Effectiveness of apnoeic oxygenation during intubation: systematic review and meta-analysis.
Annals of Emergency Medicine;2017:x:1-12
Presented by: Dr M. Gallagher
- Concept-> administration oxygen during apnoeic period of intubation.
- Rationale-> ability of alveoli to capture oxygen via passive process without ventilation.
- Importance-> higher risk hypoxaemia during the intubation of the critically ill patient in ICU or ED setting.
Design & Setting
- Systematic review and meta-analysis
- Study overall effect of apnoeic oxygenation during emergency intubation on
2) ‘first pass’ success intubation
3) lowest oxygen saturation
- Oxygenation during apnoeic period via
– nasal cannula (NO DESATURATION)
– high flow oxygen nasal cannula (THRIVE)
– nasopharyngeal catheter or modified laryngoscope.
- Intubations performed in ICU or ED settings.
- RCT’s and observational studies in the last 10 years.
- Intubations in ‘out-of hospital’ settings or in theatres.
- Lowest SpO2 peri-intubation
- ‘First pass’ success
- Incidence hypoxaemia
- SpO2 <93%
- SpO2 < 80%
- SpO2 <70%
- Duration of mechanical ventilation
- ICU length of stay and mortality
- Included 8 emergency department or intensive care based studies
- Total 1837 patients
- Apnoeic oxygenation 982 patients
- No apnoeic oxygenation 855 patients
- High flow oxygen nasal cannula (NO DESAT) most studies.
- Standard nasal cannula in ED.
For apnoeic oxygenation
- Lowest peri-intubation SpO2 was higher than for standard oxygenation.
- Associated with increased ‘first pass- success rates.
- Decreased risk of incidence SpO2 < 93%.
- Not associated with SpO2 < 805 or <70%.
- No association with duration of mechanical ventilation.
- Decreased length of stay on ICU.
- No association with ICU mortality.
- Overall no difference between study design or risk of bias.
- Apnoeic oxygenation favoured trainees ‘subgroup when proceduralist expertise was evaluated.
- Results were not statistically significant
- No adverse effects for very simple procedure -> ?beneficial in emergency scenarios particularly when a trainee is intubating.
- Different techniques used
- Emergency Department = standard nasal cannula
- Intensive Care Unit = high flow nasal cannula.
- No clear overall consensus in the literature.
- Meta-analysis-> good use of statistical analysis to try overcome any bias.
- Relevant to patient groups in question
- Quality of included studies (low-moderate).
- Clinical heterogenitcity ( clinical setting, context for intubation, methods of pre-oxygenation and apnoeic oxygenation).
- Not able to assess publication bias.
- Potentially a useful adjunct in emergency intubation
Potential for impact
- Seems to be of benefit
- Relatively simple and safe intervention with few complications
- Evidence surrounding apnoeic oxygenation still not certain and some concerns raised about quality of available studies