC at 15lpm, a NRB at 15lpm, and try to achieve an SP02 of 100 % for at least 3 minutes prior to intubation. Because this provides little positive pressure, it will likely not work in a patient with physiological shunting. If you HAVE to ventilate a patient due to inadequate peri-intubation ventilation, then the use of CPAP or BVM with a PEEP valve will be needed. By utilizing Henry’s law we can not only increase the surface area of alveoli by recruitment, but also apply pressure to the oxygen to assist in diffusion. Tip 4. Ditch The Stylet! I may be crucified by some for saying this, but statistics and anecdotal experience has shown you are much more likely to achieve first pass success if you utilize a bougie. Now the old way that we were taught to use the bougie required two people to perform. One person would intubate the trachea with the bougie, and the other would assist in railroading an ET tube over the bougie. A more common and efficient trick in the pre-hospital realm, is to preload the bougie with either a Kiwi grip or D grip. The cudae tip allows for easier anterior access, and the tactile feel of the bougie allows you to feel the tracheal rings upon successful placement. The bougie is commonly used as an emergency tool for difficult airways. If we are intubating a patient, it is an emergency, and we need to use everything possible to optimize our FPS. The occasional intubator recognizes the need to utilize every strategy possible to achieve their goal. A study showed providers increased their FPC success rates from 66% to 96% just by utilizing the bougie. This is a must in every pre-hospital airway kit. Sources: Comparison of the stylet and the gum elastic bougie in tracheal intubation in a simulated difficult airway Riaz Ahmed Khan*,Farah Ashraf Khan **, Muhammad Azam*** Anaesthesia, Pain & Intensive Care ISSN 1607-8322, ISSN (Online) 2220-5799