Natalie Napolitano, MPH, MPH, RRT-NPS (she/her/hers)
Research Clinical Specialist
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Lee Polikoff, MD (he/him/his)
Hasbro Children's Hospital
Providence, Rhode Island
Disclosure information not submitted.
Lauren Edwards, MD
MD
Arkansas Children's Hospital, Arkansas, United States
Disclosure information not submitted.
Keiko Tarquinio, MD
Assistant Professor of Pediatrics
Emory University Department of Pediatrics, United States
Disclosure information not submitted.
Sholeen Nett, MD, PhD
professor
Childrens Hospital at Dartmouth, United States
Disclosure information not submitted.
Conrad Krawiec, MD
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania
Disclosure information not submitted.
Aileen Kirby, MD,
Attending Physician
Oregon Health Sciences University / Doernbecher Children's Hospital, United States
Disclosure information not submitted.
Nina Azer, MD
Physician
Phoenix Children's Hospital, United States
Disclosure information not submitted.
David Tellez, MD, FCCM
MD
Phoenix Children's Hospital, United States
Disclosure information not submitted.
Peter Skippen, MD, MBBS, FRCPC
Pediatric Intensivist
BC Children's Hospital, United States
Disclosure information not submitted.
Ryan Breuer, MD
Associate Professor of Pediatrics, PCCM Fellowship Program Director
Women and Children's Hospital of Buffalo, United States
Disclosure information not submitted.
Simon Parsons, MD
Attending Physician
Alberta Children's Hospital, United States
Disclosure information not submitted.
Christopher Page-Goertz, MD
Assistant Professor
Akron Childrens Hospital, United States
Disclosure information not submitted.
Justine Shults, PhD
Professor of Biostatistics
Perelman School of Medicine, United States
Disclosure information not submitted.
.jpg "Vinay Nadkarni, MD, MS, FCCM (he/him/his) photo")
Vinay Nadkarni, MD, MS, FCCM (he/him/his)
Professor, Anesthesiology, Critical Care and Pediatrics
University of Pennsylvania Perelman School of Medicine, CHOP
Media, Pennsylvania, United States
Disclosure information not submitted.
Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Apneic oxygenation implementation as a multicenter quality improvement in the PICU
BACKGROUND/HYPOTHESIS:
Tracheal intubation (TI) in critically ill children is associated with severe peri-intubation hypoxemia. We hypothesize that apneic oxygenation (AO), providing nasal cannula oxygen during the apneic phase of intubation, may reduce the adverse TI associated events (TIAEs), severe TIAEs, and peri-intubation hypoxemia (SpO2 < 80%).
Method:
AO was implemented across 14 ICUs as a quality improvement intervention during 2016-2020. Implementation strategy utilized an intubation safety checklist, leadership endorsement, identifying local champion, and data feedback to frontline clinicians. We standardized the oxygen flow: 5L/min for infant, 10L/min for young child (1-7y), and 15L/min for older child (>8y) with standard nasal cannula. Primary and secondary outcomes were the occurrence of adverse TIAE, severe TIAE, and hypoxemia (SpO2 < 80%). Multivariable logistic regression with generalized estimating equations was used to account for covariates and clustering by site.
Results:
Of 6,549 TIs, 2,554 were reported during pre-implementation and 3,995 during implementation. AO utilization substantially increased from 23% to 68%, p< 0.001. AO was utilized less often in infants, cardiac diagnosis, indication for respiratory/neurological failure, shock, and patients with difficult airway history/features. AO was utilized more often in TIs for procedure. AO use was often used together with video laryngoscopy (AO 64% vs. without AO 34%, p< 0.001). AO use was associated with lower incidence of TIAEs (AO 10.5% vs without AO 13.5%, p< 0.001), aOR 0.75 (95% CI 0.58-0.98, p=0.03) after adjusting for site clustering. After further adjusting for covariates, AO use was not associated with occurrence TIAEs: aOR 0.90, 95% CI 0.72-1.12, p=0.33. For secondary outcomes, AO was associated with lower occurrence of severe TIAEs (AO 4.0% vs. without AO 5.8%, p=0.001). After adjusting for covariates and site clustering, AO was not associated with occurrence of severe TIAEs: aOR 0.84, 95% CI 0.57-1.24, p=0.38. The occurrence of hypoxemia was similar: AO 14.2% vs without AO 15.2%, p=0.43.
Conclusions:
While AO implementation across 14 ICUs was associated with substantially lower occurrence of adverse TIAE and severe TIAE in patients who received AO, this result may be explained by differences in patient, provider, and practice factors.