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11]

84 Original article

Management of early postoperative hypoxemia: a comparative

performance of Hudson face mask with nasal prongs
Suleiman A. Adetunjia, Oyebola O. Adekolaa,b, Ibironke Desalua,b,
Olushola T. Kushimoa,b
a
Department of Anaesthesia, Lagos University
Teaching Hospital, bDepartment of
Anaesthesia, College of Medicine, University of
Lagos, Lagos, Nigeria
Correspondence to Suleiman A. Adetunji,
FWACS, Department of Anaesthesia, Lagos
University Teaching Hospital, PMB - 12003,
Surulere, Lagos, Nigeria
e-mail: drbayoadetunji@yahoo.com
Received 17 April 2016
Accepted 30 November 2016
Ain-Shams Journal of Anaesthesiology
2017, 10:84–90
Introduction
Early postoperative hypoxemia may occur when patients breathe room air
during their initial recovery period. Prolonged hypoxemia can result in delirium,
dysrhythmia, and cardiac arrest.
Aim
The aim of the present study was to compare the performance of face mask
compared with that of the nasal prong in the management of early postoperative
hypoxemia.
Patients and methods
All procedures were performed using standard anesthetic and surgical techniques
modified to the specific procedures. All patients had peripheral oxygen saturation
(SpO2) at least 97% before being transferred to the recovery room.
On arrival to the recovery room, 120 patients whose SpO2 decreased up to 94%
were randomly allocated to either the face mask or nasal prong groups. They
were commenced on oxygen therapy at 4 l/min through either device. A modified
visual analogues scale was used to evaluate the level of comfort during oxygen
therapy.
Results
Early postoperative hypoxia occurred in 18.1%. The increase in oxygen saturation
after commencement of oxygen therapy was significantly faster with nasal prongs
(0.63±1.42 min) than with face mask (1.78±1.10 min) (P=0.001). The maximum
SpO2 obtained was significantly higher with nasal prongs (98.77±1.29%) than with
face mask (97.63±1.89%) (P<0.001). There was no significant association found
between early postoperative hypoxemia and site or duration of surgery, as well as
the volume of intravenous fluid (crystalloids) administered intraoperatively
(P>0.05). Nasal prongs (91.7%) were significantly more comfortable compared
with face mask (61.7%) (P=0.001). We have demonstrated that the use of nasal
prongs was more efficient and comfortable compared with face mask in the
management of early postoperative hypoxemia.

Keywords:
early postoperative hypoxemia, face mask, nasal prongs
Ain-Shams J Anaesthesiol 10:84–90
© 2018 Ain-Shams Journal of Anaesthesiology
1687-7934

cardiac arrhythmia, and myocardial ischemia [5,7,8]. In

Introduction
addition, there was an increase in both time of recovery
Early postoperative hypoxemia, which occurs within
room stay and the incidence of admission in ICUs [5].
minutes to 2 h after surgery, has an incidence of
35–60% [1–3]. Hypoxemia may increase the risk for
Oxygen therapy must be administered at an appropriate
surgical wound infection, reduce anastomosis integrity,
dose and using an appropriate device for effective
and result in poor wound healing [4–6]. It may also
outcome [4,5]. The modes of delivery of oxygen to
contribute to loss of gastrointestinal mucosal integrity,
spontaneously breathing, nonintubated patients during
thus causing bacterial translocation into the circulation,
their presence in the recovery room include nasal
leading to sepsis [4–6].
cannula, nasal catheter, nasal prongs, face mask, or
face tent [4,5].
Hypoxemia may decrease cognitive function and cause
delirium, which can cause patients to remove nasogastric
tubes, surgical drains, and intravascular devices. Oxygen
therapy has been reported to be beneficial in the treatment This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
of postoperative delirium secondary to hypoxia [5,7,8]. License, which allows others to remix, tweak, and build upon the work
Other secondary effects of hypoxemia include increased non-commercially, as long as appropriate credit is given and the new
production of catecholamine, hypertension, tachycardia, creations are licensed under the identical terms.

© 2018 Ain-Shams Journal of Anaesthesiology | Published by Wolters Kluwer - Medknow DOI: 10.4103/1687-7934.238469
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Face mask versus nasal prongs in postoperative hypoxemia Adetunji et al.
At our institution, variable performance oxygen
devices such as Hudson face mask and nasal prongs
are often used in the recovery room in patients at risk
for postoperative hypoxemia, such as the elderly,
sickler, and patients who underwent thoracic or
upper abdominal surgeries. The choice of oxygen
therapy usually depends on the experience of
the anesthetist, availability of the device, and
cooperation of the patient. The aim of this study
was to compare the performance of Hudson face
mask and nasal prongs in the management of
postoperative hypoxia.
Patients and methods
This was a comparative study on the performance
of Hudson face mask and nasal prongs in the
management of early postoperative hypoxemia. The
study was conducted at the Lagos University Teaching
Hospital between October 2013 and October 2014.
The approval of the Institutional Human Research and
Ethics Committee and written informed consent were
obtained.
Individuals of American Society of Anesthesiology
(ASA) physical status I and II aged 18–80 years
undergoing elective surgical procedures under general
anesthesia using muscle relaxants were recruited. Those
excluded from the study included patients with abnormal
electrolyte/urea, upper respiratory tract infection, chronic
cigarette smokers, chronic obstructive pulmonary disease
patients, patients with sickle cell disease, preoperative
hypoxemia, and sepsis, individuals of ASA III to IV
status, those with anemia following hemorrhagic shock,
as seen in ectopic pregnancy, and those who underwent
post-thoracotomy and neurosurgery. In addition, those
undergoing regional anesthesia and patients in whom the
use of pulse oximeter may result in inappropriate results
(peripheral vascular disease, severe anemia, or recent use of
colored dyes) were excluded.
For the purpose of this study the following definitions
were used:
Hypoxemia was graded into four values of peripheral
oxygen saturation (SpO2): mild (86–90%), moderate
(81–85%), severe (76–80%), and extreme (<80) [9].
The trigger value of oxygen saturation for commencement
of oxygen therapy was SpO2 less than 94% [9].
The level of consciousness or sensorium was graded as
follows: (a) fully awake; (b) asleep, but easily aroused;
and (c) asleep and difficult to arouse [10].
85
The modified visual analogue scale (VAS) was used to
assess the patient’s comfort in the use of the oxygen
therapy devices (modified VAS score, 100 mm=worst
possible discomfort, 0 mm=most comfortable).
Anesthetic technique
In the preoperative period, all patients were educated on
the use of VAS to assess their level of comfort during the
use of the oxygen therapy devices. Diazepam 5 mg oral
was administered at night and on call to theater. On
arrival to the theater, standard monitoring of the blood
pressure (BP), heart rate (HR), and SpO2 was performed
every 5 min with a multiparameter monitor (Datex
Ohmeda Cardiocap 7100; Metropolitan Medical
Services, Asheville, North Carolina, USA) until the
end of surgical procedure.
Preoxygenation was carried out with oxygen 6 l/min for
3–5 min, followed by induction of general anesthesia
with intravenous sodium thiopentone (5 mg/kg),
and endotracheal intubation was facilitated with
pancuronium (0.1 mg/kg). Anesthesia was main-
tained with isoflurane (1.5–2%) in 100% oxygen
according to our institution protocol as there was no
facility for nitrous oxide and air during the study
period. Analgesia was induced through a multimodal
approach, which included intravenous diclofenac 1 mg/
kg, tramadol 1 mg/kg, and paracetamol 15 mg/kg
intravenous over 15 min. Intravenous fluids were
given based on maintenance of 110 ml/h and
ongoing loses (from nasogastric tube and surgical
drains). It is suggested that, in patients who received
neuromuscular blockers, monitoring of reversal with a
peripheral nerve stimulator should be encouraged;
however, there was no such facility at the time
of the investigation. At the end of surgery, residual
neuromuscular blockade was reversed with intravenous
atropine 0.02 mg/kg and neostigmine 0.04 mg/kg.
After extubation, all patients were given 100%
oxygen using a well-fitted face mask through the
anesthetic machine for 3 min. Oxygen saturation was
recorded at the end of the 3 min (time 0). All patients
were ensured to have maintained SpO2 at 97% or
more before being transferred to the recovery room
by the researcher. During transfer, the patients were
continuously monitored for SpO2 using a pulse
oximeter (Nonin Avant 9600; Medical Product
Service GmbH, Borngasse, Germany). The alarm on
the pulse oximeter was preset at SpO2 up to 95%, and
thus when the SpO2 fell below 95%, it was recorded.
The frequency of hypoxemic events during
transportation of patients was noted from the
monitor and recorded. Supplemental oxygen was not
administered during transport.
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86 Ain-Shams Journal of Anaesthesiology, Vol. 10 No. 1, January-March 2017
On arrival to the recovery room, standard monitoring
of SpO2, BP, HR, and respiratory rate (RR) was carried
out. The level of consciousness on arrival using
postanesthetic recovery score was also monitored [11].
Patients with oxygen saturation at least 94% underwent
continuous monitoring as per standard protocol in the
recovery room. However, those with SpO2 less than 94%
underwent humidified supplemental oxygen therapy
commenced using variable performance oxygen devices,
face mask or nasal prongs, at an oxygen flow rate of 4 l/
min. The patients were randomly assigned to two groups
by the researcher, from a sealed envelope, which contained
the groups written on a folded piece of paper. Group A
(face mask) received oxygen therapy through Hudson face
mask, and group B (nasal prongs) received oxygen therapy
through nasal prongs. Continuous monitoring of vital
signs and the sensorium was continued every 5 min in the
recovery room for 30 min. Thereafter, patients with SpO2
greater than 94% were monitored every 15 min until they
were discharged from the recovery room.
The efficacy of the devices was determined by comparing
the proportion of the participants who desaturated while
on oxygen therapy, the time required to achieve a
saturation at least 95%, and the ability of the
participant to maintain SpO2 greater than 94% without
carbon dioxide retention. The ability to provide good
comfort/convenience for the patient during the procedure
was assessed by the use of a modified VAS for 2 h in the
recovery room before their discharge to the ward [12].
The data collated included demographic data such as age,
weight, height, BMI, and hemoglobin concentration.
Other data included the type, duration, and site of
surgery and incision, the presence of shivering, the
choice of oxygen therapy device, the presence of
carbon dioxide retention, and the type and volume of
intraoperative fluids transfused.
Statistical analysis
The sample size calculation was based on a predetermined
statistical formula used for the comparison of proportion
of two independent groups [13]. The reported incidence
of early postoperative hypoxemia was 35–60% [2–4], with
an average incidence of 45% (1=0.45). We aimed to
achieve a reduction of 20% incidence (2), using α=95%
and β=80%; a sample size of 60 participants per group was
considered appropriate for the study.
Data were expressed as means±SD, frequency, and
percentile as indicated. Student’s t-test was used for
comparison of means, while whereas the χ 2-test was
used to compare frequencies. The risk for development
of hypoxia, such as the site of surgery, duration of
surgery, volume of fluid used intraoperatively, and the
type of incision made, were analyzed using univariate
analysis. A P value of less than 0.05 was considered
significant for all tests. All analyses were performed
using the statistical package for the social sciences
(SPSS) for Windows version 17 (SPSS Inc.,
Chicago, Illinois, USA).
Results
A total of 120 adult patients were enrolled in this study,
including 60 adult patients for each group throughout
the course of the study. The mean age, weight, BMI,
and preoperative hemoglobin concentration were
comparable between the groups. Similarly, female
preponderance was noted (24 : 36 in group A; 14 :
46 in group B) in both groups (Table 1). The most
common surgery was pelvic surgery (myomectomy)
in both groups (62 cases, 51.67%), followed by
mastectomy (14 cases, 11.67%), varicocelectomy (18
cases, 15%), and others (tonsillectomy, laryngoscopy,
biopsy, and excision of lipoma) (24 cases, 20%), and the
least common surgery was thyroidectomy (two cases,
1.66%).
The oxygen saturation was observed to be highest
(99–100%) at the immediate postextubation period
following 3 min on supplemental oxygen (time 0).
Thereafter, saturation declined steadily during
transportation (Fig. 1).
Figure 2 shows the comparative performance of the two
oxygen therapy devices during oxygen therapy in the
recovery room. Although the mean oxygen saturation
decreased before the administration of oxygen
(preoxygen therapy) in both groups, the difference
was nonsignificant between the face mask group
(93.2±7.0%) and the nasal prong group (93.3±2.6%)
(P=0.461). However, the patients in the nasal prong
group responded faster (0.63±1.42 min) to oxygen
Table 1 Demographic data and clinical characteristics of the
face mask group versus the nasal prong group
Variables Face mask Nasal prongs P value
(n=60) (n=60)
Age (years) 41.2±14.2 42.7±17.9 0.61
Weight (kg) 69.8±10.7 72.9±9.5 0.22
BMI (kg/m2) 26.7±5.6 27.6±4.8 0.23
Preoperative 12.0±4.6 11.8±4.9 0.81
Hb (g/dl)
ASA (I : II) ratio 34 : 26 35 : 25 0.75
Sex (M : F) 24 : 36 14 : 46 0.06†
ratio
Values represent mean±SD and frequency. ASA, American
Society of Anesthesiology; F, female; Hb, hemoglobin; M, male.
P<0.05 is considered significant. †Indicate level of significant.
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Face mask versus nasal prongs in postoperative hypoxemia Adetunji et al. 87

Figure 1 Table 2 The comparison of the efficacy of SpO2 for the face
mask group versus the nasal prong group
Time Face mask Nasal prongs P value
(n=60) (n=60)
Preoxygen 93.2±7.0 93.3±2.6 0.461
therapy
5 min 96.0±3.5 97.4±2.5 0.002†
10 min 98.0±1.9 97.8±2.8 0.163
15 min 98.6±1.8 99.1±1.2 0.211
20 min 99.0±1.4 99.3±1.1 0.657
25 min 99.1±1.5 99.3±1.1 0.810
30 min 99.0±1.6 99.2±1.2 0.317
Values represent mean±SD. P<0.05 is considered significant.
†
Indicate level of significant.

Figure 3

Mean oxygen saturation trend during theater/recovery room transit.

Time 0 corresponds to oxygen saturation after extubation and 3 min
of supplemental oxygen after extubation

Figure 2

Comparison of mean heart rate with the two devices. Values repre-
sent mean±SD heart rate and P value for both devices

mask group exhibited higher mean values, this was not

Comparison of peripheral oxygen saturation (SpO2) during oxygen
therapy with the two devices. Statistically significant difference at
5 min (P=0.002)
statistically significant until 30 min into the study when
the mean MAP was significantly higher in the face
mask group (70.4±16.5 mmHg) than in the nasal prong
group (57.9±16.2 mmHg) (P=0.008) and also at
45 min (69.8±15.5 mmHg and 51.1±30.0 mmHg,
respectively; P=0.001) (Table 3).

The mean RR was significantly higher in the face mask

therapy than those in the face mask group
(1.78±1.10 min) (P=0.001). A significantly higher
SpO2 value (97.4±2.5%) was achieved in the nasal
prong group than in the face mask group (96.0±3.5%)
at 5-min duration of oxygen therapy (P=0.002). There
was no incidence of hypoxemia or desaturation when
patients were on oxygen therapy with either of the
devices during the study (Table 2).
The mean HR was significantly higher in the face mask
group than in the nasal prong group at 5, 10, 30, and
45 min in the recovery room (Fig. 3). There was a
gradual drop in mean arterial blood pressure (MAP)
during the study period. Although patients in the face
group than in the nasal prong group at 5, 25, 30, 45,
and 60 min (P≤0.05) (Table 4).
Using univariate analysis to determine the risk factors for
the development of postoperative hypoxemia, none of
the confounding variables investigated were implicated
(Table 5).
The mean level of convenience using modified VAS
was similar in the face mask group (0) versus the nasal
prongs group (0). However, a higher proportion of
patients in the nasal prong group (55 cases, 91.7%)
were comfortable with the device compared with the
face mask group (37 cases, 61.7%) (P=0.001) (Table 6).
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88 Ain-Shams Journal of Anaesthesiology, Vol. 10 No. 1, January-March 2017

The nasal prongs cost ≈6 USD per unit, whereas the and anesthetic and surgical techniques. The lower
facemask costs ≈7.5 USD per unit. incidence of hypoxemia in the present study was
attributed to the maintenance of anesthesia with
isoflurane in 100% oxygen. The observation might
Discussion differ with the use of nitrous oxide for maintenance,
We have demonstrated that early postoperative because the latter is associated with diffusion hypoxia if
hypoxia occurred in 18.07% of patients, which is oxygen (100%) is not administered for about 10 min
within the stated range of 7.8–60% [1–3]. The wide after its discontinuation. Other factors that may
variation in incidence has been attributed to differences increase the incidence of early hypoxemia include
in participant cohort, type of oxygen delivery device, residual effect of incomplete reversal of neuromuscular
agent. In the present study, there was no patient who had
Table 3 The comparison of the mean arterial blood pressure oxygen saturation up to 90% during the theater–recovery
between the face mask group and the nasal prong group room transit period; moreover, no patient desaturated up
Time (min) Face mask Nasal prongs P value to 94% (our oxygen therapy trigger). Thus, oxygen
(n=60) (mmHg) (n=60) (mmHg)
therapy may not be required during transit to the
Preoxygen 74.9±11.9 71.1±12.3 0.128 recovery room postoperatively. This has previously
therapy
been reported by other researchers in the subregion
5 min 74.2±12.8 70.0±12.2 0.188
10 min 72.69±12.7 71.52±12.7 0.651
[3]. The use of maneuvers such as placing patients in
15 min 71.1±12.7 70.4±12.3 0.794 a recovery position or propping-up during transport,
20 min 69.8±13.4 67.8±14.4 0.469 which prevents airway obstruction, and splinting of
25 min 70.3±12.9 65.5±12.7 0.182 the diaphragm may just be enough to prevent
30 min 70.4±16.5 57.9±16.2 0.008† hypoxemia or desaturation, which may occur during
45 min 69.8±15.5 61.1±12.1 0.001† transport. Nevertheless, it has been reported that
Values represent mean±SD. P<0.05 considered is significant. when the duration of transport without supplemental
†
Indicates significant difference between the groups.
oxygen is prolonged, the risk of developing postoperative
hypoxemia is increased [3].
Table 4 The comparison of mean respiratory rate during
oxygen therapy between the face mask group and the nasal
prong group Other factors implicated in the occurrence of desaturation
Time (min) Face mask Nasal prong P value or hypoxemia during transport include premorbid state
(n=60) (n=60)
of the patient (preoperative hypoxemia and airway
(breaths/min) (breaths/min)
obstruction), hypoventilation secondary to the residual
Preoxygen 18.3±4.1 18.4±5.2 0.380
therapy
effect of inhalation agents, and the use of opioids and
5 min 21.0±4.7 18.8±4.2 0.017† neuromuscular blockers. To reduce the influence of
10 min 19.3±3.5 18.0±5.1 0.135 confounding factors, only ASA I and II patients were
15 min 18.6±3.7 17.6±4.2 0.180 recruited. It was observed that desaturation in the recovery
20 min 18.0±3.1 16.6±2.7 0.130 room occurred within 30 min of arrival. This is similar to a
25 min 17.7±3.4 16.2±2.5 0.010† previous observation that early postoperative hypoxemia
30 min 17.6±3.4 15.8±2.2 0.030†
occurred most commonly less than 1 h after anesthesia in
45 min 15.5±2.2 13.9±1.8 0.001†
older children and adults [2]. During oxygen therapy with
60 min 14.4±1.8 13.4±1.30 0.003†
either of the devices, none of our participants developed
Values represent mean±SD of respiratory rate. P<0.05 is
considered significant. †Indicates significant difference between hypoxemia. This may suggest that either the nasal prongs
the groups. or face mask were effective in delivering oxygen in the

Table 5 The univariate analysis of risk factors in the development of postoperative hypoxemia
Prognostic factors Class n/N (%) Relative risk P value
Sex Male (n=43) 11/43 (20.9) 1.33 0.770
Female (n=77) 14/77 (14.3)
Site of surgery Abdominal (n=90) 15/90 (13.3) 1.58 0.407
Others (n=30) 10/30 (26.7)
Volume of infusion <2 l (n=70) 13/70 (14.3) 1.22 0.603
>2 l (n=50) 12/50 (20)
Duration of surgery <2 h (n=50) 10/50 (14) 1.75 0.507
>2 h (n=70) 15/70 (18.6)
Values represent frequency, percentile, and relative risk for confounding risk factors in the development of early postoperative hypoxemia.
P<0.05 is considered significant. †Indicates significant difference between the groups.
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Face mask versus nasal prongs in postoperative hypoxemia Adetunji et al.
Table 6 Comparison of patient satisfaction between the face
mask group and the nasal prong group
Modified visual Group face Group nasal P value
analogue scale mask prongs
Preoxygen therapy 0 (0) 0 (0) – therapy. In the present study, a significant increase was
10–40 37 (61.7) 55 (91.7) 0.001†
50–70 23 (38.3) 5 (8.3) 0.001†
80–100 0 (0) 0 (0) –
Values represent frequency and percentile for patient’s comfort
with oxygen delivery devices. P<0.05 is considered significant.
†
Indicates significant difference between the groups.
early postoperative period in patients with oxygen
saturation up to 94%. The findings in the present study
are in agreement with previous observations [2,10,14].
However, a high incidence of hypoxemia (25%) was
observed with the use of the aerosol face tent during
oxygen therapy [15]. This may be because the design of
the face tent allows significant air entrainment, thereby
reducing the fractional inspired oxygen concentration
(FiO2) [14].
The nasal prong was observed to be more efficient
compared with the face mask for oxygen therapy in the
present study. This could be due to a larger dead space
volume reservoir of the face mask, which takes longer
to be filled, compared with the smaller nasopharyngeal
reservoir of the nasal prong. It is also possible that the
claustrophobic effect of the face mask affected patient
compliance and hence oxygen delivery (FiO2) to the
patients.
It has been documented that arterial blood gas (ABG)
analysis of oxygen pressure (PaO2) is the gold standard
for the evaluation of oxygen therapy [12,16].
Nevertheless, several scholars have reported that the
results obtained from pulse oximeter (SpO2) correlated
well with ABG PaO2 [12,16].
In the present study it was observed that there was no
association between early postoperative hypoxemia
and sex, volume of intraoperative infusion, and
duration and site of surgery. This may be because
surgeries involving big cavity were excluded, as a high
proportion (>50%) in the present study underwent
myomectomy and exploratory laparotomy. A similar
observation was reported by other scholars in relation to
the duration and site of surgery [3,9]. In contrast, the site of
surgery has been implicated in the development of
hypoxemia in the late postoperative periods [5,16]. It
has been reported that early postoperative hypoxemia is
mainly due to anesthetic factors, whereas late postoperative
hypoxemia is related to reduced functional residual
capacity of the lung, especially with upper abdominal
surgeries [5].
89
The ability of the devices to cause carbon dioxide
retention (the incidence of development of carbon
dioxide retention in both devices) was evaluated with
changes in HR and BP in the patients during oxygen
observed in the HR, MAP, and RR within the first 5 min
of commencement of oxygen therapy with the two
devices. The increase was higher in the face mask
group compared with the nasal prong group. These
initial cardiovascular changes during oxygen therapy
could be attributed to the period in which the
reservoir (dead space) of the device was equilibrating
with oxygen, which was more pronounced in the face
mask group. This observation was corroborated by early
researchers such as Bethune and Collins [17], who noted
that some variable performance devices can cause
rebreathing (carbon dioxide retention). However,
there is paucity of knowledge on how best to measure
volume of rebreathing through the direct measurement
of end-tidal carbon dioxide while patients are on these
devices. Waldau et al. [18] made an attempt using
oxygraph, a modern gas analyzer, to measure the end-
tidal oxygen fraction (FeCO2) and then calculate the
end-tidal carbon dioxide (FeCO2) from alveolar gas
equation. However, their results were based on
mathematical assumptions, which may not hold good
in clinical situations in which these devices were being
used. It is also possible that the increase in HR and the
BP noted with the use of face mask above is due to an
increase in the work of breathing. Jensen et al. [19] have
demonstrated in healthy volunteers that minute
ventilation is greater when using a face mask at a flow
rate less than 5 l/min compared with that when no face
mask was used. They, however, observed no changes in
PaCO2, measured using ABG analysis.
The use of HR and BP to monitor rebreathing in the
present study may not be ideal, as other clinical
conditions such as pain can result in such changes.
The ABG analysis would have been more ideal to
measure PaCO2 to confirm carbon dioxide retention.
The increase in HR, BP, and RR observed during
oxygen therapy may be hazardous in patients with
poor cardiopulmonary reserve and coexisting medical
conditions such as hypertension and diabetes mellitus.
A previous study has reported an association between
the presence of perioperative tachycardia and the
development of perioperative myocardial ischemia [5].
The results in the present study showed that the use of
nasal prongs was associated with better satisfaction for
our patients compared with the face mask; this result is
similar to the findings by other researchers [2,10].
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90 Ain-Shams Journal of Anaesthesiology, Vol. 10 No. 1, January-March 2017
Nasal prongs have also been shown to be cost-effective,
when compared with the face mask. This is very
important in this period of global economic recession.
This study is limited by the fact that the assessment of
adequacy of oxygenation was determined with the pulse
oximeter. In the present study the arterial blood analyzer
was not used due to the cost implication and invasiveness
of the technique, when its use was not indicated. The
clinical signs of carbon dioxide retention were used
instead of a capnography or capnometer, which were
unavailable in our recovery room at the time of our study.
Despite this, we have demonstrated that the nasal prongs
were a more effective device of delivering oxygen in
patients with early postoperative hypoxia; it is also
comfortable and cost-effective.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1 Sia S, D’Andrea V, Mamone D, Pagnotta L, Verre M. Early postoperative
hypoxemia: incidence and effectiveness of oxygen administration. Minerva
Anestesiol 1994; 60:657–662.
2 Xue FS, Huang YG, Tong MY, Liu QH, Liao X, An G, et al. A comparative
study of early postoperative hypoxemia in infants, children, and adults
undergoing elective plastic surgery. Anesth Analg 1996; 83:709–715.
3 Amanor-Boadu S, Osinaike B, Oyeleke S. Routine oxygen administration in
the PACU: should everybody have it? Int J Third World Med 2006; 3:1–6.
4 Strachan L, Noble DW. Hypoxia and surgical patients − prevention and
treatment of an unnecessary cause of morbidity and mortality. J R Coll Surg
Edinb 2001; 46:297–302.
5 Ayhan H, Iyigun E, Tastan S, Orhan ME. Comparison of two different
oxygen delivery methods in the early postoperative period: randomized
trial. J Adv Nurs 2009; 65:1237–1247.
6 Waldau T, Larsen VH, Bonde J. Evaluation of five oxygen delivery devices
in spontaneously breathing subjects by oxygraphy. Anaesthesia 1998;
53:256–263.
7 Deiner S, Silverstein J. Postoperative delirium and cognitive dysfunction.
Br J Anaesth 2009; 103(Suppl 1):i41–i46.
8 Gift AG, Stanik J, Karpenick J, Whitmore K, Bolgiano CS. Oxygen
saturation in postoperative period; patients at low risk for hypoxemia: is
oxygen therapy needed? Anesth Analg 1995; 80:368–372.
9 Kitamura H, Sawa T, Ikezono E. Postoperative hypoxemia: the contribution
of age to maldistribution of ventilation. Anaesthesiology 1972; 36:244–252.
10 Aakerland LP, Rosenberg J. Postoperative delirium: treatment with
supplementary oxygen. Br J Anaesth 1994; 72:286–290.
11 Gennari R, Alexander JW. Effects of hyperoxia on bacterial translocation
and mortality during gut-derived sepsis. Arch Surg 1996; 131:57–62.
12 Razi E, Akbari HA. Comparison of arterial oxygen saturation measured both
by pulse oximeter and arterial blood gas analyzer in hypoxaemic and non-
hypoxaemic pulmonary disease. Turk R J 2006; 7:43–47.
13 Allan D. Approaches to sample size estimation in design of clinical trial − a
review. Stat Med 1984; 3:199–214.
14 Russell GB, Graybeal JM. Hypoxemic episodes of patients in the
postanesthesia care unit. Chest 1993; 104:899–903.
15 Stausholm K, Rosenberg-Adamsen S, Skriver M, Kehlet H, Rosenberg J.
Comparison of three devices for oxygen administration in the late
postoperative period. Br J Anaesth 1995; 74:607–609.
16 Akinyemi OA, Sanusi AA, Eyelade OR. Evaluation of a modified APACHE II
scoring system in the intensive care unit of a tertiary hospital in Nigeria. Afr
J Anaesth Intens Care 2011; 11:1–6.
17 Bethune DN, Collins JM. Comparative performance of six oxygen delivery
equipments. Thorax 1967; 22:221.
18 Waldau T, Larsen VH, Bond J. Evaluation of five oxygen delivery devices in
spontaneously breathing subjects by oxygraphy. Anaesthesia 1998; 53:
256–263.
19 Jensen AG, Johnson A, Sandstedt S. Rebreathing during oxygen therapy
with face mask. The effect of oxygen flow rates on ventilation. Acta
Anaesthesiol Scand 1991; 35:289–292.