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Apneic oxygenation proves beneficial in this ED study

July 26, 2016

Short Attention Span Summary

Apneic oxygenation is the use of high flow NC oxygen during RSI to provide passive oxygenation during the apneic phase.  The recent FELLOW trial called this into question. However, in this ED-based study, apneic oxygenation resulted in a marked improvement in first-pass success with no hypoxia, 82% with AP OX vs 69% without.  There seems to me to be no reason not to use such a simple intervention during ED RSI to prevent hypoxia.  There are some excellent FOAM resources on this article: R.E.B.E.L. EM; Minh Le Cong’s PHARM podcast with the lead author.


Acad Emerg Med. 2016 Jun;23(6):703-10. doi: 10.1111/acem.12931. Epub 2016 May 13.

First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department.

Sakles JC1, Mosier JM1, Patanwala AE2, Arcaris B3, Dicken JM3.

Author information:

1Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ.

2Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ.

3University of Arizona College of Medicine, Tucson, AZ.



The objective was to determine the effect of apneic oxygenation (AP OX) on first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).


Continuous quality improvement data were prospectively collected on all patients intubated in an academic ED from July 1, 2013, to June 30, 2015. During this period the use of AP OX was introduced and encouraged for all patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data form that included information on patient, operator, and intubation characteristics. Adult patients 18 years of age or greater who underwent RSI in the ED by emergency medicine residents were included in the analysis. The primary outcome was FPS-H, which was defined as successful tracheal intubation on a single laryngoscope insertion without oxygen saturation falling below 90%. A multivariate logistic regression analysis was performed to determine the effect of AP OX on FPS-H.


During the 2-year study period, 635 patients met inclusion criteria. Of these, 380 (59.8%) had AP OX utilized and 255 (40.2%) had no AP OX utilized. In the AP OX cohort the FPS-H was 312/380 (82.1%) and in the no AP OX cohort the FPS-H was 176/255 (69.0%) (difference = 13.1%, 95% confidence interval [CI] = 6.2% to 19.9%). In the multivariate logistic regression analysis, the use of AP OX was associated with an increased odds of FPS-H (adjusted odds ratio = 2.2, 95% CI = 1.5 to 3.3).


The use of AP OX during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of AP OX has the potential to increase the safety of RSI in the ED by reducing the number of intubation attempts and the incidence of hypoxemia.

© 2016 by the Society for Academic Emergency Medicine.

PMID: 26836712 [PubMed – in process]

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