Incidence Of Arterial Oxygen Desaturation Research Articles

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

BackgroundThe objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). MethodsIn this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients’ age (older or younger than 1 year). ResultsComplete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). ConclusionsResults of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.

HELP-VDL: study protocol for a multicentre, open, randomised, controlled clinical trial comparing the use of the head-elevated laryngoscopy position and the use of a videolaryngoscope to facilitate orotracheal intubation in a patient population without predictable difficulty of intubation

IntroductionTracheal intubation remains an everyday challenge for anaesthesiologists, even in patients without suspected difficult airways. The ideal positioning of the patient’s head (flat, raised a few centimetres on a cushion...

Capnography monitoring in procedural intravenous sedation: a systematic review and meta-analysis.

Currently, procedural sedation in the clinical setting relies heavily on the use of pulse oximetry to monitor hypoxemia. Different studies suggest that incidence of hypoxemia and incidence of arterial oxygen desaturation are reduced by early intervention via capnography monitoring. The aim of this article was to discuss the importance of implementing capnography monitoring during procedural sedations performed in a dental setting and determine whether additional capnographic monitoring reduces the incidence of arterial oxygen desaturation and the overall complications rate. Two independent reviewers conducted electronic (PubMed and EMBASE) and manual searches up to February 2020. Randomized clinical trials (RCTs), including both patients under procedural sedation monitored by capnography and oximetry, and reporting the incidence of hypoxemia or episodes of oxygen desaturation were included. Risk ratio was used to compare the outcomes (i.e., the incidence of hypoxemia, the episodes of oxygen desaturation, the detection of apnea, the reduction of events of bradycardia, and hypotension) between patients monitored by capnography and standard approach. Fourteen randomized clinical trials fulfilling the inclusion criteria were selected. The analysis revealed that capnography monitoring group showed the lower incidence of hypoxemia (RR 0.76, 95%CI 0.70 to 0.83, p < 0.001) and the episodes of oxygen desaturation (RR 0.79, 95%CI 0.71 to 0.87, p < 0.001) compared with the oximetry monitoring group. Apnea was detected in capnography monitoring earlier than standard monitoring (RR 2.60, 95%CI 2.30 to 2.93, p < 0.001). No significant difference was found between capnography and standard monitoring groups in terms of reduction of events of bradycardia (RR 1.17, 95%CI 0.91 to 1.50, p = 0.225) and hypotension (RR 0.96, 95%CI 0.76 to 1.21, p = 0.746). Capnography monitoring reduced incidence of hypoxemia during procedural sedations. Within the limitations of this review, we suggest that the application of capnography during procedural sedation would decrease the frequency of oxygen desaturation events and incidence of hypoxemia. Training and instructing dental providers on using capnography monitoring would help in reducing adverse events during intravenous sedation.

High-flow versus standard nasal cannula in morbidly obese patients during colonoscopy: A prospective, randomized clinical trial

Study objectiveMorbid obesity is associated with adverse airway events including desaturation during deep sedation. Prior works have suggested that proprietary high-flow nasal cannula devices generate positive pressure to all airway structures and may be superior to standard (low-flow) nasal cannula for prevention of desaturation. We hypothesized that, at a similar fraction of inspired oxygen (FiO2), use of a High-Flow Nasal Cannula (HFNC) at maximum flow rate would result in a lower incidence of intra-procedural desaturation episodes in morbidly obese patients compared to standard nasal cannula (SNC) during deep sedation with propofol. DesignThis is a pragmatic, prospective, randomized clinical trial at one hospital (NCT03148262, UTSW#112016-058). Morbidly obese patients were randomized to HFNC during propofol sedation for colonoscopy. HFNC was performed using maximum flow rates of 60 liters per minute (LPM) and FiO2 of 0.36–0.40, whereas SNC was performed at 4LPM. The primary endpoint was incidence of arterial oxygen desaturation <90% measured by pulse oximetry. At midpoint enrollment the Data Monitoring Committee (DMC) performed a pre-planned O'Brien and Fleming futility test. Main resultsPatients were randomized to HFNC (n = 28) or SNC (n = 31). Interim analysis of the primary endpoint showed that the desaturation rates in the HFNC group (39.3%) and the SNC group (45.2%) were not significantly different (p = 0.79). The DMC halted the trial at that point due to futility. ConclusionAt similar FiO2, HFNC was not significantly different from SNC for prevention of arterial oxygen desaturation in morbidly obese patients undergoing propofol sedation for colonoscopy.

Erratum to: The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review.

During the process of tracheal intubation, patients are apneic or hypoventilating and are at risk of becoming hypoxemic. This risk is especially high in patients with acute or chronic respiratory failure and accompanying compromised respiratory reserve. To address this concern, apneic oxygenation can be administered during tracheal intubation to aid in maintaining arterial oxygen saturation. The objective of this narrative review is to examine the utilization of apneic oxygenation within the operating room, intensive care unit (ICU), emergency department, and pre-hospital settings and to determine its efficacy compared with controls. For this narrative review, we obtained pertinent articles using MEDLINE® (1946 to April 2016), EMBASE™ (1974 to April 2016), Google Scholar, and manual searches. Apneic oxygenation was administered using various techniques, including the use of nasal prongs, nasopharyngeal or endotracheal catheters, or laryngoscopes. First, all 12 operating room studies showed that apneic oxygenation significantly prolonged the duration to, and incidence of, desaturation. Second, two of the five ICU studies showed a significantly smaller decline in oxygen saturation with apneic oxygenation, with three studies showing no statistically significant difference vs controls. Lastly, two emergency department or pre-hospital studies showed that the use of apneic oxygenation resulted in a significantly lower incidence of desaturation and smaller declines in oxygen saturation. Sixteen of the 19 studies showed that apneic oxygenation prolongs safe apneic time and reduces the incidence of arterial oxygen desaturation. Overall, studies in this review show that apneic oxygenation prolongs the time to oxygen desaturation during tracheal intubation. Nevertheless, the majority of the studies were small in size, and they neither measured nor were adequately powered to detect adverse respiratory events or other serious rare complications. Prolonged apneic oxygenation (with its consequent hypercarbia) can have risks and should be avoided in patients with conditions such as increased intracranial pressure, metabolic acidosis, hyperkalemia, and pulmonary hypertension.

The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review.

During the process of tracheal intubation, patients are apneic or hypoventilating and are at risk of becoming hypoxemic. This risk is especially high in patients with acute or chronic respiratory failure and accompanying compromised respiratory reserve. To address this concern, apneic oxygenation can be administered during tracheal intubation to aid in maintaining arterial oxygen saturation. The objective of this narrative review is to examine the utilization of apneic oxygenation within the operating room, intensive care unit (ICU), emergency department, and pre-hospital settings and to determine its efficacy compared with controls. For this narrative review, we obtained pertinent articles using MEDLINE® (1946 to April 2016), EMBASE™ (1974 to April 2016), Google Scholar, and manual searches. Apneic oxygenation was administered using various techniques, including the use of nasal prongs, nasopharyngeal or endotracheal catheters, or laryngoscopes. First, all 12 operating room studies showed that apneic oxygenation significantly prolonged the duration to, and incidence of, desaturation. Second, two of the five ICU studies showed a significantly smaller decline in oxygen saturation with apneic oxygenation, with three studies showing no statistically significant difference vs controls. Lastly, two emergency department or pre-hospital studies showed that the use of apneic oxygenation resulted in a significantly lower incidence of desaturation and smaller declines in oxygen saturation. Sixteen of the 19 studies showed that apneic oxygenation prolongs safe apneic time and reduces the incidence of arterial oxygen desaturation. Overall, studies in this review show that apneic oxygenation prolongs the time to oxygen desaturation during tracheal intubation. Nevertheless, the majority of the studies were small in size, and they neither measured nor were adequately powered to detect adverse respiratory events or other serious rare complications. Prolonged apneic oxygenation (with its consequent hypercarbia) can have risks and should be avoided in patients with conditions such as increased intracranial pressure, metabolic acidosis, hyperkalemia, and pulmonary hypertension.

Sidestream capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol ambulatory anesthesia for surgical abortion.

BackgroundThis study investigated whether early intervention based on additional use of sidestream capnography could reduce the incidence of oxygen desaturation and hypoxic events in patients receiving propofol anesthesia during surgical abortion.Material/MethodsWe recruited 704 ASAI-III female patients, 18–52 years old and scheduled for planned painless surgical abortion, and randomized them into a control group (n=359) receiving standard monitoring and an experimental group (n=341) receiving standard monitoring and additional capnography. Exclusion criteria were preexisting cardiovascular disease, preexisting hypotension, bradycardia or arrhythmia, and drug allergy. Anesthesia was induced in all patients with propofol using target-controlled infusion at a target propofol plasma concentration of 4 μg/ml. All patients received flurbiprofen axetil 50 mg and 0.5 μg/kg fentanyl 5 min before anesthesia. Bispectral index was used and maintained between 45 and 60. Main outcome measures were apnea or abnormal ventilation status, rate of oxygen desaturation, occurrence of hypoxia and severe hypoxia, and perioperative side effects.ResultsThe experimental group had significantly higher rate of apnea or abnormal ventilation, significantly lower rate of oxygen desaturation, and significant lower occurrence of hypoxia and severe hypoxia compared to the control group. We found no statistically significant differences between the 2 groups in the rates of increased oxygen supplementation, assisted ventilation, bradycardia, hypotension, dosage of atropine, dosage of ephedrine or phenylephrine, and the amount of propofol consumed.ConclusionsSidestream capnographic monitoring improves early detection of alterations in ventilation parameters and reduces the incidence of oxygen desaturation and hypoxemia resulting from propofol anesthesia during surgical abortion.

Capnographic Monitoring Reduces the Incidence of Arterial Oxygen Desaturation and Hypoxemia During Propofol Sedation for Colonoscopy: A Randomized, Controlled Study (ColoCap Study)

The aim of this randomized study was to determine whether intervention based on additional capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol sedation for colonoscopy. Patients (American Society of Anesthesiologists classification (ASA) 1-3) scheduled for colonoscopy under propofol sedation were randomly assigned to either a control arm with standard monitoring (standard arm) or an interventional arm in which additional capnographic monitoring (capnography arm) was available. In both study arms, detection of apnea or altered respiration induced withholding propofol administration, stimulation of the patient, chin lift maneuver, or further measures. The primary study end point was the incidence of arterial oxygen desaturation (defined as a fall in oxygen saturation (SaO(2)) of ≥5% or <90%); secondary end points included the occurrences of hypoxemia (SaO(2) <90%), severe hypoxemia (SaO(2) ≤85%), bradycardia, hypotension, and the quality of sedation (patient cooperation and patient satisfaction). A total of 760 patients were enrolled at three German endoscopy centers. The intention-to-treat analysis revealed a significant reduction of the incidence of oxygen desaturation in the capnography arm in comparison with the standard arm (38.9% vs. 53.2%; P<0.001). The numbers of patients with a fall in SaO(2) <90% and ≤85% were also significantly different (12.5% vs. 19.8%; P=0.008 and 3.7 vs. 7.8%; P=0.018). There were no differences regarding the rates of bradycardia and hypotension. Quality of sedation was similar in both groups. Results of statistical analyses were maintained for the per-protocol population. Additional capnographic monitoring of ventilatory activity reduces the incidence of oxygen desaturation and hypoxemia during propofol sedation for colonoscopy.

Microstream Capnography Improves Patient Monitoring During Moderate Sedation: A Randomized, Controlled Trial

Investigative efforts to improve monitoring during sedation for patients of all ages are part of a national agenda for patient safety. According to the Institute of Medicine, recent technological advances in patient monitoring have contributed to substantially decreased mortality for people receiving general anesthesia in operating room settings. Patient safety has not been similarly targeted for the several million children annually in the United States who receive moderate sedation without endotracheal intubation. Critical event analyses have documented that hypoxemia secondary to depressed respiratory activity is a principal risk factor for near misses and death in this population. Current guidelines for monitoring patient safety during moderate sedation in children call for continuous pulse oximetry and visual assessment, which may not detect alveolar hypoventilation until arterial oxygen desaturation has occurred. Microstream capnography may provide an "early warning system" by generating real-time waveforms of respiratory activity in nonintubated patients. The aim of this study was to determine whether intervention based on capnography indications of alveolar hypoventilation reduces the incidence of arterial oxygen desaturation in nonintubated children receiving moderate sedation for nonsurgical procedures. We included 163 children undergoing 174 elective gastrointestinal procedures with moderate sedation in a pediatric endoscopy unit in a randomized, controlled trial. All of the patients received routine care, including 2-L supplemental oxygen via nasal cannula. Investigators, patients, and endoscopy staff were blinded to additional capnography monitoring. In the intervention arm, trained independent observers signaled to clinical staff if capnograms indicated alveolar hypoventilation for >15 seconds. In the control arm, observers signaled if capnograms indicated alveolar hypoventilation for >60 seconds. Endoscopy nurses responded to signals in both arms by encouraging patients to breathe deeply, even if routine patient monitoring did not indicate a change in respiratory status. Our primary outcome measure was patient arterial oxygen desaturation defined as a pulse oximetry reading of <95% for >5 seconds. Secondary outcome measures included documented assessments of abnormal ventilation, termination of the procedure secondary to concerns for patient safety, as well as other more rare adverse events including need for bag-mask ventilation, sedation reversal, or seizures. Children randomly assigned to the intervention arm were significantly less likely to experience arterial oxygen desaturation than children in the control arm. Two study patients had documented adverse events, with no procedures terminated for patient safety concerns. Intervention and control patients did not differ in baseline characteristics. Endoscopy staff documented poor ventilation in 3% of all procedures and no apnea. Capnography indicated alveolar hypoventilation during 56% of procedures and apnea during 24%. We found no change in magnitude or statistical significance of the intervention effect when we adjusted the analysis for age, sedative dose, or other covariates. The results of this controlled effectiveness trial support routine use of microstream capnography to detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children. In addition, capnography allowed early detection of arterial oxygen desaturation because of alveolar hypoventilation in the presence of supplemental oxygen. The current standard of care for monitoring all patients receiving sedation relies overtly on pulse oximetry, which does not measure ventilation. Most medical societies and regulatory organizations consider moderate sedation to be safe but also acknowledge serious associated risks, including suboptimal ventilation, airway obstruction, apnea, hypoxemia, hypoxia, and cardiopulmonary arrest. The results of this controlled trial suggest that microstream capnography improves the current standard of care for monitoring sedated children by allowing early detection of respiratory compromise, prompting intervention to minimize hypoxemia. Integrating capnography into patient monitoring protocols may ultimately improve the safety of nonintubated patients receiving moderate sedation.

Arterial oxygen desaturation during esophagogastroduodenoscopy.

This prospective study evaluated the incidence and severity of arterial oxygen desaturation during esophagogastroduodenoscopy (EGD) and assessed clinical factors in relation to arterial oxygen desaturation. Following pulmonary function testing, 192 patients underwent elective EGD with continuous recording of arterial oxygen saturation (SaO2). 62 patients (32.3%) showed arterial oxygen desaturation (SaO2 decrease greater than 4% from baseline SaO2); severe arterial oxygen desaturation (SaO2 less than or equal to 85%) reflecting hypoxemia (arterial oxygen tension less than or equal to 50 mmHg) was found in 17 patients (8.9%). These changes were most frequent at the esophageal stage of EGD but most marked at the gastroduodenal stage of EGD. The incidence of arterial oxygen desaturation was not related to age, sex, preendoscopic pulmonary function tests, smoking, or duration of endoscopy. These data support that continuous monitoring of SaO2 should be standard procedure during endoscopy because there was no identifiable preendoscopic risk factor for arterial oxygen desaturation during EGD. But there was no persistent drop in SaO2 longer than 2 minute. We suppose that oxygen supplement may not be required during EGD even in patients with modestly impaired pulmonary function tests.

An alternative oxygen delivery system for infants and children in the post-anaesthesia care unit

This randomized controlled trial compared the compliance of a blow-by oxygen method with the standard face mask by children recovering from anaesthesia. The rate at which a face mask was rejected when applied to infants and children in PACU was compared with that of a proposed "hose" method. The efficacy of the "hose" as a method of oxygen supplementation in children at low and high risk for developing postoperative hypoxaemia was also compared with the face mask. Using a Nellcor N-200 pulse oximeter, 66 infants and children (mean age 2.3 yr, range 2 mo-6 yr) were continuously monitored for 30 min upon arrival in the PACU. Patients were randomized to receive oxygen supplementation with either the face mask or the proposed "hose" method. The results showed a greater than 80 per cent rejection of the face mask in contrast to 100 per cent compliance with the "hose" method. The SaO2 measurements following 5, 15 and 30 min of O2 supplementation with the hose were all significantly higher than the SaO2 measurements obtained on room air upon arrival to the PACU. Patients with pre-existing cardiopulmonary disease had a 20 per cent incidence of arterial oxygen desaturation upon arrival to the PACU versus 2.1 per cent of patients with no pre-existing disease. It is concluded that the "hose" is associated with high patient compliance and is effective in the PACU in increasing the SaO2 in children at low or high risk of developing postoperative hypoxaemia.

Hypoxemia during outpatient general anesthesia

A high incidence of arterial oxygen desaturation during outpatient general anesthesia was found when patients were continuously monitored with the ear oximeter. The incidence of hypoxemia is minimized by the use of supplemental oxygen.

Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men

Using standard sleep techniques, we performed a placebo-controlled and randomized study to assess the effect of alcohol ingestion (2 ml/kg of body weight) on breathing and oxygen saturation during sleep. Twenty asymptomatic men volunteered for the two-night study: 11 were given a placebo on night 1, and alcohol on night 2 (group A); nine were given alcohol on night 1 and a placebo on night 2 (group B). We compared the incidence of sleep events (apnea, hypopnea and arterial oxygen desaturation) during the nights the subjects received alcohol and during the nights they received the placebo. Alcohol was associated with significant increases in the occurrence of the following: the number of sleep events (207 to 383, p < 0.01), the events of arterial oxygen desaturation (118 to 226, p < 0.01) and the number of apneic events (20 to 110, p < 0.01). Alcohol had no significant effects on the number of times hypopnea occurred. Values obtained during sleep on the control night after alcohol ingestion also showed that the episodes of arterial oxygen desaturation remained statistically increased over control values before the ingestion of any alcohol (p = 0.01). These results show that in asymptomatic men alcohol ingestion increases the incidence of arterial oxygen desaturation and disordered breathing during sleep and that the increase in arterial oxygen desaturation persists for an additional night, even when no alcohol is consumed.