Prevention of Hypoxemia During Apnea Testing: A Comparison of Oxygen Insufflation And Continuous Positive Airway Pressure.

Abstract

Apnea testing is an essential step in the clinical diagnosis of brain death. Current international guidelines recommend placement of an oxygen (O2) insufflation catheter into the endotracheal tube to prevent hypoxemia, but use of a continuous positive airway pressure (CPAP) valve may be more effective at limiting arterial partial pressure of O2 (PO2) reduction. We performed a multicenter study assessing consecutive apnea tests in 14 intensive care units (ICUs) in two cities utilizing differing protocols. In one city, O2 catheters are placed and arterial blood gases (ABGs) performed at intervals determined by the attending physician. In the other city, a resuscitation bag with CPAP valve is attached to the endotracheal tube, and ABGs performed every 3-5min. We assessed arterial PO2, partial pressure of carbon dioxide (PCO2), pH, and blood pressure at the beginning and termination of each apnea test. Thirty-six apnea tests were performed using an O2 catheter and 50 with a CPAP valve. One test per group was aborted because of physiological instability. There were no significant differences in the degree of PO2 reduction (-59 vs. -32mmHg, p=0.72), rate of PCO2 rise (3.2 vs. 3.9mmHg per min, p=0.22), or pH decline (-0.02 vs. -0.03 per min, p=0.06). Performance of ABGs at regular intervals was associated with shorter test duration (10 vs. 7min, p<0.0001), smaller PCO2 rise (30 vs. 26mmHg, p=0.0007), and less pH reduction (-0.20 vs. -0.17, p=0.0012). Lower pH at completion of the apnea test was associated with greater blood pressure decline (p=0.006). Both methods of O2 supplementation are associated with similar changes in arterial PO2 and PCO2. Performance of ABGs at regular intervals shortens apnea test duration and may avoid excessive pH reduction and consequent hemodynamic effects.