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Lyons C, McElwain J, Young O, O'Gorman DA, Harte BH, Kinirons B, Grady D, Laffey JG, Callaghan M. The effect of high-flow nasal oxygen flow rate on gas exchange in apnoeic patients: a randomised controlled trial. Anaesthesia 2024; 79:576-582. [PMID: 38100148 DOI: 10.1111/anae.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 05/12/2024]
Abstract
High-flow nasal oxygen can be administered at induction of anaesthesia for the purposes of pre-oxygenation and apnoeic oxygenation. This intervention is claimed to enhance carbon dioxide elimination during apnoea, but the extent to which this occurs remains poorly quantified. The optimal nasal oxygen flow rate for gas exchange is also unknown. In this study, 114 patients received pre-oxygenation with high-flow nasal oxygen at 50 l.min-1. At the onset of apnoea, patients were allocated randomly to receive one of three nasal oxygen flow rates: 0 l.min-1; 70 l.min-1; or 120 l.min-1. After 4 minutes of apnoea, all oxygen delivery was ceased, tracheal intubation was performed, and oxygen delivery was recommenced when SpO2 was 92%. Mean (SD) PaCO2 rise during the first minute of apnoea was 1.39 (0.39) kPa, 1.41 (0.29) kPa, and 1.26 (0.38) kPa in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.16. During the second, third and fourth minutes of apnoea, mean (SD) rates of rise in PaCO2 were 0.34 (0.08) kPa.min-1, 0.36 (0.06) kPa.min-1 and 0.37 (0.07) kPa.min-1 in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, respectively; p = 0.17. After 4 minutes of apnoea, median (IQR [range]) arterial oxygen partial pressures in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups were 24.5 (18.6-31.4 [12.3-48.3]) kPa; 36.6 (28.1-43.8 [9.8-56.9]) kPa; and 37.6 (26.5-45.4 [11.0-56.6]) kPa, respectively; p < 0.001. Median (IQR [range]) times to desaturate to 92% after the onset of apnoea in the 0 l.min-1, 70 l.min-1 and 120 l.min-1 groups, were 412 (347-509 [190-796]) s; 533 (467-641 [192-958]) s; and 531 (462-681 [326-1007]) s, respectively; p < 0.001. In conclusion, the rate of carbon dioxide accumulation in arterial blood did not differ significantly between apnoeic patients who received high-flow nasal oxygen and those who did not.
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Affiliation(s)
- C Lyons
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - J McElwain
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - O Young
- Department of Ear, Nose and Throat Surgery, Galway University Hospitals, Galway, Ireland
| | - D A O'Gorman
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - B H Harte
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - B Kinirons
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - D Grady
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - J G Laffey
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
- Anaesthesia and Intensive Care Medicine, University of Galway, Galway, Ireland
| | - M Callaghan
- Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
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Engelhardt T, Disma N. Paediatric anaesthesia: it is not only what you do, but how you do it. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00145-0. [PMID: 38788749 DOI: 10.1016/s2213-2600(24)00145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Affiliation(s)
- Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada.
| | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
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Kaiser HA, Bauer T, Riva T, Greif R, Riedel T, Theiler L, Nabecker S. Carbon dioxide and cardiac output as major contributors to cerebral oxygenation during apnoeic oxygenation. Sci Rep 2024; 14:3617. [PMID: 38351038 PMCID: PMC10864331 DOI: 10.1038/s41598-023-49238-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/06/2023] [Indexed: 02/16/2024] Open
Abstract
Apnoeic oxygenation has experienced a resurgence in interest in critical care and perioperative medicine. However, its effect on cerebral oxygenation and factors influencing it, have not yet been investigated in detail. By using near-infrared spectroscopy, we intended to provide further evidence for the safety of apnoeic oxygenation and to increase our understanding of the association between cerebral perfusion, haemodynamic, respiratory and demographic factors. In this secondary analysis of a prospective randomized controlled noninferiority trial, we recruited 125 patients, who underwent surgery under general anaesthesia with neuromuscular blockade. Arterial blood samples were taken every 2 min for a total of 15 min under apnoeic oxygenation with 100% oxygen. Near-infrared spectroscopy and cardiac output were continuously measured. Statistical analysis was performed using uni- and multivariable statistics. Ninety-one complete data sets were analysed. In six patients the SpO2 fell below 92% (predefined study termination criterion). The significant average increase of cerebral oxygenation was 0.5%/min and 2.1 mmHg/min for the arterial pressure of carbon dioxide (paCO2). The median cardiac output increased significantly from 5.0 l/min (IQR 4.5-6.0) to 6.5 l/min (IQR 5.7-7.5). The most significant effect on cerebral oxygenation was exhibited by the variable paCO2 and non-specific patient factors, followed by cardiac output and paO2. Apnoeic oxygenation proves to have a high safety profile while significantly increasing cerebral oxygenation, paCO2 and cardiac output. In reverse, NIRS might act as a reliable clinical surrogate of paCO2 and cardiac output during stable arterial oxygenation.
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Grants
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
- no ID The study was supported by a departmental research grant of the Department of Anaesthesiology and Pain Medicine, University Hospital of Bern, Bern, Switzerland.
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Affiliation(s)
- Heiko Andreas Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Bauer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research and Innovation, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genova, Italy
| | - Robert Greif
- University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Thomas Riedel
- Department of Paediatrics, Cantonal Hospital Graubünden, Chur, Switzerland
- Division of Respiratory Medicine, Department of Paediatrics, Inselspital, University Children's Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Theiler
- Department of Anaesthesia, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Sabine Nabecker
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Anaesthesiology and Pain Management, Sinai Health System, University of Toronto, Toronto, Canada.
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Fuchs A, Koepp G, Huber M, Aebli J, Afshari A, Bonfiglio R, Greif R, Lusardi AC, Romero CS, von Gernler M, Disma N, Riva T. Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis. Br J Anaesth 2024; 132:392-406. [PMID: 38030551 DOI: 10.1016/j.bja.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Gabriela Koepp
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Aebli
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Arash Afshari
- Department of Paediatric And Obstetric Anesthesia, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Institute of Clinical Medicine, Copenhagen, Denmark
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria; University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina S Romero
- Anesthesia, Critical Care and Pain Department, Hospital General Universitario De Valencia, Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | | | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Lei G, Wu L, Xi C, Xiao Y, Wang G. Transnasal Humidified Rapid Insufflation Ventilatory Exchange Augments Oxygenation in Children With Juvenile Onset Recurrent Respiratory Papillomatosis During Surgery: A Prospective Randomized Crossover Controlled Trial. Anesth Analg 2023; 137:578-586. [PMID: 37590935 DOI: 10.1213/ane.0000000000006521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Evidence is lacking regarding the efficacy of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) in tubeless anesthesia, especially in pediatric patients. This study aimed to evaluate the use of THRIVE for juvenile onset recurrent respiratory papillomatosis (JORRP) patients. METHODS Twenty-eight children aged 2 to 12 years with JORRP, abnormal airways, and ASA physical status II-III that presented for surgical treatment under general anesthesia were included in this study. Each patient received 2 interventions in random order, with a 5-minute washout period between treatments: apnea without oxygen supplementation and apnea with THRIVE intervention. The primary outcome apnea time was defined as the duration from withdrawal of intubation to reintubation and resumption of controlled ventilation. The secondary outcomes were the mean transcutaneous carbon dioxide (tc co2 ) increase rate, the minimum pulse oxygen saturation (Sp o2 ) during apnea, and the occurrence of unexpected adverse effects. RESULTS The median apnea time in the THRIVE period was significantly longer than that in the control period (8.9 [8.6-9.4] vs 3.8 [3.4-4.3] minutes; mean difference [95% confidence interval (CI)], 5.0 [4.4-5.6]; P < .001) for all patients. The rate of CO 2 change in the control period was higher than that in the THRIVE period both for patients aged 2 to 5 years old (6.29 [5.19-7.4] vs 3.22 [2.92-3.76] mm Hg min -1 ; mean difference [95% CI], 3.09 [2.27-3.67]; P < .001) and for patients aged 6 to 12 years old (4.76 [3.7-6.2] vs 3.38 [2.64-4.0] mm Hg min -1 ; mean difference [95% CI], 1.63 [0.75-2.56]; P < .001). The minimum Sp o2 was significantly higher in the THRIVE period than in the control period (mean difference [95% CI], 19.7 [14.8-22.6]; P < .001). CONCLUSIONS Our findings demonstrate that THRIVE safely increased the apnea time among children with JORRP undergoing surgery and decreased the rate of carbon dioxide increase. THRIVE is clinically recommended as an airway management technique for tubeless anesthesia in apneic children.
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Affiliation(s)
- Guiyu Lei
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lili Wu
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chunhua Xi
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yang Xiao
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology, Head and Neck Surgery (Ministry of Education of China), Beijing, China
| | - Guyan Wang
- From the Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Ran L, Huang G, Yao Y, Wu Y, Zhang C, Wang Y, Yu C. Efficacy of high-flow nasal oxygenation compared with laryngeal mask airway in children undergoing ambulatory oral surgery under deep sedation: A randomized controlled non-inferiority trial. Front Med (Lausanne) 2022; 9:1001213. [PMID: 36530879 PMCID: PMC9755657 DOI: 10.3389/fmed.2022.1001213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/04/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND High-flow nasal oxygenation (HFNO) has been suggested as an alternative oxygenation method during procedural sedation. This randomized, non-inferiority trial evaluated the safety and efficacy of HFNO compared with laryngeal mask airway (LMA) in pediatric ambulatory oral surgery under deep sedation. METHODS In total, 120 children aged 2-7 years (weight: 10-30 kg) were equally assigned into two groups, namely, HFNO with propofol total intravenous anesthesia infusion (HFNO-IV) or LMA with propofol total intravenous anesthesia infusion (LMA-IV). The primary objective was to monitor carbon dioxide (CO2) accumulation during perioperative surgery. Secondary objectives included monitoring transcutaneous oxygen saturation, grade exposure to the surgical field, perioperative adverse events, or other events. The predefined non-inferiority margin was 7 mmHg. During the COVID-19 pandemic, a novel WeChat applet was implemented to gather follow-up data after discharge. RESULTS Non-inferiority could be declared for HFNO relative to LMA (mean difference in transcutaneous CO2 (TcCO2) = -1.4 mmHg, 95% CI: -2.9, 0.1 mmHg; P > 0.05). The pre-surgical TcCO2 of the HFNO-IV group (45.4 ± 4.5 mmHg) was similar to that of the LMA-IV group (44.0 ± 3.5 mmHg), within the clinically acceptable normal range. All the children maintained SpO2 levels of >97%. The surgical field exposure score of the HFNO group was significantly better than that of the LMA group. There was no significant difference between the two groups regarding risk or adverse events. CONCLUSION HFNO was not inferior to LMA for maintaining oxygenation and ventilation in patients undergoing pediatric ambulatory oral surgery under deep sedation under strict isolation from the oral cavity to the upper airway.
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Affiliation(s)
- Longkuan Ran
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Guijin Huang
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Ying Yao
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yujia Wu
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Chao Zhang
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Yan Wang
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
| | - Cong Yu
- Department of Anesthesiology, Stomatology Hospital Affiliated Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China
- Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, Chongqing, China
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Changes in lung volume estimated by electrical impedance tomography during apnea and high-flow nasal oxygenation: A single-center randomized controlled trial. PLoS One 2022; 17:e0273120. [PMID: 36170281 PMCID: PMC9518885 DOI: 10.1371/journal.pone.0273120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Previous studies concerning humidified, heated high-flow nasal oxygen delivered in spontaneously breathing patients postulated an increase in functional residual capacity as one of its physiological effects. It is unclear wheter this is also true for patients under general anesthesia.
Methodology
The sincle-center noninferiority trial was registered at ClinicalTrials.gov (NCT NCT03478774). This secondary outcome analysis shows estimated differences in lung volume changes using electrical impedance tomography between different flow rates of 100% oxygen in apneic, anesthetized and paralyzed adults prior to intubation. One hundred and twenty five patients were randomized to five groups with different flow rates of 100% oxygen: i) minimal-flow: 0.25 l.min-1 via endotracheal tube; ii) low-flow: 2 l.min-1 + continuous jaw thrust; iii) medium-flow: 10 l.min-1 + continuous jaw thrust; iv) high-flow: 70l.min-1 + continuous jaw thrust; and v) control: 70 l.min-1 + continuous video-laryngoscopy. After standardized anesthesia induction with non-depolarizing neuromuscular blockade, the 15-minute apnea period and oxygen delivery was started according to the randomized flow rate. Continuous electrical impedance tomography measurements were performed during the 15-minute apnea period. Total change in lung impedance (an estimate of changes in lung volume) over the 15-minute apnea period and times to 25%, 50% and 75% of total impedance change were calculated.
Results
One hundred and twenty five patients completed the original study. Six patients did not complete the 15-minute apnea period. Due to maloperation, malfunction and artefacts additional 54 measurements had to be excluded, resulting in 65 patients included into this secondary outcome analysis. We found no differences between groups with respect to decrease in lung impedance or curve progression over the observation period.
Conclusions
Different flow rates of humidified 100% oxygen during apnea result in comparable decreases in lung volumes. The demonstrated increase in functional residual capacity during spontaneous breathing with high-flow nasal oxygenation could not be replicated during apnea under general anesthesia with neuromuscular blockade.
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Abstract
PURPOSE OF REVIEW Apneic oxygenation is increasingly used in pediatric anesthesia. Its benefit for specific applications depends on the effect of apneic oxygenation on safe apnea time and carbon dioxide (CO2) elimination, on differences between low and high flow oxygen delivery, and on possible adverse effects. The present review summarizes current evidence on these pathophysiological aspects of apneic oxygenation as well as its applications in pediatric anesthesia. RECENT FINDINGS Apneic oxygenation with both low flow and high flow nasal oxygen increases the safe apnea time, but does not lead to increased CO2 elimination. Airway pressures and adverse effects like atelectasis formation, oxidative stress and aerosol generation under apneic oxygenation are not well studied in pediatric anesthesia. Data from adults suggest no important effect on airway pressures when the mouth is open, and no significant formation of atelectasis, oxidative stress or aerosol generation with high flow nasal oxygen. SUMMARY Apneic oxygenation in pediatric anesthesia is mainly used during standard and difficult airway management. It is sometimes used for airway interventions, but CO2 accumulation remains a major limiting factor in this setting. Reports highlight the use of high flow nasal oxygen in spontaneously breathing rather than in apneic children for airway interventions.
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Song JL, Sun Y, Shi YB, Liu XY, Su ZB. Comparison of the effectiveness of high-flow nasal oxygen vs. standard facemask oxygenation for pre- and apneic oxygenation during anesthesia induction: a systematic review and meta-analysis. BMC Anesthesiol 2022; 22:100. [PMID: 35387583 PMCID: PMC8985355 DOI: 10.1186/s12871-022-01615-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/14/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In recent years, high flow nasal oxygen (HFNO) has been widely used in clinic, especially in perioperative period. Many studies have discussed the role of HFNO in pre- and apneic oxygenation, but their results are controversial. Our study aimed to examine the effectiveness of HFNO in pre- and apneic oxygenation by a meta-analysis of RCTs. METHODS EMBASE, PUBMED, and COCHRANE LIBRARY databases were searched from inception to July 2021 for relevant randomized controlled trails (RCTs) on the effectiveness of HFNO versus standard facemask ventilation (FMV) in pre- and apenic oxygenation. Studies involving one of the following six indicators: (1) Arterial oxygen partial pressure (PaO2), (2) End expiratory oxygen concentration (EtO2), (3) Safe apnoea time, (4) Minimum pulse oxygen saturation (SpO2min), (5) Oxygenation (O2) desaturation, (6) End expiratory carbon dioxide (EtCO2) or Arterial carbon dioxide partial pressure(PaCO2) were included. Due to the source of clinical heterogeneity in the observed indicators in this study, we adopt random-effects model for analysis, and express it as the mean difference (MD) or risk ratio (RR) with a confidence interval of 95% (95%CI). We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome. RESULTS Fourteen RCTs and 1012 participants were finally included. We found the PaO2 was higher in HFNO group than FMV group with a MD (95% CI) of 57.38 mmHg (25.65 to 89.10; p = 0.0004) after preoxygenation and the safe apnoea time was significantly longer with a MD (95% CI) of 86.93 s (44.35 to 129.51; p < 0.0001) during anesthesia induction. There were no significant statistical difference in the minimum SpO2, CO2 accumulation, EtO2 and O2 desaturation rate during anesthesia induction between the two groups. CONCLUSIONS This systematic review and meta-analysis suggests that HFNO should be considered as an oxygenation tool for patients during anesthesia induction. Compared with FMV, continuous use of HFNO during anesthesia induction can significantly improve oxygenation and prolong safe apnoea time in surgical patients.
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Affiliation(s)
- Jian-li Song
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Rd, Changchun, 130000 China
| | - Yan Sun
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Rd, Changchun, 130000 China
| | - Yu-bo Shi
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Rd, Changchun, 130000 China
| | - Xiao-ying Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Rd, Changchun, 130000 China
| | - Zhen-bo Su
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Rd, Changchun, 130000 China
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Carbon Dioxide Changes during High-flow Nasal Oxygenation in Apneic Patients: A Single-center Randomized Controlled Noninferiority Trial. Anesthesiology 2022; 136:82-92. [PMID: 34758057 DOI: 10.1097/aln.0000000000004025] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anesthesia studies using high-flow, humidified, heated oxygen delivered via nasal cannulas at flow rates of more than 50 l · min-1 postulated a ventilatory effect because carbon dioxide increased at lower levels as reported earlier. This study investigated the increase of arterial partial pressure of carbon dioxide between different flow rates of 100% oxygen in elective anesthetized and paralyzed surgical adults before intubation. METHODS After preoxygenation and standardized anesthesia induction with nondepolarizing neuromuscular blockade, all patients received 100% oxygen (via high-flow nasal oxygenation system or circuit of the anesthesia machine), and continuous jaw thrust/laryngoscopy was applied throughout the 15-min period. In this single-center noninferiority trial, 25 patients each, were randomized to five groups: (1) minimal flow: 0.25 l · min-1, endotracheal tube; (2) low flow: 2 l · min-1, continuous jaw thrust; (3) medium flow: 10 l · min-1, continuous jaw thrust; (4) high flow: 70 l · min-1, continuous jaw thrust; and (5) control: 70 l · min-1, continuous laryngoscopy. Immediately after anesthesia induction, the 15-min apnea period started with oxygen delivered according to the randomized flow rate. Serial arterial blood gas analyses were drawn every 2 min. The study was terminated if either oxygen saturation measured by pulse oximetry was less than 92%, transcutaneous carbon dioxide was greater than 100 mmHg, pH was less than 7.1, potassium level was greater than 6 mmol · l-1, or apnea time was 15 min. The primary outcome was the linear rate of mean increase of arterial carbon dioxide during the 15-min apnea period computed from linear regressions. RESULTS In total, 125 patients completed the study. Noninferiority with a predefined noninferiority margin of 0.3 mmHg · min-1 could be declared for all treatments with the following mean and 95% CI for the mean differences in the linear rate of arterial partial pressure of carbon dioxide with associated P values regarding noninferiority: high flow versus control, -0.0 mmHg · min-1 (-0.3, 0.3 mmHg · min-1, P = 0.030); medium flow versus control, -0.1 mmHg · min-1 (-0.4, 0.2 mmHg · min-1, P = 0.002); low flow versus control, -0.1 mmHg · min-1 (-0.4, 0.2 mmHg · min-1, P = 0.003); and minimal flow versus control, -0.1 mmHg · min-1 (-0.4, 0.2 mmHg · min-1, P = 0.004). CONCLUSIONS Widely differing flow rates of humidified 100% oxygen during apnea resulted in comparable increases of arterial partial pressure of carbon dioxide, which does not support an additional ventilatory effect of high-flow nasal oxygenation. EDITOR’S PERSPECTIVE
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