Apnoeic oxygenation was associated with decreased desaturation rates during rapid sequence intubation in multiple Australian and New Zealand emergency departments

Abstract

Apnoeic oxygenation (ApOx) has been demonstrated to reduce the incidence of desaturation, although evidence of benefit has been conflicting depending on the technique used. The aim of this study was to compare the incidence of desaturation between patients who received ApOx via conventional nasal cannula (NC) and those who did not, using a large, multicentre airway registry.MethodsThis study is an analysis of 24 months of prospectively collected data in the Australia and New Zealand Emergency Department Airway Registry (June 2013–June 2015). The registry includes information on all intubated adults from 43 emergency departments. Patients intubated during cardiac arrest (n=393), those who received active ventilation prior to the first intubation attempt (n=486), and where the use of ApOx was not recorded either way (n=312) were excluded. The proportion of patients who desaturated (Sa02 <93) in the group that received ApOx and those that did not were compared. To evaluate the association of ApOx with patient desaturation, a logistic regression model based on factors expected to influence desaturation was performed.ResultsOf 2519 patients analysed, 1669 (66.3%) received ApOx via NC while 850 (33.7%) did not. Desaturation in the cohort receiving ApOx was 10.4% compared with standard care (no ApOx) 13.7%. ApOx had a protective effect for desaturation (OR 0.71 95% CI 0.53 to 0.95). Single intubation attempt was associated with reduced risk of desaturation of (OR 0.10, 95% CI 0.06 to 0.17); this was increased on second attempt (OR 0.37, 95% CI 0.21 to 0.68). Desaturation was also associated with the physician recording that they had anticipated a difficult airway (OR 1.83, 95% CI 1.34 to 2.48).ConclusionThis large multicentre registry study provides evidence that ApOx delivered through a conventional NC is associated with a lower incidence of desaturation in patients undergoing rapid sequence intubation.Trial registration numberACTRN12613001052729.

Unintended consequences: The impact of airway management modifications introduced in response to COVID‐19 on intubations in a tertiary centre emergency department

“…We must infer therefore that the increased rates of hypoxia are a consequence of the modifications to established standard practice. This is likely to be multifactorial but could include specific changes such as the removal of nasal cannula apnoeic oxygenation, 9,10 avoidance of BVM ventilation during apnoea, and recommending a 60‐s delay to laryngoscopy after muscle relaxant administration, 6 as well as a general shift in focus toward minimising aerosolisation to protect HCWs. In terms of positioning, patient's intubated supine during the COVID‐19 era were also less likely to be positioned with a pillow or occipital raise which may have impacted preoxygenation and apnoeic oxygenation efficacy.…”

The efficacy of apneic oxygenation to prevent hypoxemia during rapid sequence intubation in trauma patients

“…Although most intubations are performed in the operating room under ideal conditions, intubations performed outside the operating often are performed under suboptimal conditions and are associated with severe complications, occurring in up to 28% of patients [7]. One of the primary complications is desaturation, which may be reported in up to 38% of patients with multiple intubation attempts [8 ▪ ]. Trauma patients undergoing RSI in the emergency department are often in extremis.…”

“…facial, oral, neck, or airway) [9]. As a result, RSIs performed in this setting are often associated with an increased risk of aspiration, hypoxia, hypotension and cardiac arrest, irreversible brain damage, and airway trauma [8 ▪ ]. In patients with TBI, hypoxemia has devastating consequences including increased risk of hypoxic brain injury, further worsening of the neurologic insult, increased mortality, and worsened clinical outcomes [10].…”

“…In patients with TBI, hypoxemia has devastating consequences including increased risk of hypoxic brain injury, further worsening of the neurologic insult, increased mortality, and worsened clinical outcomes [10]. To optimize intubation conditions, patients are likely to be administered a sedative or muscle relaxant, resulting in a prolonged period of apnea until successful intubation is achieved [8 ▪ ].…”

Studying ApOx in the ED: forget associations, the truth is in the design

“…This is likely due to the generalisation of the technique to a broad cohort when really the type of technique used and the particular patient in front of the provider really need to be taken into consideration. Observational studies, such as those offered by Perera et al and Wimalasena et al as examples, offer no real insight into who could benefit from the technique due to lack of proper methodology and design 4 5. Data collection and analytics should be more granular in order to tease out which technique works and who it works on.…”