Oxygen desaturation during anesthesia induction is a dangerous possibility for infants and children undergoing medical procedures due to their vulnerable physiology. Prolonged desaturation can lead to severe outcomes such as hypoxia, hypoxemia, cardiac arrest, and death, especially when combined with hypotension and anemia.1 Apneic oxygenation is a technique that delivers oxygen during periods of apnea—cessations in breathing—to extend the time before oxygen saturation falls to dangerous levels. Apneic oxygenation can be a highly beneficial complement to pediatric anesthesia, as it has potential to improve patient safety and intubation success.
A 2024 systematic review analyzed data from 9,802 children who received tracheal intubation under general anesthesia. Tracheal intubation secures a patent airway and ensures ventilation of the lungs during surgery or respiratory insufficiency. After intubation, apneic oxygenation is delivered via a standard nasal cannula using 100% oxygen without ventilating the patient. Successfully intubating on the first attempt is crucial in pediatric patients because of the anatomically complex airways in infants and neonates and because repeated attempts at intubation may further increase the risk of desaturation.3 Oxygen desaturation during tracheal intubation is associated with longer duration of mechanical ventilation, longer length of stay in the ICU, and mortality.4 The review found that apneic oxygenation successfully increased the intubation first-pass success rate with no additional physiological instabilities (p=0.04). Compared to patients who did not receive supplementary oxygen administration, patients receiving apneic oxygenation experienced higher oxygen saturation during intubation and had a decreased risk of hypoxemia.1
A survey asked 304 German anesthesiologists about their experience with this technique for pediatric patients. 63% of participants indicated adding apneic oxygenation to pediatric anesthesia regimes is not standard procedure in their practicing hospitals. Similarly, 63% of survey responders were unaware of the current European guidelines and their recommendation to incorporate this strategy for neonates and infants. While most participating physicians (54%) indicated they do not anticipate significant complications when performing apneic oxygenation for anesthesia induction, 16.8% indicated uncertainty regarding potential complications. The survey revealed only 12% of respondents had experience employing this technique in their practice, while 40% indicated they had never employed apneic oxygenation as part of pediatric anesthesia, highlighting low utilization and awareness.2
Oxygen desaturation remains a serious risk during pediatric anesthesia, especially in neonates and infants who inherently have anatomically complex airways. Apneic oxygenation offers a simple, cost-effective strategy to extend safe apnea time, improve first-pass intubation success, and reduce the incidence of hypoxemia. Despite its demonstrated benefits and endorsement by recent European guidelines, it remains underutilized in clinical practice. Increasing awareness, standardizing its use, and integrating apneic oxygenation into pediatric anesthesia protocols could significantly enhance patient safety and clinical outcomes in vulnerable pediatric populations.
References
- Fuchs A., Koepp G., Huber M., Aebli J., Afshari A., Bonfiglio R., Greif R., Lusardi A.C., Romero C.S., von Gernler M., et al. “Apnoeic Oxygenation During Paediatric Tracheal Intubation: A Systematic Review and Meta-analysis.” British Journal of Anaesthesiology. 2024; 132(2), 392–406
- Uzun, D. D., et al. “Apnoeic Oxygenation in Pediatric Anesthesia: Better Safe than Sorry!” BMC Anesthesiology, 25(1), 2025, 116. https://doi.org/10.1186/s12871-025-02995-2
- Oliveira J., Lucas, S., et al. “Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis.” Annals of Emergency Medicine, 70(4), 2017, 483-494.e11. ScienceDirect, https://doi.org/10.1016/j.annemergmed.2017.05.001
- Napolitano, N., et al. “Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU.” Pediatric Critical Care Medicine, 20(12), 2019, e531–37. https://doi.org/10.1097/PCC.0000000000002123