Supraglottic jet oxygenation and ventilation decreased hypoxemia during gastrointestinal endoscopy under deep sedation at high altitudes: a randomized clinical trial

Bailin Jiang, Yi Li, Deji Ciren, Ouzhu Dawa, Yi Feng, Ciren Laba, Bailin Jiang, Yi Li, Deji Ciren, Ouzhu Dawa, Yi Feng, Ciren Laba

Abstract

Background: Hypobaric hypoxia is common at high altitudes. Whether this exacerbates hypoxia during procedural sedation and whether hypoxia can be alleviated by the use of supraglottic jet oxygenation and ventilation (SJOV) are unknown. This study aimed to compare the incidence of hypoxia during gastrointestinal endoscopy under deep sedation at high altitudes with oxygen supply techniques using either a nasal cannula or SJOV.

Methods: This study was conducted from April 2022 to July 2022 in a tertiary hospital located 3650 m above sea level. Adult patients scheduled for routine gastrointestinal endoscopy under sedation were enrolled and randomized 1:1 to receive SJOV or a nasal cannula during sedation. Moderate hypoxia was the primary outcome, defined as an SPO2 of 75-89% for < 60 s. The secondary outcomes were respiratory-, cardiovascular-, and SJOV-related complications. The influence of characteristics regarding acclimatization to high altitudes (Tibetan ethnic group and erythrocytosis) on the occurrence of hypoxia was analyzed.

Results: None of the patients were lost to follow-up. A total of 72 patients were included in the analysis (36 patients in each group). There were 20 (27.8%) patients who experienced moderate hypoxia events. Significantly fewer hypoxic events occurred in the SJOV group than in the nasal cannula group [3 (8.3%) vs. 17 (47.2%), absolute risk difference (95% CI): - 38.9 (- 57.5, - 20.2) %, risk ratio (RR, 95% CI): 0.18 (0.06, 0.55), P < 0.001]. Significantly fewer patients in the SJOV group experienced mild hypoxia (P < 0.001) and severe hypoxia (P = 0.002). No serious adverse events occurred in either of the groups. The Tibetan ethnic group (P = 0.086) and erythrocytosis (P = 0.287) were not associated with the occurrence of hypoxia events.

Conclusions: The incidence of hypoxia was lower with SJOV than with nasal cannula in patients undergoing gastrointestinal endoscopy under deep sedation at high altitudes. The Tibetan ethnic group and erythrocytosis did not influence the occurrence of hypoxia.

Trial registration: This study was registered at ClinicalTrials.gov (NCT05304923) before enrollment by Dr. Yi Feng on 31/03/2022.

Keywords: Airway management; Gastrointestinal endoscopy; High altitudes; Hypoxia; Sedation; Supraglottic jet oxygenation and ventilation (SJOV); Wei nasal jet tube (WNJ).

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Supraglottic jet oxygenation and ventilation using a Wei nasal jet tube . SJOV was conducted using a WNJ connected to a manual jet ventilator via its jet port. The WNJ is a regular nasopharyngeal airway with two modified nozzles. One is the jet nozzle connected to the manual jet ventilator. Another nozzle is used to monitor breathing connected to a PaCO2 monitor (breathing was not monitored in this study). The regular nasal cannula could also supply up to 6 l/minute of oxygen. Only the jet nozzle was used for oxygen administration in this study. SJOV, supraglottic jet oxygenation and ventilation; WNJ, Wei nasal jet tube
Fig. 2
Fig. 2
Flow diagram of patients included in this study
Fig. 3
Fig. 3
The primary outcome was adjusted for the baseline characteristics. Stratification variable: Upper endoscopy or colonoscopy; demographic characteristics: age, sex, ethnic group (Tibetan/Zang or not), body mass index, clinical characteristics, history of obstructive sleep apnea-hypopnea syndrome, erythrocytosis, and original hypoxia before oxygenation. RR, risk ratio; CI, confidence interval; SJOV, supraglottic jet oxygenation and ventilation

References

    1. Early DS, Lightdale JR, Vargo JJ, 2nd, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018;87(2):327–337. doi: 10.1016/j.gie.2017.07.018.
    1. Goudra B. Big sleep: beyond Propofol sedation during GI endoscopy. Dig Dis Sci. 2019;64(1):1–3. doi: 10.1007/s10620-018-5287-x.
    1. Luks AM, Swenson ER, Bärtsch P. Acute high-altitude sickness. Eur Respir Rev. 2017;26(143):160096. 10.1183/16000617.0096-2016.
    1. Bell GD, Bown S, Morden A, Coady T, Logan RF. Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae. Lancet (London, England) 1987;1(8540):1022–1024. doi: 10.1016/S0140-6736(87)92282-3.
    1. Jiang B, Wei H. Oxygen therapy strategies and techniques to treat hypoxia in COVID-19 patients. Eur Rev Med Pharmacol Sci. 2020;24(19):10239–10246.
    1. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31–81. 10.1097/ALN.0000000000004002.
    1. Craft TM, Chambers PH, Ward ME, Goat VA. Two cases of barotrauma associated with transtracheal jet ventilation. Br J Anaesth. 1990;64(4):524–527. doi: 10.1093/bja/64.4.524.
    1. Qin Y, Li LZ, Zhang XQ, Wei Y, Wang YL, Wei HF, Wang XR, Yu WF, Su DS. Supraglottic jet oxygenation and ventilation enhances oxygenation during upper gastrointestinal endoscopy in patients sedated with propofol: a randomized multicentre clinical trial. Br J Anaesth. 2017;119(1):158–166. doi: 10.1093/bja/aex091.
    1. Huang YY, Chu YC, Chang KY, Wang YC, Chan KH, Tsou MY. Performance of AEP monitor/2-derived composite index as an indicator for depth of sedation with midazolam and alfentanil during gastrointestinal endoscopy. Eur J Anaesthesiol. 2007;24(3):252–257. doi: 10.1017/S0265021506001633.
    1. Chernik DA, Gillings D, Laine H, Hendler J, Silver JM, Davidson AB, Schwam EM, Siegel JL. Validity and reliability of the Observer's assessment of alertness/sedation scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990;10(4):244–251.
    1. Liang H, Hou Y, Wei H, Feng Y. Supraglottic jet oxygenation and ventilation assisted fiberoptic intubation in a paralyzed patient with morbid obesity and obstructive sleep apnea: a case report. BMC Anesthesiol. 2019;19(1):40. doi: 10.1186/s12871-019-0709-7.
    1. Qadeer MA, Lopez AR, Dumot JA, Vargo JJ. Hypoxemia during moderate sedation for gastrointestinal endoscopy: causes and associations. Digestion. 2011;84(1):37–45. doi: 10.1159/000321621.
    1. Zhou S, Zhu Z, Dai W, Qi S, Tian W, Zhang Y, Zhang X, Huang L, Tian J, Yu W, et al. National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals. Br J Anaesth. 2021;127(1):56–64. doi: 10.1016/j.bja.2021.01.028.
    1. Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World journal of gastrointestinal endoscopy. 2013;5(11):527–533. doi: 10.4253/wjge.v5.i11.527.
    1. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008;67(6):910–923. doi: 10.1016/j.gie.2007.12.046.
    1. Li Q, Xie P, Zha B, Wu Z, Wei H. Supraglottic jet oxygenation and ventilation saved a patient with 'cannot intubate and cannot ventilate' emergency difficult airway. J Anesth. 2017;31(1):144–147. doi: 10.1007/s00540-016-2279-x.
    1. Schmidt WFJ, Wachsmuth N, Jimenez J, Soria R. Hemoglobin mass and blood volume in patients with altitude-related polycythemia. Front Physiol. 2022;13:867108. doi: 10.3389/fphys.2022.867108.
    1. Yi H, Yu Q, Zeng D, Shen Z, Li J, Zhu L, Zhang X, Xu Q, Song H, Kong P. Serum inflammatory factor profiles in the pathogenesis of high-altitude polycythemia and mechanisms of acclimation to high altitudes. Mediat Inflamm. 2021;2021:8844438. doi: 10.1155/2021/8844438.
    1. Gaur P, Prasad S, Kumar B, Sharma SK, Vats P. High-altitude hypoxia induced reactive oxygen species generation, signaling, and mitigation approaches. Int J Biometeorol. 2021;65(4):601–615. doi: 10.1007/s00484-020-02037-1.
    1. Murray AJ, Montgomery HE, Feelisch M, Grocott MPW, Martin DS. Metabolic adjustment to high-altitude hypoxia: from genetic signals to physiological implications. Biochem Soc Trans. 2018;46(3):599–607. doi: 10.1042/BST20170502.
    1. Teixeira AL. Lifelong high-altitude hypoxia induces arterial baroreflex adaptations: new insights and future directions. J Physiol. 2019;597(13):3253–3254. doi: 10.1113/JP278174.
    1. Jiang P, Wang Z, Yu X, Qin Y, Shen Y, Yang C, Liu F, Ye S, Du X, Ma L, et al. Effects of long-term high-altitude exposure on fibrinolytic system. Hematology (Amsterdam, Netherlands) 2021;26(1):503–509.
    1. Ortiz-Prado E, Cordovez SP, Vasconez E, Viscor G, Roderick P. Chronic high-altitude exposure and the epidemiology of ischaemic stroke: a systematic review. BMJ Open. 2022;12(4):e051777. doi: 10.1136/bmjopen-2021-051777.
    1. Mazzeffi MA, Petrick KM, Magder L, Greenwald BD, Darwin P, Goldberg EM, Bigeleisen P, Chow JH, Anders M, Boyd CM, et al. High-flow nasal cannula oxygen in patients having anesthesia for advanced esophagogastroduodenoscopy: HIFLOW-ENDO, a randomized clinical trial. Anesth Analg. 2021;132(3):743–751. doi: 10.1213/ANE.0000000000004837.
    1. Kim SH, Bang S, Lee KY, Park SW, Park JY, Lee HS, Oh H, Oh YJ: Comparison of high flow nasal oxygen and conventional nasal cannula during gastrointestinal endoscopic sedation in the prone position: a randomized trial. Canadian j of anaesth Journal canadien d'anesthesie 2021, 68(4):460–466.
    1. Teng WN, Ting CK, Wang YT, Hou MC, Chang WK, Tsou MY, Chiang H, Lin CL. High-flow nasal cannula and mandibular advancement bite block decrease hypoxic events during sedative esophagogastroduodenoscopy: a randomized clinical trial. Biomed Res Int. 2019;2019:4206795. doi: 10.1155/2019/4206795.
    1. Sacks D, Baxter B, Campbell BCV, Carpenter JS, Cognard C, Dippel D, Eesa M, Fischer U, Hausegger K, Hirsch JA, et al. Multisociety consensus quality improvement revised consensus statement for endovascular therapy of acute ischemic stroke. International journal of stroke : official journal of the International Stroke Society. 2018;13(6):612–632.

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