Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU
Natalie Napolitano1, Elizabeth K Laverriere2,3, Nancy Craig4
11Respiratory Care, Department of Nursing and Clinical Services, Children's Hospital of Philadelphia, Philadelphia, PA. 2Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. 3Division of General Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. 4Nursing, Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, PA. 5Critical Care Medicine, Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 6Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ. 7Critical Care Medicine, Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, NY. 8Department of Pediatrics, Section of Pediatric Critical Care, UAMS/Arkansas Children's Hospital, Little Rock, AR. 9Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Objectives:
To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation.
Design:
Prospective pre/post observational study.
Setting:
A large single-center noncardiac PICU in North America.
Patients:
All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018.
Interventions:
Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement.
Measurements And Main Results:
Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34-0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31-0.96) while adjusting for tracheal intubation indications and device.
Conclusions:
Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.
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