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Three Part Question

In [adult patients requiring endotracheal intubation] does [adding supplemental nasal oxygen during the procedure] reduce [oxygen desaturation]?

Clinical Scenario

A 55 year old man has presents to the emergency department with severe hypoxia secondary to an exacerbation of congestive heart failure. His initial saturation is 83% with a reservoir oxygen mask; he is tachypneic with a respiratory rate of 35. You decide to intubate this patient and want to optimize his oxygen saturation before induction. You place a standard reservoir face mask with a flow rate of oxygen set as high as possible. After 3 minutes the saturation has improved to 95%. One of your colleagues suggests using high-flow nasal cannula oxygen during the intubation procedure to reducing desaturation (apneic oxygenation).

Search Strategy

Medline 1966-08/16 using OVID interface, Cochrane Library (2016), and Embase


[(exp apneic oxygenation/ or exp oxygen cannula/ or exp nasal oxygen/) AND (exp intubation/)]. Limit to clinical trials and English language

Search Outcome

57 studies were identified; three randomized clinical trials addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
M. W. Semler et. al Feb 1, 2016 United States	150 adults undergoing endotracheal intubation in an medical intensive care unit.	Adult patients were randomized to receive 15 L/min of 100% oxygen with a high-flow nasal cannula during laryngoscopy or given no supplemental oxygenation.	The lowest arterial oxygen saturation after induction until 2 minutes after endotracheal intubation was reported.	For apneic oxygenation vs usual care, O2 saturation <90% 44.7% vs 47.2% of patients (P=0.87). For oxygenation <80% was 15.8% vs 25.0% for patients (P=0.22). Decrease in oxygen saturation >3% was 53.9% vs. 55.6% (P=0.87).	Small sample size was used. Patients were not emergently intubated. Performed in an intensive care unit setting by pulmonary and critical care medicine fellows.
			Duration of mechanical ventilation, ICU stay, and mortality.	No statistical significance between the two groups.
M. Vourc'h et. al. Feb 18, 2015 France	124 patients from multiple hospitals who required intubation in a intensive care unit setting.	Patient's were randomized to receive high flow nasal cannula throughout the procedure or high fraction-inspired oxygen facial mask which was removed at end of general anesthesia induction.	Lowest oxygen saturation throughout intubation procedure	For high flow nasal cannula,the lowest median O2 saturation was 91.5% (80-96%) and high fraction-inspired oxygen facial mask was 89.5% (81-95%) with a P=0.44.	Small sample size was used. Patients were not emergently intubated. Performed in an intensive care unit setting.
			Adverse events related to intubation, duration of mechanical ventilation, and death.	At least one complication with high flow nasal cannula vs high-flow face mask, 36 vs 39 (P=0.24)
S. K. Ramachandran et. al. May 27, 2009 United States	30 obese men undergoing general anesthesia in a operating room setting prior surgery.	Patient's were randomized to receive high flow nasal cannula during the apneic phase vs no oxygen during intubation prior to surgical procedure in an operating room setting.	Duration of SpO2 greater than 95% for a maximum of 6 minutes	In the experimental group SpO2 was significantly prolonged (5.29min +/- 1.02 vs 3.49min +/- 1.33, mean +/- SD) (P=0.001)	Very small sample size was used. Obese patient's were only used in the study. Patients were not emergently intubated. Performed in an operating room setting with an anesthesiologist. No long term outcome data was collected.
			Lowest SpO2	Significantly higher minimum SpO2 (94.3% +/- 4.4% vs 87.7 +/- 9.3%) (P=0.34)
			Time to regain 100% SpO2	No significant difference with 0.7 +/- 0.4 vs 1.5 +/- 1.5 min (P=0.42)

Comment(s)

Supplemental oxygen via nasal cannula during the apneic phase of endotracheal intubation does not appear to show benefit or harm in two studies performed in the intensive care unit setting. A third study performed in the operating room showed statistically significant SpO2 numbers but no data was collected for long term outcomes for the patients.

Clinical Bottom Line

In adult patients requiring endotracheal intubation adding supplemental nasal oxygen during the procedure does not show any long-term benefit in the intensive care unit or operating room setting. Further studies need to be performed to determine benefit in the emergency department setting.

References

1. Semler MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ,McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW; FELLOW Investigators and the Pragmatic Critical Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill Am J Respir Crit Care Med. 2016 Feb 1;193(3):273-80.
2. Vourc'h M, Asfar P, Volteau C, Bachoumas K, Clavieras N, Egreteau PY, Asehnoune K, Mercat A, Reignier J,Jaber S, Prat G, Roquilly A, Brule N, Villers D, Bretonniere C, Guitton C. High-flow nasal cannula oxygen during endotracheal intubation in hypoxiemic patients: a randomized controlled clinical trial Intensive Care Med 2015;41:1538-1548
3. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010 May;22(3):164-8.