SPA Annual Meeting Reviews
Session I: PEDx Continuous Oxygenation During Intubation
Reviewed by Ashlee Holman, MD
Assistant Professor of Anesthesiology
University of Michigan
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Dr. Holman |
Oxygenation During Intubation: The Science, Technologies, and Techniques
Jeff Steiner, DO, MBA
Jeff Steiner, DO, MBA (Children’s Health UT Southwestern Medical Center, Associate Professor) began his talk with the objectives:
- List the various methods of providing oxygen during intubation in the pediatric population.
- Describe apneic oxygenation in children
- Develop strategies at their own institution on how to add supplemental oxygen during intubation.
He initially stressed the importance of maintaining blood-oxygen levels with supplemental oxygen during intubation, as children have limited respiratory reserve in comparison with adults. In children, desaturation is dependent on adequate preoxygenation and the patient’s functional residual capacity, oxygen consumption, and pulmonary function. Risk of hypoxia increases with increased number of intubation attempts.
The first article Dr. Steiner referenced was from Fiadjoe et al1 which published data from 13 children’s hospitals detailing 1018 difficult pediatric intubation encounters, with the most common non-severe complication of hypoxia in 8% of anticipated difficult airways and 15% of unanticipated difficult airways. The second article Dr. Steiner referenced was Galvez et al2 which stated that multiple laryngoscopic attempts in infants age < 1 year may result in hypoxemia (35%), bradycardia (8.9%), or both (3.7%).
Dr. Steiner discussed the use of the TruView Infant EVO2 laryngoscope (laryngoscope with an oxygen insufflation side-port) in neonates and infants, in which several studies concluded that the glottic view obtained and time to obtaining glottic view were equivalent to standard laryngoscopes. One study from Mutlak et al3 hypothesized that “the absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety”. Dr. Steiner described modification of standard blades with an endotracheal tube and tegaderm to supplement oxygen during intubation in lieu of a TruView Infant EVO2 laryngoscope itself.
The idea of apneic oxygenation is not new. In 1959, an article describing apneic oxygenation was published in Anesthesiology. In 1976, a patent was submitted for development of a suctioning/oxygenating laryngoscope blade. In 1981, intubation of infants with a modified laryngoscope was investigated, and this study found that the procedure of intubation was less stressful to both the patient and to the operator. In 1998, evaluation of apneic oxygenation and changes in blood-gas tensions in pediatric patients showed that children desaturate three times faster than adults.
Dr. Steiner described the use of supplemental oxygen via nasal cannula during intubation as well as use of deep laryngeal oxygenation (better than nasal cannula) in the Emergency Department literature. He suggested using supplemental oxygen during intubations which may take longer or be more difficult (e.g. intubations by trainees or in dental cases requiring nasal intubations). Dr. Steiner referenced an article by Steiner et al4 which concluded that laryngeal oxygen insufflation reduces the overall rate of desaturation during pediatric laryngoscopy. See graph from article below.
Dr. Steiner recommended three techniques during intubation to decrease the risk of oxygen desaturation:
- Adequate preoxygenation
- Addition of nasal cannula oxygen
- Use of minimum oxygen flows of 0.2 L/kg/min.
References:
- Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016 Jan;4(1):37-48.
- Galvez JA, Acquah S, Ahumada L, et al. Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study. Anesthesiology. 2019 Oct;131(4):830-839.
- Mutlak H, Rolle U, Rosskopf W, et al. Comparison of the TruView EVO2 PCDTM and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways. Clinics (Sao Paulo). 2014;69(1):23-27.
- Steiner JW, Sessler DI, Makarova N, et al. Use of deep laryngeal oxygen insufflation during laryngoscopy in children: a randomized clinical trial. Br J Anaesth. 2016 Sep;117(3):350-7.
