Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, Australia.
Intensive Care Medicine, Royal North Shore Hospital, St Leonards, Australia.
Cochrane Database Syst Rev. 2023 Aug 2;8(8):CD013558. doi: 10.1002/14651858.CD013558.pub2.
Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality.
To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation.
We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022.
We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports.
We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8.
We used GRADE to assess certainty of evidence.
We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence).
AUTHORS' CONCLUSIONS: There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.
在进行气管插管之前的窒息期给予氧气，即窒息氧合，这是一种医学操作。该操作可预防气管插管引起的呼吸并发症，这些并发症有可能导致严重不良事件，包括心律失常、血流动力学失代偿、缺氧性脑损伤和死亡。在气管插管的窒息期通过鼻导管输送氧气（窒息氧合），可以作为一种非侵入性的辅助措施，以降低低氧血症、发病率和死亡率的发生率。
与气管插管期间不进行窒息氧合相比，评估在院前、急诊科、重症监护病房和手术室环境中，成人在气管插管前进行窒息氧合的获益与危害。
我们使用标准的、广泛的 Cochrane 检索方法。最新检索日期为 2022 年 11 月 4 日。
我们纳入了随机对照试验（RCT）和准随机对照试验，比较了在气管插管期间使用任何形式的窒息氧合（包括低流量和高流量鼻导管）与不进行窒息氧合的效果。我们将准随机化定义为参与者按照非真正随机的方式分配到每个组，例如交替、病历号或出生日期。我们排除了比较前瞻性队列研究和比较回顾性队列研究、生理模型研究和病例报告。
我们使用标准的 Cochrane 方法。我们的主要结局是 1. 住院时间和 2. 严重低氧血症的发生率。我们的次要结局是 3. 低氧血症的发生率、4. 脉搏血氧饱和度（SpO）的最低记录值、5. 重症监护病房（ICU）入住时间、6. 首次通过成功率、7. 不良事件和 8. 死亡率。我们使用 GRADE 评估证据的确定性。
我们纳入了 23 项 RCT（2264 名参与者）的分析。8 项研究（729 名参与者）调查了低流量（15 L/min 或以下）的使用，15 项研究（1535 名参与者）调查了高流量（大于 15 L/min）的使用。研究环境各不相同，包括急诊科（2 项研究，327 名参与者）、重症监护病房（7 项研究，913 名参与者）和手术室（14 项研究，1024 名参与者）。我们认为两项研究在所有领域的偏倚风险都较低。没有一项研究报告了医院住院时间的结果。在以危重患者为主的人群中，从窒息开始到气管插管成功期间，使用任何流量的窒息氧合时，严重低氧血症（SpO 低于 80%）的发生率可能没有差异（风险比（RR）0.86，95%置信区间（CI）0.66 至 1.11；P = 0.25，I² = 0%；15 项研究，1802 名参与者；低确定性证据）。没有充分的证据表明窒息氧合对低氧血症（SpO 低于 93%）的发生率有任何影响（RR 0.58，95%CI 0.23 至 1.46；P = 0.25，I² = 36%；3 项研究，489 名参与者；低确定性证据）。可能会改善最低记录的氧饱和度，平均增加 1.9%（95%CI 0.75% 至 3.05%；P < 0.001，I² = 86%；15 项研究，1525 名参与者；低确定性证据）。使用窒息氧合可能会缩短 ICU 入住时间（平均差值（MD）-1.13 天，95%CI -1.51 至 -0.74；P < 0.0001，I² = 46%；5 项研究，815 名参与者；低确定性证据）。首次通过成功率可能没有差异（RR 1.00，95%CI 0.93 至 1.08；P = 0.79，I² = 0%；8 项研究，826 名参与者；中等确定性证据）。使用窒息氧合时，口腔外伤、心律失常、误吸、低血压、肺炎和心脏骤停等不良事件的发生率可能没有差异。关于死亡率的影响，证据不足（RR 0.84，95%CI 0.70 至 1.00；P = 0.06，I² = 0%；6 项研究，1015 名参与者；低确定性证据）。
有一些证据表明，在气管插管的窒息期给予氧气可能会改善最低记录的氧饱和度。然而，氧饱和度的差异不太可能具有临床意义。在一组以危重患者为主的人群中，这并没有转化为对低氧血症或严重低氧血症发生率的任何可衡量的影响。我们无法评估对住院时间的影响；然而，在窒息氧合组中，ICU 入住时间有所减少。其机制尚不清楚，因为首次通过成功率或不良事件发生率没有差异。
