Apneic Oxygenation Did Not Help in This ICU-Based Study

Be sure to check the links to EMCrit and EM Lit of Note below.  They are helpful in understanding some of the limitations of the study and how it applies to us in the ED.

Semler MW, Janz DR, Lentz RJ et al for the FELLOW Investigators and the Pragmatic Critical Care Research Group. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. Am J Respir Crit Care Med. 2015 Oct 1. [Epub ahead of print]

CONCLUSIONS: Apneic oxygenation does not appear to increase lowest arterial oxygen saturation during endotracheal intubation of critically ill patients compared to usual care. These findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. PMID: 26426458

Comments: Smaller RCTs have shown benefit for apneic oxygenation.  This Vanderbilt study is the largest RCT to tackle this topic, and it showed no difference.  Many of these patients had severe problems with oxygenation already, as opposed to prior RCTs with healthy patients in the OR.  Possibly a higher flow rate, such as 60mL/min as in other studies, may have added benefit.  The authors also note, "High compliance with pre-oxygenation (including non-invasive ventilation for patients with hypoxemia), patient positioning, and equipment preparation best practices may have reduced the potential additive impact of apneic oxygenation. Had we used a standardized intubation protocol or a highly-uniform group of operators, we might have reduced practice-related variation in lowest arterial oxygen saturation, making any effect of apneic oxygenation easier to detect."  I plan to continue using HFNC + NRB mask to preoxygenate prior to intubation.  I see no downside, and the benefit is clearer in patients without severe preexisting pulmonary disease and in obese patients.  Here is what the EMCrit podcast, EMCrit blog and EMLitofNote had to say.