Plan to maximize oxygenation in every instance of procedural sedation. Use gravity to reduce the risk of aspiration, and always ask, “Do you need the patient flat?” We rarely do, and head elevation adds tremendously to patient safety.

The highest-risk patients may be those sedated for hip reduction because they need to be lying flat. Even a slight amount of head elevation (ie, 10 degrees) tilts the pannus down and improves lung function tremendously. Once the hip reduction is complete, bring the head higher and pull on the mandible with the nasal cannula on. Often the most dangerous part of sedation occurs after the reduction because pain input drops but the drugs haven’t worn off.

If positioning, pulling on the mandible, and nasal oxygen at high flow does not resolve hypoxia, add PEEP by using a BVM with a PEEP valve. Install PEEP valves on every BVM in your department so when PEEP is needed, you don’t need to locate one.

Be mindful of patients at high risk of desaturation due to alveolar disease (ie, heart failure, acute respiratory distress syndrome, multi-lobar pneumonia, aspiration, etc.). The sickest of the sick may require combining both upright positioning and PEEP for pre-oxygenation, and also during the onset phase of muscle relaxation when performing rapid sequence intubation. Even after successful intubation, these patients can prove difficult to oxygenate. Increase the fraction of inspired O2, increase PEEP, lower tidal volumes, and increase the ventilator rate in these challenging cases.

Finally, consider prone positioning if upright positioning doesn’t allow for sufficient oxygenation.