Supplemental Oxygen Compromises the Use of Pulse Oximetry for Detection of Apnea and Hypoventilation During Sedation in Simulated Pediatric Patients

Keidan, Ilan; Gravenstein, Dietrich; Berkenstadt, Haim; Ziv, Amitai; Shavit, Itay; Sidi, Avner

doi:10.1542/peds.2007-2385

Cited by 61 publications

(31 citation statements)

References 19 publications

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“…However, pulse oximetry might be a late indicator of hypoventilation [10]. The decline in SpO 2 might be delayed especially in sedated patients receiving supplemental oxygen [11,12]. In a previous study, we found that the median delay between the onset of an apnea episode and a significant SpO 2 decline was 31 s [7].…”

Section: Discussionmentioning

confidence: 94%

Efficacy of End-Tidal Capnography Monitoring during Flexible Bronchoscopy in Nonintubated Patients under Sedation: A Randomized Controlled Study

et al. 2018

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Background: Although appropriate sedation is recommended during flexible bronchoscopy (FB), patients are at risk for hypoventilation due to inadvertent oversedation. End-tidal capnography is expected as an additional useful monitor for these patients during FB. Objectives: The aim of this study was to evaluate the benefit of additional end-tidal capnography monitoring in reducing the incidence of hypoxemia during FB in patients under sedation. Methods: Patients undergoing FB under moderate sedation without tracheal intubation were randomly assigned to receive standard monitoring including pulse oximetry or additional capnography monitoring. Bronchoscopy examiners for the only capnography group were informed of apnea events by alarms and display of the capnography monitor. Results: A total of 185 patients were enrolled. Patient characteristics were well balanced between the two groups. Hypoxemia (at least one episode of pulse oximeter oxygen saturation [SpO₂] < 90%) was observed in 27 out of 94 patients in the capnography group (29%) and in 42 out of 91 patients in the control group (46%; p = 0.014), resulting in an absolute risk difference of −17.4% (95% confidence interval, −31.1 to −3.7). In the capnography group, hypoxemia duration was shorter (20.4 vs. 41.7 s, p = 0.029), severe hypoxemic events (SpO₂ < 85%) were observed less frequently (16 [17%] vs. 29 [32%], p = 0.019), and the mean lowest SpO₂ value was higher (90.5 vs. 87.6%, p = 0.002). Conclusion: End-tidal capnography monitoring can reduce the incidence and duration of hypoxemia during FB in nonintubated patients under sedation.

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Section: Discussionmentioning

confidence: 94%

Efficacy of End-Tidal Capnography Monitoring during Flexible Bronchoscopy in Nonintubated Patients under Sedation: A Randomized Controlled Study

et al. 2018

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“…In many centres, pulse oximetry is used as a surrogate monitor for respiration, although the sensitivity of this monitor to detect apnea is attenuated when oxygen is administered. 4 Other monitors, such as capnography and plethysmography, for tracking respiration during transport and monitoring sedation on the ward have their limitations (e.g., cost, size, weight, and reliability) which preclude their routine use. [5][6][7] We identified the need for a new monitor based on simple physiological principles that would track respiration in advance of apnea and address the above shortcomings of the current monitors.…”

Section: Résumémentioning

confidence: 99%

Linshom respiratory monitoring device: a novel temperature-based respiratory monitor

Lerman

Feldman

Feldman³

et al. 2016

Can J Anesth/J Can Anesth

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Purpose We sought to develop a temperature-based respiratory instrument to measure respiration noninvasively outside critical care settings. Method Respiratory temperature profiles were recorded using a temperature-based noninvasive instrument comprised of three rapid responding medical-grade thermistors-two in close proximity to the mouth/nose (sensors) and one remote to the airway (reference). The effect of the gas flow rate on the amplitude of the tracings was determined. The temperature-based instrument, the Linshom Respiratory Monitoring Device (LRMD) was mounted to a face mask and positioned on a mannequin face. Respiratory rates of 5-40 breathsÁmin -1 were then delivered to the mannequin face in random order using artificial bellows (IngMar Lung Model). Data from the sensors were collected and compared with the bellows rates using least squares linear regression and coefficient of determination. The investigators breathed at fixed rates of 0-60 breathsÁmin -1 in synchrony with a metronome as their respiratory temperature profiles were recorded from sensors mounted to either a face mask or nasal prongs. The recordings were compared with a contemporaneously recorded sidestream capnogram from a CARESCAPE GEB450 Monitor. The extracted respiratory rates from the LRMD tracings and capnograms were compared using linear regression with a coefficient of determination and a Bland-Altman plot. Results The amplitude of the sensor tracings was independent of the oxygen flow rate. Respiratory rates from the new temperature-based sensor were synchronous and correlated identically with both the artificial bellows (r 2 = 0.9997) and the capnometer mounted to both the face mask and nasal prongs (r 2 = 0.99; bias = -0.17; 95% confidence interval, -2.15 to 1.8).Conclusions Respiratory rates using the LRMD, a novel temperature-based respiratory instrument, were consistent with those using capnometry. RésuméObjectif Nous avons tenté de mettre au point un instrument respiratoire se fondant sur la température afin de mesurer la respiration de façon non invasive en dehors des unités de soins critiques.

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“…Supplemental oxygen prevents or delays oxygen desaturation resulting from hypoventilation induced by sedation. For similar reduction in pulse oximeter reading, hypercarbia is more pronounced in the setting of supplemental oxygen because of the longer duration of hypoventilation [7][8][9] . A supplemental oxygen-induced nor mal pulse oximetry reading creates a false sense of security for the person monitoring the patient and sets him or her up for a delay in the intervention directed towards improving ventilation in these early stages [10] .…”

Section: Administration Of Supplemental Oxygen To Increase Patient Samentioning

confidence: 99%

Myths, fallacies and practical pearls in GI lab

Kumar¹

2014

WJGE

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Many prevalent practices and guidelines related to Gastrointestinal endoscopy and procedural sedation are at odds with the widely available scientific-physiological and clinical outcome data. In many institutions, strict policy of pre-procedural extended fasting is still rigorously enforced, despite no evidence of increased incidence of aspiration after recent oral intake prior to sedation. Supplemental oxygen administration in the setting of GI procedural sedation has been increasingly adopted as reported in the medical journals, despite clear evidence that supplemental oxygen blunts the usefulness of pulse oximetry in timely detection of sedation induced hypoventilation, leading to increased number of adverse cardiopulmonary outcomes. Use of Propofol by Gastroenterologist-Nurse team is erroneously considered dangerous and often prohibited in various institutions, at the same time worldwide reports of remarkable safety and patient satisfaction continue to be published, dating back more than a decade. Of patient monitoring practices that have been advocated to be standard, many merely add cost, not value. Advances in the technology often are not incorporated in a timely manner in guidelines or clinical practices, e.g. , Capsule endoscopy or electrocautery during GI procedures do not interfere with proper functioning of the current pacemakers or defibrillators. Orthopedic surgeons have continued to recommend prophylactic antibiotics for joint replacement patients prior to GI procedures, without any evidence of need. These myths are explored for a succint review to prompt a change in clinical practices and institutional policies. Core tip: Many prevalent endoscopic procedural practices and policies are not only unsupported by clinical and scientific evidence, but are counterproductive. Rather than enhancing patient safety and comfort, these increase risk and expense, introduce unnecessary delays. Evidence to reach proper decisions about these topics has been available for a while, but is not appropriately acknowledged and implemented. Avoiding these pitfalls can have a significant positive impact because these policies cover routine events, actions and decisions, including: required prolonged pre-procedural fasting, routine supplemental oxygen during sedation, prohibition of Propofol use by nonanesthesia personnel, multiple monitoring practices and prophylactic recommendations.Kumar P. Myths, fallacies and practical pearls in GI lab. World J Gastrointest Endosc 2014; 6(12): 584-591 Available from: URL:

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Supplemental Oxygen Compromises the Use of Pulse Oximetry for Detection of Apnea and Hypoventilation During Sedation in Simulated Pediatric Patients

Abstract: Hypoventilation and apnea are detected more quickly when patients undergoing sedation breathe only air. Supplemental oxygen not only does not prevent oxygen desaturation but also delays the recognition of apnea.

Cited by 61 publications

References 19 publications

Efficacy of End-Tidal Capnography Monitoring during Flexible Bronchoscopy in Nonintubated Patients under Sedation: A Randomized Controlled Study

Efficacy of End-Tidal Capnography Monitoring during Flexible Bronchoscopy in Nonintubated Patients under Sedation: A Randomized Controlled Study

Linshom respiratory monitoring device: a novel temperature-based respiratory monitor

Myths, fallacies and practical pearls in GI lab

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