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ANESTH ANALG 1990:71:516-9

Preoxygenation in the Elderly: A Comparison of the Four-MaximalBreath and Three-Minute Techniques
Stephen J. Valentine, FFARCS, Robert Marjot, FFARCS, and Christopher R. Monk,
VALENTINE SJ, MARJOT R, MONK CR. Preoxygenation in the elderly: a comparison of the four-maximal-breath and three-minute techniques. Anesth Analg 1990;71:51&9.


To compare the effectiveness of two routinely used methods of preoxygenation in protecting against hypoxia in the elderly, the arterial 0, saturation was measured using an oximeter. Twenty-four elderly patients (265 yr) presenting for elective orthopedic surgery were randomly allocated to receive either 3-min or four-maximal-breaths of 100% 0, via a Bain circuit. After preoxygenation, anesthesia was induced, tracheal intubation performed with patients kept apneic, and the endotracheal tube 1tft open to air. The arterial

0, saturation was measured before preoxygenation and continually recorded during desaturation. Although attaining similar arterial 0, saturation values after preoxygenation, patients in the four-maximal-breath group had significantly shorter times (P < 0.0001) to all ltwels of desaturation. W e suggest that preoxygenation with 3-min breathing of 100% 0, offers more protection against hypoxia due to prolonged apnea after induction of anesthesia in the elderly than does four maximal breaths of 100% 0,.

Key Words: OXYGEN, DENITROGENATION, preinduction. INDUCTION, ANESTHESIApreoxygenation.

Preoxygenation is recommended before the induction of anesthesia and muscle paralysis, particularly if there is increased risk of gastric regurgitation or if a difficult intubation is expected. The preoxygenation with 100% oxygen (0,) replaces the nitrogen contained in the functional residual capacity and so prolongs the time before hypoxia occurs after the onset of apnea. Previous studies have compared the different methods of preoxygenation but mainly in younger ASA physical status I and I1 patients (1-5). The question of the relative efficacies of a four-maximal-breath and a 3-min technique has not been addressed in an elderly population, and yet it has important connotations for both routine and emergency geriatric anesthesia where both methods are accepted practice.

Patients and Methods
The study was approved by the hospital ethical committee, and written informed consent was obtained from all patients. Twenty-four elderly patients
Received from the Sir Humphry Davy Department of Anaesthesia, Bristol Royal Infirmary, Marlborough Street, Bristol, United Kingdom. Accepted for publication July 2, 1990. Address correspondence to Dr. Valentine, Sir Humphry Davy Department of Anaesthesia, Bristol Royal Infirmary, Marlborough Street, Bristol, 852 8HW, United Kingdom.
01990 by the International Anesthesia Research Society

(aged 265 yr) presenting for routine orthopedic surgery were prospectively studied after being randomly allocated to receive either the 3-min or fourmaximal-breath technique of preoxygenation. Patients excluded were those with clinically significant cardiovascular, respiratory, neurologic, or endocrine disease, as were patients with obesity or those in whom difficult intubation could be predicted. During the preoperative assessment, the appropriate method of preoxygenation was explained to each patient. Premedication was with oral tempazepam (0.1-0.2 mg/kg) given 90 min preoperatively. In the anesthetic room the patients were again instructed in the technique of preoxygenation, and intravenous access was secured with a 16-gauge cannula. Monitoring was with a Dinamap (1846SX) automated blood pressure device, electrocardiogram in the CM5 configuration, and a pulse oximeter (Datex Satlite) applied to a thumb. Baseline measurements were recorded with patients breathing air. Patients were pretreated with atropine (10 p g k g ) and vecuronium (10 pglkg) 3 min before induction. Preoxygenation was accomplished with an appropriately sized face mask connected to a Bain circuit that had been flushed with 100%02. The O2 flow rate was 10 Wmin in the 3-min group and 35 L/min in the four-maximal-breath group to maintain the filling of the reservoir bag during inspiration and prevent any

71:51&9 517 Table 1. 0 . Demographic Data and Times to Apnea Age Group 4 VCJ ( n = 12) 3 rnin” ( n = 12) (Y‘) 74. P values of less than 0. weight. Times to decrease in saturation from peak Sao.65 k 0.2 2 5. Supplemental doses of thiopental (1 mg/kg) and succinylcholine (0.4 k 8.3 2 1. the lungs then being ventilated with 100% O2 until the Sao. v. obtained after preoxygenation.0 (62-73) 79.57-1. Immediately after completing the preoxygenation maneuvers anesthesia was induced with thiopental ( 2 4 mg/kg) and succinylcholine (1.0 (3045) 39. was greater than 97%. After successful intubation was visually confirmed the endotracheal tube was left open to air. There is no significant difference in age. had decreased to 90%.5 mg/kg). saturation while breathing air.7) Time to apnea (s) 40. If visual confirmation was not possible the patient was excluded from the trial. They were then told to breathe normally. The demographic data were compared by analysis of variance.8) 14. Patients in the 3-min group were asked 3 continue to breathe normally after application of the face mask while preoxygenation was performed for 3 min. levels. the peak Sao. P a 95 94 93 92 U az Figure 1.6-16. to lowest Sao. Values are mean 2 SD. Results The demographic data for the two groups are shown in Table 1. X.05 were considered to be statistically significant.71 k 0.9 (7G92) Height (m) 1. and then requested to take four maximal breaths.88) 1.07 (1. with range given in parentheses. and the patients’ trachea intubated under direct vision. 5 CI * 0 x 2 91 90 89 8a I 0 PEAK SaO. an effective seal being obtained with the face mask.2 2 9.5 (20-50) Hb. and mean times to the onset of apnea and each desaturation point were compared using the Mann-Whitney U test. or time to apnea after induction of anesthesia. A continuous recording of the arte~~ rial 0. Arterial 0. height.5 mg/kg) were given every 2 min to maintain anesthesia and muscle paralysis.78) Weight (kg) 63.4 2 5. The number of men and women was similar in each group. The patients were not ventilated until the end of the study. hemoglobin.1 (53-74) Sex (M/F) 913 913 Hb (g/dL) 14. No . The study was completed when the Sao. ”Patients receiving the 3-min method of preoxygenation 100 99 98 97 96 2 I - X .8-16. and the lungs ventilated with 100% 0. saturation (Sao.4 2 1.551.PREOXYGENATION IN THE ELDERLY ANESTH ANALG 1990. the airway secured.8 (51-74) 62.. With the onset of anesthesia and muscle paralysis cricoid pressure was applied.8 k 8.) was made and the heart rate and blood pressure recorded at 1-min intervals.3 (11.6 2 6.09 (1. Patients in the four-breath group were asked to exhale maximally. hemoglobin concentration. four-maximalbreath group. “Patients receiving the four-vital-capacity-breath method of preoxygenation. 1 I 6 ba 9 e I I I I 1 1 2 3 4 5 0 l a + TIME(minuter) rebreathing. with a similar distribution of smokers and nonsmokers.2 (12. 3-min group.

They suggested that three vital capacity breaths of 100% 0.9 t 74.5 (99-100) 99.8 + 75. reserve was measured by observation of the time required for arterial desaturation to occur after induction of anesthesia.5 (220450) Time to 95% Sao. with the range given in parentheses. while breathing air. Oxygen Saturation Levels Before and After Preoxygenation and Times to Arterial Desaturation Group 4 VC" (n = 12) 3 minb (n = 12) Sao.7 (93-97) 95.1 + 91. implying that the period of breathing 100% 0. The times to 90% saturation were 212. 'P < 0.8 (98-100) Time to 97% Sao. reported that although the Sao. significant hemodynamic disturbance occurred in any patient.5 2 82. The patients assigned to the four-maximal-breath technique had two . 147. Patients in our four-maximal-breath group were told to breathe normally after their last maximal breath.8 2 0. values in all patients were 97% or greater within 45 s . The design of the study ensured airway protection allowing for rapid oxygenation once the saturation had decreased to 90% or if any deterioration in patient condition occurred. thus avoiding the possibility of active exhalation and loss of the expiratory reserve volume immediately before apnea. or in the peak Sao. No patient recalled any events after induction.4 2 1. remained above 90% for more than 4 min of apnea in both groups.4 (30-260)" 296. forced vital capacity. There was no significant difference between the two groups in Sao.2 (92-98) Peak Sao.8 2 75. 'Patients receiving the 3-min method of preoxygenation. Without preoxygenation. Patients in the fourmaximal-breath group had significantly shorter times to desaturation to each Sao. level recorded (P < 0. and times to apnea were the same. These studies suggest that the four-maximal-breath technique affords adequate protection against inadvertent desaturation.. Table 2. Time is given in seconds.0001.. would allow a 3-min period of apnea before the onset of hypoxemia. but factors other than Pao. but that obesity was (1). and all patients were successfully intubated at the first attempt. Norris and Dewan (5) showed that in the pregnant patient there was no difference in the Pao.7 (50-31 0)c 315. the 0. Our investigation was designed to test the efficacyof this technique in geriatric patients presenting for elective orthopedic surgery.4 s in the 3-min group.518 ANESTH ANALG 1990.1 (70-315)c 382. No comment was made on the effect of age on Pao. values higher in the preoxygenation group at the time of intubation (2). Other investigators have estimated 0. Drummond and Park have shown that age. reserve indirectly by measuring arterial O2 tension (Pao.71:5169 VALENTINE ET AL. The saturation results are shown in Table 2 and Figure 1. arterial oxygen saturation. the latter technique gave longer protection against desaturation (3).8 (80-320)" 405. against air in patients (aged 4CL73 yr).5 2 0.8 s in the four-breath group and 405.7 2 92. only 1 min elapsed before significant desaturation occurred. reserve (3). on air 95. The shortest time to this level of desaturation in the 3-min group was 4 min 50 s .3 5 69. Values are mean 5 SD. 99.0001). at completion of preoxygenation may influence 0. Four patients in the maximal-breath group desaturated to 90% in 2 min or less.1 2 90. Discussion Various methods of preoxygenation to protect against hypoxemia after induction of anesthesia have been recommended. on 100%0. Gold and Muraavchick compared four maximally deep breaths of 100% 0.5 (265-500) Time to 93% Sao. "Patients receiving the four-vital-capacity-breath method of preoxygenation. By leaving the endotracheal tube open to air and keeping the patient anesthetized and apneic. This study has examined the efficacy of two standard techniques of preoxygenation in an elderly population scheduled for elective surgery.1 2 91. after preoxygenation. Previous studies of these techniques have been primarily restricted to fit young adult patients or volunteers (1-5). Sao. forced expiratory volume. in maternal or fetal samples after 3 min or four maximal breaths of preoxygenation. and found Pao.. 212. There were no demographic differences between the two groups of patients in our study.7 f 72. was similar in the two groups after induction of anesthesia but before onset of muscle paralysis. 177. and smoking habits were not related to the rapidity of desaturation after induction of anesthesia.2 t 2. In comparing four maximal breaths with 3 min of preoxygenation in ASA physical status I patients (aged 23-37 yr) Gambee et al.) (2).4 (290-550) Sao. After completion of the study and hand ventilation with 100% O. 193.2 (275-530) Time to 90% Sao.

Anaesthesiology 1985. Br J Anaesth 1984. However. 10.60:313-5. Fisher DM. London: Butterworth. We therefore suggest that if preoxygenation is to be performed in the elderly. In summary. This rehearsal and cooperation might not be possible with some geriatric patients. the 3-min technique should be used. Drummond GB. The respiratory muscles (diaphragm and intercostal and accessory muscles) act on a less compliant chest wall and are themselves weaker.38:9&102. Physical fitness in relation to age. Airway resistance and mechanics of breathing in normal subjects 75 to 90 years of age. Arterial oxygenation in conscious patients after 3 minutes and after 30 seconds of oxygen breathing. The aging process is associated with parenchymal changes of the diffuse emphysematous type within the lungs. J Appl Physiol 1965. Assaf RAE. eds. This encroachment of the closing volume into the tidal volume creates ventilation-perfusion mismatch. Moyer JH. Norris MC. Four patients in this group desaturated to 90% in 2 min or less. The aged lung. Azcuy A. Berthoud M. New York: Grune & Stratton. Stephen CR. Gold MI. Mittman C. 1964:156-62. it does not give reliable protection against desaturation during apnea. Pump KK. References 1. Foraker AG. 2. In: Cander L. Anderson AE Jr. eds. The reduced total elastic recoil of the lungs impairs the function of the distal airways with airway closure occurring at the higher lung volumes (8). values to the 3-min technique after preoxygenation. Ageing of the lung: perspectives. The shortest time to 90% saturation in the 3-min group was 4 min 50 s. In: Cander L. Geriatric anaesthesia: principles and practice. 1964:287-301. 4.56:987-92. Alaela R.66:46&70. Norris AH. Park GR.7). Du Bois AB. Muraavchick S. 9. These effects combine to reduce the pulmonary reserve of the elderly in general and appear in particular to render the four-maximalbreath technique less effective in denitrogenating the functional residual capacity. values before and after preoxygenation with these two techniques. Hertzka RE. and all cooperated to the best of their ability. Edelman NH. Anesth Analg 1987. Moyer JH. However. 5. there was a significantly shorter time to all levels of desaturation associated with the four-maximal-breath method. with decreased strength and speed of contraction (9-11). changes that decrease the alveolar surface area (6.71:51&9 519 rehearsals of the procedure preoperatively (once in the ward and once in the anesthetic room).571-17. 7.PREOXYGENATION IN THE ELDERLY ANESTH ANALG 1990. This difference between our two groups is presumably due to physiologic changes in the respiratory system of the elderly. we found that in this study of elective geriatric patients the four-maximal-breath technique gives similar peak Sao. Preoxygenation for cesarian section: a comparison of two techniques. We found in our elderly patients similar Sao. New York: Grune & Stratton. Read DH.62:827-9. 1986:69.20:1211-6. Gambee AM. Arterial oxygen saturation before intubation of the trachea: an assessment of oxygenation techniques. Chest 1971. Ann Intern Med 1962. Preoxygenation-how long? Anaesthesia 1983. Robinson S. Anesth Analg 1981. Dewan MD. 8. 3. 11. Ageing of the lung: perspectives. . The vital capacity and inspiratory and expiratory reserve volumes are all diminished. Relationship between chest wall and pulmonary compliance and age.60:571-7. 6. The morphological spectrum of aging and emphysematous lungs. Preoxygenation techniques: comparison of three-minutes and four-breaths. Norman J.