Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

John Schutzer-Weissmann, Thomas Wojcikiewicz, Anil Karmali, Asta Lukosiute, Ruoyi Sun, Rafiq Kanji, Ahmed R Ahmed, Sanjay Purkayastha, Stephen J Brett, Jonathan Cousins, John Schutzer-Weissmann, Thomas Wojcikiewicz, Anil Karmali, Asta Lukosiute, Ruoyi Sun, Rafiq Kanji, Ahmed R Ahmed, Sanjay Purkayastha, Stephen J Brett, Jonathan Cousins

Abstract

Background: Obesity is a risk factor for airway-related incidents during anaesthesia. High-flow nasal oxygen has been advocated to improve safety in high-risk groups, but its effectiveness in the obese population is uncertain. This study compared the effect of high-flow nasal oxygen and low-flow facemask oxygen delivery on duration of apnoea in morbidly obese patients.

Methods: Morbidly obese patients undergoing bariatric surgery were randomly allocated to receive either high-flow nasal (70 L min-1) or facemask (15 L min-1) oxygen. After induction of anaesthesia, the patients were apnoeic for 18 min or until peripheral oxygen saturation decreased to 92%.

Results: Eighty patients were studied (41 High-Flow Nasal Oxygen, 39 Facemask). The median apnoea time was 18 min in both the High-Flow Nasal Oxygen (IQR 18-18 min) and the Facemask (inter-quartile range [IQR], 4.1-18 min) groups. Five patients in the High-Flow Nasal Oxygen group and 14 patients in the Facemask group desaturated to 92% within 18 min. The risk of desaturation was significantly lower in the High-Flow Nasal Oxygen group (hazard ratio=0.27; 95% confidence interval [CI], 0.11-0.65; P=0.007).

Conclusions: In experienced hands, apnoeic oxygenation is possible in morbidly obese patients, and oxygen desaturation did not occur for 18 min in the majority of patients, whether oxygen delivery was high-flow nasal or low-flow facemask. High-flow nasal oxygen may reduce desaturation risk compared with facemask oxygen. Desaturation risk is a more clinically relevant outcome than duration of apnoea. Individual physiological factors are likely to be the primary determinant of risk rather than method of oxygen delivery.

Clinical trial registration: NCT03428256.

Keywords: THRIVE; apnoeic oxygenation; apnoeic ventilation; bariatric anaesthesia; desaturation risk; high-flow nasal oxygen; obesity; safe apnoea time.

Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.

Figures

Fig 1
Fig 1
CONSORT diagram. CONSORT, Consolidated Standards of Reporting Trials; HFNO, high-flow nasal oxygen.
Fig 2
Fig 2
Risk of desaturation during apnoea. Proportion of study participants in HFNO (purple line) and FM (blue line) groups with oxygen saturation >92% during apnoea. Hazard ratio comparing FM and HFNO groups, 0.27 (95% confidence interval, 0.11–0.65; log-rank P=0.007). TA, onset of apnoea. TA+x, apnoea duration where x denotes min after TA; FM, facemask oxygen; HFNO, high-flow nasal oxygen.
Fig 3
Fig 3
Pao2 and Paco2 change over time during apnoea. Change in arterial oxygen and carbon dioxide tension during apnoea. TA, onset of apnoea; TA+x, apnoea duration where x denotes min after TA. Each line represents an individual participant (purple: high flow nasal oxygen group; blue: facemask group). Light lines represent participants whose oxygen saturation level remained >92% during apnoea throughout the 18 min period. Dark lines represent participants who desaturated to 92% during the study period.

References

    1. Lyons C., Callaghan M. Uses and mechanisms of apnoeic oxygenation: a narrative review. Anaesthesia. 2019;74:497–507.
    1. Patel A., El-Boghdadly K. Apnoeic oxygenation and ventilation: go with the flow. Anaesthesia. 2020;75:1002–1005.
    1. Toner A.J. Carbon dioxide clearance during apnoea with high-flow nasal oxygen: epiphenomenon or a failure to THRIVE? Anaesthesia. 2020;75:580–582.
    1. Huang L., Athanasiadis T., Woods C., Dharmawardana N., Ooi E.H. The use of transnasal humidified rapid insufflation ventilatory exchange in laryngeal and pharyngeal surgery: flinders case series. Aust J Otolaryngol. 2019;2 17–17.
    1. Organisation for Economic Co-operation and Development. Obesity update 2017. Available from: (accessed 1 August 2019).
    1. Nightingale C.E., Margarson M.P., Shearer E., et al. Peri-operative management of the obese surgical patient 2015. Anaesthesia. 2015;70:859–876.
    1. Cook T.M., Woodall N., Frerk C. Major complications of airway management in the UK: results of the fourth national audit project of the royal college of anaesthetists and the difficult airway society. Br J Anaesth. 2011;106:617–631.
    1. Shaw M., Waiting J., Barraclough L., Ting K., Jeans J., Black B. Airway events in obese vs. non-obese elective surgical patients: a cross-sectional observational study. Anaesthesia. 2021;76:1585–1592.
    1. Gustafsson I.M., Lodenius, Tunelli J., Ullman J., Jonsson Fagerlund M. Apnoeic oxygenation in adults under general anaesthesia using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) — a physiological study. Br J Anaesth. 2017;118:610–617.
    1. Patel A., Nouraei S.A.R. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70:323–329.
    1. Association of Anaesthetists of Great Britain and Ireland Recommendations for standards of monitoring during anaesthesia and recovery 2015. Anaesthesia. 2016;71:85–93.
    1. Ramachandran S.K., Cosnowski A., Shanks A., Turner C.R. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010;22:164–168.
    1. Lyons C., Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for laryngeal surgery: a case series. Anaesthesia. 2017;72:1379–1387.
    1. Heard A., Toner A.J., Evans J.R., Aranda Palacios A.M., Lauer S. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of buccal RAE tube oxygen administration. Anesth Analg. 2017;124:1162–1167.
    1. Hamp T., Prager G., Baron-Stefaniak J., Müller J., Bichler C., Plöchl W. Duration of safe apnea in patients with morbid obesity during passive oxygenation using high-flow nasal insufflation versus regular flow nasal insufflation, a randomized trial. Surg Obes Relat Dis. 2021;17:347–355.
    1. Moon T.S., Tai K., Kim A., et al. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, double-blinded, controlled trial of nasal cannula oxygen administration. Obes Surg. 2019;29:3992–3999.
    1. Hua Z., Liu Z., Li Y., Zhang H., Yang M., Zuo M. Transnasal humidified rapid insufflation ventilatory exchange vs. facemask oxygenation in elderly patients undergoing general anaesthesia: a randomized controlled trial. Sci Rep. 2020;10:5745.
    1. Mullen T., Tan E., Malpas G., Law J.A., Phipps S. Apnoeic oxygenation via nasal cannulae: 15 L min–1 versus high flow. Br J Anaesth. 2019;123:e445.
    1. Achar S., Pai A., Shenoy Uk. Apneic oxygenation during simulated prolonged difficult laryngoscopy: comparison of nasal prongs versus nasopharyngeal catheter: a prospective randomized controlled study. Anesth Essays Res. 2014;8:63–67.
    1. Toner A.J., Douglas S.G., Bailey M.A., et al. Effect of apneic oxygenation on tracheal oxygen levels, tracheal pressure, and carbon dioxide accumulation: a randomized, controlled trial of buccal Oxygen administration. Anesth Analg. 2019;128:1154–1159.
    1. Wong D.T., Dallaire A., Singh K.P., et al. High-flow nasal oxygen improves safe apnea time in morbidly obese patients undergoing general anesthesia. Anesth Analg. 2019;129:1130–1136.
    1. Ricottilli F., Ickx B., Van Obbergh L. High-flow nasal cannula preoxygenation in obese patients undergoing general anaesthesia: a randomised controlled trial. Br J Anaesth. 2019;123:e443–e444.
    1. Dixon B.J., Dixon J.B., Carden J.R., et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102:1110–1115.
    1. Boyce J.R., Ness T., Castroman P., Gleysteen J.J. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;13:4–9.
    1. Stock M.C., Schisler J.Q., McSweeney T.D. The PaCO2 rate of rise in anesthetized patients with airway obstruction. J Clin Anesth. 1989;1:328–332.
    1. O’Loughlin C.J., Phyland D.J., Vallance N.A., et al. Low-flow apnoeic oxygenation for laryngeal surgery: a prospective observational study. Anaesthesia. 2020;75:1070–1075.
    1. Forsberg I.-M., Ullman J., Hoffman A., Eriksson L.I., Lodenius Å., Fagerlund M.J. Lung volume changes in apnoeic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) compared to mechanical ventilation in adults undergoing laryngeal surgery. Acta Anaesthesiol Scand. 2020;64:1491–1498.
    1. Hermez L.A., Spence C.J., Payton M.J., Nouraei S.A.R., Patel A., Barnes T.H. A physiological study to determine the mechanism of carbon dioxide clearance during apnoea when using transnasal humidified rapid insufflation ventilatory exchange (THRIVE) Anaesthesia. 2019;74:441–449.
    1. Sud A., Patel A. THRIVE: five years on and into the COVID-19 era. Br J Anaesth. 2021;126:768–773.
    1. Piosik Z.M., Dirks J., Rasmussen L.S., Kristensen C.M., Kristensen M.S. Exploring the limits of prolonged apnoea with high-flow nasal oxygen: an observational study. Anaesthesia. 2021;76:798–804.
    1. Baraka A.S., Taha S.K., Siddik-Sayyid S.M., et al. Supplementation of pre-oxygenation in morbidly obese patients using nasopharyngeal oxygen insufflation. Anaesthesia. 2007;62:769–773.
    1. Gaszynski T. Nasal continuous positive airway pressure during intubation in superobese patients prolongs safe apnea period. Anesth Analg. 2019;129:e34–e35.
    1. Nay M.A., Fromont L., Eugene A., et al. High-flow nasal oxygenation or standard oxygenation for gastrointestinal endoscopy with sedation in patients at risk of hypoxaemia: a multicentre randomised controlled trial (ODEPHI trial) Br J Anaesth. 2021;127:133–142.
    1. Stolady D., Laviola M., Pillai A., Hardman J.G. Effect of variable pre-oxygenation endpoints on safe apnoea time using high flow nasal oxygen for women in labour: a modelling investigation. Br J Anaesth. 2021;126:889–895.
    1. Fraioli R.L., Sheffer L.A., Steffenson J.L. Pulmonary and cardiovascular effects of apneic oxygenation in man. Anesthesiology. 1973;39:588–596.
    1. Cantineau J.P., Porte F., D’Honneur G., Duvaldestin P. Neuromuscular effects of rocuronium on the diaphragm and adductor pollicis muscles in anesthetized patients. Anesthesiology. 1994;81:585–590.
    1. Pühringer F.K., Keller C., Kleinsasser A., Giesinger S., Benzer A. Pharmacokinetics of rocuronium bromide in obese female patients. Eur J Anaesthesiol. 1999;16:507–510.
    1. Chung F., Abdullah H.R., Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149:631–638.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅