Koninklijke Bibliotheek, National Library of the Netherlands
IP1508843247360
Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis
Oliveira J. e Silva, Lucas
Cabrera, Daniel
Barrionuevo, Patricia
Johnson, Rebecca L.
Erwin, Patricia J.
Murad, M. Hassan
Bellolio, M. Fernanda
text
article
monographic
Annals of emergency medicine
continuing
01960644
0000000012025
70
4
text
Born digital tijdschriften
KB collectiekavel
text
Elektronische Wetenschappelijke Tijdschriften
EWTIJ
10.1016/j.annemergmed.2017.05.001
urn:nbn:nl:kb-1508843247104
Automatisch gegenereerd op basis van de EWTIJ XML in release 1.5 van het digitaal magazijn.
YMEM
7304
S0196-0644(17)30582-6
10.1016/j.annemergmed.2017.05.001
American College of Emergency Physicians
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses study flow. ApOx, Apneic oxygenation.
Figure 2
Forest plots of meta-analyses on periprocedural outcomes. A, Lowest oxygen saturation (SpO2) peri-intubation. B, First-pass success. C, Hypoxemia (SpO2 <93%). D, Severe hypoxemia (SpO2 <80%). E, Life-threatening hypoxemia (SpO2 <70%).
Figure 3
Forest plots of meta-analyses on postprocedural outcomes. A, Duration of mechanical ventilation. B, ICU length of stay. C, ICU mortality.
Figure E1
Lowest peri-intubation SpO2 by proceduralist expertise.
Figure E2
First-pass success by proceduralist expertise.
Figure E3
Hypoxemia (SpO2 <93%) by proceduralist expertise.
Figure E4
Severe hypoxemia (SpO2 <80%) by proceduralist expertise.
Figure E5
Lowest peri-intubation SpO2 by study design.
Figure E6
First-pass success by study design.
Figure E7
Hypoxemia (SpO2 <93%) by study design.
Figure E8
Severe hypoxemia (SpO2 <80%) by study design.
Figure E9
Lowest peri-intubation SpO2 by risk of bias.
Figure E10
First-pass success by risk of bias.
Figure E11
Hypoxemia (SpO2 <93%) by risk of bias.
Figure E12
Severe hypoxemia (SpO2 <80%) by risk of bias.
Table 1
ED and ICU studies: main baseline characteristics.
Study
Study Design
Setting
Population
Proceduralist Expertise
Intervention [Number of Participants]
Comparison [Number of Participants]
Besnier, 2016
26
Observational study
ICU
Adult patients with ARF intubated in the ICU
Majority of intubations performed by an expert
THRIVE techniquePreOx: HFNC (50 L/min, FiO2 100%)ApOx: HFNC (50 L/min, FiO2 100%)[n=13]
PreOx: NIV (FiO2 100%, PEEP minimum of 5 cm H2OApOx: not used[n=39]
Dyett, 2015
38
Observational study
ED, ICU, and wards
Adults and children urgently intubated in the ED, ICU, and wards. ARF was the most common underlying cause for intubation.
Majority of intubations performed by trainees
NO DESAT techniquePreOx: most common was BVMApOx: standard NC (15 L/min)[n=47]
PreOx: most common was BVMApOx: not used[n=92]
Fogg, 2016
32
Observational study
ED
Adults and children intubated in the ED. Overdose was the most common underlying cause for intubation.
Majority of intubations performed by an expert.
NO DESAT technique as part of a new airway protocolPreOx: not describedApOx: standard NC (15 L/min). Few patients in the postimplementation period did not receive ApOx[n=360]
Period before the implementation of a new airway protocolPreOx: not describedApOx: not used[n=259]
Horan, 2016
23
RCT
ED
Patients (age not specified) who underwent RSI in a community ED
Not specified
Method of ApOx not specified[n=13]
Not specified
Jaber, 2016
27
RCT
ICU
Adult patients with severe hypoxemic ARF intubated in the ICU
Majority of intubations performed by an expert
PreOx: HFNC (60 L/min, FiO2 100%) plus NIV (PS 10 cm H2O, PEEP 5 cm H2O, FiO2 100%)ApOx: HFNC (60 L/min, FiO2 100%)[n=23]
PreOx: NIV (PS 10 cm H2O, PEEP 5 cm H2O, FiO2 100%)ApOx: not used[n=24]
Sakles, 2016
35
Observational study
ED
Adult patients intubated in the ED. Patients intubated mostly for airway protection.
All intubations performed by a trainee
NO DESAT techniquePreOx: NRB face mask (15 L/min) plus standard NC (different flows)ApOx: standard NC (different flows, but mostly ≥15 L/min)[n=380]
PreOx: NRB face mask (15 L/min)ApOx: not used[n=255]
Sakles, 2016
36
Observational study
ED
Adult patients with ICH intubated in the ED
All intubations performed by a trainee
NO DESAT techniquePreOx: NRB face mask (15 L/min) plus standard NC (different flows)ApOx: standard NC (different flows, but mostly ≥15 L/min)[n=72]
PreOx: NRB face mask (15 L/min)ApOx: not used[n=55]
Semler, 2016
29
RCT
ICU
Adult patients intubated in the ICU. ARF was the most common underlying cause for intubation.
Majority of intubations performed by a trainee
NO DESAT techniquePreOx: BVM was the most common methodApOx: standard NC (15 L/min, FiO2 100%)[n=77]
PreOx: NRB face mask was the most common methodApOx: not used[n=73]
Simon, 2016
30
RCT
ICU
Adult patients with ARF intubated in the ICU
All intubations performed by an expert
THRIVE techniquePreOx: HFNC (50 L/min, FiO2 100%)ApOx: HFNC (50 L/min, FiO2 100%)[n=20]
PreOx: BVM without PEEP valve (10 L/min)ApOx: not used[n=20]
Vourc’h, 2015
31
RCT
ICU
Adult patients with hypoxemic ARF intubated in the ICU
Majority of intubations performed by a trainee
THRIVE techniquePreOx: HFNC (60 L/min, FiO2 100%)ApOx: HFNC (60 L/min, FiO2 100%)[n=62]
PreOx: NRB high FiO2 face mask (15 L/min)ApOx: not used[n=57]
Doyle, 2016
37
(ED/ICU cohort)
Observational study
ED and ICU
Adult patients intubated in the ICU and ED. ARF was the most common underlying cause for intubation.
Not specified
THRIVE techniquePreOx: HFNC (60 L/min)ApOx: HFNC (60 L/min)[n=34]
No control group
Grant, 2016
33
Observational study
ED
Adult patients intubated in the ED deemed to be clinically at high risk of oxygen desaturation
Not specified
NO DESAT techniquePreOx: NIV (NIV-ST mode, PEEP 5 cm H2O, PS 10 cm H2O) plus standard NC (15 L/min)ApOx: standard NC (15 L/min)[n=8]
No control group
Kim, 2016
34
Observational study
ED
Adult patients intubated in the ED. ARF was the most common underlying cause for intubation.
Majority of intubations performed by an expert
THRIVE techniquePreOx: HFNC (50 L/min, FiO2 100%)ApOx: HFNC (50 L/min, FiO2 100%)[n=30]
No control group
Miguel-Montanes, 2015
28
Observational study
ICU
Adult patients intubated in the ICU. Shock patients, altered mental status, and ARF (mild to moderate) were the most common underlying causes for intubation.
Majority of intubations performed by a trainee
THRIVE techniquePreOx: HFNC (60 L/min, FiO2 100%)ApOx: HFNC (60 L/min, FiO2 100%)[n=51]
PreOx: NRB face mask (15 L/min)ApOx: nasopharyngeal catheter (6 L/min)[n=50]
ARF, Acute respiratory failure; FiO2
, fraction of inspired oxygen; PreOx, preoxygenation; HFNC, high-flow nasal cannula; NIV, noninvasive ventilation; PS, pressure support; PEEP, positive end-expiratory pressure; BVM, bag-valve-mask; NC, nasal cannula; RCT, randomized controlled trial; RSI, rapid sequence intubation; NRB, nonrebreather; ICH, intracranial hemorrhage.
Table 2
Summary of evidence findings for main outcomes using the Grading of Recommendations Assessment, Development and Evaluation approach.
Quality Assessment
No. of Patients (%)
Effect
Quality
No. of Studies
Study Design
Risk of Bias
Inconsistency
Indirectness
Imprecision
Other Considerations∗
Use of ApOx
Controls Without ApOx
Relative (95% CI)
Absolute (95% CI)
Lowest SpO
2
peri-intubation
6
4 RCTs2 Observ.
Not serious
Serious
†
‡
Not serious
Not serious
None
575
468
—
MD 2.21% higher (0.81 higher to 3.61 higher)
⊕⊕⊕◯Moderate
First-pass success
6
3 RCTs2 Observ.
Serious
§
Serious
‡
||
Not serious
Not serious
None
807/915 (88.2)
594/743 (79.9)
OR 1.59 (1.04–2.44)
64 more per 1.000 (from 6 more to 107 more)
⊕⊕◯◯Low
Hypoxemia (SpO
2
<93%)
8
4 RCTs4 Observ.
Serious
¶
Serious
†
‡
Not serious
Not serious
None
163/982 (16.6)
209/855 (24.4)
OR 0.66 (0.52–0.84)
68 fewer per 1.000 (from 31 fewer to 100 fewer)
⊕⊕◯◯Low
Severe hypoxemia (SpO
2
<80%)
6
4 RCTs2 Observ.
Not serious
Serious
†
‡
Not serious
Serious
#
None
62/575 (10.8)
65/468 (13.9)
OR 0.86 (0.47–1.57)
17 fewer per 1.000 (from 63 more to 68 fewer)
⊕⊕◯◯Low
Life-threatening hypoxemia (SpO
2
<70%)
5
3 RCTs2 Observ.
Not serious
Serious
†
‡
Not serious
Serious
#
None
32/555 (5.8)
33/448 (7.4)
OR 0.90 (0.52–1.55)
7 fewer per 1.000 (from 34 fewer to 36 more)
⊕⊕◯◯Low
Observ., Observational studies; MD, mean difference.
∗
Other considerations include assessment of publication bias, magnitude of effect, plausible confounding, and dose-response gradient.
†
ApOx may have a larger effect in less sick populations intubated in the ED/ICU, as shown indirectly by the increased safe apnea time when using ApOx in elective intubated patients in the operating room without cardiorespiratory disease.
‡
Different approaches to ApOx (NO DESAT vs THRIVE) could also play a role in the direction of effect.
§
Inclusion of a before-after observational study with high risk of bias (Fogg
32
); however, when sensitivity analysis was performed excluding this study, there was still a benefit of using ApOx.
||
ApOx may have larger effect when trainees perform intubations.
¶
Inclusion of 2 studies with high risk of bias (Fogg
32
and Dyett
38
); however, when sensitivity analysis excluding these studies was performed, there was still a benefit of using ApOx.
#
95% CI around the pooled estimate of effect includes both benefit and no benefit of using ApOx.
Appendix E1
Search strategies: Epub ahead of print, in-process and other non-indexed citations, Ovid MEDLINE daily, and Ovid MEDLINE; 1946 to present.
#
Searches
Results
Type
1
Intubation, Intratracheal/
31593
Advanced
2
((intratracheal or endotracheal or tracheal) adj3 intubat*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
38137
Advanced
3
1 or 2 or intubat*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
72200
Advanced
4
(((apneic or apnoeic) adj2 oxygenation*) or “ap ox”).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
168
Advanced
5
(preoxygenat* or “pre oxygenat*”).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
648
Advanced
6
((passive adj2 oxygen*) or (diffusion adj2 respirat*) or (oxygen* adj2 insufflat*) or (mask* adj2 flow* adj2 ventilat*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
479
Advanced
7
((nasal or nasopharyngeal*) adj2 (cannula* or prong*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
1313
Advanced
8
((“high flow” or “high frequency”) adj3 (nasal or nasopharyng*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
436
Advanced
9
(hfnc or hfnp or hhfnox).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
148
Advanced
10
(((noninvasive or “non invasive”) adj2 (positive or respirat* or ventil*)) or nppv or ninppv or nippv).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
6025
Advanced
11
(operating room* or “OR” or emergent or emergency* or ards or (respiratory adj2 (distress* or fail*)) or icu*1 or ccu*1 or “critical care” or “intensive care” or “airway manage*” or urgen*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
7563071
Advanced
12
postoperative complications/or intraoperative complications/
331681
Advanced
13
exp Intensive Care Units/
64939
Advanced
14
(critical* adj2 ill*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
44998
Advanced
15
Critical Care/or rsi.mp. or “rapid sequence.”mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
46529
Advanced
16
or/11-15
7778162
Advanced
17
or/4-10
8407
Advanced
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3 and 16 and 17
1783
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3 and laryngoscop*.mp. and 17 [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
88
Advanced
20
3 and 15
2946
Advanced
21
17 and 20
239
Advanced
22
18 or 19 or 21
1803
Advanced
23
22 and (desaturat* or hypox* or anox* or success* or sp02 or “first pass” or outcome* or death* or mortality or complicat* or surviv* or los or optimi*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
1440
Advanced
24
23 and (apneic or preoxygen* or “pre oxygen*”).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
171
Advanced
25
23 or 24
1440
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25 and (compar* or study or studies or observation* or trial* or prospective* or series or cohort*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
1123
#
Searches
Results
Type
1
Intubation, Intratracheal/
34159
Advanced
2
((intratracheal or endotracheal or tracheal) adj3 intubat*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
38219
Advanced
3
1 or 2 or intubat*.mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
84322
Advanced
4
(((apneic or apnoeic) adj2 oxygenation*) or “ap ox”).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
141
Advanced
5
(preoxygenat* or “pre oxygenat*”).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
875
Advanced
6
((passive adj2 oxygen*) or (diffusion adj2 respirat*) or (oxygen* adj2 insufflat*) or (mask* adj2 flow* adj2 ventilat*)).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
394
Advanced
7
((nasal or nasopharyngeal*) adj2 (cannula* or prong*)).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
2521
Advanced
8
((“high flow” or “high frequency”) adj3 (nasal or nasopharyng*)).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
781
Advanced
9
(hfnc or hfnp or hhfnox).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
284
Advanced
10
(((noninvasive or “non invasive”) adj2 (positive or respirat* or ventil*)) or nppv or ninppv or nippv).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
11265
Advanced
11
(operating room* or “OR” or emergent or emergency* or ards or (respiratory adj2 (distress* or fail*)) or icu*1 or ccu*1 or “critical care” or “intensive care” or “airway manage*” or urgen*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
8291392
Advanced
12
postoperative complications/or intraoperative complications/
40776
Advanced
13
exp Intensive Care Units/
103859
Advanced
14
(critical* adj2 ill*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
65337
Advanced
15
Critical Care/or rsi.mp. or “rapid sequence.”mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
61564
Advanced
16
or/11-15
8329344
Advanced
17
or/4-10
14769
Advanced
18
3 and 16 and 17
3549
Advanced
19
3 and laryngoscop*.mp. and 17 [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
179
Advanced
20
3 and 15
4740
Advanced
21
17 and 20
444
Advanced
22
18 or 19 or 21
3571
Advanced
23
22 and (desaturat* or hypox* or anox* or success* or sp02 or “first pass” or outcome* or death* or mortality or complicat* or surviv* or los or optimi*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
2946
Advanced
24
23 and (apneic or preoxygen* or “pre oxygen*”).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
267
Advanced
25
23 or 24
2946
Advanced
26
25 and (compar* or study or studies or observation* or trial* or prospective* or series or cohort*).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
2213
Advanced
27
clinical study/or exp case control study/or exp case study/or exp clinical trial/or exp “clinical trial (topic)”/ or exp intervention study/or exp major clinical study/or exp prospective study/or exp retrospective study/
3498048
Advanced
28
26 and (27 or observational*.mp. or cohort*.mp.) [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
1431
Advanced
29
25 and 27
1238
Advanced
30
28 or 29
1431
Advanced
31
limit 30 to human
1376
Advanced
32
31 not case report/
1361
Advanced
33
remove duplicates from 32
1322
Cochrane Collaboration’s tool for assessment of risk of bias in randomized controlled trials.
Study
Adequate Sequence Generation
Adequate Allocation Concealment
Adequate Blinding of Personnel and Outcome Assessors
Incomplete Outcome Data Addressed
Free of Selective Outcome Reporting
Free of Other Bias
Overall Risk of Bias
Horan
23
Unclear
Unclear
Unclear
Unclear
Unclear
Unclear
High risk
Jaber
27
Yes
Yes
Yes
Yes
Yes
Yes
Low risk
Semler
29
Yes
Yes
Yes
Yes
Yes
Unclear
Low risk
Simon
30
Yes
Yes
Unclear
Yes
Yes
No
Moderate risk
Vourc’h
31
Yes
Yes
Unclear
Yes
Yes
Unclear
Moderate risk
Modified Newcastle-Ottawa Scale for assessing the quality of nonrandomized studies.
Study
Representative of Exposed
Selection of the Nonexposed Cohort (May Not Be Included)
Ascertainment of Exposure (Description of ApOx)
Demonstration That Outcome of Interest Was Not Present at Start of Study
Comparability of Cohorts on Basis of Design or Analysis
Assessment of Outcome
For Case Series: Consecutive Selection of Patients
Overall Risk of Bias
Besnier
26
Somewhat
Same community
Good
Yes
Yes
Other than the proceduralist
—
Low risk
Dyett
38
Truly
Same community
Poor
No description
No description
Other than the proceduralist
—
High risk
Fogg
32
Truly
Same community
Poor
No description
No description
Assessed by proceduralist
—
High risk
Sakles
35
Somewhat
Same community
Good
Yes
Yes
Assessed by proceduralist
—
Moderate risk
Sakles
36
Somewhat
Same community
Good
Yes
Yes
Assessed by proceduralist
—
Moderate risk
Doyle
37
Truly
N/A
Good
Yes
N/A
No description
Yes
Moderate risk
Grant
33
Somewhat
N/A
Good
N/A
N/A
No description
Unclear
High risk
Kim
34
Truly
N/A
Good
Yes
N/A
No description
Unclear
High risk
Miguel-Montanes
28
Truly
Same community
Good
Yes
Yes
No description
—
Moderate risk
Subgroup analysis by proceduralist expertise.
Outcomes
Trainees Subgroup
Experts Subgroup
Lowest oxygen saturation, SpO2, % (WMD, 95% CI)
2.07 (0.57 to 3.57)[n=904]
2.59 (–2.83 to 8.00)[n=139]
First-pass success, OR (95% CI)
1.53 (1.04 to 2.25)[n=904]
1.47 (0.52 to 4.16)[n=754]
Hypoxemia, OR (95% CI)
0.66 (0.49 to 0.90)[n=1,043]
0.64 (0.35 to 1.16)[n=794]
Severe hypoxemia, OR (95% CI)
0.77 (0.51 to 1.17)[n=904]
1.08 (0.10 to 11.90)[n=139]
WMD, Weighted mean difference.
Subgroup analysis by study design.
Outcomes
RCTs
Observational
Lowest oxygen saturation, SpO2, % (WMD, 95% CI)
2.83 (0.49 to 5.16)[n=356]
1.11 (–2.83 to 5.06)[n=687]
First-pass success, OR (95% CI)
1.14 (0.70 to 1.87)[n=316]
2.02 (1.13 to 3.62)[n=1,342]
Hypoxemia, OR (95% CI)
0.68 (0.44 to 1.06)[n=356]
0.65 (0.48 to 0.87)[n=1,481]
Severe hypoxemia, OR (95% CI)
0.75 (0.38 to 1.47)[n=356]
2.26 (0.16 to 31.65)[n=687]
Please see page 484 for the Editor’s Capsule Summary of this article.
Supervising editor: Henry E. Wang, MD, MS
All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
Trial registration number: PROSPERO (Study ID: CRD42016052438)
A
podcast
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Airway/systematic review/meta-analysis
Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis
Lucas
Oliveira J. e Silva
a
f
Daniel
Cabrera
MD
a
Patricia
Barrionuevo
MD
b
Rebecca L.
Johnson
MD
c
Patricia J.
Erwin
MLS
g
M. Hassan
Murad
MD, MPH
b
d
M. Fernanda
Bellolio
MD, MS
a
e
∗
Bellolio.Fernanda@mayo.edu
http://twitter.com/mfbellolio
http://twitter.com/lucasojesilva12
a
Department of Emergency Medicine, Mayo Clinic, Rochester, MN
Department of Emergency Medicine
Mayo Clinic
Rochester
MN
b
Knowledge Synthesis and Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
Knowledge Synthesis and Kern Center for the Science of Health Care Delivery
Mayo Clinic
Rochester
MN
c
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic
Rochester
MN
d
Division of Preventive, Occupational and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
Division of Preventive
Occupational and Aerospace Medicine
Department of Medicine
Mayo Clinic
Rochester
MN
e
Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
Department of Health Science Research
Division of Health Care Policy and Research
Mayo Clinic
Rochester
MN
f
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Faculdade de Medicina
Universidade Federal do Rio Grande do Sul
Porto Alegre
RS
Brazil
g
Mayo Clinic Libraries, Rochester, MN
Mayo Clinic Libraries
Rochester
MN
∗
Corresponding Author.
Study objective
We conduct a systematic review and meta-analysis to evaluate the effectiveness of apneic oxygenation during emergency intubation.
Methods
We searched Ovid MEDLINE, Ovid EMBASE, Ovid CENTRAL, and Scopus databases for randomized controlled trials and observational studies from 2006 until July 2016, without language restrictions. Gray literature, clinicaltrials.gov, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate first-pass success rates, incidence of hypoxemia, and lowest peri-intubation SpO2 between apneic oxygenation and standard oxygenation cases.
Results
A total of 1,386 studies were screened and 77 selected for full-text review. A total of 14 studies were included for qualitative analysis, and 8 studies (1,837 patients) underwent quantitative analysis. In the meta-analysis of 8 studies (1,837 patients), apneic oxygenation was associated with decreased hypoxemia (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.52 to 0.84), but was not associated with decreased severe hypoxemia (6 studies; 1,043 patients; OR 0.86; 95% CI 0.47 to 1.57) or life-threatening hypoxemia (5 studies; 1,003 patients; OR 0.90; 95% CI 0.52 to 1.55). Apneic oxygenation was associated with increased first-pass success rate (6 studies; 1,658 patients; OR 1.59; 95% CI 1.04 to 2.44) and increased lowest peri-intubation SpO2 (6 studies; 1,043 patients; weighted mean difference 2.2%; 95% CI 0.8% to 3.6%).
Conclusion
In this meta-analysis, apneic oxygenation was associated with increased peri-intubation oxygen saturation, decreased rates of hypoxemia, and increased first-pass intubation success.
Introduction
Background
Apneic oxygenation consists in the administration of oxygen during the apneic period of the intubation procedure to extend the safe apnea time beyond that which can be achieved by preoxygenation alone.
1-5
This concept was first introduced in the operating room setting,
6
and more recently its use has been rapidly adopted during airway management in the emergency department (ED) and ICU.
7-10
The rationale for apneic oxygenation revolves around the physiologic capacity of continuous oxygen capture by alveoli through a passive process without providing ventilation.
6,11
During laryngoscopy, apneic oxygenation may be provided as continuous oxygen delivery throughout the intubation with nasal cannulas, nasopharyngeal catheters, and modified laryngoscopes.
Editor’s Capsule Summary
What is already known on this topic
Apneic oxygenation may prolong safe apnea time and increase first-pass success during emergency intubation.
What question this study addressed
Is apneic oxygenation, typically delivered by high-flow nasal cannula, associated with lower peri-intubation hypoxemia and higher first-pass intubation success?
What this study adds to our knowledge
In this meta-analysis of 8 emergency department and ICU studies comprising 1,837 patients, apneic oxygenation was associated with lower odds of peri-intubation hypoxemia (SpO2 <93%; odds ratio 0.66; 95% confidence interval 0.52 to 0.85) and higher odds of first-pass intubation success (odds ratio 1.59; 95% confidence interval 1.04 to 2.44).
How this is relevant to clinical practice
These results support the role of apneic oxygenation in emergency intubation.
Importance
Airway management is commonly performed by anesthesiologists, emergency physicians, and critical care providers as part of their daily practice. Most intubations are performed in the operating room under controlled, often ideal situations. However, out-of-operating-room intubations have been associated with higher risks of adverse events because they are frequently performed urgently in critically ill patients,
12
for whom the rates of severe complications can be as high as 28%.
13
Hypoxemia is an adverse effect that can occur during intubation.
14
If oxygen were administered through the pharynx during the apneic period, one could increase the uptake of oxygen into the bloodstream, thus reducing occurrences of potentially harmful oxygen desaturation events.
Goals of This investigation
The use of apneic oxygenation has been recommended by experts for management of high-risk airway situations, including emergency intubations in the ED,
10
and for patients at risk for difficult laryngoscopy and intubation in the operating room
15
; however, the evidence supporting apneic oxygenation is still not well established. The objective of this systematic review and meta-analysis was to evaluate the effectiveness of apneic oxygenation on hypoxemia, first-pass success, and lowest oxygen saturation during emergency intubation.
Materials and Methods
Study Design
This was a systematic review and meta-analysis conducted to evaluate the effectiveness of apneic oxygenation during intubations performed in the ED and ICU settings. A protocol was developed a priori and it is available for access in the PROSPERO Web site. This report adheres to recommendations made in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
16
Eligibility Criteria
We included original research articles, including randomized controlled trials and observational studies, in which apneic oxygenation was used as part of the intubation procedure. We did not exclude any studies according to language, and only studies published in the past 10 years were included. This time restriction was based on the recent implementation of apneic oxygenation in clinical practice and advances in capnography and intubation monitoring in the included settings.
Studies of pediatric and adult patients who received apneic oxygenation during the apneic period of intubation in the ED or ICU were included. Studies performed in the out-of-hospital setting and in the operating room were excluded. There was no restriction by age, sex, or any other baseline characteristic.
To meet the eligibility criteria, patients had to have received oxygen during the apneic period. All types of oxygen devices were considered, including standard nasal cannula, high-flow nasal cannula, nasopharyngeal catheters, modified laryngoscopes, or any other device. Apneic oxygenation is most commonly performed with high-flow nasal cannula through the transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) technique and with standard nasal cannula through the technique of nasal oxygen during efforts securing a tube (NO DESAT). The THRIVE technique consists of the use of a high-flow warmed humidified oxygen delivery system up to 70 L/min to perform both preoxygenation and apneic oxygenation. This technique combines the benefits of apneic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent dead-space flushing.
17,18
The technique of NO DESAT uses a standard nasal cannula with cold dry oxygen set as high as 15 L/min, together with the traditional techniques of preoxygenation, and allows apneic oxygenation to continue while attempts at intubation are performed.
10,19
Outcome Measures and Study Selection
The following outcomes were included: lowest SpO2 peri-intubation; first-pass success (success on the first laryngoscopy attempt); incidences of hypoxemia (SpO2 <93%), severe hypoxemia (SpO2 <80%), and life-threatening hypoxemia (SpO2 <70%) during the procedure; duration of mechanical ventilation; ICU length of stay; and mortality in the ICU. In studies in which an episode of hypoxemia was defined by SpO2 less than 90%, these events were included as episodes of SpO2 less than 93%.
A medical librarian (P.J.E.) designed and conducted a comprehensive search of 4 electronic databases, including Ovid MEDLINE, Ovid EMBASE, Ovid CENTRAL, and Scopus from 2006 to July 2016. The initial search was designed in Ovid MEDLINE (Appendix E1, available online at http://www.annemergmed.com) and then translated into terms appropriate to Ovid CENTRAL and Ovid EMBASE. The strategies used a combination of controlled vocabulary (in MEDLINE, this is Medical Subject Headings), eg, “intubation,” “intratracheal,” text words. This was done for each concept: intubation, setting (eg, ED), purpose (apneic oxygenation), and outcomes (eg, hypoxemia). Gray literature databases suggested by the Cochrane handbook,
20
ongoing trials (through clinicaltrials.gov), and reference lists of eligible articles were hand searched.
In phase 1, 2 investigators (L.O.J.S. and D.C.), working independently, screened all titles and abstracts for eligibility. Records considered potentially relevant were assessed in full text for eligibility by 2 independent reviewers (L.O.J.S. and D.C.) in phase 2. We used Cohen’s unweighted κ to measure chance corrected agreement between reviewers for phase 2. Disagreements were discussed with the senior author (M.F.B.) and resolved by consensus. All studies were included for qualitative analysis and only those with available data were included for the quantitative analysis.
Primary Data Analysis
Pertinent data were extracted with a standardized predefined form. Data from the first 10 studies were extracted at the beginning of the process independently in duplicate by 2 reviewers (L.O.J.S. and P.B.) to identify variables prone to misinterpretation. Extracted data included study design, study size, study setting, study population, details of the intubation procedure, and outcomes of interest. In regard to the intubation procedure, data collected included clinical predictors of difficult intubation (ie, Cormack-Lehane grades III and IV), methods of preoxygenation, use of rapid sequence intubation, context for intubation, proceduralist expertise (trainee versus expert), and type of laryngoscope used. Trainee proceduralist was defined as physicians undergoing a training program (residents and fellows). Expert proceduralist was defined as emergency physicians, intensivists, and anesthesiologists.
For randomized controlled trials, we assessed the risk of bias with the Cochrane Collaboration Bias Appraisal Tool.
20
We assessed the risk of bias for observational studies with a modified Newcastle-Ottawa Scale tool.
21
Quality assessment of all studies included was performed in duplicate and independently by 2 reviewers (L.O.J.S. and P.B.). The quality of evidence for the main outcomes was evaluated with the Grading of Recommendations Assessment, Development and Evaluation methods.
22
We collected the outcomes included in the published reports, and authors were contacted by e-mail if data were missing or unclear. Most studies contained the desired clinical outcomes. We directly contacted the authors of the 14 studies and received additional data from 12. One conference abstract of an ongoing trial had no data for outcomes of interest.
23
We considered it reasonable to pool the data from ED and ICU studies to have a better understanding of the overall benefit of apneic oxygenation in an emergency setting. Data were managed following Cochrane recommendations.
20
We used Review Manager (version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) for meta-analyses, using a random-effects model as described by DerSimonian-Laird.
24
The pooled-effect estimates of using apneic oxygenation during intubation versus not using it were reported as odds ratio (OR) and weighted mean difference with 95% confidence intervals (CIs). Statistical heterogeneity was assessed among studies by the I
2 statistic proposed by Higgins and Thompson.
25
Between-studies heterogeneity was also evaluated visually. To account for the clinical and statistical heterogeneity between studies, we used a random-effects model.
During the development of the protocol, we planned to perform subgroup analyses by proceduralist expertise, study design, and risk of bias. Sensitivity analyses were conducted excluding studies with high risk of bias.
Results
The search strategy identified 1,386 studies for review (Figure 1
). After screening the titles and abstracts and removing duplicates, we identified 77 potentially relevant studies. After full-text review, a total of 14 studies met the inclusion criteria: 6 ICU studies,
26-31
6 ED studies,
23,32-36
and 2 mixed ED and ICU studies.
37,38
Interobserver agreement (κ) for phase 2 of study selection was moderate (κ 0.54; 95% CI 0.34 to 0.74), with an overall agreement of 79.2% (95% CI 70.2% to 88.3%).
Among the studies including patients intubated in the ED or ICU, there were 9 observational studies and 5 randomized controlled trials (Table 1
and Appendix E2, available online at http://www.annemergmed.com).
The included studies involved 2,023 participants, with 1,168 patients receiving apneic oxygenation during intubation and 855 not receiving it. Eight studies,
26,27,29-32,35,38
including 982 patients receiving apneic oxygenation and 855 not receiving it, underwent meta-analysis. Three studies had no control groups,
33,34,37
1 study had both arms receiving apneic oxygenation,
28
and 1 conference abstract did not have enough data details.
23
There were 2 studies with overlapping cohorts, and we included only the most comprehensive one in the meta-analyses.
35,36
Two ED studies included pediatric patients within a mixed pediatric and adult cohort,
32,38
with a median age greater than 50 years. Most studies included patients with acute respiratory failure requiring emergency intubation.
Apneic oxygenation was performed through high-flow nasal cannula in most studies,
26,28,30,31,34,37
with the oxygen flow set as high as 60 L/min. Standard nasal cannula with oxygen set as high as 15 L/min, used in combination with traditional techniques of preoxygenation, was mostly used in the ED studies.
32,35,36,38
Main Results
We evaluated the body of evidence for the main outcomes with the Grading of Recommendations Assessment, Development and Evaluation approach, which assessed the confidence in our meta-analytic effects accounting for different criteria rather than the risk of bias alone (Table 2
and Appendix E3, available online at http://www.annemergmed.com). Sources of clinical heterogeneity included setting and context for intubation, approaches to preoxygenation and apneic oxygenation, and proceduralist expertise.
The timeframe for measurement of the lowest peri-intubation SpO2 and incidences of hypoxemia were unclear in most studies; among those that reported it in detail, it was measured from drug injection until the initiation of mechanical ventilation.
In the meta-analysis of 6 studies including 1,043 patients,
26,27,29-31,35
the lowest peri-intubation SpO2 was higher for apneic oxygenation than standard oxygenation (difference 2.21%; 95% CI 0.81% to 3.61%; I
2=0%) (Figure 2
A).
In the meta-analysis of 6 studies including 1,658 patients,
25,26,28,30,31,34
apneic oxygenation during intubation was associated with increased first-pass success rates (OR 1.59; 95% CI 1.04 to 2.44; I
2=48%) (Figure 2
B).
Hypoxemia was defined differently across studies. For the meta-analysis, we defined hypoxemia as SpO2 less than 93%. In studies in which an episode of hypoxemia was defined by SpO2 less than 90%, these events were included as episodes of SpO2 less than 93%. In the meta-analysis of 8 studies including 1,837 patients,
26,27,29-32,35,38
apneic oxygenation during intubation was associated with decreased incidence of hypoxemia (OR 0.66; 95% CI 0.52 to 0.84; I
2=0%) (Figure 2
C).
In the meta-analysis of 6 studies including 1,043 patients,
26,27,29-31,35
apneic oxygenation during intubation was not associated with severe hypoxemia (SpO2 <80%) (OR 0.86; 95% CI 0.47 to 1.57; I
2=44%) (Figure 2
D).
In the meta-analysis of 5 studies including 1,003 patients,
26,27,29,31,35
apneic oxygenation during intubation was not associated with life-threatening hypoxemia (SpO2 <70%) (OR 0.90; 95% CI 0.52 to 1.55; I
2=2%) (Figure 2
E).
In the meta-analysis of 4 studies including 368 patients,
26,27,29,31
apneic oxygenation during intubation was not associated with decreased duration of mechanical ventilation (weighted mean difference 1.42 days; 95% CI 0.59 to 3.42; I
2=63%) (Figure 3
A). In the meta-analysis of 4 studies including 368 patients,
26,27,29,31
apneic oxygenation during intubation was associated with a decreased ICU length of stay of 2.88 days (95% CI 1.40 to 4.37 days; I
2=0%) (Figure 3
B). In the meta-analysis of 4 studies including 258 patients,
26,27,30,31
apneic oxygenation was not associated with ICU mortality (OR 0.82; 95% CI 0.38 to 1.76; I
2=32%). Deaths included 36 of 118 patients (30.5%) in the apneic oxygenation group and 49 of 140 (35.0%) in the control group, with an absolute difference of –4% (95% CI –18% to 14%) (Figure 3
C).
Additional Analyses
Forest plots of subgroup analyses by proceduralist expertise, study design, and risk of bias are shown in Appendix E4, available online at http://www.annemergmed.com. Apneic oxygenation favored the trainees’ subgroup when proceduralist expertise was evaluated; however, differences between subgroups were not statistically significant. Sensitivity analysis excluding the study with high risk of bias
32
did not significantly change the pooled effect estimates. When randomized controlled trials and studies with low risk of bias were analyzed separately, apneic oxygenation was not associated with better periprocedural outcomes.
We were unable to statistically assess the presence of publication bias because the number of studies included in each analysis was small, which makes analysis of funnel plots unreliable.
39
Limitations
There are several limitations in this systematic review and meta-analysis. The major limitation relates to the quality of included studies, which warrants a moderate to low level of certainty in the estimates. Another important limitation is the different approaches used to apneic oxygenation in terms of preoxygenation and other peri-intubation variables and cointerventions. The different methods of preoxygenation between groups could affect the likelihood of developing hypoxemia during the apneic period; therefore, the effect of apneic oxygenation was not isolated in some of the included studies. The maintenance of airway patency during apneic oxygenation was not described in most of the studies, and that might affect the quality of this intervention. The clinical heterogeneity of patients intubated in the ED and ICU in regard to their cardiorespiratory baseline status is also an important factor to be considered, and which approach is better among the spectrum of sickness in patients requiring emergency intubation still has to be studied.
To decrease selection bias, we included all eligible studies including those published in gray literature and not indexed in PubMed or major databases, and abstracts. We included all studies even if they had a low number of participants or high risk of bias. This likely introduced heterogeneity into the analyses. However, we assessed clinical and statistical heterogeneity and accounted for this in the statistical analyses. To mitigate some of these limitations, we used subgroup analyses. Also we contacted the authors when published data were not clear or missing, and we received several responses.
Discussion
This systematic review and meta-analysis demonstrated that the use of apneic oxygenation during intubation appears to be associated with increased peri-intubation oxygen saturation and first-pass success rates, as well as decreased incidence of hypoxemia in patients intubated in the ED or ICU. The use of apneic oxygenation was associated with a decrease in ICU length of stay, but there was no difference in duration of mechanical ventilation and ICU mortality. We found no reports of adverse events related to the use of apneic oxygenation, despite different approaches and settings.
The concept and use of apneic oxygenation for the optimization of peri-intubation conditions, especially apnea time, has been introduced in the practice of emergency medicine after ED observational studies,
32,35,38
anesthesiology literature,
1,3,4
and recommendations by experts in the field.
10,19
EDs and ICUs have used different techniques for apneic oxygenation, with most ICU studies using high-flow nasal cannula and most ED studies using the standard nasal cannula.
32,35,36,38
The THRIVE technique combines preoxygenation and apneic oxygenation using a high-flow nasal cannula up to 70 L/min, creating a flow-dependent positive pharyngeal pressure, with potentially more benefit for patients with more severe respiratory disease.
8,40
The relative simplicity and safety of this intervention and the potential to turn intubation in a safer procedure, with higher success rates and fewer complications, led to a rapid and widespread use of the concept and to its even being considered by some as standard of care despite relatively scarce evidence to support its use.
10
Recently, ICU-based studies have shown conflicting results on the effectiveness of apneic oxygenation using different approaches.
26-31
Patients intubated outside of the operating room represented emergency intubations in the setting of critical illness in an ED or ICU environment, in whom the lowest SpO2 and incidences of hypoxemia during the peri-intubation period are different from those in the elective operating room population. Although there was variable level of bias and heterogeneity in the included studies, apneic oxygenation was associated with increased SpO2 peri-intubation, increased first-pass success rates, and decreased incidence of hypoxemia in patients intubated in the ED or ICU. Severe and life-threatening hypoxemia was not affected. These findings likely represent an overall benefit of using apneic oxygenation during emergency intubations, reflecting better periprocedural outcomes and prolonged safe apnea time. The physiologic improvements noted likely have little effect on the underlying disease, which may explain the lack of improvement in mortality.
In the subgroup analysis, proceduralist experience showed that peri-intubation oxygen saturation, first-pass success, and hypoxemia were improved in the trainees’ subgroup; however, these outcomes were not significantly improved in the experts’ subgroup. The potential decrease in hypoxemia in urgently intubated patients with the use of apneic oxygenation might have allowed less experienced operators more time for laryngoscopy, and thus led them to achieve higher first-pass success rates. Apneic oxygenation may be of less benefit to operators who are very skilled at laryngoscopy and can complete intubation quickly.
35
Higher first-pass success rates could also explain the decreased incidence of hypoxemia, given the direct relationship between number of attempts and the incidence of desaturations,
9,35,41
and secondary increase in patients’ safety.
35
Subgroup analysis by risk of bias showed that when only studies with low risk of bias were included, none of the outcomes analyzed showed an improvement with the use of apneic oxygenation, likely because the sample sizes were significantly reduced; however, this also raises a concern about the quality of the evidence of the available studies in regard to the use of apneic oxygenation.
In summary, in this meta-analysis apneic oxygenation was associated with increased peri-intubation SpO2, decreased hypoxemia, and increased first-pass intubation success. Apneic oxygenation is a potentially important adjunct for emergency airway management.
Appendix
Ovid EMBASE; 1988 to 2016 week 29
Scopus
(TITLE-ABS-KEY(intubat*) AND TITLE-ABS-KEY(preoxygenat* OR “pre oxygen*” OR “ap ox” OR ((apneic OR apnoeic OR passive OR insufflat*) W/2 oxygen*) OR ((“high flow” OR “high frequency” OR cannula* OR prong*) W/2 (nose OR nasal OR binasal OR nasopharyn*)) OR hfnc OR hfnp OR hhfnox)) AND AFT 2005 AND NOT (PMID(1* OR 2* OR 3* OR 4* OR 5* OR 6* OR 7* OR 8* OR 9*)) 183.
Ovid CENTRAL: 253 results
The asterisk (∗) is a commonly used “wildcard” symbol that broadens a search by finding words that start with the same letters. Use it with distinctive word stems to retrieve variations of a term with less typing.
Appendix E3
Risk-of-Bias Assessment of ED and ICU Studies
Appendix E4
Subgroup Analyses
Forest Plots for the Subgroup Analyses
Proceduralist Expertise (Trainees vs Experts)
Study Design (RCTs vs Observational Studies)
Risk of Bias
Supplementary Data
Appendix E2
ED and ICU study characteristics.
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1627
1630
35
J.C.
Sakles
J.M.
Mosier
A.E.
Patanwala
First pass success without hypoxemia is increased with the use of apneic oxygenation during rapid sequence intubation in the emergency department
Acad Emerg Med
23
2016
703
710
36
J.C.
Sakles
J.M.
Mosier
A.E.
Patanwala
Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department
Intern Emerg Med
11
2016
983
992
37
A.J.
Doyle
D.
Stolady
M.
Mariyaselvam
Preoxygenation and apneic oxygenation using transnasal humidified rapid-insufflation ventilatory exchange for emergency intubation
J Crit Care
36
2016
8
12
38
J.F.
Dyett
M.S.
Moser
A.E.
Tobin
Prospective observational study of emergency airway management in the critical care environment of a tertiary hospital in Melbourne
Anaesth Intensive Care
43
2015
577
586
39
J.
Lau
J.P.A.
Ioannidis
N.
Terrin
The case of the misleading funnel plot
BMJ
333
2006
597
600
40
L.
Papazian
A.
Corley
D.
Hess
Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review
Intensive Care Med
42
2016
1336
1349
41
K.
Hasegawa
K.
Shigemitsu
Y.
Hagiwara
Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study
Ann Emerg Med
60
2012
749
754.e742
YMEM
7304
S0196-0644(17)30582-6
10.1016/j.annemergmed.2017.05.001
American College of Emergency Physicians
Please see page 484 for the Editor’s Capsule Summary of this article.
Supervising editor: Henry E. Wang, MD, MS
All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
Trial registration number: PROSPERO (Study ID: CRD42016052438)
A
podcast
for this article is available at www.annemergmed.com.
Airway/systematic review/meta-analysis
Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis
Lucas
Oliveira J. e Silva
a
f
Daniel
Cabrera
MD
a
Patricia
Barrionuevo
MD
b
Rebecca L.
Johnson
MD
c
Patricia J.
Erwin
MLS
g
M. Hassan
Murad
MD, MPH
b
d
M. Fernanda
Bellolio
MD, MS
a
e
∗
Bellolio.Fernanda@mayo.edu
http://twitter.com/mfbellolio
http://twitter.com/lucasojesilva12
a
Department of Emergency Medicine, Mayo Clinic, Rochester, MN
Department of Emergency Medicine
Mayo Clinic
Rochester
MN
b
Knowledge Synthesis and Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
Knowledge Synthesis and Kern Center for the Science of Health Care Delivery
Mayo Clinic
Rochester
MN
c
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic
Rochester
MN
d
Division of Preventive, Occupational and Aerospace Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
Division of Preventive
Occupational and Aerospace Medicine
Department of Medicine
Mayo Clinic
Rochester
MN
e
Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
Department of Health Science Research
Division of Health Care Policy and Research
Mayo Clinic
Rochester
MN
f
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Faculdade de Medicina
Universidade Federal do Rio Grande do Sul
Porto Alegre
RS
Brazil
g
Mayo Clinic Libraries, Rochester, MN
Mayo Clinic Libraries
Rochester
MN
∗
Corresponding Author.
Study objective
We conduct a systematic review and meta-analysis to evaluate the effectiveness of apneic oxygenation during emergency intubation.
Methods
We searched Ovid MEDLINE, Ovid EMBASE, Ovid CENTRAL, and Scopus databases for randomized controlled trials and observational studies from 2006 until July 2016, without language restrictions. Gray literature, clinicaltrials.gov, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate first-pass success rates, incidence of hypoxemia, and lowest peri-intubation SpO2 between apneic oxygenation and standard oxygenation cases.
Results
A total of 1,386 studies were screened and 77 selected for full-text review. A total of 14 studies were included for qualitative analysis, and 8 studies (1,837 patients) underwent quantitative analysis. In the meta-analysis of 8 studies (1,837 patients), apneic oxygenation was associated with decreased hypoxemia (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.52 to 0.84), but was not associated with decreased severe hypoxemia (6 studies; 1,043 patients; OR 0.86; 95% CI 0.47 to 1.57) or life-threatening hypoxemia (5 studies; 1,003 patients; OR 0.90; 95% CI 0.52 to 1.55). Apneic oxygenation was associated with increased first-pass success rate (6 studies; 1,658 patients; OR 1.59; 95% CI 1.04 to 2.44) and increased lowest peri-intubation SpO2 (6 studies; 1,043 patients; weighted mean difference 2.2%; 95% CI 0.8% to 3.6%).
Conclusion
In this meta-analysis, apneic oxygenation was associated with increased peri-intubation oxygen saturation, decreased rates of hypoxemia, and increased first-pass intubation success.
KBJ00000000007456
2017-10-23T19:12:01
S300.2
S300
S0196-0644(17)30582-6
10.1016/j.annemergmed.2017.05.001
YMEM
0196-0644
7304
REV
NON-CRC
UNLIMITED
NONE
2017-07-14T16:28:55Z
01960644/v70i4/S0196064417305826/main.xml
130457
MAIN
JA 5.4.0 ARTICLE
FULL-TEXT
01960644/v70i4/S0196064417305826/main.assets/fx2.sml
13640
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx11.sml
14921
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx3.sml
12807
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx8.sml
14522
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx9.sml
13938
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/gr2.sml
14458
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/gr3.sml
19226
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx6.sml
14117
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx7.sml
14654
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx4.sml
14270
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx10.sml
14047
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx5.sml
12364
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx12.sml
14470
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/gr1.sml
13586
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx1.sml
12491
IMAGE-THUMBNAIL
01960644/v70i4/S0196064417305826/main.assets/fx2.jpg
71917
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx11.jpg
75925
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx3.jpg
65312
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx8.jpg
69934
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx9.jpg
69193
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/gr2.jpg
183083
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/gr3.jpg
103212
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx6.jpg
72907
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx7.jpg
75023
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx4.jpg
69808
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx10.jpg
68441
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx5.jpg
62748
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx12.jpg
70649
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/gr1.jpg
74670
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/fx1.jpg
62484
IMAGE-DOWNSAMPLED
01960644/v70i4/S0196064417305826/main.assets/mmc1.docx
42521
APPLICATION
01960644/v70i4/S0196064417305826/main.pdf
5178386
MAIN
1.7 6.5
DISTILLED OPTIMIZED BOOKMARKED
01960644/v70i4/S0196064417305826/main.raw
55712
S0196-0644(17)X0010-3
YMEM
0196-0644
70
4
201710
A1
A66
e39
e42
449
606
S0196-0644(17)30582-6
10.1016/j.annemergmed.2017.05.001
483
494.e11
main.pdf
PDF
1.7
local
1508843247104
collectiebehoudsniveau 1
2017-10-24T13:01:52.544+02:00
local
1508843247616
0
SHA-512
bd572f7db594a912f30c64ed106f76f4de34ae776727b04f643e0f9cec238694a08d377a96c44a099fe7af7f638538347f9abc905da0d45ff815fc1a629cfbbc
java.security.MessageDigest
5178386
Adobe Acrobat Document
1.7
DIAS
62
DIAS tentative identification
main.pdf
local
1508843247617
0
SHA-512
ed0f0c82dd766258cade327b1762568631a0a5518a97e22b60211e3f5cb4f77fe89abeeff04152df41293111f3d97212cb038279df3feff033ec50107f4475cb
java.security.MessageDigest
55712
not checked
main.raw
local
1508843247618
0
SHA-512
5383fb2a02009057ee9e0ba081e10bbf86a9f01e6fc4d834dd194f8b037d59c357c737050a58137ce9c3e5735918fba0e35bea70315e6a0a9366e390a3f78ebc
java.security.MessageDigest
130457
not checked
main.xml
local
1508843247619
0
SHA-512
e022b33a5d35801481f87408c28b2ff4b221e8d4872664caaf307885735069d73a282e912554edb592922c26f906ed6e3a6b07e6ae31c7ad741a3325d3925d77
java.security.MessageDigest
1025
not checked
podcst_o.gif
local
1508843247620
0
SHA-512
a3910e0dce7607a9431ecbf88bfa5827744225f835f5b60777edcd1e7a2c3defc0fa0d055bb0823957be951ad1f32f2ce7b56a9621318017d53562ec450f44aa
java.security.MessageDigest
933
not checked
podcst_s.gif
local
1508843247621
0
SHA-512
26e4de5594309069998f2f50196d04caca689ff341544f285f7da3bf1d917001a4a1d98d743dfece769e5784a6b69cb6866cc93a48accc47a578573dbf99695f
java.security.MessageDigest
62484
not checked
fx1.jpg
local
1508843247622
0
SHA-512
4406e8fe06847717d80e2d50cf3a5e0d4a4104afb00f4397cd95ac2da13bec23780d40bd1d15d1728702ddec20b2e9f705e2f46ae0b28a8c85f8fc7796489763
java.security.MessageDigest
12491
not checked
fx1.sml
local
1508843247623
0
SHA-512
291b231eaf073f2e620a9b29e70d1e4d95ad67c520801f76992ec8e76d44ce8f419ed5804058a0efa24075d35cfba91481fcba6fcab7ba16e2b73d9106ec1c89
java.security.MessageDigest
68441
not checked
fx10.jpg
local
1508843247624
0
SHA-512
7f3709d12b16f4cddbf6c9674d48d8e45c5b7047eac18df0b9d852ba55095dc1a1943bd006d4d76aa480f78acb058fb73ed2cfda3d1a932a7bee3142ec66f52d
java.security.MessageDigest
14047
not checked
fx10.sml
local
1508843247625
0
SHA-512
0f82a6b378c62fe7d932f53c8686b70eaa6adca1b4f5b8681195f6f59f165cf5e5e2bc9dd6227233b7541b612c4ef0a4209045602d9b38345ce40d189b139d5c
java.security.MessageDigest
75925
not checked
fx11.jpg
local
1508843247626
0
SHA-512
c05d18553059e63f383cb0595298b644e7ead377d4a277c2d044e894199e5396df33c1ec8e30f66eecaf1580d414c7bd35f427c439f93a464e4dc7c09a69f74e
java.security.MessageDigest
14921
not checked
fx11.sml
local
1508843247627
0
SHA-512
b4e9e0c48db1530f8c3aa7b53844541f6ca5e86299c1b3349c61f4ffb620c57ae1dea53ecdbe00757f09729404e9dd2696f246b7bfc5905d311fcac9e649c6f0
java.security.MessageDigest
70649
not checked
fx12.jpg
local
1508843247628
0
SHA-512
15a4c8c485247dee963365ac73ad322c5526ba1e9112262e9cc6f4cfad1bc64764af7e4b425820ec9091e4176869ee4824c34156ff88d38cf902a31f143ea814
java.security.MessageDigest
14470
not checked
fx12.sml
local
1508843247629
0
SHA-512
f0182219a2804c1a7b79c5385152bc45d17ddbbb85e77eacf3f6720bdc82a1469f18df01679f4685d48687f23cbe42fdf03e99c9a28a627c709d97219bb35335
java.security.MessageDigest
71917
not checked
fx2.jpg
local
1508843247630
0
SHA-512
899fc6a64dab5963cd05d27544f8f388e01059b61d66c6afc07aade9e4c6466ded2b874b62049277bab7c338b22025580f809fa871e28472882a03a79dc923f6
java.security.MessageDigest
13640
not checked
fx2.sml
local
1508843247631
0
SHA-512
6b0ec9871f7501a57b9172d3379f979f9803970cf9aabd88e3bd271fbe50606beb1eece2a8b7dace55351fc8d912c97b0bcee78b4886557816b4fa0d677b2d31
java.security.MessageDigest
65312
not checked
fx3.jpg
local
1508843247632
0
SHA-512
584e48b35ef44b19e9ab4a467699d9fd4fc8d153152782f642822ff8b28555373a81b4b9d2e6fa7c4858d317e4a65777c69564007f24b2614b1fd57ac3c1680a
java.security.MessageDigest
12807
not checked
fx3.sml
local
1508843247633
0
SHA-512
e20fcd7a7bb463c0b61e475b7c47b405f8e661ccbd1a45b77b25d5c3d53673d9d7a4a6eaa5347108a129f9e094e38700bcc6b8e632a0b716e4f8ddc57d931eab
java.security.MessageDigest
69808
not checked
fx4.jpg
local
1508843247634
0
SHA-512
c8db665a4b4803b2ecd6ca6bd0d38acc1c3abb240a5982725884393e679802fbcace542aeaa3867bda946f452284c3c7a04ce9c489c3af578987b3e819889279
java.security.MessageDigest
14270
not checked
fx4.sml
local
1508843247635
0
SHA-512
93e39df4e500b673808f83f8ae09fb5bd675dcca4fd41a8c8f8428b71fc4e8240db949c5489066aaf23d007077acf89077e6e7bd0fa8afb2b8c51f64e5e668e1
java.security.MessageDigest
62748
not checked
fx5.jpg
local
1508843247636
0
SHA-512
e489a6aa6d928a6e6c528931aca753669c40363b7ef028b0c815653678c53042cff8055bbf4bb5a364d0ef45ccc13b3f84055cd273dea717aeb6f70c73be3502
java.security.MessageDigest
12364
not checked
fx5.sml
local
1508843247637
0
SHA-512
3d4aa5ba711b3d5d7c9329f6fc6f763bf95c4ce4697701465bf5517704ebf97e579b145250eea0318630b7f695a74cfd61e8552ae8f28d64f671f95544e5672c
java.security.MessageDigest
72907
not checked
fx6.jpg
local
1508843247638
0
SHA-512
40122d6f73a51c8573f3bad86655c42b47cdc9b996896bdadd71c8839ab63dfee5f44dc0f327fa83cdf12ee7d2b79ec2e3a4116cab7e7e6b05bd5f19f03a8526
java.security.MessageDigest
14117
not checked
fx6.sml
local
1508843247639
0
SHA-512
1d231022550033bcc012f74355d50c42f8f582884ebef4102779e8447f7d20025880a7d4920f62527082b1e52103a9a4a7806d2478266fff059712725b90c66f
java.security.MessageDigest
75023
not checked
fx7.jpg
local
1508843247640
0
SHA-512
b132d6f7ae0ef6c4378fd60efa8e3d811f6f440be5213bf1496abc644a70bbca68e5a03b0b2748a083f0e0d584b5aba09082de138d82a58d56135db89bb14a19
java.security.MessageDigest
14654
not checked
fx7.sml
local
1508843247641
0
SHA-512
d2c15cfa0b1de971de2530ff01b6dd6fb89e0213947f2bf4a982146bcda8c37fd313f25fdb5269bfc8f3204c08b75e2bc58cbe8d93b97f0f050e778f59d7d9b8
java.security.MessageDigest
69934
not checked
fx8.jpg
local
1508843247642
0
SHA-512
5c2f2158bb7fffb3c57407bca1dd48b11ffef367299856452594b759a16b3ea434187b89cdabe7a2055fbd8e9b909c2e8418907b0f971547f6bd6767c0e37623
java.security.MessageDigest
14522
not checked
fx8.sml
local
1508843247643
0
SHA-512
10181de5603511e859adc2b2cd23ad825dbac12fdfc5d72b1ada9f56720bb2f51e00b04230f31cd77cf01423d8129559d9ab7a9db36480cf4f48291cbfdd8550
java.security.MessageDigest
69193
not checked
fx9.jpg
local
1508843247644
0
SHA-512
5e1cbaeacfc90c4a7ec5a0335bd9c007a9731d9670d86d383a511198988fb12711a7a6813eaefb810ab3e1dc94caddc0c13a07b78864c512f4dcee5aae5d82c3
java.security.MessageDigest
13938
not checked
fx9.sml
local
1508843247645
0
SHA-512
92c86e28e2c4e3b212ea4a9c6186a603b537c38c39d25998bbe17500fb1fc62c4ec1bbfdd8f524e911b69bc854956be821585057693a84598d4079b37719e21b
java.security.MessageDigest
74670
not checked
gr1.jpg
local
1508843247646
0
SHA-512
09e101fd4764c2cdf80ad6961a62b72a3e6c48c2a6e7c5acda792c5262b2c9f7e6213b130b7f6fc9fab00fffe41b0c3c93813745904f153348ece62a0f266e41
java.security.MessageDigest
13586
not checked
gr1.sml
local
1508843247647
0
SHA-512
0dace4ed8d9ef644bd6715c73e963388b64d2a16dede5be0a9a179fa3450a17d6f0a1347c76cb6164999b35dc80aa45853d1ec3b806a56e2a297f15096d4169b
java.security.MessageDigest
183083
not checked
gr2.jpg
local
1508843247648
0
SHA-512
534414009a362d16a204c11ab7878c8d23bcdbc4f8d40109437e55604dc7f2474bc0d4034d35f0434fb753c30adce3c9fa67cb97e5eb6730128c67ceadc1690a
java.security.MessageDigest
14458
not checked
gr2.sml
local
1508843247649
0
SHA-512
7f20a9388e087825851c87d3d057ed53e3a571ac48c75194a8b7c6f2492afa6676d9f47ae9b0dc9ba7b48f107419d554a06947c4416b19d75f1c575a8bf1a82a
java.security.MessageDigest
103212
not checked
gr3.jpg
local
1508843247650
0
SHA-512
5d7884aafa61b10dc602e8a21d27b5710bf71dc81312e10dd8839e1378fae54275629e94963729e349be35251cdeab36d321d096f3946be42c29dca870953e91
java.security.MessageDigest
19226
not checked
gr3.sml
local
1508843247651
0
SHA-512
dd1e452b48cde626e524dd01286fe6678c03cb55fa1861d0bd94ff16c14211842a63624f2c69b5f9936b49bb9d08e79c6a6041baadea1e18db9d77653c151585
java.security.MessageDigest
42521
not checked
mmc1.docx
local
1508843247652
0
SHA-512
3970b4fe2337dca8e7b60f835bcbbd8872771e5d5cb4475d7cd901ccf8ee0afd1578a5d6c1f5b0c59c3af50787ab378a703c97f94ec38996a84a182ca627a397
java.security.MessageDigest
28522
not checked
metadata.xml
free
00001
American College of Emergency Physicians
KB-agent-id
1
supplier
KB-owner-id
00001
KB-agent-id
1
Elsevier
organization
American College of Emergency Physicians
ingestion
2017-10-24T13:01:52.544+02:00
Connector
software
Digitaal Magazijn release 1.5
ejournals_esp_1
streamprofile
ingestion2017-10-24T13:06:08.183+01:00Generic IngestsoftwareDigitaal Magazijn release 1.5