Apneic oxygenation to prevent oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis

BACKGROUND

Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.

METHODS

This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.

RESULTS

After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.

CONCLUSION

This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.

CLINICAL TRIAL REGISTRATION

Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.

Sustained pharyngeal inflation in infant airway-Flexible bronchoscopy measurements

Sustained pharyngeal inflation (SPI) with pharyngeal oxygen flow and nasal closure (PhO2-NC) technique create positive inflation pressure in the airway. This study measured the peak inflation pressure (PIP) levels and image changes with SPI-assisted flexible bronchoscopy (SPI-FB) and compared the effects in the pharyngeal space and mid-tracheal lumen. This prospective study enrolled 20 participants aged 6 months to 3 years. Each participant underwent sequential SPI-FB of four different durations (0, 1s, 3s, and 5s) for three cycles. We used a 3.8 mm OD flexible bronchoscope to measure and analyze PIP levels, images, and lumen dimension scores. A total of 480 data were collected. The mean (SD) age and body weight were 12.0 (11.5) months and 7.8 (7.5) kg, respectively. The mean (IQR) PIPs were 4.2 (2.0), 18.5 (6.1), 30.6 (13.5), and 46.1 (25.0) cmH2O in the pharynx and 5.0 (1.6), 17.5 (6.5), 28.0 (12.3), 46.0 (28.5) cmH2O in the mid-trachea at SPI durations of 0, 1s, 3s, and 5s, respectively. The PIP levels had a positive correlation (p <0.001) with different SPI durations in both pharynx and trachea, and were nearly identical (p = 0.695, 0.787, and 0.725 at 1s, 3s, and 5s, respectively) at the same duration except the 0 s (p = 0.015). Lumen dimension scores also significantly increased with increasing SPI durations (p <0.05) in both locations. The identified lesions significantly increased as PIP levels increased (p <0.001). Conclusion: SPI-FB using PhO2-NC with durations up to 3s is safe and informative technique that provides controllable PIP, dilates airway lumens, and benefits lesion detection in the pharyngeal space and mid-tracheal lumen.

Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial

BACKGROUND

Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction.

METHODS

This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO₂) ≤92%.

RESULTS

Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO₂ was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069).

CONCLUSIONS

In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20210802002.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Flexible Endoscopy With Non-invasive Ventilation Enables Clinicians to Assess and Manage Infants With Severe Bronchopulmonary Dysplasia

OBJECTIVES

The objectives of the study were to determine the efficacy of flexible endoscopy (FE) to assess the approachable aeroesophageal tract (AET) and subsequent changes in clinical management in infants with severe bronchopulmonary dysplasia (sBPD).

METHODS

This retrospective study investigated sBPD infants who received FE measurement from 2011 to 2020. FE was supported with non-invasive ventilation (FE-NIV) of pharyngeal oxygen with nose closure and abdominal compression without any mask or laryngeal mask airway. Data on AET lesions, changes in subsequent management, and FE therapeutic interventions were collected and analyzed.

RESULTS

Forty-two infants were enrolled in the study. Two thin scopes (1.8- and 2.6-mm outer diameter) were used. FE analysis revealed 129 AET lesions in 38 (90.5%) infants. Twenty-eight infants (66.7%) had more than one lesion. Thirty-five (83.3%) infants had 111 airway lesions where bronchial granulations (28, 25.2%), tracheomalacia (18, 16.2%), and bronchomalacia (15, 13.5%) were the main complications. Eighteen esophageal lesions were found in 15 (35.7%) infants. No significant FE-NIV complications were observed. The FE findings resulted in changes in management in all 38 infants. Thirty-six (85.7%) infants underwent altered respiratory care with pressure titrations (29, 45.3%), shortened suction depth (17, 26.6%), immediate extubation (8, 12.5%), changed insertion depth of endotracheal tube (7, 10.9%) and tracheostomy tube (3, 4.7%). Twenty-one (50%) infants had 50 pharmacotherapy changes, including added steroids, anti-reflux medicine, antibiotics, and stopped antibiotics. Eighteen (42.8%) infants received 37 therapeutic FE-NIV procedures, including 14 balloon dilatations, 13 laser-plasty, and 10 stent implantations. Seven (16.7%) infants underwent surgeries for four tracheostomies and three fundoplications.

CONCLUSION

Flexible endoscopy with this non-invasive ventilation could be a safe and valuable technique for direct and dynamic visual measurement of AET, which is essential for subsequent medical decision making and management in infants with sBPD.

Apnoeic oxygenation during paediatric intubation: A systematic review

OBJECTIVE

This review assesses the effect of apnoeic oxygenation during paediatric intubation on rates of hypoxaemia, successful intubation on the first attempt and other adverse events.

DATA SOURCES

The databases searched included PubMed, Medline, CINAHL, EMBASE and The Cochrane Library. An electronic search for unpublished studies was also performed.

STUDY SELECTION

We screened studies that include children undergoing intubation, studies that evaluate the use of apnoeic oxygenation by any method or device with outcomes of hypoxaemia, intubation outcome and adverse events were eligible for inclusion.

DATA EXTRACTION

Screening, risk of bias, quality of evidence and data extraction was performed by two independent reviewers, with conflicts resolved by a third reviewer where consensus could not be reached.

DATA SYNTHESIS

From 362 screened studies, fourteen studies (N = 2442) met the eligibility criteria. Randomised controlled trials (N = 482) and studies performed in the operating theatre (N = 835) favoured the use of apnoeic oxygenation with a reduced incidence of hypoxaemia (RR: 0.34, 95% CI: 0.24 to 0.47, p < 0.001, I ² = 0% and RR: 0.27, 95% CI: 0.11 to 0.68, p = 0.005, I ² = 68% respectively). Studies in the ED and PICU were of lower methodological quality, displaying heterogeneity in their results and were unsuitable for meta-analysis. Among the studies reporting first attempt intubation success, there were inconsistent effects reported and data were not suitable for meta-analysis.

CONCLUSION

There is a growing body of evidence to support the use of apnoeic oxygenation during the intubation of children. Further research is required to determine optimal flow rates and delivery technique. The use of humidified high-flow oxygen shows promise as an effective technique based on data in the operating theatre, however its efficacy has not been shown to be superior to low flow oxygen in either the elective anesthetic or emergency intubation situations Systematic Review Registration: This review was prospectively registered in the PROSPERO international register of systematic reviews (Reference: CRD42020170884, registered April 28, 2020).

Continuous positive airway pressure to reduce the risk of early peripheral oxygen desaturation after onset of apnoea in children: A double-blind randomised controlled trial

Continuous positive airway pressure (CPAP) during anaesthesia induction improves oxygen saturation (SpO₂) outcomes in adults subjected to airway manipulation, and could similarly support oxygenation in children. We evaluated whether CPAP ventilation and passive CPAP oxygenation in children would defer a SpO₂ decrease to 95% after apnoea onset compared to the regular technique in which no positive airway pressure is applied. In this double-blind, parallel, randomised controlled clinical trial, 68 children aged 2–6 years with ASA I–II who underwent surgery under general anaesthesia were divided into CPAP and control groups (n = 34 in each group). The intervention was CPAP ventilation and passive CPAP oxygenation using an anaesthesia workstation. The primary outcome was the elapsed time until SpO₂ decreased to 95% during a follow-up period of 300 s from apnoea onset (T1). We also recorded the time required to regain baseline levels from an SpO₂ of 95% aided by positive pressure ventilation (T2). The median T1 was 278 s (95% confidence interval [CI]: 188–368) in the CPAP group and 124 s (95% CI: 92–157) in the control group (median difference: 154 s; 95% CI: 58–249; p = 0.002). There were 17 (50%) and 32 (94.1%) primary events in the CPAP and control groups, respectively. The hazard ratio was 0.26 (95% CI: 0.14–0.48; p<0.001). The median for T2 was 21 s (95% CI: 13–29) and 29 s (95% CI: 22–36) in the CPAP and control groups, respectively (median difference: 8 s; 95% CI: -3 to 19; p = 0.142). SpO₂ was significantly higher in the CPAP group than in the control group throughout the consecutive measures between 60 and 210 s (with p ranging from 0.047 to <0.001). Thus, in the age groups examined, CPAP ventilation and passive CPAP oxygenation deferred SpO₂ decrease after apnoea onset compared to the regular technique with no positive airway pressure.

Sustained pharyngeal inflation on upper airway effects in children-Flexible bronchoscopy measurement

OBJECTIVE

Sustained pharyngeal inflation (SPI) with pharyngeal oxygen and nose-closure (PhO₂ -NC) can create positive peak inflation pressure (PIP) inside the pharyngolaryngeal space (PLS). This study measured and compared the effects of four different SPI durations in the PLS.

METHODS

A prospective study, 20 consecutive children aged between 6 months and 3 years old, scheduled for elective flexible bronchoscopy (FB) suspected positive PLS findings were enrolled. SPI was performed twice in four different durations (0, 1, 3, and 5 s) sequentially in each infant. PIP was measured for each SPI in the pharynx, while simultaneously record images at two locations of the oropharynx and supra-larynx. Patient demographic details, PIP levels, lumen expansion scores, and images of PLS were measured and analyzed.

RESULTS

Twenty patients with 40 measurements were collected. The mean (SD) age and weight were 11.6 (9.1) months and 6.8 (2.4) kg, respectively. The measured mean (SD) pharyngeal PIPs were 4.1 (3.3), 21.9 (7.0), 42.2 (12.3), and 65.5 (18.5) cmH₂ O at SPI duration of 0, 1, 3, and 5 s, respectively, indicating significant (p<.001) positive correlation. At assigned locations, corresponding PLS images also displayed a significant increase in lumen expansion scores and a number of detected lesions with an increase in SPI duration (p < .004). The mean (SD) procedural time was 5.7 (1.2) min. No study-related complication was noted.

CONCLUSIONS

FB utilizing PhO₂ -NC as SPI of 1-3 s is a simple, less invasive, and valuable ventilation modality. It provides an adequate PIP level to expand the PLS and improve FB performance in children.

Just Breathe: Tips and Highlights for Managing Pediatric Respiratory Distress and Failure

Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children

BACKGROUND

The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).

METHODS

In this prospective observational study, arterial desaturation < 95% SaO₂ before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year).

RESULTS

Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01).

CONCLUSIONS

Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

BACKGROUND

The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED).

METHODS

This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria.

RESULTS

Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively.

CONCLUSIONS

We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.

Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department

Introduction

Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group.

Methods

A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each.

Results

This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation.

Conclusion

Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.

Vallecular cyst with coexisting laryngomalacia: Successful diagnosis and laser therapy by flexible endoscopy with a novel noninvasive ventilation support in infants

OBJECTIVE

Vallecular cyst coexisting with laryngomalacia (VC-LM) can cause significant pharyngolaryngeal obstruction. Traditionally, it is diagnosed with flexible endoscopy (FE) and treated by rigid endoscopy. This study evaluates the effectiveness of solely using FE with novel noninvasive ventilation (NIV) of sustained pharyngeal inflation (SPI) support for both diagnosis and treatment in such infants.

METHODS

A retrospective review of consecutive infants who were diagnosed and treated for VC-LM in the 12-year period, 2007 to 2018, was conducted. Clinical variables, techniques, and outcomes were analyzed and reported.

RESULTS

Eighteen infants (10 males) were included. The mean age was 3.0 ± 0.6 months and the mean body weight was 4.6 ± 1.3 kg. Before FE, 14 infants were supported with bi-nasal prongs NIV (BN-NIV) and four infants with tracheal intubation. During diagnostic and therapeutic FE, all infants supported with a nasopharyngeal NIV (NP-NIV) only. All diagnoses were made in the first FE inspection of 3.5 ± 1.2 minutes. Thirteen lesions were immediately treated with FE laser therapy in 18.1 ± 1.7 minutes in the same FE course. Total FE time was 24.6 ± 2.8 minutes. Three infants needed revision laser therapy 4 days later. There was no desaturation (<90%), bradycardia (<100/min), or pneumothorax. After FE therapy, all infants were supported with BN-NIV only with significantly (<0.01) lower pressure and completely weaned off before being discharged 8.4 ± 1.5 days later. All infants, followed up for a 6-month period, showed many clinical improvements.

CONCLUSIONS

FE, with this NP-NIV and SPI supports, could offer accurate diagnosis and successful laser therapy of the VC-LM with procedural sedation in the same session in infants.

Apnoeic oxygenation in paediatric anaesthesia: a narrative review

Apnoeic oxygenation refers to oxygenation in the absence of any patient or ventilator effort to move the lungs. This phenomenon was first described in humans in the mid-20th century but has seen renewed interest in the last decade following the demonstration of apnoeic oxygenation with low-flow, and subsequently high-flow, nasal oxygen. This narrative review summarises our understanding of apnoeic oxygenation in the paediatric population. We examine the evidence supporting oxygenation via tracheal tube, modified laryngoscopes and nasal cannulae. The evidence for prolongation of safe apnoea time at induction of anaesthesia is also appraised. We explore the capacity for carbon dioxide clearance, flow rate selection with high-flow nasal oxygen and complications associated with the technique. It remains uncertain whether apnoeic oxygenation in paediatric patients results in a meaningful clinical benefit compared with standard care for outcomes such as the number of tracheal intubation attempts or the incidence of hypoxaemia. In particular, the role of apnoeic oxygenation in paediatric difficult airway management is unclear as this has not been the targeted focus of any published research to date.

Emerging trends, techniques, and equipment for airway management in pediatric patients

Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.

Apneic Oxygenation for Emergency Intubations in the Pediatric Emergency Department-A Quality Improvement Initiative

Introduction

Emergency airway management of critically ill children in the Emergency Department (ED) is associated with the risk of intubation-related desaturation, which can be minimized by apneic oxygenation. We evaluated the use of apneic oxygenation in the pediatric ED and reported a quality improvement initiative to incorporate apneic oxygenation as a routine standard of care during rapid sequence intubations (RSIs).

Methods

A baseline period from June 2016 to April 2017 highlighted the practice gaps. Quality improvement interventions were subsequently developed and implemented as a care bundle consisting of a pre-intubation checklist, placing reminders and additional oxygen source in resuscitation bays, incorporating into the responsibilities of the airway doctor and the airway nurse (copiloting), education during airway workshops and simulation training for doctors and nurses, as well as enhancing documentation of the intubation process. We monitored a post-intervention observation period from May 2017 to April 2018 for the effectiveness of the care bundle.

Results

Apneic oxygenation was not performed in all 22 RSIs during the baseline period. Among 25 RSIs in the post-intervention observation period, providers performed apneic oxygenation in 17 (68%) cases. There was no significant difference in the utilization of apneic oxygenation among emergency physicians and pediatric anesthetists performing RSIs in the pediatric ED.

Conclusions

We successfully implemented a care bundle targeted at incorporating apneic oxygenation as a routine standard of care during emergency intubations performed in ED. This method could be adopted by other pediatric EDs to improve airway management in critically ill children.

Apneic Oxygenation for Pediatric Endotracheal Intubation: A Narrative Review

Apneic oxygenation (ApOx) has shown to be effective in adult populations in a variety of settings, including prehospital, emergency departments, intensive care units, and elective surgery. This review aims to assess the available literature for ApOx in the pediatric population to determine its effects on hypoxemia, safe apnea times, and flow rates employed safely.

Apneic nasal oxygenation and safe apnea time during pediatric intubations by learners

BACKGROUND

Apneic nasal oxygenation (ApOx) prolongs the time to desaturation during intubation of adult patients, but there is limited prospective evidence for apneic oxygenation in pediatric patients.

AIMS

We hypothesized that ApOx during operating room intubation of pediatric patients by inexperienced learners would prolong the interval before desaturation.

METHODS

This prospective observational study compared intubation data for 196 pediatric surgical patients intubated by learners under baseline practice (no nasal cannula), to 160 patients enrolled after adoption of routine apneic nasal cannula oxygenation at 5 L/min. The primary outcome was elapsed time between anesthetic induction and pulse oximetry (SpO₂ ) falling to 95, if ever.

RESULTS

Nasal cannula oxygenation during intubation by learners delayed desaturation to SpO₂ 95 (risk ratio for this event before intubation 0.05, 95% CI 0.03-0.09; P < 0.0001).

CONCLUSIONS

Apneic oxygenation via nasal cannula during intubation of pediatric surgical patients prolongs time before desaturation, thus extending the safe interval for airway management by learners.