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Apneic Oxygenation In the PED

February 6, 2019

Written by Clay Smith

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Apneic oxygenation (AO) works in children, with half as many becoming hypoxemic during endotracheal intubation (ETI).

Why does this matter?
There is debate over the effectiveness of AO in adults. However, it is a simple, low-risk technique with a majority report that it is effective. The practice was also largely adopted in this PED (at Vanderbilt). Many of us work in both the adult and PED, so there is significant cross-pollination of ideas. Did AO make a difference?

Baby ApOx works
This was a before/after study of an era prior to widespread adoption of AO and after it was adopted as a standard prior to ETI. They identified 149 patients with prospectively collected QI data during all ETIs: 59 before AO, 90 after AO. Use of video laryngoscopy (VL) was higher during the AO era, 31% AO, 10% pre-AO. Lowest median SpO2 in the pre-AO era was 93%, compared to 100% in the post-AO era. Nearly half of patients in the pre-AO era had desaturation <90% vs. just under 25% post-AO. Adjusted odds ratio of hypoxemia with AO vs without was 0.3 (95%CI, 0.1–0.8). This means the odds of serious desaturation decreased 70% when AO was used. The study is limited by relying on the accurate real-time collection of data by the nurse scribe during the resuscitation. It may also be confounded by increased use of VL. My take is to use it. There is little downside, except the mask seal may be more difficult. If so, it is easy to remove the cannula. I use it in both children and adults.

Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department. Vukovic AA1, Hanson HR2, Murphy SL2, Mercurio D2, Sheedy CA3, Arnold DH4. Am J Emerg Med. 2019 Jan;37(1):27-32. doi: 10.1016/j.ajem.2018.04.039. Epub 2018 Apr 18.

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Reviewed by Thomas Davis

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