Utility of Apneic Oxygenation with Intubation to Reduce Severe Desaturation and Adverse Tracheal Intubation Associated Events in Critically Ill Children

Abstract

Abstract Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units (ICUs) as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO were as follows: 5 liters/minute for infants (< 1 year), 10 liters/minute for young children (1–7 years), and 15 liters/minute for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). Results Of 6,549 TIs during the study period, 2,554 (39.0%) occurred during the pre-implementation phase and 3,995 (61.0%) during post-implementation phase. AO utilization increased from 23–68%, p < 0.001. AO was utilized less often when intubating infants, those with a primary cardiac diagnosis or difficult airway features, and patient intubated due to respiratory or neurological failure or shock. Conversely, AO was used more often in TIs done for procedures and those assisted by video laryngoscopy. AO utilization was associated with a lower incidence of adverse TIAEs (AO 10.5% vs without AO 13.5%, p < 0.001), aOR 0.75 (95% CI 0.58–0.98, p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72–1.12, p = 0.33. The occurrence of hypoxemia was not different: AO 14.2% vs without AO 15.2%, p = 0.43. Conclusion AO utilization was associated with a lower occurrence of adverse TIAEs in patients undergoing TI in the pediatric ICU.