[Utilization of apneic oxygenation in anesthesiology: a nationwide survey in Germany]

Abstract

Background and research question: While patient safety during general anesthesia has improved in recent years, incidents still occur during anesthesia, particularly in the area of extended airway management. During the induction of general anesthesia, spontaneous breathing is routinely suspended thereby increasing the risk of hypoxemia during the apneic phase. To prevent desaturation and clinically significant hypoxemia, preoxygenation is performed before anesthesia induction. While preoxygenation can extend the safe apnea time, certain high-risk patient groups, such as obese patients, pregnant women, children and those with difficult airways, may require additional stabilization strategies. Apneic oxygenation (ApOx), a technique first described in the early twentieth century, delivers 100% oxygen at a flow rate of 15 l per min or more during the apneic phase to prolong oxygenation. While current airway management guidelines recommend ApOx during the laryngoscopy phase for patients at risk, its widespread utilization in clinical practice remains limited.

Objective: This study presents the findings of a multicenter, web-based survey investigating the use of ApOx in anesthesiology departments across Germany, highlighting the challenges in implementation and identifying areas for further improvement.

Materials and methods: Between 1 July 2024 and 3 September 2024 a multicenter, exploratory, anonymous survey of anesthetists in various German hospitals was conducted. The survey was conducted via the online platform Lime Survey (Hamburg/Germany). Participants were asked about their personal and institutional background and the use of ApOx in their institution The study is based on descriptive statistics.

Results: The survey was completed by a total of n = 310 anesthetists and after excluding incomplete data sets, n = 306 questionnaires could be analyzed. The majority of participants were male (63%), with an average age of 41 years (± 10.4). In terms of professional roles, there was an even split between senior physicians (34%) and residents (34%), followed by consultants (25%) or heads of departments (8%). The work settings included university hospitals (37%), maximum care hospitals (27%), intermediate care hospitals (19%) and basic and standard care hospitals (15%). The majority of the participants (59%) had an additional qualification in emergency medicine. In addition, 48% of the respondents had an additional qualification in intensive care medicine. In 84% of cases it was found that neither in-hospital nor prehospital standard operating procedures on ApOx exist. Of the respondents 18% indicated that they regularly perform ApOx. The procedure is employed in the following scenarios: 54% for respiratory insufficiency, 42% for expected difficult airway and 34% for rapid sequence intubation. In the clinical practice 51% of procedures utilize a high-flow nasal cannula, while 33% employ a standard nasal cannula.

Conclusion: Despite the scientific evidence indicating that the utilization of ApOx is associated with a markedly reduced incidence of hypoxemia and an elevated probability of first-pass intubation success, it is not employed on a routine basis in Germany. Currently, there is an absence of standardization with respect to the indications and administration technique of ApOx. The underlying factors contributing to this phenomenon are believed to be numerous and multifaceted.

Keywords: Airway management; Anesthesia; Narcosis; Oxygen; Patient safety; Preoxygenation.

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Flow-Chart zum Teilnehmer-Recruitment

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Verteilung der Karrierestufen in der Studienpopulation