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Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department

  • Adam A. Vukovic
    Correspondence
    Corresponding author at: Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 1025, Nashville, TN 37232, USA.
    Affiliations
    Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
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  • Holly R. Hanson
    Affiliations
    Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
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  • Shelley L. Murphy
    Affiliations
    Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
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  • Danielle Mercurio
    Affiliations
    Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
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  • Craig A. Sheedy
    Affiliations
    Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Avenue South, 703 Oxford House, Nashville, TN 37232, USA
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  • Donald H. Arnold
    Affiliations
    Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA

    Department of Pediatrics, Division of Pulmonary Medicine and the Center for Asthma Research Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN 37232, USA
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Published:April 18, 2018DOI:https://doi.org/10.1016/j.ajem.2018.04.039

      Abstract

      Background

      Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted.

      Objective

      Determine association between AO and hypoxemia in pediatric patients undergoing ETI.

      Methods

      Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011–June 2011) and with (August 2014–March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) < 90%. The χ2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia.

      Results

      149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1–0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7–1.0), lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8–1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2–7.2).

      Conclusions

      Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.

      Abbreviations:

      AO (apneic oxygenation), ETI (endotracheal intubation), PED (pediatric emergency department)

      Keywords

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