Is NODESAT Overhyped?

In the last few years, we’ve had a little bit of a sea-change in oxygenation during intubation.  We’ve stopped relying solely on pre-oxygenation to bridge our patients through apnea, and started providing passive oxygenation during intubation.  Usually supplied by high-flow nasal cannula, this takes advantage of physiology and diffusion to distribute oxygen into circulation.

But, as these authors state, the evidence for this practice is spotty – mostly observational evidence from controlled intubation settings.  Our critically-ill patients hardly have the same physiology as those undergoing elective airway procedures, and are generally less responsive to oxygenation adjuncts.  So, this is the FELLOW trial, a pragmatic, open-label randomized trial comparing apneic oxygenation vs. “usual care” – which was none.

With 150 patients in their intention-to-treat analysis, this cartoon sums up the results sufficiently:

Not much difference!

Their two groups were relatively well-balanced in terms of physiology and airway comorbidities.  The intubating operators were reasonably experienced (median >50 intubations), and 2/3rds of the patients were intubated on the first attempt.  There were probably no important differences in pre-oxygenation or procedural factors.

But, it is quite a small trial.  There are small differences here favoring the apneic oxygenation arm that simply might not reach statistical significance.  The exclusion criteria included “if the treating clinicians felt a specific approach to intra-procedural oxygenation or a specific laryngoscopy device was mandated for the safe performance of the procedure”, which could have introduced a selection bias.  The open-label effects may or may not be confounding.  The ICU environment and exclusion criteria also affect generalizability to the Emergency Department.

In the end, the answer is: apneic oxygenation still probably helps, particularly considering the pre-study evidence favored the intervention, and this one study does not move the needle much.  However, the observation here of a clinically unimportant effect size is not unreasonable.  If the effect size is small, the cost of an intervention becomes important.  However, in this case, the cost is fairly minimal – a small addition to set-up time and procedural complexity.  Considering the low cost and the post-test odds still favoring the intervention, it would be erroneous to stop providing apneic oxygenation based on this trial, and further study is indicated.

“Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill”

FEEL Part 1


Focused Echocardiography in Emergency Life Support (FEEL) is a learning program including a one-day course, which is designed to introduce the student to the use of transthoracic echocardiography (TTE) and lung ultrasound in the emergency setting.

A FEEL scan is performed during the 10 second pulse and rhythm check within the ALS algorithm, with the scanner then assessing the images while CPR continues. It is important to note it is an adjunct to the ALS algorithm and should not detract from effective CPR.

It is most useful in the non-shockable side of the algorithm and can be an aid when considering the 4 Hs and the 4 Ts of the ALS Algorithm. In particular the things you are looking for are:

  • Tension pneumothorax
  • Cardiac Tamponade
  • Thrombus – Pulmonary and Coronary
  • Hypovolaemia

Lt Col Pynn’s Top Tips:

  1. Correct Depth – Increase the depth especially in sub-xiphoid or sub-costal view to gain a good view of the heart, the heart is a lot further form the probe than you may expect.
  2. The Sub xiphoid and sub-costal view is the most appropriate in cardiac arrest as it doesn’t interfere with the person doing compressions and the other views may be more difficult if there is an automated compression device.

If this has given you an interest and you want to book on a course then follow this link, which will take you to the website.

Please have a look at the attached vodcast which has some very useful scans of Anatomy and Pathology which was kindly given to us by Susanna Price

If you have any questions or feedback, or want to get involved in making a Podcast yourself, please do get in contact via Twitter: @militaryfoamed or on Email:

Episode 35 – The Trachea

(ITUNES OR Listen Here) The Free Open Access Medical Education (FOAM) Jane Brody wrote an article, “What Comes After the Heimlich Maneuver” that ran in the NY Times and stirred up a ruckus on Twitter. This is a reasonable article on choking and details the limitations of the Heimlich maneuver.  Unfortunately, the article ends  instructing the layperson […]

CCP Podcast 037: How to Make Ultrasound Easier!

In this episode I talked to Jennifer Cotton (@sonomojo) who runs the website Sonomojo which is a guide to ultrasound education and she talks about her reasons for setting up the site. The aim of the site is about connecting people to resources about ultrasound. Jennifer is just about to become a doctor and has worked [...]

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