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• W3010996938 abstract "See Article, p 831 We applaud the efforts of Else and Kovatsis1 on their comprehensive narrative review of oxygenation during pediatric intubation and airway procedures and providing a summary of the evidence available to date regarding the use of high-flow and low-flow apneic oxygenation. The review is timely, as low-flow oxygenation is re-examined and perioperative use of high-flow systems moves from the innovation phase and on to the early adoption phase, toward the reduction of hypoxemia and subsequent cardiorespiratory adverse events. Hypoxemia during airway management is widely recognized as the most common complication during difficult or prolonged tracheal intubation attempts and tubeless surgery in pediatric patients.2 The risk for significant adverse events is higher in smaller children due to their greater oxygen consumption rates and relatively decreased functional residual capacity when compared to adults under anesthetized conditions. Oxygenation during tracheal intubation is not a new concept, but no study has provided enough evidence to identify one superior technique for this purpose. Despite the paucity of high-quality studies in pediatric patients, the evidence thus far supports the use of low-flow apneic oxygenation, and even a simple nasal cannula should be considered in patients at risk for challenging airway management or those with poor cardiopulmonary reserve. Preventing significant oxygen desaturations can improve the likelihood of successful tracheal intubation by minimizing prematurely terminated attempts and providing a less time-pressured environment in what may already be a high stress situation. High-flow nasal oxygenation systems have not definitively been shown to increase the time to oxygen desaturation in pediatric patients when compared to low-flow oxygenation techniques. Although having promising potential for clinical use in operating rooms, such as in airway procedures, high-flow nasal oxygenation systems may not be readily available to most clinicians and are more complex, costly, and cumbersome than low-flow options. In contrast, low-flow oxygen delivery can be easily achieved with existing equipment found in most operating rooms, such as a nasal cannula, modified nasopharyngeal airway, or tracheal tube placed near the glottis with limited risk to the patient. Table 4 of the paper provides an informative summary of the advantages and disadvantages of these supplemental oxygenation techniques. In addition, in order for supplemental apneic oxygenation to be maximally effective, certain physiologic conditions are necessary, including alveolar preoxygenation, recruitment, unobstructed airways, and minimal entrainment of room air (Figure 1 of the paper). Determining the best method for supplemental oxygen delivery for specific pediatric populations still requires additional study but does not take away from the fact that oxygenation is critical to reducing morbidity and mortality during airway management. With this fundamental goal in mind, the applicability of supplemental low-flow oxygenation should be part of every clinician’s safety checklist and as routine as utilizing an oxygen facemask or a supraglottic airway. Subject matter experts continue to advocate the importance of supplemental oxygen during predicted times of prolonged apnea, as might be encountered during a difficult tracheal intubation, especially in infants.3–6 Yet, despite increasing evidence and logical arguments for the use of apneic oxygenation, it may still be underutilized in routine clinical practice. Any tracheal intubation attempt can turn into a life-threatening event and should not be undertaken without measures to prevent morbidity and mortality related to hypoxemia, especially when challenges are anticipated. Even with the general acceptance of the importance of oxygenation in preventing hypoxemia-related critical events, many clinicians may still be slow to adopt low-flow oxygenation techniques during airway management. Changes to routine practice require deliberate thought and action, and adding this additional step may be seen as a hassle or inconvenience when most desaturation events may be mild or temporary. In reality, the use of a nasal cannula should have minimal impact on the clinician’s ability to bag mask ventilate but can also be quickly removed if needed.7 Because it remains outside of the oropharynx, there is no concern for visual obstruction during laryngoscopy, unlike some insufflation techniques. Some degree of functional fixedness bias may make the use of commonly used low-flow oxygenation products less than intuitive for use during times of apnea. Not all difficult intubation attempts are anticipated, and if the use of low-flow oxygenation is not already part of one’s mental safety checklist or difficult airway algorithm, it may not come to mind under pressure. Figure 2 of the paper offers a helpful guideline and tips for utilizing nasal cannula for low-flow apneic oxygenation during tracheal intubation. In addition to ongoing studies, bringing awareness to clinicians beyond airway enthusiasts may require further advocacy by airway societies. Explicit inclusion of low- or high-flow techniques in published difficult airway management algorithms would give further validation and endorsement of this practice, more so than the current algorithms that broadly recommend “oxygenate and ventilate” or “ensure oxygenation.” Training programs can also help provide support in making this change. Utilizing supplemental apneic oxygenation at academic institutions during challenging airway management with trainees would confer immediate benefit to the patient and propagate the practice to subsequent generations of clinicians. As this practice becomes less of an afterthought, and more of a planned consideration, supplemental oxygenation during difficult airway management should become standard of care.8 As highlighted by Else et al,1 further studies are required to more clearly define the role of high-flow nasal oxygenation systems in procedural clinical practice, prolonged apneic oxygenation, and carbon dioxide (CO2) clearance and may not always be a practical option. Similar to Riva et al,9 who compared low-flow oxygen and high-flow oxygen at different inspired oxygen concentrations, further “dose-response” studies at various oxygen concentrations across low- and high-flow conditions in various patient populations are warranted. Modeling studies of laminar and turbulent flow across various patient age, sizes, and airway morphologies could shed light on the basic physiology and mechanisms of (CO2) clearance. Finally, landscape survey studies gauging provider and institutional practice adoption and prospective multi-institutional collaborative efforts would be a step in collecting robust safety and efficacy data. Despite gaps in knowledge, low-flow apneic oxygenation during difficult airway management should be an undisputable part of every clinician’s armamentarium. It is readily available and has a low-risk profile with significant potential to improve conditions for successful tracheal intubation attempts and reduce hypoxemia-related adverse events. Oxygenation is the priority; therefore, the use of simple low-flow apneic oxygenation in most cases can allow for a greater margin of safety and should routinely be considered for patients at risk for hypoxemic events during airway management. We hope this review prompts clinicians to have these oxygenation techniques at the forefront of their mental checklists, rather than being an afterthought. DISCLOSURES Name: Lisa Sohn, MD, MS. Contribution: This author helpedin the conception of the editorial, analysis, and interpretation of the data; drafting the article; and final approval of the version to be published. Conflicts of Interest: None. Name: John Hajduk, BS. Contribution: This author helpedin the conception of the editorial, analysis, and interpretation of the data; drafting the article; and final approval of the version to be published. Conflicts of Interest: None. Name: Narasimhan Jagannathan, MD, MBA. Contribution: This author helpedin the conception of the editorial, analysis, and interpretation of the data; drafting the article; and final approval of the version to be published. Conflicts of Interest: N. Jagannathan serves on the editorial boards of Anesthesia & Analgesia, Pediatric Anesthesia, Journal of Clinical Anesthesia, and Journal of Anesthesia (Japan). He has received products free of charge from Ambu and Teleflex corporations. He has received travel support for meetings involving future developments for upcoming airway devices from Teleflex and Mercury Medical and is on the Medical Advisory Board of Vyaire. This manuscript was handled by: James A. DiNardo, MD, FAAP." @default.
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• W3010996938 title "Apneic Oxygenation as a Standard of Care in Children: How Do We Get There?" @default.
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