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Apneic oxygenation to prevent oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department

  • Kevin M. Overmann
    Correspondence
    Corresponding author at: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, United States of America.
    Affiliations
    Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, United States of America

    Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, United States of America
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  • Stephanie D. Boyd
    Affiliations
    Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, United States of America
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  • Yin Zhang
    Affiliations
    Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, United States of America
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  • Benjamin T. Kerrey
    Affiliations
    Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, United States of America

    Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, United States of America
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Published:October 18, 2018DOI:https://doi.org/10.1016/j.ajem.2018.10.030

      Abstract

      Background

      Apneic oxygenation is the delivery of oxygen to the nasopharynx during intubation. It may mitigate the risk of oxyhemoglobin desaturation but has not been well-studied in children.

      Methods

      We conducted a retrospective, observational study of patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department. We compared patients who received apneic oxygenation, delivered via simple nasal cannula at age-specific flow rates, to patients who did not receive apneic oxygenation. The main outcome was occurrence of oxyhemoglobin desaturation during RSI, defined as oxyhemoglobin saturation dropping to <90% at any time after the administration of paralytic medication and before the endotracheal tube was secured. Data were analyzed using logistic regression, with groups as a fixed effect and patients' age and number of attempts as covariates.

      Results

      Data were collected for 305 of 323 patients who underwent RSI over a 49 month period. Oxyhemoglobin desaturation occurred for 50 patients when apneic oxygenation was used (22%, 95% CI 17% to 28%) and 11 patients without apneic oxygenation (14%, 95% CI 7% to 24%; p > 0.05). There was no difference in the median duration of desaturation or depth of desaturation for the apneic oxygenation group (52 s, 71%) compared to the group without apneic oxygenation (65 s, 79%; p > 0.05). Controlling for covariates, apneic oxygenation was not associated with a lower risk of oxyhemoglobin desaturation, time to desaturation, or depth/duration of desaturation episodes.

      Conclusions

      In an observational, video-based study of pediatric patients, apneic oxygenation was not associated with a lower risk of oxyhemoglobin desaturation during RSI.

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      References

        • Cabrini L.
        • Landoni G.
        • Baiardo Radaelli M.
        • et al.
        Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials.
        Crit Care. 2018; 22: 6
        • Weingart S.D.
        • Levitan R.M.
        Preoxygenation and prevention of desaturation during emergency airway management.
        Ann Emerg Med. 2012; 59 ([e161]): 165-175
        • Vallance J.
        • Kesselman M.
        • Burzynski J.
        • Mortimer T.
        • Hansen G.
        Apneic oxygenation during rapid sequence intubation in critically ill children.
        J Pediatr Intensive Care. 2015; 05: 028-031
        • Graciano A.L.
        • Tamburro R.
        • Thompson A.E.
        • Fiadjoe J.
        • Nadkarni V.M.
        • Nishisaki A.
        Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for children: NEAR4KIDS.
        Intensive Care Med. 2014; 40: 1659-1669
        • Nishisaki A.
        • Turner D.A.
        • Brown 3rd, C.A.
        • et al.
        A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs.
        Crit Care Med. 2013; 41: 874-885
        • Laycock G.J.
        • McNicol L.R.
        Hypoxaemia during induction of anaesthesia–an audit of children who underwent general anaesthesia for routine elective surgery.
        Anaesthesia. 1988; 43: 981-984
        • Frumin M.J.
        • Epstein R.M.
        • Cohen G.
        Apneic oxygenation in man.
        Anesthesiology. 1959; 20: 789-798
        • Gustafsson I.M.
        • Lodenius A.
        • Tunelli J.
        • Ullman J.
        • Jonsson Fagerlund M.
        Apnoeic oxygenation in adults under general anaesthesia using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) - a physiological study.
        Br J Anaesth. 2017; 118: 610-617
        • Lee S.C.
        Improvement of gas exchange by apneic oxygenation with nasal prong during fiberoptic intubation in fully relaxed patients.
        J Korean Med Sci. 1998; 13: 582-586
        • Gander S.
        • Frascarolo P.
        • Suter M.
        • Spahn D.R.
        • Magnusson L.
        Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients.
        Anesth Analg. 2005; 100: 580-584
        • Miguel-Montanes R.
        • Hajage D.
        • Messika J.
        • et al.
        Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia.
        Crit Care Med. 2015; 43: 574-583
        • Jaber S.
        • Monnin M.
        • Girard M.
        • et al.
        Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: the single-centre, blinded, randomised controlled OPTINIV trial.
        Intensive Care Med. 2016; 42: 1877-1887
        • Binks M.J.
        • Holyoak R.S.
        • Melhuish T.M.
        • Vlok R.
        • Bond E.
        • White L.D.
        Apneic oxygenation during intubation in the emergency department and during retrieval: a systematic review and meta-analysis.
        Am J Emerg Med. 2017; 35: 1542-1546
        • Pavlov I.
        • Medrano S.
        • Weingart S.
        Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: a systematic review and meta-analysis.
        Am J Emerg Med. 2017; 35: 1184-1189
        • White L.D.
        • Melhuish T.M.
        • White L.K.
        • Wallace L.A.
        Apnoeic oxygenation during intubation: a systematic review and meta-analysis.
        Anaesth Intensive Care. 2017; 45: 21-27
        • Gleason J.M.
        • Christian B.R.
        • Barton E.D.
        Nasal cannula apneic oxygenation prevents desaturation during endotracheal intubation: an integrative literature review.
        West J Emerg Med. 2018; 19: 403-411
        • Oliveira J.E.S.L.
        • Cabrera D.
        • Barrionuevo P.
        • et al.
        Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis.
        Ann Emerg Med. 2017; 70 (e411): 483-494
        • Wong D.T.
        • Yee A.J.
        • Leong S.M.
        • Chung F.
        The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review.
        Can J Anaesth. 2017; 64: 416-427
        • Sakles J.C.
        • Mosier J.M.
        • Patanwala A.E.
        • Arcaris B.
        • Dicken J.M.
        First pass success without hypoxemia is increased with the use of apneic oxygenation during rapid sequence intubation in the emergency department.
        Acad Emerg Med. 2016; 23: 703-710
        • Sakles J.C.
        • Mosier J.M.
        • Patanwala A.E.
        • Dicken J.M.
        Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department.
        Intern Emerg Med. 2016; 11: 983-992
        • Caputo N.
        • Azan B.
        • Domingues R.
        • et al.
        Emergency department use of apneic oxygenation versus usual care during rapid sequence intubation: a randomized controlled trial (the ENDAO trial).
        Acad Emerg Med. 2017; 24: 1387-1394
        • Semler M.W.
        • Janz D.R.
        • Lentz R.J.
        • et al.
        Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill.
        Am J Respir Crit Care Med. 2016; 193: 273-280
        • Kernisan G.
        • Adler E.
        • Gibbons P.
        • Runions D.
        Apneic oxygenation in pediatric patients.
        Anesthesiology. 1987; 67A521
        • Patel R.
        • Lenczyk M.
        • Hannallah R.S.
        • McGill W.A.
        Age and the onset of desaturation in apnoeic children.
        Can J Anaesth. 1994; 41: 771-774
        • Vukovic A.A.
        • Hanson H.R.
        • Murphy S.L.
        • Mercurio D.
        • Sheedy C.A.
        • Arnold D.H.
        Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department.
        Am J Emerg Med. 2018; https://doi.org/10.1016/j.ajem.2018.04.039
        • Kerrey B.T.
        • Rinderknecht A.S.
        • Geis G.L.
        • Nigrovic L.E.
        • Mittiga M.R.
        Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
        Ann Emerg Med. 2012; 60: 251-259
        • Rinderknecht A.S.
        • Dyas J.R.
        • Kerrey B.T.
        • Geis G.L.
        • Ho M.H.
        • Mittiga M.R.
        Studying the safety and performance of rapid sequence intubation: data collection method matters.
        Acad Emerg Med. 2017; 24: 411-421
        • Oakley E.
        • Stocker S.
        • Staubli G.
        • Young S.
        Using video recording to identify management errors in pediatric trauma resuscitation.
        Pediatrics. 2006; 117: 658-664
        • Lane B.
        • Finer N.
        • Rich W.
        Duration of intubation attempts during neonatal resuscitation.
        J Pediatr. 2004; 145: 67-70
        • Mackenzie C.F.
        • Jefferies N.J.
        • Hunter W.A.
        • Bernhard W.N.
        • Xiao Y.
        Comparison of self-reporting of deficiencies in airway management with video analyses of actual performance. LOTAS group. Level One Trauma Anesthesia Simulation.
        Hum Factors. 1996; 38: 623-635
        • Cemalovic N.
        • Scoccimarro A.
        • Arslan A.
        • Fraser R.
        • Kanter M.
        • Caputo N.
        Human factors in the emergency department: is physician perception of time to intubation and desaturation rate accurate?.
        Emerg Med Australas. 2016; 28: 295-299
      1. Kerrey BT, Mittiga MR, Rinderknecht AS, et al. Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department. BMJ quality & safety. 2015.

        • Kerrey B.T.
        • Mittiga M.R.
        • Rinderknecht A.S.
        • et al.
        Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department.
        BMJ Qual Saf. 2015; 24: 709-717
        • Ramachandran S.K.
        • Cosnowski A.
        • Shanks A.
        • Turner C.R.
        Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration.
        J Clin Anesth. 2010; 22: 164-168
        • Teller L.E.
        • Alexander C.M.
        • Frumin M.J.
        • Gross J.B.
        Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea.
        Anesthesiology. 1988; 69: 980-982
        • Isono S.
        Developmental changes of pharyngeal airway patency: implications for pediatric anesthesia.
        Paediatr Anaesth. 2006; 16: 109-122
        • Oshan V.
        • Plant N.
        • Gopal P.
        • Rajai A.
        • Roberts S.A.
        • Walker R.W.
        The effect of age and increasing head-up tilt on pre-oxygenation times in children: a randomised exploratory study.
        Anaesthesia. 2016; 71: 429-436
        • Rinderknecht A.S.
        • Mittiga M.R.
        • Meinzen-Derr J.
        • Geis G.L.
        • Kerrey B.T.
        Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data.
        Acad Emerg Med. 2015; 22: 431-440