I was eager to share this idea with others in emergency medicine and had just been introduced to Scott Weingart, MD. I came up with an acronym to describe the technique—NO DESAT for “nasal oxygen during efforts securing a tube”—and using the rapidly developing platform of social media, it became one of the first things to go viral. Although Scott was initially reluctant to write an article (believing it was an antiquated way to share knowledge), I convinced him otherwise, and soon thereafter, we published an article in the Annals of Emergency Medicine that became one of the most commonly downloaded articles for the next few years.1
Now we are five years down the road. Multiple articles and systematic reviews have been published regarding the utility of apneic oxygenation (ApOx) during intubation, and while many emergency physicians changed their practice, much skepticism remains. Here is a review of some of the literature on NO DESAT (ApOx).
- Denton and Howard performed a “shortcut review” and found four trials, concluding that there is emerging evidence that the use of ApOx decreases the incidence of critical desaturation during endotracheal intubation.2
- Silva et al performed a comprehensive search of medical databases and gray literature. The authors included 14 studies for qualitative analysis and eight studies (1,837 patients) for the quantitative analysis (meta-analysis). The authors reported that ApOx was associated with decreased hypoxemia (odds ratio [OR], 0.66), increased first-pass success rate (OR, 1.59,) and increased lowest peri-intubation SpO2 (mean difference 2.2 percent).3
- Pavlov et al included eight studies and 1,953 patients and reported absolute risk of clinically significant hypoxemia of 27.6 percent in the usual care group and 19.1 percent in the ApOx group, plus reduced relative risk of hypoxemia by 30 percent in the ApOx group.4
- Binks et al included six trials and 1,822 cases of ApOx during ED and retrieval intubations. The authors reported reductions in desaturation (relative risk [RR], 0.76) and critical desaturation (RR, 0.51), plus improvement in first-pass intubation success rate (RR, 1.09) when ApOx was implemented.5
So Does It Work?
Probably. The effect is small; we are very good at intubations in the emergency department, and hypoxemia is uncommon. That is why systematic reviews with more than 1,000 patients are needed to prove efficacy. Smaller studies with better preoxygenation techniques and few hypoxemic events have not demonstrated a difference in the effect.6