medwireNews: Use of high-flow nasal oxygen during tubeless upper airway surgery in children does not significantly reduce the chances of the surgery being interrupted to allow for rescue oxygenation compared with standard care, report researchers.
The high-flow technique, which delivers weight-specific oxygen flows – of 2 L/kg per min for most children – at a fraction of inspired oxygen of 1.0 via nasal cannulae, and the standard delivery of oxygen up to 6 L/min via nasopharyngeal or oropharyngeal catheter, resulted in successful anesthesia with no interruptions for the majority (88%) of surgeries in both cases, show the findings from the HAMSTER trial.
“[S]hared airway procedures pose challenges to both anaesthetist and surgeon,” explain Andreas Schibler, from the Wesley Research Institute in Brisbane, Queensland, Australia, and colleagues in The Lancet Respiratory Medicine.
“Hypoventilation and apnoea occur frequently,” they remark, noting that the resultant oxygen desaturation “typically results in the surgery being interrupted while ventilation and oxygenation are re-established.”
The team assessed the efficacy of high-flow nasal oxygen compared with standard oxygen delivery in 483 children (293 boys) aged a median of 1.7 years (range 0–16 years). The cohort was randomly assigned before anesthesia to receive one of the two oxygen delivery methods for a total of 528 tubeless airway procedures (267 high-flow and 261 standard oxygen).
As well as resulting in similar overall rates of successfully anesthetized uninterrupted surgery, outcomes were comparable for high-flow oxygen and standard oxygen across all ages, at a respective 80% and 87% for participants aged up to 1 year, 91% and 87% for those aged 1 and up to 5 years of age, and 94% and 90% for those aged 5 years and up to 16 years of age.
A total of 19% of procedures in the high-flow oxygen group involved a hypoxemic event, defined as a saturation of peripheral oxygen below 90%, note Schibler and co-workers, compared with 22% of procedures with standard care – a nonsignificant difference.
There were few incidences of major or minor adverse events in either the high-flow or standard oxygen groups, reports the team, with the most common being hypoxemia requiring treatment (3 vs 5%) and laryngospasm (3 vs 2%), and there were no significant differences between the two groups. Further, the lowest median saturation on high-flow oxygen was only 1% higher than with standard care.
“Our study findings are in contrast to those of adult trials, in which prolonged maintenance of saturation during upper airway surgery with high-flow oxygen has been observed,” Schibler and team conclude.
In an accompanying editorial, Thomas Engelhardt (McGill University Health Centre, Montreal, Quebec, Canada) and Nicola Disma (IRCCS Istituto Giannina Gaslini, Genova, Italy) highlight that: “The clinical skills required to tolerate and manage moderate apnoea during critical parts of airway surgery are substantial and not to be underestimated.”
The editorialists suggest that while high-flow oxygen delivery may not be essential in a pediatric cohort for all airway interventions, Schibler et al’s trial will lead to further “crucial work” to identify the best use for this intervention in the pediatric setting, taking into account factors including patient selection criteria, optimal flows, and suitable equipment solutions.
“In the end, as this study has elegantly shown, it does not really matter what you do, but – most importantly – how you do (and possibly teach) it,” conclude Engelhardt and Disma.
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Lancet Respir Med 2024; doi:10.1016/ S2213-2600(24)00115-2
Lancet Respir Med 2024; doi.org:10.1016/ S2213-2600(24)00145-0
