Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU*

Abstract

Objectives: To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. Design: Prospective pre/post observational study. Setting: A large single-center noncardiac PICU in North America. Patients: All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. Interventions: Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. Measurements and Main Results: Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34–0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31–0.96) while adjusting for tracheal intubation indications and device. Conclusions: Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.

Normal and difficult airways in children: “What’s New”—Current evidence

“…While the definition of adverse TIAEs does not include hypoxemia, these are often reported together. Current evidence suggests 1. adverse TIAEs and hypoxemia are common in airway management in the pediatric ICUs, Emergency Department, and neonatal ICUs, 2. patient, clinician, and practice factors are associated with the occurrence of these adverse events, and 3. interdisciplinary quality improvement has helped reduce these events . Pediatric anesthesiologists can partner with nonanesthesiologists to improve the safety of airway management in these clinical locations.…”

“…The use of apneic oxygenation has been explored in the adult EDs and ICUs . Napolitano et al recently published a single‐center experience to implement apneic oxygenation as a quality improvement interventions in a single pediatric ICU . Among 1,373 tracheal intubations, the implementation of apneic oxygenation was associated with lower oxygen desaturation (SpO2 < 80%): apneic oxygenation 15.4% vs. without apneic oxygenation 11.8%, P = .049.…”

Pediatric airway: What is new in approaches and treatments?

“…An old technique consisting of the use of high flow nasal cannula (up to 15 liters per minute in adolescents) besides the conventional facial mask during anesthetic induction in order to achieve longer safe apnea time (23) and reduce the possibility of arterial desaturation which is faster and more severe in pediatric patients because of their lower functional residual capacity (oxygen reserve) and higher tissue oxygen consumption. The effectiveness of this simple practice has been proven, especially in the presence of DA, in patients with prior lung compromise, in critically ill patients (24), or whenever there is a risk of aspiration, where positive pressure ventilation during induction would be contraindicated (25). Isolated cases of pneumothorax have been described with the use of high flow devices in children (26).…”

Apneic Oxygenation for Pediatric Endotracheal Intubation: A Narrative Review

“…A review of five databases (SCOPUS, Web of Science, CINAHL, Medline, and PubMed) for primary studies on the use of pediatric ApOx in endotracheal intubation up to and including August 2018 yielded eight studies for inclusion [9][10][11][12][13][14][15][16] (►Table 1). Articles were included if they assessed the performance of ApOx during intubation with that of a control group in a pediatric population.…”