Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation

Abstract

BACKGROUND:

Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors.

METHODS:

Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as ${\mathbf{\text{S}}}_{{\mathbf{\text{pO}}}_{\mathbf{\text{2}}}}$ < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5–2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV).

RESULTS:

Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving ${\mathbf{\text{F}}}_{{\mathbf{\text{IO}}}_{\mathbf{\text{2}}}}$ ≥ 0.6 at the time of the decision to intubate (19.6%) versus ${\mathbf{\text{F}}}_{{\mathbf{\text{IO}}}_{\mathbf{\text{2}}}}$ < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08–10.5).

CONCLUSIONS:

Results of our study suggest that ${\mathbf{\text{F}}}_{{\mathbf{\text{IO}}}_{\mathbf{\text{2}}}}$ > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.