Apneic Oxygenation During Airway Management in Pediatric Patients

This observational (i.e. nonrandomized) study aims to investigate the effect of a planned
practice change; instituting oxygenation via nasal cannula during induction of anesthesia.
The use of a nasal cannula during the peri-intubation period is of minimal risk and is not
considered a standard of care in pediatric anesthesia. Some providers use it in certain
clinical situations, but it is not broadly used and has virtually no pediatric literature to
support or refute its use. At our institution, intubation of pediatric patients by
inexperienced (learner) providers under expert supervision is routine. The attending
physician intervenes if necessary before the patient experiences excessive loss of
oxygenation.

Participants will be enrolled in the study once they have entered the pre-operative area and
are determined by the attending anesthesiologist to be an eligible study participant.
Participants enrolled in the first three months of the study (up to N=200) will be assigned
to the baseline condition as described below. Participants enrolled in the second phase of
the study (up to N=300) will be assigned to the with-cannula condition described below.

Apneic oxygenation is based on the physiology of the lungs: they absorb a greater volume of
oxygen, 250 ml/min in an adult, than the volume of carbon dioxide, 8-20 mL/min, that is
released by the lungs, because the majority of carbon dioxide is buffered in the blood stream
during apnea. With the imbalanced volumes of absorption and release of gases in the lungs
there is a lower than atmospheric pressure in the lungs, creating a passive movement of gases
from pharynx to alveoli. If the gas in the pharynx has a significantly higher percentage of
oxygen instead of room air at 21% oxygen, a higher amount of oxygen can be passively
delivered to the lungs for absorption prolonging the time to hemoglobin desaturation.

For the Baseline Group of this observational (nonrandomized) study, all intubation procedures
will be performed as per usual practice. Patients will receive premedication as determined by
anesthesiologist/resident/midlevel. Once patients are brought to the operating room and vital
signs are being monitored, patients will be preoxygenated via mask per standard of care, with
an expired oxygenation concentration minimum of 0.75. Vitals will be recorded at the moment
prior to removal of the face mask at the end of the preoxygenation period. Anesthetic
induction will be performed with agents and dosages as per the provider's clinical judgment.
Airway management consisting of oral endotracheal intubation or laryngeal mask airway
insertion will take place. As per standard of care, an attending physician who is expert in
pediatric airway management will supervise the procedure and intervene before the patient
experiences excessive oxygen desaturation.

For the With-Cannula Group, all of the above steps will be maintained. The sole difference
will be nasal cannula placement after induction. It will be set to deliver oxygen at 5 liters
per minute. Airway management consisting of oral endotracheal intubation or laryngeal mask
airway insertion will take place. As per standard of care, an attending physician who is
expert in pediatric airway management will supervise the procedure and intervene before the
patient experiences excessive oxygen desaturation.

Apneic oxygenation will not be used as a long-term oxygenation strategy. No patient will be
allowed to become hypoxic for research reasons.

All intubation procedures in both study groups will proceed as per usual practice. The goal
of all intubation procedures has always been and remains the maintenance of adequate oxygen
saturation.

Inclusion Criteria:

- Pediatric patients presenting for surgery at University of New Mexico Children's
Hospital

- Age range: adjusted gestational age 40 weeks, to 8 years

Exclusion Criteria:

- Patients whose airways would be maintained with mask ventilation only

- American Society of Anesthesiologists classes 4-6