R.E.B.E.L. EM - Posted by Salim Rezaie - February 8, 2016
"Background: Tracheal intubation is a procedure that is often performed in the ED on patients in critical condition. Because of this, there is the potential for complications such as hypoxemia, hypotension, dysrhythmias, aspiration, and cardiac arrest. Apneic Oxygenation (ApOx) is a concept first explored decades ago in the anesthesia literature and more recently, has gained acceptance in the ED. Studies in the operating room (OR) show that delivery of oxygen through the use of nasal cannula during periods of apnea significantly delays the onset of oxygen desaturation. These studies however, were in controlled settings with elective surgical patients who were not in critical condition. Physiologically, ApOx makes sense, its low cost, and low complexity and could improve the safety of RSI in the ED, by extending the safe apnea time. To date there have been no RCTs on ApOx in the ED. The recently published Fellow Trial questioned the use of ApOx in critically ill patients, but had some significant issues with 2/3 of the usual care arm not being apneic (i.e. Bag Valve Mask Ventilation or Non-Invasive Ventilation) prior to intubation...
What Trial are we Discussing?
HOT OFF THE PRESS: Sackles JC et al. First Pass Success Without Hypoxemia is Increased with the Use of Apneic Oxygenation During RSI in the Emergency Department. Acad Emerg Med 2016. [epub ahead of print] PMID: 26836712
Author Conclusion: “The use of ApOx during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of ApOx has the potential to increase the safety of RSI in the ED by reducing the number of attempts and incidence of hypoxemia.”
Clinical Take Home Point: Use of ApOx during RSI in adult patients in the ED, is low cost, low complexity, and not proven to cause harm while also reducing incidence of hypoxemia and increasing first pass attempt intubation. It is time for a RCT evaluating this modality."