EmergeNcy Department Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation

Hypoxia may occur during rapid sequence intubation (RSI) of emergency department patients
(1-4). This condition may increase the risk of the patient suffering a cardiac arrest
secondary to securing the airway. A part of RSI is pre-oxygenation, which is defined as
placing the patient on 100% fraction of inspired O2 for 3 minutes prior to administering the
induction agents (i.e. sedative and neuromuscular blocker) in order to increase the amount of
oxygen present in the functional residual capacity of the patients lungs to prolong oxygen
saturating during the apneic period of endotracheal intubation (5-9). In the last decade,
physicians have developed a process known as diffuse apneic oxygenation (DAO) in order to
mitigate the risk of oxygen desaturation during this apneic period. The process entails
leaving the patient on high flow nasal cannula (HFNC) oxygen during the act of visualizing
the vocal cords and placing the endotracheal tube. Over the years the practice has started to
become more common in emergency departments, operating rooms and ICU's all over the world.
Recently, a randomized controlled trial (called The FELLOW Trial) of this practice
demonstrated no difference in desaturation rates between those patients that received DAO and
those that did not (usual practice) in patients in the ICU (10). Some have commented that the
findings of this study cannot be applied to emergency department patients, and so evidence is
lacking in regards to this population.

Purpose of the study:

Although studies have started to investigate the efficacy of DAO in preventing desaturation
during RSI, evidence is still lacking in the emergency department patient population. The
primary question being asked is: does diffuse apneic oxygenation increase the average lowest
arterial oxygen saturation during rapid sequence intubation when compared to usual care?
Secondary question being asked is: does diffuse apneic oxygenation decrease the incidence of
desaturation in general, as well as hypoxemia and severe hypoxemia? The third question being
asked is: does diffuse apneic oxygenation increase the time to desaturation?

Inclusion Criteria:

Any patient greater than 18 years of age that presents to the Lincoln medical and Mental
Health Center Emergency Department requiring endotracheal intubation.

Exclusion Criteria:

Patients will be excluded from the primary outcome analysis, but included in the intention
to treat analysis for the secondary outcome if they are not pre-oxygenated to the standard
RSI protocol of 3 minutes with 100% fraction of inspired oxygen (FiO2) by means of bag
valve mask, HFNC and/or non-rebreather; patients will be excluded from the study in general
if they are in cardiac or traumatic arrest or they are intubated without an apneic period
(awake intubation)