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Pre-Oxygenation for Refractory Hypoxia


Pre-oxygenation of your patient is its own procedure with a distinct bundle of concepts and skills required to be successful. The goal is to improve safe apnea time. In this space we focus on the patient with refractory hypoxia despite attempts at standard pre oxygenation strategies shown in the algorithm here.

For these patients, the addition of sedation and NIPPV for the purposes of oxygenation before intubation can prevent the adverse consequences of prolonged hypoxia. Dive in to the content below and then use the guided practice tools and in person coaching in our pop-up physical spaces and live events.

Refractory Hypoxia Rapid Review

Critically ill patients can remain refractory to your initial efforts at pre-oxygenation. When this happens you need a strategy. Let us give you ours in under 44 seconds.

The Triple 15 Rule For Pre-oxygenation

Memory Aid Pearl: The Triple 15 Rule for preoxygenation – an easy way to remember how to maximize oxygen delivery during the pre-intubation phase

  • 15 L O2 by nasal cannula +
  • 15 L O2 by non-rebreather & if oxygen saturation <100% then replace NRB with
  • 15 cm H2O of CPAP while maintaining nasal cannula
about dsi

Think of DSI is as procedural sedation for preoxygenation prior to RSI. Instead of an agitated and hypoxic patient, we want them to be calm, spontaneously breathing, and protecting their airway. This makes ketamine the ideal induction agent, as it preserves respiratory drive and airway reflexes.

It’s great for patients who need intubation, but cannot tolerate pre-oxygenation by any other means, Patients with agitated delirium from hypoxia, hypercapnia, or an underlying medical condition are all potentially great candidates for DSI.

curated learning

We love this short video on DSI by @EricShappell and wanted to share it. Check out some of his other great YouTube education videos on similar topics.


A great flowchart adapted from Chris Nickerson and Life in the Fast Lane. Two great online resources to help you build your learning network.

guided practice

Objective: optimize your patient on NIV for maximal preoxygenation prior to intubation.

  1. Look for this poster & snap the QR code.
  2. Listen to the clinical scenario
  3. Work with the coach at this station to complete the learning objectives for this station.

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