Validation of the Apnea Test Performed by High-flow Oxygen Therapy in Patients With Clinical Brain Death (APNEAFLOW)

Validation of Apnea Test Conducted Using High-flow Oxygen Therapy in Patients With Clinical Brain Death

Brain death is a clinical and paraclinical diagnosis established in a known etiological context. It involves the irreversible destruction of cerebral functions in a beating-heart individual.

In the context of organ and tissue donation from a critically ill patient, the clinical diagnosis of brain death is confirmed through a mandatory apnea test. This test is conducted by disconnecting the patient from the ventilator for a duration of 8 to 10 minutes. The test is considered validated when there is no spontaneous respiratory movement and the presence of hypercapnia. Hypercapnia is defined as a PaCO2 (carbon dioxide partial pressure) greater than 60 mmHg or an increase of more than 20 mmHg compared to the pre-ventilator disconnection capnia. These thresholds are meant to provide a strong stimulus to the respiratory centers, objectively confirming the absence of spontaneous ventilation.

In practice, the apnea test is performed under CPAP (Continuous Positive Airway Pressure) or by administering oxygen at 6-10L/min through the endotracheal tube.

High-flow oxygenation could be a simple alternative for the apnea test during the validation of the clinical diagnosis of brain death while reducing the risk of lung derecruitment and compromising organ viability and/or lung donation.

However, due to the high gas flow used (60 L/min), high-flow oxygenation can lead to a "washout" effect in the anatomical dead space, which may lower the carbon dioxide partial pressure. Consequently, even in a patient in a state of brain death, where spontaneous ventilation is absent by definition, it is not certain that the carbon dioxide partial pressure will increase to the threshold of 60 mmHg or more than 20 mmHg in 10 minutes during an apnea test conducted with high-flow oxygenation.

The purpose of this study is, therefore, to examine the feasibility of clinically diagnosing brain death through an apnea test performed with high-flow oxygenation.

To determine whether the validation criterion which involves observing an arterial capnia > 60 mmHg or an increase > 20 mmHg (compared to the capnia at the beginning of the test) after 10 minutes can be achieved during an apnea test conducted under high-flow oxygen therapy in patients with clinically confirmed brain death by standard apnea test (under standard oxygen therapy)

Study Overview

• Status: Completed
• Conditions: Brain Death
• Intervention / Treatment: Diagnostic test: Apnea test under high-flow oxygenation

Detailed Description

The protocol is based on performing two consecutive apnea tests on a patient in clinical brain death in intensive care unit. The first apnea test will be conducted under standard oxygen therapy and confirms clinical brain death (standard procedure). The second apnea test (for the study) will be conducted under high-flow oxygen therapy. Only patients whose apnea test is initially validated under standard oxygen therapy will have the second apnea test under high-flow oxygen therapy.

After a standardized preoxygenation, the 1st apnea test will be performed under standard oxygen therapy through the endotracheal tube (flow at 8L/min) for 10 minutes. An arterial blood gas sampling will be sampled every 2 minutes during the1st apnea test.

The confirmation of clinical brain death by validating the apnea test under standard oxygen therapy will be done if the following two conditions are met: 1) absence of a spontaneous respiratory movements AND 2) an arterial capnia > 60 mmHg or an increase > 20 mmHg (compared to the capnia at the end of preoxygenation).

Then the patient will be reconnected to the ventilator for 15 minutes. A second standardized preoxygenation will be performed before the 2nd apnea test. The second apnea test will be performed under high-flow oxygen therapy through the endotracheal tube (flow at 50L/min, FiO2 100%) for 10 minutes. An arterial blood gas sampling will be sampled every 2 minutes during the1st apnea test.

Then the patient will be reconnected to the ventilator with the same settings before the start of the study.

• Study Type: Interventional
• Enrollment (Actual): 15
• Phase: Not Applicable

Contacts and Locations

Study Locations

• France
  • Orléans, France
    • CHR d'Orléans

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• All patients in critical care with clinical brain death and potential organ and tissue donors for whom an apnea test is indicated.

Exclusion Criteria:

• Minor patients.
• Person under guardianship
• Protected Majors
• Not affiliated to French social security
• Pregnant women.
• Patients with a history of Chronic Obstructive Pulmonary Disease with a GOLD score of III or IV.
• Patients with at least one absolute contraindication to organ donation.
• Patients whose relatives have spontaneously expressed the patient's refusal to donate organs for therapeutic purposes.
• Patients on VA ECMO and, in general, any patient with a contraindication to performing the apnea test (DV, significant hemodynamic instability...).
• Patients whose relatives have refused the patient's participation in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Diagnostic
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Other: Clinical brain death; The protocol is based on performing two consecutive apnea tests on a patient in clinical brain death in intensive care unit. The first apnea test will be conducted under standard oxygen therapy and confirms clinical brain death (standard procedure). The second apnea test (for the study) will be conducted under high-flow oxygen therapy. Only patients whose apnea test is initially validated under standard oxygen therapy will have the second apnea test under high-flow oxygen therapy.

Diagnostic test: Apnea test under high-flow oxygenation; Apnea test under high-flow oxygenation in patients with a confirmed clinical brain death by a standard apnea test (under standard oxygen therapy)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of patients exceeding the hypercapnia threshold	Percentage of patients exceeding the hypercapnia threshold after an apnea test conducted under high-flow oxygen therapy among patients who have already been validated for the apnea test under standard oxygen therapy.	48 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time required after ventilator disconnection to exceed 60mmHg of PaCO2 or for which PaCO2 increases by more than 20mmHg compared to the PaCO2 before disconnection.	Determine the maximum PaCO2 value reached by all included subjects at the 10-minute mark of the apnea test with high-flow oxygen therapy	48 hours
Recording of PaO2 and PaCO2 values measured in 2-minute intervals during the standard apnea test and apnea test under high-flow oxygen therapy.		48 hours
Recording of the PaO2/FiO2 ratio before and after each apnea test.		48 hours
Recording of heart rate,measured every minute during the two apnea tests	Describe the evolution of hemodynamic parameters during the standard apnea test and the apnea test with high-flow oxygen therapy	48 hours
Recording of pulse oximetry, measured every minute during the two apnea tests	Describe the evolution of hemodynamic parameters during the standard apnea test and the apnea test with high-flow oxygen therapy	48 hours
Recording of systolic blood pressure, measured every minute during the two apnea tests	Describe the evolution of hemodynamic parameters during the standard apnea test and the apnea test with high-flow oxygen therapy	48 hours
Recording of diastolic blood pressure, measured every minute during the two apnea tests	Describe the evolution of hemodynamic parameters during the standard apnea test and the apnea test with high-flow oxygen therapy	48 hours

Collaborators and Investigators

• Sponsor: Centre Hospitalier Régional d'Orléans
• Investigators: Principal Investigator: Damien BARRIER, CHR d'Orléans

Publications and helpful links

General Publications

• Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P, Halpin DM, Lopez Varela MV, Nishimura M, Roche N, Rodriguez-Roisin R, Sin DD, Singh D, Stockley R, Vestbo J, Wedzicha JA, Agusti A. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017 Mar 1;195(5):557-582. doi: 10.1164/rccm.201701-0218PP.
• Lyons C, Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for laryngeal surgery: a case series. Anaesthesia. 2017 Nov;72(11):1379-1387. doi: 10.1111/anae.14036.
• Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW, Baldisseri M, Bleck T, Citerio G, Dawson R, Hoppe A, Jacobe S, Manara A, Nakagawa TA, Pope TM, Silvester W, Thomson D, Al Rahma H, Badenes R, Baker AJ, Cerny V, Chang C, Chang TR, Gnedovskaya E, Han MK, Honeybul S, Jimenez E, Kuroda Y, Liu G, Mallick UK, Marquevich V, Mejia-Mantilla J, Piradov M, Quayyum S, Shrestha GS, Su YY, Timmons SD, Teitelbaum J, Videtta W, Zirpe K, Sung G. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA. 2020 Sep 15;324(11):1078-1097. doi: 10.1001/jama.2020.11586.
• Levesque S, Lessard MR, Nicole PC, Langevin S, LeBlanc F, Lauzier F, Brochu JG. Efficacy of a T-piece system and a continuous positive airway pressure system for apnea testing in the diagnosis of brain death. Crit Care Med. 2006 Aug;34(8):2213-6. doi: 10.1097/01.CCM.0000215114.46127.DA.
• Fossat G, Nay MA, Jacquier S, Desmalles E, Boulain T. High-flow oxygen during spontaneous breathing trial for patients at high risk of weaning failure. Intensive Care Med. 2021 Aug;47(8):916-917. doi: 10.1007/s00134-021-06450-x. Epub 2021 Jun 14. No abstract available.
• Wijdicks EF, Manno EM, Holets SR. Ventilator self-cycling may falsely suggest patient effort during brain death determination. Neurology. 2005 Sep 13;65(5):774. doi: 10.1212/01.wnl.0000174626.94197.62. No abstract available.
• Shapiro BA. The apnea-PaCO2 relationship: some clinical and medico-legal considerations. J Clin Anesth. 1989;1(5):323-7. doi: 10.1016/0952-8180(89)90069-x. No abstract available.
• Birks EJ, Burton PB, Owen VJ, Latif N, Nyawo B, Yacoub MH. Molecular and cellular mechanisms of donor heart dysfunction. Transplant Proc. 2001 Aug;33(5):2749-51. doi: 10.1016/s0041-1345(01)02178-9. No abstract available.

Study record dates

Study Major Dates

• Study Start (Actual): July 10, 2023
• Primary Completion (Actual): April 7, 2024
• Study Completion (Actual): April 7, 2024

Study Registration Dates

• First Submitted: July 10, 2023
• First Submitted That Met QC Criteria: July 10, 2023
• First Posted (Actual): July 18, 2023

Study Record Updates

• Last Update Posted (Actual): August 2, 2024
• Last Update Submitted That Met QC Criteria: August 1, 2024
• Last Verified: August 1, 2024

More Information

Terms related to this study

• Keywords: High-flow oxygen therapy; Standard oxygen therapy; Clinical brain death; Apnea test; High-flow oxygenation
• Additional Relevant MeSH Terms: Pathologic Processes; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurologic Manifestations; Neurobehavioral Manifestations; Unconsciousness; Consciousness Disorders; Coma; Death; Brain Death
• Other Study ID Numbers: CHRO-2022-10

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No