Effect of variable pre-oxygenation endpoints on safe apnoea time using high flow nasal oxygen for women in labour: a modelling investigation

Stolady, Daniel; Laviola, Marianna; Pillai, A.; Hardman, Jonathan G.

doi:10.1016/j.bja.2020.12.031

Cited by 19 publications

(12 citation statements)

References 26 publications

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“…In these cases the apnoea time was less than 5 min, comparable with time to desaturation in obese patients who were not given supplemental oxygen during apnoea. 14,34 This pattern, an apparent dichotomy between patients who do and do not 'tolerate' apnoea, was reported as early as 1973 35 and has been replicated in studies in both obese 14,18 and non-obese patients. 17 Clinically, this is an important finding: the implication is that for some patients e whatever the delivery method e supplying oxygen does not greatly increase the duration of apnoea without desaturation.…”

Section: Strengths and Limitationsmentioning

confidence: 91%

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Schutzer-Weissmann¹,

Wojcikiewicz²,

Karmali³

et al. 2023

British Journal of Anaesthesia

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Background: Obesity is a risk factor for airway-related incidents during anaesthesia. High-flow nasal oxygen has been advocated to improve safety in high-risk groups, but its effectiveness in the obese population is uncertain. This study compared the effect of high-flow nasal oxygen and low-flow facemask oxygen delivery on duration of apnoea in morbidly obese patients. Methods: Morbidly obese patients undergoing bariatric surgery were randomly allocated to receive either high-flow nasal (70 L min À1 ) or facemask (15 L min À1 ) oxygen. After induction of anaesthesia, the patients were apnoeic for 18 min or until peripheral oxygen saturation decreased to 92%. Results: Eighty patients were studied (41 High-Flow Nasal Oxygen, 39 Facemask). The median apnoea time was 18 min in both the High-Flow Nasal Oxygen (IQR 18e18 min) and the Facemask (inter-quartile range [IQR], 4.1e18 min) groups. Five patients in the High-Flow Nasal Oxygen group and 14 patients in the Facemask group desaturated to 92% within 18 min. The risk of desaturation was significantly lower in the High-Flow Nasal Oxygen group (hazard ratio¼0.27; 95% confidence interval [CI], 0.11e0.65; P¼0.007). Conclusions: In experienced hands, apnoeic oxygenation is possible in morbidly obese patients, and oxygen desaturation did not occur for 18 min in the majority of patients, whether oxygen delivery was high-flow nasal or low-flow facemask. High-flow nasal oxygen may reduce desaturation risk compared with facemask oxygen. Desaturation risk is a more clinically relevant outcome than duration of apnoea. Individual physiological factors are likely to be the primary determinant of risk rather than method of oxygen delivery. Clinical trial registration: NCT03428256.

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Section: Strengths and Limitationsmentioning

confidence: 91%

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Schutzer-Weissmann¹,

Wojcikiewicz²,

Karmali³

et al. 2023

British Journal of Anaesthesia

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“…[34][35][36] However, a modelling investigation by Stolady et al showed that despite generating lower EtO2, continuous application of HFNO could provide longer safe apnoea time in pregnant subjects in labour. [37] In our study, meta analysis showed that there was no significant difference(p=0. 23) in EtO2 during anesthesia induction between FMV group and HFNO group and subgroup analysis also showed no significant difference(p=0.49) in EtO2 between after preoxygenation and after intubation.…”

Section: Discussionmentioning

confidence: 46%

Comparison of the Effectiveness of High-Flow Nasal Oxygen vs. Standard Facemask Oxygenation for pre- and apneic oxygenation during Anesthesia Induction: A Systematic Review and Meta-analysis

Song

Sun

Shi

et al. 2021

Preprint

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BackgroundIn recent years, high flow nasal oxygen(HFNO) has been widely used in clinic, especially in perioperative period.Many studies have discussed the role of HFNO in pre- and apneic oxygenation, but their results are controversial.Our study aimed to examine the effectiveness of HFNO in pre- and apneic oxygenation by a meta-analysis ofRCTs.MethodsEMBASE, PUBMED, and COCHRANE LIBRARY databases were searched from inception to July 2021 for relevantrandomized controlled trails(RCTs) on the effectiveness of HFNO versus standard facemask ventilation(FMV) inpre- and apenic oxygenation. Studies involving one of the following six indicators: (1)Arterial oxygen partialpressure(PaO2), (2)End expiratory oxygen concentration(EtO2), (3)Safe apnoea time, (4)Minimum pulse oxygensaturation(SpO2min), (5)Oxygenation(O2) desaturation, (6)End expiratory carbon dioxide(EtCO2) or Arterial carbondioxide partial pressure(PaCO2) were included. We select random effect model or fixed effect model for analysisaccording to the heterogeneity of the article, and express it as the mean difference(MD) or risk ratio(RR) with aconfidence interval of 95%(95%CI). We conducted a risk assessment of bias for eligible studies and assessed theoverall quality of evidence for each outcome.Results14 RCTs and 1012 participants were finally included. We found the PaO2 was higher in HFNO group than FMVgroup with a MD(95% CI) of 57.38 mmHg(25.65 to 89.10; p=0.0004) after preoxygenation and the safe apnoeatime was significantly longer with a MD(95% CI) of 86.93 seconds(44.35 to 129.51; p<0.0001) during anesthesiainduction. There were no significant statistical difference in the minimum O2 saturation, CO2 accumulation, endexpiratory oxygen concentration and O2 desaturation rate during anesthesia induction between the two groups.ConclusionsThis systematic review and meta-analysis suggests that HFNO should be considered as an airway managementtool for patients with high-risk hypoxemia or difficult airway during anesthesia induction. Compared with FMV,continuous use of HFNO during anesthesia induction can significantly improve oxygenation and prolong safeapnoea time in surgical patients.

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“…Although studies on the use of high-flow nasal oxygen in the obstetric population have not demonstrated significant benefits over traditional facemask for pre-oxygenation (see Table 1) [8][9][10][11][12], there is likely to be a benefit during the apnoeic phase, which is logistically more difficult to study. A clinical surrogate of desaturation was explored in a study using high-fidelity computer simulated models of pregnant patients [13]. The findings illustrated a significant prolongation in time to onset of apnoea to SaO 2 90% of > 60 min in lower BMI 24 kg.m -2 , even when the starting end-tidal oxygen fraction was at 60%.…”

Section: Preparation For Safe General Anaesthesiamentioning

confidence: 99%

Emergencies in obstetric anaesthesia: a narrative review

2022

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We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.

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Effect of variable pre-oxygenation endpoints on safe apnoea time using high flow nasal oxygen for women in labour: a modelling investigation

Cited by 19 publications

References 26 publications

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Comparison of the Effectiveness of High-Flow Nasal Oxygen vs. Standard Facemask Oxygenation for pre- and apneic oxygenation during Anesthesia Induction: A Systematic Review and Meta-analysis

Emergencies in obstetric anaesthesia: a narrative review

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