P026: A LOW-FLOW INFANT FACEMASK-FACE TENT PROVIDED SPONTANEOUS NASAL CPAP VENTILATION/OXYGENATION AND REDUCED AEROSOL/DROPLET SPREAD IN AN OBESE PATIENT WITH POSSIBLE OSA AND A-FIB DURING OUTPATIENT TEE/CARDIOVERSION
James Tse, PhD, MD; Rishika Voruganti, BS; Pankti Acharya, DO; Antonio Chiricolo, MD
Rutgers Robert Wood Johnson Medical School
Introduction: A pediatric facemask has been shown to provide nasal CPAP ventilation and improve O2 delivery in deeply sedated obese patients with OSA. 1-2
At the beginning of COVID-19 pandemic, a combined nasal mask-face tent provided pre/apneic nasal oxygenation and reduced aerosol/droplet spread during rapid sequence induction (RSI), video laryngoscopic (VL) endotracheal intubation and extubation in COVID-19 patients (Fig. 1). 3-4
We used this technique to provide nasal CPAP oxygenation in an obese patient during outpatient TEE/cardioversion.
Case Report: A 55-y/o male 5’8”, 232 lb, BMI 35.33 kg/m2, with HTN, possible OSA, dyspnea on exertion and atrial-fibrillation, presented for outpatient TEE with possible cardioversion in Echo Lab.
He had a Mallampati Class III airway. He was pre-oxygenated with 4L O2/min via NC with air sampling tubing. After he received viscous lidocaine gargle and oral benzocaine spray, a nasal mask-face tent was secured over his nose with elastic head-straps and connected to a breathing circuit and the anesthesia machine. A bandage with 6 layers of silk tape was placed over his nasal bridge to reduce the pressure on his nose. The face tent covered his mouth that was kept open by a bite block to reduce aerosol/droplet spread (Fig. 2).
Following nasal CPAP pre-oxygenation, his SpO2 increased from 97-98% (with NC O2 4L/min) to 100%. Deep sedation was titrated with lidocaine (100 mg), propofol boluses (80 mg) and propofol infusion (100-75 mcg/kg/min). Following insertion of TEE probe, his airway was obstructed, Bilateral jaw thrust was applied to maintain spontaneous ventilation and SpO2 in mid-90’s%. A jaw elevation device was applied. However, the left side support was malfunctioned and could not stay in position (Fig. 3). It was then secured in proper position with tapes (Fig. 2, 4). The patient maintained spontaneous nasal CPAP ventilation and 97-100% SpO2 during the procedure (Fig 4, 5). He maintained stable hemodynamics and tolerated the procedure and cardioversion well. He was awake and elated soon following the successful cardioversion. He was discharged home without any complications.
Conclusion: This simple low-flow nasal mask-face tent maintained spontaneous nasal CPAP ventilation/oxygenation in an obese patient with possible OSA and A-Fib during outpatient TEE/cardioversion. It also reduced aerosol/droplet spread during the aerosol generating procedure. Amid ongoing COVID-19 variant surges, it may improve patient safety and provide additional provider protection at no extra cost.
References:1. www.tsemask.com; 2. SAMBA 28th AM, MCC, 2013; 3. ASA virtual AM: MC1280, 2020; 4. ASA AM: MP460, 2024
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Fig. 1. A nasal mask-face tent was secured over the nose with elastic head-straps and connected to a breathing circuit.
Fig. 2. An infant face mask-face tent provided nasal CPAP ventilation/oxygenation with a malfunctioning jaw elevation device.
Fig. 3. The left side control button was broken.
Fig. 4. After the broken jaw elevation device was repaired with tape, the patient maintained spontaneous nasal CPAP ventilation/oxygenation.
Fig. 5. The patient maintained spontaneous nasal CPAP ventilation/oxygenation with a repaired JED during TEE/cardioversion.