The Australian New Zealand ED airway registry (ANZEDAR) includes 43 ED’s that prospectively submit data on patients they intubate. It has provided a wealth of information on how we manage airways.
This study
looked at patients who got apnoeic oxygenation (ApOx) during RSI vs. those
that did not. (ApOx was defined as patients getting up to 15L of oxygen via
a nasal cannula.) They excluded patients intubated during cardiac arrest and
those that got BVM or NIV during the apnoeic period.
The primary
outcome was rates of desaturation to <93%.
Results
1669 (66%)
patients got ApOx and 850 (33%) did not. Desaturation occurred in 10% of the
ApOx group vs. 13% in the other group.
ApOx rules!!!
Maybe…
maybe not…
This was not
a randomized trial. As such, there could have been confounding factors
or that led to the differences observed. (But to be fair, I would imagine that
doctor would have been more likely to provide ApOx in those patients that they were
worried might desaturate. Therefore, making the ApOx group look potentially
worse. But perhaps I’m wrong…)
This was a
study of registry data. Unfortunately, this data is often of poor
quality. It’s possible we may have a “garbage in, garbage out” phenomenon. Intubation
is often an anxiety provoking procedure where doctors get task focused. They
may have not really been aware of how low the saturations dropped. Ideally, one
would get the data from a research assistant who is tasked to collect accurate
data at the time.
Desaturation
is not really a patient-oriented outcome. Transient hypoxemia probably causes no harm
in most patients. Ideally, we would look at more important outcomes involving real patient morbidity and mortality. But good luck powering such a study!
If ApOx
doesn’t really change any important patient outcomes than arguably it may be
one extra step that distracts us from getting the job done. In times of
high stress, we need to keep our processes as simple as possible.
The debate continues…
Covering:
Perera A,
Alkhouri H, Fogg T, et al. Apnoeic oxygenation was associated with decreased
desaturation rates during rapid sequence intubation in multiple Australian and
New Zealand emergency departments. Emerg Med J 2021;38:118-124. [Link to article]
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