The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review
Open accessAbstract
Purpose 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. Source 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. Principal findings 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. Conclusion 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.
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The balance of evidence suggests that high-flow nasal oxygenation as an adjunct to preoxygenation for RSI is both safe and effective.
“Numerous studies have evaluated to effectiveness of HFNO as an adjunct to preoxygenation for RSI, and the balance of evidence suggest the procedure as both safe and effective.104”
From Airway Management in Trauma (2018) · cites this paper as [104]
The section on apneic oxygenation in clinical settings reports reduced desaturation in some intubation studies, including one using high-flow nasal oxygen and one involving rapid sequence intubation. But the Conclusion (page unavailable) says most studies were too small to assess serious adverse events and warns that prolonged apneic oxygenation may be risky. The review therefore supports possible effectiveness, not the unqualified claim that HFNO is both safe and effective as an adjunct for RSI. (LLM, conf=0.89)
Experimental — accuracy not yet measuredThe most important determinant of time to desaturation remains preoxygenation status.
“Although recent literature has focused on extending safe apnea time with passive high-flow nasal oxygenation (HFNO) with or without noninvasive ventilation, the most important determinant of time to desaturation remains preoxygenation status.104”
From Airway Management in Trauma (2018) · cites this paper as [104]
The practical guide in “Limitations of this review” recommends preoxygenation before intubation and checking that end-tidal oxygen reaches 85–90%. The review also reports that apneic oxygenation can prolong time to desaturation, but it does not establish that preoxygenation status is the most important determinant of that time. Page numbers are unavailable in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredApneic oxygenation using conventional or specialized nasal prongs to administer high-flow oxygen (10-70 LPM) may extend the safe apnea time after an RSI by continuously replenishing the FRC oxygen stores.
“By continuously replenishing the FRC oxygen stores, apneic oxygenation using conventional or specialized nasal prongs to administer high-flow oxygen (10-70 LPM) may extend the safe apnea time after an RSI.103,104”
From Airway Management in Trauma (2018) · cites this paper as [104]
Apneic oxygenation is facilitated by the pressure gradient between the oropharynx and the alveoli created by the differential uptake of oxygen and delivery of CO2 to and from the alveoli, resulting in the passive transfer of oxygen.
“AO is facilitated by the pressure gradient between the oropharynx and the alveoli created by the differential uptake of oxygen and delivery of CO2 to and from the alveoli, resulting in the passive transfer of oxygen.104,107”
From Airway Management in Trauma (2018) · cites this paper as [104]
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Research works printed but not linked: 26
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Kovacs, G., & Sowers, N. (2018) · Emergency Medicine Clinics of North America · doi:10.1016/j.emc.2017.08.006 · Cited by 115 · see citing works
- Authors
- Wong, D. T., Yee, A. J., Leong, S. M., & Chung, F.
- Affiliations
- University Health Network (CA)
- Corresponding author
- Wong, David T.
- Venue
- Canadian Journal of Anesthesia/Journal canadien d'anesthésie
- Published
- 2017-01-03
- Volume
- 64
- Issue
- 4
- Pages
- 416-427
- ISSN
- 0832-610X (ISSN-L)
- 1496-8975
- OpenAlex
- W2563460907
- Cited by
- 89
- References
- 0
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 9 · 2023: 12 · 2022: 14 · 2021: 7 · 2020: 5 · 2019: 9 · 2018: 9 · 2017: 12 · 2016: 1 · 2015: 1
- FWCI
- 2.09
- Type
- journal article
- Language
- en
- Update notices
- correction (2017-02-27)
- Open access
- bronze
- doi.org
- Locations
- Canadian Journal of Anesthesia/Journal canadien d anesthésie (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Department of Anesthesia, University Health Network, University of Toronto, Toronto
- Topics
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Airway Management and Intubation Techniques
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
- Keywords
- apneic oxygenation, endotracheal intubation, oxygen desaturation, arterial oxygen saturation, hypoxemia, respiratory failure, operating room, intensive care unit, emergency department, prehospital care, hypercapnia, intracranial pressure, metabolic acidosis, hyperkalemia, pulmonary hypertension
- MeSH terms
- Hypoxia, Apnea, Emergency Service, Hospital, Humans, Intensive Care Units, Intubation, Intratracheal, Operating Rooms, Oxygen Inhalation Therapy
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