Comparison of the effectiveness of high-flow nasal oxygen vs. standard facemask oxygenation for pre- and apneic oxygenation during anesthesia induction: a systematic review and meta-analysis

Abstract

Background: In recent years, high flow nasal oxygen (HFNO) has been widely used in clinic, especially in perioperative period. Many studies have discussed the role of HFNO in pre- and apneic oxygenation, but their results are controversial. Our study aimed to examine the effectiveness of HFNO in pre- and apneic oxygenation by a meta-analysis of RCTs.

Methods: EMBASE, PUBMED, and COCHRANE LIBRARY databases were searched from inception to July 2021 for relevant randomized controlled trails (RCTs) on the effectiveness of HFNO versus standard facemask ventilation (FMV) in pre- and apenic oxygenation. Studies involving one of the following six indicators: (1) Arterial oxygen partial pressure (PaO₂), (2) End expiratory oxygen concentration (EtO₂), (3) Safe apnoea time, (4) Minimum pulse oxygen saturation (SpO_2min), (5) Oxygenation (O₂) desaturation, (6) End expiratory carbon dioxide (EtCO₂) or Arterial carbon dioxide partial pressure(PaCO₂) were included. Due to the source of clinical heterogeneity in the observed indicators in this study, we adopt random-effects model for analysis, and express it as the mean difference (MD) or risk ratio (RR) with a confidence interval of 95% (95%CI). We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.

Results: Fourteen RCTs and 1012 participants were finally included. We found the PaO₂ was higher in HFNO group than FMV group with a MD (95% CI) of 57.38 mmHg (25.65 to 89.10; p = 0.0004) after preoxygenation and the safe apnoea time was significantly longer with a MD (95% CI) of 86.93 s (44.35 to 129.51; p < 0.0001) during anesthesia induction. There were no significant statistical difference in the minimum SpO₂, CO₂ accumulation, EtO₂ and O₂ desaturation rate during anesthesia induction between the two groups.

Conclusions: This systematic review and meta-analysis suggests that HFNO should be considered as an oxygenation tool for patients during anesthesia induction. Compared with FMV, continuous use of HFNO during anesthesia induction can significantly improve oxygenation and prolong safe apnoea time in surgical patients.

Keywords: Airway management; Anesthesia induction; Facemask ventilation; High flow nasal oxygen; Preoxygenation.