Apneic Oxygenation for Avoiding Hypoxemia in ED Intubations

By now we’re all pretty used to employing apneic oxygenation for RSI in the ED. However, most of the data comes from the OR and elective setting or is retrospective.

A recent randomized trial of apneic oxygenation in ICU patients actually failed to show benefit, though this population may have already been maximally preoxygenated and too sick to benefit from apneic oxygenation.

Sackles et al just published the results of their prospective data collection on apneic oxygenation in ED intubations by EM residents in Academic Emergency Medicine.

They found a 13.1% increase (CI 6.2% to 19.9%, OR 2.2 CI 1.5 to 3.3) in first pass success without hypoxemia when apneic oxygenation was used.

Other factors associated with first pass success without hypoxemia were a normal baseline SpO2 (OR 4.8, CI 2.2 to 10.3), used of video laryngoscopy (OR 2.7, CI 1.6 to 4.6), and intubation performed by a senior resident (OR 2.1, CI 1.1 to 3.7).

There are certainly many limitations to this study as it was prospective, non-randomized, and self-reported by the residents. Apneic oxygenation was not required but was its use was encouraged in every intubation. It may be that those who chose to use it were more likely to be successful in the first place.

In any case, apneic oxygenation was independently associated with an increased chance of first pass success without hypoxemia. This study bolsters the evidence for this fast, cheap, easy, low-risk, high-reward intervention for emergency department airway management.

How many intubations do I need to be successful?

Buis et al recently published an article in Resuscitation reviewing studies that evaluated intubation success in trainees.

To achieve a 90% success rate with no more than two attempts, most learners needed to have performed at least 50 prior intubations. While this seems like an easily achievable number to get in residency, these studies were all done in the OR in an elective setting. Certainly more practice would be required for the many difficult airways we encounter in the ED.

This is more evidence that we should take every opportunity to continue to hone our airway skills and get as many repetitions as possible.