ISSN: 2377-4630

Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081 DOI: 10.23937/2377-4630/1410081 International Journal of
Volume 5 | Issue 2 Open Access Anesthetics and Anesthesiology
Review ARTicle Apneic Oxygenation and High Flow
Ayten Saracoglu1*, Halime Hanim Pence2, Mehmet Yilmaz3 and Kemal Tolga
Saracoglu3
1 Department of Anesthesiology and Reanimafion, Marmara University, School of Medicine, Turkey

Check updates for 2Department of Medical Biochemistry, Health Sciences University, Turkey 3Department of

Anesthesiology and Reanimafion, Health Sciences University, Turkey

*Corresponding author: Dr. Ayten Saracoglu, Assoc. Prof. MD, Department of Anesthesiology and
Reanimafion, Mar- mara University Medical School Hospital, Fevzi Cakmak Mh. Muhsin Yazicioglu
Cd. No: 10, Pendik, Istanbul, Turkey, Tel: +902166570606
Abstract
Prevention and minimizing serious complications during difficult airway management is an important goal for anes-
thesia providers. Using the high flow cannula oxygenation systems it is possible to improve the clinical outcomes, in-
crease patient safety and reduce the rate of complications. A possible mechanism of this method can be explain by
‘Aventilatory Mass Flow’ which is a physilogical phenom- enon. Several methods can be used to implement apneic
oxygenation such as nasopharyngeal catheter, nasal can- nula, face mask, Venturi mask, transtracheal
endobronchial catheters, dual blade laryngoscopes and High Flow Nasal Cannula Oxygenation (HFNCO) systems.
However each method has some restrictions. In this review we aim to focus on the important features of HFNCO
systems including the indications, contraindications and possible complications.
Keywords
Apneic oxygenation, Aventilatory mass flow, High flow
Introduction
Cardiovascular collapse, anoxic brain injury or death are some of the results of serious
complications that may occur during difficult airway management. Mini- mizing the risk of these
complications is only possible by improving airway management strategies. Apneic oxygenation
is a beneficial method adopted incremen- tally for this purpose. Actually this is historically an old
method, first defined by German Anesthesiologists in 1905 [1]. Holmdahl [2] defined apneic
diffusion oxy- genation during bronchoscopies in 1956. Frumin, et al. [3] demonstrated that it
was possible to maintain high levels of oxygen saturation for 18 to 55 minutes with-
Citation: Saracoglu A, Pence HH, Yilmaz M, Saracoglu KT (2018) Apneic Oxygenation and High Flow. Int J
Anesthetic Anesthesiol 5:081. doi.org/10.23937/2377-4630/1410081 Accepted: November 14, 2018: Published:
November 16, 2018 Copyright: © 2018 Saracoglu A, et al. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081
• Page 1 of 4 • out
ventilation. Following these reports, Weingart and Levitan [4] introduced apneic
oxygenation to prevent desaturation. And popularity of this method has been peaking in this
century. Fick principle explains uptake and consumption output and oxygen of rates O2 by
peripheral tissues. Cardiac in arterial and venous com- partments play major role in this
equation. A normo- thermic adult human consumes 3 mL/kg oxygen. Crit- ical threshold of
oxygen consumption is 250 mL/min. Oxygen consumption increases with increased alveolar
 ventilation in parturients [5].
During apnea, from lungs. As long PaOas 2 decreases hemoglobin as keeps O2 gets removed
being oxy- genated in lungs, saturation levels remain over 90%. When oxygen the level in lungs

start decreasing, is around 45-50 mmHg at this point. Denitrogenation PaOof 2 functional residual
capacity (FRC) may increase oxygen capacity of lungs. This is possible by increasing oxygen
percentage in breathing tinuous positive airway gas pressure (FiO2(CPAP) ). Also applying con-
and elevating patient’s head to 25-30 degrees prevents atelectasia and improves FRC
respectively.
Safe apnea period is the time from discontinuation of ventilation to the beginning of desaturation
90%). Anesthesiologists have limited time to provide (SpO2 <
safe airway when patients are unconscious. This peri- od is called “apneic window”. Decrease in
causes propriate rapid preoxygenation, deceleration in airway SaO2 below occlusion, this
PaOlevel. 2 levels Inap- pulmonary shunt, critical diseases, obesity, pregnancy and pediat- ric
patients are some risk factors of short apneic win-
ISSN: DOI: 10.23937/2377-4630/1410081 2377-4630 dow. Time from succinylcholine administration to de-
valves is placed in exhalation port and the other is lo- saturation and 2.7 min (SpOin 2 normal <
90%) has adults, been moderately found as 8 min, ill Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081 •
Page 2 of 4 • 5 min, patients and obese patients respectively [6]. Recommended pre-
cated between reservoir and face mask. This prevents air tes slip over in. 15 This L/min.
increases Oxygenation FiO2 up is to also 60-70% possible for through flow ra-
oxygenation techniques include tidal volume ventilation
cricothyrotomi or a cannula inserted through endotra- with high FiO2 [7].
FiO2 for 3 min or 8 deep breaths with 100%
Aventilatory Mass Flow
cheal tube. Endotracheal catheters placed in right or left bronchi is another method of apneic
oxygenation. Another technique is dual-use laryngoscope. Oxygen is applicable through a canal

inside the blade. This makes This is a physilogical phenomenon. consumption patient are 250

rate mL/min and COand 2 production 200 Metabolic rate in an adult O2 mL/min respectively.

Following pillary production almost blood denitrogenation with 250 mL/min of FRC, rate. O2

During diffuses does not change, but elimination paused and diffusion slows down to to the ca-

apnea, of only CO10-20 CO2 is 2 mL/min [8,9]. As a result of this negative pressure gra- dient, a
mass flow of gas from pharynx to alveoli occur. COand through 2 levels respiratory nasal keep
cannula increasing. acidosis. washes A This high dead causes O2 space flow a decrease of in >
15 lungs, in pH L/min thus
insufflation of oxygen up to 15 L/min possible.
In recent years, high levels of humidified oxygen the- rapy through nasal cannula has been
possible with ad- vanced devices and it is possible to apply up to 70 L/min Oto 2 application flow.
Atelectasia of 100% risk oxygen following is partially denitrogenation prevented due by forming
positive pharyngeal pressure. This method also makes application of positive pressure in low
levels with nasal interface possible and provides controlled oxy- gen concentrations. Utilizing an
 oxygen/air blender, it is possible to obtain FiO2 0.21-1 with 60-70 L/min flow. restricts via better
COgas 2 increase. washout. This In several also creates studies, a patients “stent effect” were
Gases are actively ventilated, humidified and inspi- red to the patient through a one-way circuit.
High flow able to tolerate long apnea periods [9,10]. Average ap-
is 2-8 L/min for neonatal patients, 5-20 L/min for pe- nea duration changes between 5-45 rease
has been found between 1.1 minutes. to 3.4 mmHg/min CO2 inc-
diatric patients and 6-40 L/min for adults. Vapotherm, Optiflow, Aquinox, Precision Flow and
Comfort-flow are during this 160 mmHg. application. Complications CO2 like levels seizures,
may increase up to cardiovascular
some of brands manufacturing devices for high flow applications. Flexible delivery tubing
system is able to collapse, and arrythmias related to hypercapnia have not been reported.
provide a 70 L/min flow. A heating plate vapors water and delivers respiratory gas. This unit
contains a passo- The Canadian Airway Focus Group and Difficult Airway Society proposes this
method in patients with anticipated difficult airway [4,11]. Additionally, Obstet- ric Anaesthetists’
Association also supports this method in obstetric patients with a possibility of failed airway
management. Nasopharyngeal catheter, nasal cannula, face mask, Venturi mask, transtracheal
endobronchial catheters, dual blade laryngoscopes and low flow oxy-
ver humidifier, a high performance circuit and an Optif- low heated nasal to cannula. 37 °C and
This humidified, system delivers and is 44 connectable mg H2O/L gas to jack system directly.
Nasal cannula may be in different sizes. Outer diameter of the cannula must be at least same
with nostril diameter. This unit also has an adap- ter for use in connecting to tracheostomy of
children weighing more than 15 kg. gen or High Flow Nasal Cannula Oxygenation (HFNCO)
systems are also usable for this method by applying high flow oxygen. However efficiency of
oxygen flow applied by conventional methods are limited, because, these methods doesn’t
provide enough warming and humidifying. This also causes a decrease in inspired oxy- gen
concentration. Low flow systems have no effect on ventilation and nasopharyngeal COairway 2
removal. Oxygen entrance port of permits oxygen insufflation. Na- sopharyngeal catheter helps
oxygen delivery to pharynx very effectively. If oxygen flow is between 1-8 L/min, this moves
increases humidity FiOin 2 to mucosa, 24-44%. and But may this be method disturbing also for
re-
awake patients. That’s why high flow rates over 15 L/ min is usually preferred in patients under
general anest- hesia.
AIRVO 2 is another mobile, ultrasonic, optiflow sys- tem. Pediatric nasal cannula contains a
hydrocolloid sti- cky band which helps in fixing the unit. Aquinox TM high flow applicant system
is able to deliver the gas in a flow rate of 35 L/min. Particles exiting from a Venturi heated and
humidified shoes their effect in a closed chamber. Gas flow which contains humidified particles
is delive- red to the patient via a hollow tubing. Inner chamber forms particles as a humidifier
and outer chamber de- livers the gas to the paitent. PARI Hydrate system uses pre-heated
water system as a principle and is able to create air-flow. The advantage of this system is the
abi- lity to control heating according to desired humidity le- vels. There is no guide available
created for high flow oxygen therapy application in pediatric or adult patient population. It is
recommended to begin with flow levels Venturi mask is able to deliver 100% oxygen. This
method ks has an increases oxygen reservoir FiO2 up to 50%. Re-breathless mas- and two
valves. One of the
of 8-10 fold of minute ventilation in some studies. Re- commended flow rate is 8-12 L/min in
infantile patients and 20-30 L/min in juveniles, starting with low flow and
Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081
• Page 2 of 5 •
ISSN: DOI: 10.23937/2377-4630/1410081
2377-4630 Table 1: The comparison of HFNCO and NIV systems.
HFNCO NIV Fixed flow and variable pressure levels Variable flow for fixed pressure Able to reduce dead space
Increases dead space Does not effect tidal volume May increase tidal volume Reduces respiratory workload More
effective in reducing respiratory workload Minimal gastric distention Loss of pressure when mouth is opened Pressure
can be maintained
Table 2: Potential indications of HFNCO. Preoxygenation before intubation
absolute sal clearance humidity is completely should be halted above after 20 mg 1 hour H2O/L.
when Muco- dry Acute hypoxemic respiratory failure
airflow is used. Moderate obstructive sleep apnea Oxygenation following extubation
Noninvasive Ventilation (NIV) vs. HFNCO
Sedation Decrease in CO2 levels Acute COPD flare-ups Postoperative hypoxemia
NIV connections increase anatomic dead space whe- re as HFNCO reduces it. HFNCO does
not actively cause increases in tidal volume, this only creates minor inc- reases in end-
expiratory airway pressure and reduces respiratory workload as effectively as NIV. But NIV is
more effective in comorbid patients. A certain level of providing CPAP is possible with HFNCO
therapy. This is flow-dependent and associated with mouth-opening. Features of HFNCO are
summarized in Table 1 [15]. HFNCO system is potentially useful during awake fibe- roptic
intubation [16]. Conventional methods might be insufficient in preventing desaturation during
awake in- tubation.
Miguel-Montanes, et al. [17] used non-rebreather mask and HFNCO during tracheal intubation
in intensive care unit before and during the procedure. Lowest me- dian was 94% SpO2 while
during 100% intubation for Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081 • Page 3 of 4 • for non-rebreathing
masks HFNCO. They demonstrated that HFNCO significantly reduces severe hypoxemia
prevalence and increases patient safety. Potential areas of use for HFNCO are stated in Table
2. Causes of rapid desaturation of obese patients are increased oxygen consumption, alveolar
ventilation. increased Metabolic CO2 production rate increasing the flow to the rate that is
tolerable by the patient:
-2-4 L/kg/min for 0-5 kg (up to 20 L/min)
-2 L/kg/min for 5.1-12.5 kg (up to 25 L/min)
-2 L/kg/min fow 12.6-35 kg
-Up to 70 L/min fow > 35 kg patients
i-THRIVE is successfully used in laser surgeries with FiOlimit 2 levels oxygen up dilution to 30%.
and High reduce flow respiratory nasal cannula dead systems space. This and device also this
is correlated removes with COincreases 2 in anatomic dead space in flow rate [12]. Conventional
oxygen devices provide dry and unhea- ted air to patients, and this causes dehydration in oral
and nasal mucosa, irritation of the eye with trauma risk. Heating and humidifying airway improve
pulmonary compliance and elastance [13]. Additionally, reseptors in nasal mucosa reacts to the
dry-cold air and causes a
and increased protective bronchoconstriction in normal and asthmatic
is directly propor- patients. Heated and humidified air also improves ciliary
tionate to body weight and amount of fat tissue. This activity with the removal of secretions and
prevention
reduces chest wall compliance. of atelectasia. HFNCO creates a high flow rate and redu- ce
inhalation resistance in airway passage. This is used in modification of respiratory workload.
Obese patients with BMI over 40 have a relative ba- seline hypoxemia. HFNCO reduces this
dead space and increases alveolar ventilation. This reduces the respira- Positive airway
pressure formed by HFNCO interacts
tory workload. Corley, et al. [18] evaluated end-expi- derogatorily with intrinsic PEEP partially
and helps re-
ratory lung volumes with lung impedance tomography ducing workload. Thus, dynamic
hiperinflation improves
and found it higher in patients receiving low flow oxy- patient comfort. HFNCO therapy creates a
flow-depen-
gen therapy with HFNCO. Several previous studies de- dent positive airway pressure. Every 10
L/min increase in airflow increases airway pressure by 0.5-1 cm H2O.
HFNCO is reported to increase end-expirium lung im- pedance [14]. This increase in lung
volume is also used as alveolar recruitment. HFNCO was found significantly useful when
applied to obese patients undergoing car-
monstrated pharyngeal tissue that HFNCO when 35-40 produces L/min 5 cm oxygen H2O
pressure flow is app- on
lied. However, Piastro, et al. [19] did not observe any pressure changes in middle ear. This may
suggest that HFNCO therapy is a good option for patients undergoing otological procedures.
diac surgery. This increase in EELV is thought as alveolar
Incidence of respiratory failure following extuba- recruitment and prevents alveolar collapse.
This is pos-
tion is around 10-20% and may require re-intubation sible thanks to the low positive pressure
level system
[20]. Re-intubation due to respiratory failure is associ- of HFNCO. In order to prevent
dehydration of mucosa,
ated with increased Ventilatory Associated Pneumonia
ISSN: DOI: 10.23937/2377-4630/1410081 2377-4630 (VAP), mortality, prolonged stay in hospital and Intensi- 9.
Rudlof B, Hohenhorst W (2013) Use of apneic oxygenation ve Care Unit (ICU). HFNCO is proven to be
significantly increasing patient comfort and reducing the length of
for the performance of pan-endoscopy. Otolaryngol Head Neck Surg 149: 235-239.
stay in hospital in patients undergoing lung resection.
Contraindications for this therapy include airway
10. Patel A, Nouraei SA (2015) Transnasal humidified rapid-in- sufflation ventilatory exchange (THRIVE): A
physiological method of increasing apnoea time in patients with difficult obstruction
and facial trauma [21].
Airway obstruction
airways. Anaesthesia 70: 323-329. restricts apneic oxygenation and this causes desatura-
11. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, tion. application. Increase HFNCO in CO2
therapy may also should limit be apneic avoided oxygenation if patient has risk of hypercapnia,
increased intracranial pressure,
et al. (2013) The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J
Anaesth 60: 1119-1138.
hemodynamic instability or cardiac dysrhythmia. Comp- lications are mucosal tissue damage,
hypercarbia, aci- dosis and infection [10]. Hemodynamic changes occur due to sympathetic
discharge following hypercarbia. Ri- sing in venous return increases the left ventricular filling
12. Schwabbauer N, Berg B, Blumenstock G, Haap M, Hetzel J, et al. (2014) Nasal high-flow oxygen therapy in
patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to
convention- al oxygen therapy and non-invasive ventilation (NIV). BMC Anesthesiol 14: 66. pressure,
thus
increasing cardiac output and possibi- lity of life-threatening arrythmias [22]. Apart from this,
13. Sotello D, Orellana-Barrios M, Rivas AM, Nugent K (2015) High Flow Nasal Cannulas for Oxygenation: An Audit
of Its inappropriate use of HFNCO may compromise patient
Use in a Tertiary Care Hospital. Am J Med Sci 350: 308-312. safety despite all its advantages in patients
with respi- ratory failure.
14. Parke RL, Bloch A, McGuinness SP (2015) Effect of very- high-flow nasal therapy on airway pressure and end-
expi- Conclusions
ratory lung impedance in healthy volunteers. Respir Care 60: 1397-1403. Apneic oxygenation is increasingly
used in ICU and
15. Spoletini G, Alotaibi M, Blasi F, Hill NS (2015) Heated hu- operating rooms for difficult airway
management by HFNCO systems. It is possible to deliver humidified and
midified high-flow nasal oxygen in adults: Mechanisms of action and clinical implications. Chest 148: 253-261.
heated oxygen flow rates of up to 70 L/min. Apneic ox- ygenation requires a patent airway
regardless of the technique used. Contraindications for this therapy in- clude airway obstruction
and facial trauma.
16. Badiger S, John M, Fearnley RA, Ahmad I (2015) Optimiz- ing oxygenation and intubation conditions during
awake fi- bre-optic intubation using a high-flow nasal oxygen-delivery system. Br J Anaesth 115: 629-632.
17. Miguel-Montanes R, Hajage D, Messika J, Bertrand F, Acknowledgements
Gaudry S, et al. (2015) Use of high-flow nasal cannula oxy- gen therapy to prevent desaturation during tracheal
intuba- The authors state no conflict of interest.
tion of intensive care patients with mild-to-moderate hypox- References
emia. Crit Care Med 43: 574-583.
18. Corley A, Bull T, Spooner AJ, Barnett AG, Fraser JF (2015) 1. Smith RB, Sjöstrand UH (1985) Apneic diffusion
oxygen-
Direct extubation onto high-flow nasal cannulae post-cardi- ation and continuous flow apneic ventilation. A review.
Acta
ac surgery versus standard treatment in patients with a BMI Anaesthesiol Scand 29: 101-105.
≥ 30: A randomised controlled trial. Intensive Care Med 41:
2. Holmdahl MH (1956) Pulmonary uptake of oxygen, ac-
887-894.
id-base metabolism, and circulation during apnoea. Acta
19. Piastro K, Chaskes M, Agarwal J, Parnes S (2016) The ef- Chir Scand 212: 1-128.
fect of high flow nasal cannula oxygen therapy on middle
3. Frumin MJ, Epstein RM, Cohen G (1959) Apneic oxygen-
ear pressure. Am J Otolaryngol 37: 221-224.
ation in man. Anesthesiology 20: 789-798.
20. Ansari BM, Hogan MP, Collier TJ, Baddeley RA, Scarci M,
4. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, et al. (2015) Difficult Airway Society 2015 guidelines
for management of unanticipated difficult intubation in adults.
et al. (2016) A randomized controlled trial of high-flow nasal oxygen (optiflow) as part of an enhanced recovery
program after lung resection surgery. Ann Thorac Surg 101: 459-464.
Br J Anaesth 115: 827-848.
21. Nishimura M (2015) High-flow nasal cannula oxygen thera-
5. Saracoglu A (2015) Structural differences in respiratory
py in adults. J Intensive Care 3: 15.
system and airway of parturients. Glob J Anesthesiol 2: 52.
22. Kolettas AA, Tsaousi GG, Grosomanidis V, Karakoulas KA,
6. Benumof JL, Dagg R, Benumof R (1997) Critical hemoglo- bin desaturation will occur before return to an
unparalyzed
Thomareis O, et al. (2014) Influence of apneic oxygenation on cardiorespiratory system homeostasis. J Anesth 28:
172-179.
state following 1mg/kg intravenous succinylcholine. Anes- thesiology 87: 979-982.
7. Taş Z, Hoşten T, Kuş A, Cesur S, Türkyılmaz N, et al. (2017) Comparison of tidal volume and deep breath preox-
ygenation techniques undergoing coronary artery bypass graft surgery: Effects of hemodynamicresponse and arterial
oxygenation. Turk J Med Sci 47: 1576-1582.
8. Pratt M, Miller AB (2016) Apneic oxygenation: A method to
prolong the period of safe apnea. AANA 84: 322-328.
Saracoglu et al. Int J Anesthetic Anesthesiol 2018, 5:081 • Page 4 of 4 •