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Updated: Jul 9, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis
Alexander Fuchs1, Gabriela Koepp2, Markus Huber2
1Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
Insights
Apnoeic oxygenation during tracheal intubation in children improves first-attempt success and oxygen saturation. This method reduces hypoxemia risk, ensuring stable physiological conditions for pediatric patients undergoing intubation.
Area of Science:
- Pediatric Anesthesiology
- Respiratory Medicine
- Critical Care
Background:
- Apnoeic oxygenation aims to extend safe apnea duration during laryngoscopy for tracheal intubation.
- It is intended to reduce hypoxemia and improve first-attempt intubation success rates in pediatric patients.
- This systematic review evaluates the efficacy and effectiveness of apnoeic oxygenation in children.
Conclusions:
- Apnoeic oxygenation during tracheal intubation in children significantly enhances first-pass success rates.
- The technique effectively maintains stable physiological conditions by preserving normal oxygen saturation levels.
- This supports the routine use of apnoeic oxygenation in pediatric tracheal intubations.
Background:
Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.
Methods:
This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.
Results:
After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.
Conclusion:
This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.
Clinical Trial Registration:
Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.
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