Apneic Oxygenation During Airway Management in Pediatric Patients
Condition: Hypoxia
MeSH terms: Hypoxia
Study type: Interventional

Summary: 
      Airway placement after anesthetic induction in pediatric patients is routinely performed at
      our institution without apneic oxygenation. When intubation is attempted by an inexperienced
      (learner) provider, the attending physician intervenes if necessary before the patient
      experiences excessive loss of oxygenation. The investigators plan to institute routine
      supplemental oxygenation via nasal cannula during this placement. This study will examine the
      effect of adding apneic oxygenation via nasal cannula on oxygen saturation.
    

Detailed description: 
      This observational (i.e. nonrandomized) study aims to investigate the effect of a planned
      practice change; instituting oxygenation via nasal cannula during induction of anesthesia.
      The use of a nasal cannula during the peri-intubation period is of minimal risk and is not
      considered a standard of care in pediatric anesthesia. Some providers use it in certain
      clinical situations, but it is not broadly used and has virtually no pediatric literature to
      support or refute its use. At our institution, intubation of pediatric patients by
      inexperienced (learner) providers under expert supervision is routine. The attending
      physician intervenes if necessary before the patient experiences excessive loss of
      oxygenation.

      Participants will be enrolled in the study once they have entered the pre-operative area and
      are determined by the attending anesthesiologist to be an eligible study participant.
      Participants enrolled in the first three months of the study (up to N=200) will be assigned
      to the baseline condition as described below. Participants enrolled in the second phase of
      the study (up to N=300) will be assigned to the with-cannula condition described below.

      Apneic oxygenation is based on the physiology of the lungs: they absorb a greater volume of
      oxygen, 250 ml/min in an adult, than the volume of carbon dioxide, 8-20 mL/min, that is
      released by the lungs, because the majority of carbon dioxide is buffered in the blood stream
      during apnea. With the imbalanced volumes of absorption and release of gases in the lungs
      there is a lower than atmospheric pressure in the lungs, creating a passive movement of gases
      from pharynx to alveoli. If the gas in the pharynx has a significantly higher percentage of
      oxygen instead of room air at 21% oxygen, a higher amount of oxygen can be passively
      delivered to the lungs for absorption prolonging the time to hemoglobin desaturation.

      For the Baseline Group of this observational (nonrandomized) study, all intubation procedures
      will be performed as per usual practice. Patients will receive premedication as determined by
      anesthesiologist/resident/midlevel. Once patients are brought to the operating room and vital
      signs are being monitored, patients will be preoxygenated via mask per standard of care, with
      an expired oxygenation concentration minimum of 0.75. Vitals will be recorded at the moment
      prior to removal of the face mask at the end of the preoxygenation period. Anesthetic
      induction will be performed with agents and dosages as per the provider's clinical judgment.
      Airway management consisting of oral endotracheal intubation or laryngeal mask airway
      insertion will take place. As per standard of care, an attending physician who is expert in
      pediatric airway management will supervise the procedure and intervene before the patient
      experiences excessive oxygen desaturation.

      For the With-Cannula Group, all of the above steps will be maintained. The sole difference
      will be nasal cannula placement after induction. It will be set to deliver oxygen at 5 liters
      per minute. Airway management consisting of oral endotracheal intubation or laryngeal mask
      airway insertion will take place. As per standard of care, an attending physician who is
      expert in pediatric airway management will supervise the procedure and intervene before the
      patient experiences excessive oxygen desaturation.

      Apneic oxygenation will not be used as a long-term oxygenation strategy. No patient will be
      allowed to become hypoxic for research reasons.

      All intubation procedures in both study groups will proceed as per usual practice. The goal
      of all intubation procedures has always been and remains the maintenance of adequate oxygen
      saturation.
    

Intervention name(s): Supplemental oxygen via nasal cannula
Intervention type(s): Device
Allocation: Non-Randomized
Intervention model: Sequential Assignment
Masking: None (Open Label)
Primary purpose: Treatment