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conditions, but >90% is an appropriate initial goal for most patients. While some
patients with cardiac disease may not tolerate high amounts of supplemental
oxygen depending on their physiology, in general, immediate lifesaving efforts
should include provision of supplemental oxygen while further details of the
condition are sought and risks of hyperoxygenation are considered.
Clinicians should be adept at assessing airway patency and performing
emergency maneuvers to optimize oxygen delivery and assisted ventilation. Use
of a flow-inflating resuscitation bag (aka “anesthesia bag”) can deliver 100%
oxygen and continuous positive airway pressure (CPAP). Positive-pressure
breaths utilizing a self-inflating or flow-inflating bag will further increase oxygen
delivery. Importantly, CPAP cannot be delivered though a self-inflating (Ambu)
bag.
High-flow nasal cannula (HFNC) has gained popularity in the treatment of
respiratory distress and failure. As equipment has become more widely available
and indications for use have grown, many patients are now initiated on HFNC in
the ED. It is easy to apply and well tolerated by most patients. Noninvasive
ventilation with CPAP and BPAP may also be used to provide ongoing respiratory
support in appropriate patients in whom respiratory drive and airway protection
are not compromised. Success hinges on finding an appropriate interface to
generate a good seal, and patient compliance with this mode of ventilation.
Endotracheal intubation provides the most effective means of increasing PaO2
and is required for patients with persistent hypoxemia despite other interventions,
or patients with hypercarbia and signs of respiratory failure such as tiring or
altered mental status.
As mentioned, support of ventilation is indicated if adequate oxygen saturation
cannot be maintained in spontaneously breathing patients despite 100% oxygen
delivery. Assisted ventilation may also be required to correct alveolar
hypoventilation despite adequate oxygen saturation. Adequacy of ventilation
should be assessed clinically by chest wall expansion with further data from
either ETCO2 or blood gas analysis of PCO2 . Goal tidal volumes are usually 7 to
10 mL/kg, although this will vary based on lung compliance and underlying

disease (e.g., as low as 3 to 6 mL/kg in ARDS).