Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated events in critically ill children
Natalie Napolitano,
Lee Polikoff,
Lauren Edwards,
Keiko M. Tarquinio,
Sholeen Nett,
Conrad Krawiec,
Aileen Kirby,
Nina Salfity,
David Tellez,
Gordon Krahn,
Ryan Breuer,
Simon J. Parsons,
Christopher Page-Goertz,
Justine Shults,
Vinay Nadkarni,
Akira Nishisaki,
for National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
Affiliations
Natalie Napolitano
Respiratory Therapy Department, Children’s Hospital of Philadelphia
Lee Polikoff
Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University
Lauren Edwards
Division of Critical Care, Department of Pediatrics, Children’s Healthcare of Atlanta, University of Nebraska Medical Center and Children’s Hospital and Medical Center
Keiko M. Tarquinio
Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine
Sholeen Nett
Division of Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center
Conrad Krawiec
Division of Pediatric Critical Care Medicine, Penn State Health Children’s Hospital
Aileen Kirby
Division of Pediatric Critical Care Medicine, Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and Science University
Nina Salfity
Department of Critical Care, Phoenix Children’s Hospital
David Tellez
Department of Critical Care, Phoenix Children’s Hospital
Gordon Krahn
Division of Pediatric Critical Care, University of British Columbia
Ryan Breuer
Division of Pediatric Critical Care, Oishei Children’s Hospital
Simon J. Parsons
Division of Critical Care, Alberta Children’s Hospital
Christopher Page-Goertz
Division of Critical Care Medicine, Akron Children’s Hospital
Justine Shults
Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia
Vinay Nadkarni
Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia
Akira Nishisaki
Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia
for National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
Abstract Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1–7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infants, those with a primary cardiac diagnosis or difficult airway features, and patient intubated due to respiratory or neurological failure or shock. Conversely, AO was used more often in TIs done for procedures and those assisted by video laryngoscopy. AO utilization was associated with a lower incidence of adverse TIAEs (AO 10.5% vs. without AO 13.5%, p < 0.001), aOR 0.75 (95% CI 0.58–0.98, p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72–1.12, p = 0.33 and the occurrence of hypoxemia was not different: AO 14.2% versus without AO 15.2%, p = 0.43. Conclusion While AO use was associated with a lower occurrence of adverse TIAEs in children who required TI in the pediatric ICU after accounting for site-level clustering, this result may be explained by differences in patient, provider, and practice factors. Trial Registration Trial not registered.
