High Flow Nasal Oxygen During Sedation

Study Overview
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Brief Summary
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The primary objective of this study is to test the hypothesis that using high flow nasal oxygen improves ventilation during cardiac implantable electronic device procedures performed with conscious sedation. A randomized controlled trial design will be used with participants randomized in a 1:1 ratio to oxygen supplementation through a standard facemask or high flow nasal oxygen.

Detailed Description
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High flow nasal oxygen (HFNO) is increasingly regarded as a promising technology for oxygen delivery in critical care and anesthetic management. Although promising, further high-quality studies examining the effects of using HFNO during procedural sedation are required to inform decision-making regarding implementation of this new technology into practice. The 2018 guidelines from the American Society of Anesthesiology stated that there is insufficient evidence regarding which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices such as HFNO) are more effective. This trial will address this limitation in the evidence base specifically in regard to the efficacy of using HFNO during conscious sedation in the cardiac catheterisation laboratory.

Official Title
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High Flow Nasal Oxygen During Conscious Sedation in the Cardiac Catheterisation Laboratory: A Randomized Controlled Trial

Conditions
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Anesthesia, Cardiac Disease

Intervention / Treatment
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* Device: High flow nasal oxygen
* Device: Standard oxygenation


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: 1. Adults undergoing an elective cardiac implantable electronic device procedure in the Peter Munk Cardiac Centre Cardiac Cath Labs with conscious sedation administered by an Anesthetic Assistant (de novo and replacement/revision procedures). Exclusion criteria: Under 16 years of age. Underlying condition requiring chronic oxygen supplementation. Diagnosed respiratory condition with confirmed current hypercapnia. Pre-existing untreated pneumothorax. Transesophageal echocardiography planned for the procedure. Active nasal bleeding. Complete nasal obstruction. Recent upper airway surgery or base of skull fracture. Previous participation in the study.

Ages Eligible for Study
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Minimum Age: 16 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: High flow nasal oxygen<br>The gas temperature will commence at the 'High' setting (ranges 30-32º Celsius) and titrated downwards if the patient complains of irritation. The gas flow rate will commence at 30 liters per minute prior to sedation administration and be titrated up to 70 liters per minute as tolerated by the patient after sedation has been administered. The fraction of oxygen in the gas will be commenced at 50% (same as that delivered from 6 liters per minute via facemask) and can be titrated upward according to patient requirements (i.e. increased if there is evidence of hypoventilation, airway obstruction or inadequate oxygenation, decreased during use of diathermy). Anesthesia Assistants at the site will be provided with training in the use of this mode of oxygen delivery prior to study commencement. | Device: High flow nasal oxygen<br>* The Optiflow device (Fisher and Paykel Healthcare, Auckland, New Zealand) will be used.<br>|
| Other: Standard oxygenation<br>Supplemental oxygen through a facemask with the flow rate chosen by the clinician responsible for sedation as per their standard practice. The oxygen flow rate is typically commenced at 6 liters per minute and can be titrated up to 15 liters per minute. | Device: Standard oxygenation<br>* Supplemental oxygen through a facemask.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Peak transcutaneous carbon dioxide (TcCO2) concentration. | Continuous measurements will be recorded using the Sentec Digital Monitoring with VSign 2 sensor. | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean transcutaneous carbon dioxide concentration | Continuous measurements will be recorded using the Sentec Digital Monitoring with VSign 2 sensor. | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 
| Area under SpO2 90% oxygen desaturation curve | Percentage of hemoglobin saturated with oxygen (SpO2) will be measured continuously throughout procedures as part of routine clinical practice through the anaesthetic machine. This is a composite measure comprising the incidence, depth, and duration of oxygen desaturation events. Area under SpO2 90% oxygen desaturation curve is calculated as the difference between the threshold (90%) and actual oxygen saturation (SpO2) summed every second during which oxygen saturation was below threshold. | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 
| Adverse sedation events | The Anaesthesia Assistant will be asked to complete the Tracking and reporting outcomes of procedural sedation (TROOPS) tool at the end of procedures. Completion of the tool requires identification and description of the adverse event, the intervention, the outcome and the overall severity of the adverse event. | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 
| Patient satisfaction with sedation: Iowa Satisfaction with Anesthesia Scale | Iowa Satisfaction with Anesthesia Scale. Score ranges from -3 (worse satisfaction) to +3 (better satisfaction). | After the participant has reached phase 2 post-anesthetic recovery. Estimated to be 30 minutes after procedure has finished. | 
| Costs associated with oxygen delivery | Anesthesia Assistants will document devices used for supplemental oxygen delivery and airway management in both groups as per their usual practice in the anesthesia monitoring system. | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 
| Anesthesia Assistant rating of difficulty maintaining the patient's oxygenation status | The Anaesthesia Assistant will be asked to rate their perceived level of difficulty in maintaining oxygenation using a 6-level rating scale with ratings of extremely difficult, very difficult, difficult, easy, very easy, extremely easy. | To be completed as soon as possible after the end of the procedure (within about 5 minutes). | 
| Anesthesia Assistant rating of difficulty using oxygen delivery device | The Anaesthesia Assistant will be asked to rate their perceived level of difficulty using the oxygen delivery device using a 6-level rating scale with ratings of extremely difficult, very difficult, difficult, easy, very easy, extremely easy. | To be completed as soon as possible after the end of the procedure (within about 5 minutes). | 
| Patient comfort of oxygen delivery | Participants will be asked to rate at the end of procedures their perceived overall comfort with the oxygen delivery device used during the procedure using a 6-level rating scale with ratings of 'maximal discomfort', 'very uncomfortable', 'uncomfortable', 'comfortable', 'very comfortable' and 'maximal comfort'. | After the participant has reached phase 2 post-anesthetic recovery. Estimated to be 30 minutes after procedure has finished. | 
| Trajectory of transcutaneous carbon dioxide as a function of time | Continuous measurements will be recorded using the Sentec Digital Monitoring with VSign 2 sensor | From the time between first sedative medication administration to the end of the procedure. Estimated duration of procedures is 30 minutes to 120 minutes. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Oxygen, Ventilation, High-flow nasal oxygen, Hypercapnia, Respiratory depression, Respiratory compromise, Carbon dioxide, Transcutaneous carbon dioxide