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Effect of Apneic Oxygenation on Tracheal Oxygen Levels, Tracheal Pressure, and Carbon Dioxide Accumulation: A Randomized, Controlled Trial of Buccal Oxygen Administration

Toner, Andrew J. MD (Res)*; Douglas, Scott G. FANZCA*; Bailey, Martin A. FANZCA*,†; Avis, Hans J. PhD*; Pillai, Arani V. FRCA*,‡; Phillips, Michael MMedSci*,§; Heard, Andrew FRCA*

doi: 10.1213/ANE.0000000000003810
Patient Safety: Original Clinical Research Report

BACKGROUND: Apneic oxygenation via the oral route using a buccal device extends the safe apnea time in most but not all obese patients. Apneic oxygenation techniques are most effective when tracheal oxygen concentrations are maintained >90%. It remains unclear whether buccal oxygen administration consistently achieves this goal and whether significant risks of hypercarbia or barotrauma exist.

METHODS: We conducted a randomized trial of buccal or sham oxygenation in healthy, nonobese patients (n = 20), using prolonged laryngoscopy to maintain apnea with a patent airway until arterial oxygen saturation (Spo2) dropped <95% or 750 seconds elapsed. Tracheal oxygen concentration, tracheal pressure, and transcutaneous carbon dioxide (CO2) were measured throughout. The primary outcome was maintenance of a tracheal oxygen concentration >90% during apnea.

RESULTS: Buccal patients were more likely to achieve the primary outcome (P < .0001), had higher tracheal oxygen concentrations throughout apnea (mean difference, 65.9%; 95% confidence interval [CI], 62.6%–69.3%; P < .0001), and had a prolonged median (interquartile range) apnea time with Spo2 >94%; 750 seconds (750–750 seconds) vs 447 seconds (405–525 seconds); P < .001. One patient desaturated to Spo2 <95% despite 100% tracheal oxygen. Mean tracheal pressures were low in the buccal (0.21 cm·H2O; SD = 0.39) and sham (0.56 cm·H2O; SD = 1.25) arms; mean difference, −0.35 cm·H2O; 95% CI, 1.22–0.53; P = .41. CO2 accumulation during early apnea before any study end points were reached was linear and marginally faster in the buccal arm (3.16 vs 2.82 mm Hg/min; mean difference, 0.34; 95% CI, 0.30–0.38; P < .001). Prolonged apnea in the buccal arm revealed nonlinear CO2 accumulation that declined over time and averaged 2.22 mm Hg/min (95% CI, 2.21–2.23).

CONCLUSIONS: Buccal oxygen administration reliably maintains high tracheal oxygen concentrations, but early arterial desaturation can still occur through mechanisms other than device failure. Whereas the risk of hypercarbia is similar to that observed with other approaches, the risk of barotrauma is negligible. Continuous measurement of advanced physiological parameters is feasible in an apneic oxygenation trial and can assist with device evaluation.

From the *Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia

Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Perth, Australia

Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

§Centre for Medical Research, University of Western Australia, Perth, Australia.

Published ahead of print 14 August 2018.

Accepted for publication August 14, 2018.

Funding: Royal Perth Hospital Department of Anaesthesia and Pain Medicine funded Fellows for trial recruitment and provided disposables. The Medical Research Fund of Royal Perth Hospital ( supported the statistical analysis.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Clinical trial number and registry URL: ACTRN12617000173392 ( Principal Investigator: Andrew J. Toner.

Reprints will not be available from the authors.

Address correspondence to Andrew J. Toner, MD (Res), Department of Anaesthesia and Pain Medicine, University of Western Australia, Royal Perth Hospital, Perth 6000, Australia. Address e-mail to

Copyright © 2018 International Anesthesia Research Society
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