REVIEW
Prevention of Oxygen Desaturation in Morbidly Obese
Patients During Electroconvulsive Therapy
A Narrative Review
Yukihide Koyama, MD, PhD,* Koichi Tsuzaki, MD, PhD,* Takeshi Suzuki, MD, PhD,†
Makoto Ozaki, MD, PhD,‡ and Shigeru Saito, MD, PhD§
Abstract: In general, preoxygenation is performed using a face mask with
oxygen in a supine position, and oxygenation is maintained with manual
mask ventilation during electroconvulsive therapy (ECT). However, hypoxic
episodes during ECT are not uncommon with this conventional method, es-
pecially in morbidly obese patients. The most important property of venti-
Downloaded from http://journals.lww.com/ectjournal by BhDMf5ePHKbH4TTImqenVAKJ+VrYFxwI9meKj26ccKb8qCP0blMhFAuAGGiHUCxB on 10/13/2020
latory mechanics in patients with obesity is reduced functional residual
capacity (FRC). Thus, increasing FRC and oxygen reserves is an important
step to improve oxygenation and prevent oxygen desaturation in these in-
dividuals. Head-up position, use of apneic oxygenation, noninvasive posi-
tive pressure ventilation, and high-flow nasal cannula help increase FRC
and oxygen reserves, resulting in improved oxygenation and prolonged
safe apnea period. Furthermore, significantly higher incidence of difficult
mask ventilation is common in morbidly obese individuals. Supraglottic
airway devices establish effective ventilation in patients with difficult air-
ways. Thus, the use of supraglottic airway devices is strongly recom-
mended in these patients. Conversely, because muscle fasciculation
induced by depolarizing neuromuscular blocking agents markedly in-
creases oxygen consumption, especially in individuals with obesity, the
use of nondepolarizing neuromuscular blocking agents may contribute to
better oxygenation in morbidly obese patients during ECT.
Key Words: ECT, morbidly obese patient, preoxygenation,
head-up position, supraglottic airway devices
(J ECT 2020;36: 161–167)
P revious studies and meta-analysis have revealed that there is a
significantly positive association between depression and obe-
sity as commonly co-occurring medical conditions.1–4 Furthermore,
it has also been shown that depression is positively associated with
metabolic diseases such as hyperlipidemia, type 2 diabetes, and
hypertension.4 In addition, the rate of obesity worldwide has
nearly tripled since 1975.5 In 2016, 39% of adults were over-
weight (body mass index [BMI] > 25 kg/m2) and 13% were obese
(BMI > 30 kg/m2).5 Furthermore, the rate of morbidly obese
(BMI > 40 kg/m2) patients among individuals with obesity is in-
creasing fast.6 Taken together, the number of morbidly obese pa-
tients requiring ECT is increasing.
Anesthetic management for ECT has not changed since the
late 1950s. Preoxygenation is usually applied in supine position
using a face mask with 100% oxygen, and oxygenation is maintained
From the *Department of Anesthesia, Nippon Koukan Hospital, Kawasaki;
†Department of Anesthesiology, Tokai University School of Medicine, Isehara;
‡Department of Anesthesiology, Tokyo Women's Medical University, Tokyo;
and §Department of Anesthesiology, Gunma University Graduate School of
Medicine, Maebashi, Japan.
Received for publication October 6, 2019; accepted December 3, 2019.
Reprints: Yukihide Koyama, MD, PhD, Department of Anesthesia, Nippon
Koukan Hospital, 1-2-1 Koukan-dori, Kawasaki-ku, Kawasaki-shi,
210-0852, Kanagawa Prefecture, Kawasaki, Japan
(e‐mail: yukihidekoyama1008@gmail.com).
Conflicts of interest and sources of funding: none declared.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/YCT.0000000000000664
Journal of ECT • Volume 36, Number 3, September 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
with manual mask ventilation throughout the procedure, except
for the period between ECT stimulation and termination of the sei-
zure. However, hypoxic episodes during ECT are not uncommon in
obese patients, and obesity is one of the major risk factors for oxygen
desaturation during ECT.7,8 Individuals with obesity have decreased
respiratory compliance, increased airway resistance, reduced
functional residual capacity (FRC), high closing-capacity-
to-FRC ratio, increased metabolic demand, and greater oxygen
consumption.9–12 These physiological properties are associated
with rapid decrease in oxygen saturation during apnea in morbidly
obese individuals. Furthermore, previous reports described that
obesity is one of the independent risk factors for difficult air-
ways.9,13 Accordingly, morbidly obese patients are likely to be
hypoxic, and thus, ventilatory strategies to prevent hypoxic epi-
sodes in these patients during ECT are required. Even for an-
esthesiologists, anesthetic management in morbidly obese
patients during ECT can be challenging. Consequently, practi-
tioners who perform anesthetic management of morbidly obese
patients undergoing ECT should have sufficient knowledge regard-
ing their physiological properties to protect patients from reaching a
critical status.
In this review, we propose effective anesthetic techniques to pre-
vent oxygen desaturation in morbidly obese patients during ECT.
RESPIRATORY PHYSIOLOGY IN INDIVIDUALS
WITH OBESITY
Patients with obesity show impaired respiratory physiology,
including reduced FRC, inspiratory capacity, vital capacity, de-
creased respiratory compliance, increased airway resistance, and
greater oxygen consumption.9–12 Among these physiological
properties, FRC, which serves as an oxygen reserve during apnea,
can be increased with certain interventions, described in the fol-
lowing sections. In pulmonary function test, FRC is defined as
the volume of air present in the lungs at the end of passive expiration.
Obesity severely impairs pulmonary function mainly due to the
decrease in FRC secondary to cephalad diaphragmatic displace-
ment, resulting in decrease in oxygen reserves.14 This is likely
due to the increased fat tissue in the chest wall, abdominal wall,
and abdomen that compresses the diaphragm and lungs in individ-
uals with obesity. Furthermore, FRC is significantly reduced in
supine position than in sitting position, because of further eleva-
tion of the diaphragm and increased pulmonary blood volume.15
Therefore, FRC is an important factor that maintains and improves
oxygenation and can be increased in clinical settings, especially to
treat individuals with obesity.
PREOXYGENATION
The aim of preoxygenation before anesthesia induction is to
maximize intrapulmonary oxygen reserves and prevent earlier onset
of oxygen desaturation. Considering the physiological properties
of morbidly obese individuals, some modified techniques for
preoxygenation should be considered to allow prolonged apnea
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Koyama et al
FIGURE 1. A and B, Images represent ramp position and table-ramp
position, respectively.
time without critical reduction in oxygen saturation (safe apnea
period) during ECT.
Patient Positioning
Individuals with obesity have reduced FRC leading to re-
duced oxygen reserves.9,10,14 Consequently, obesity is associated
with rapid decrease in oxygen saturation during apnea under anes-
thesia.16 Oxygen saturation and FRC are reduced, especially when
patients are in supine position.17 Compared with supine position,
upright position increases FRC due to the descent of the diaphragm
and reduced pulmonary blood volume, resulting in increased oxy-
gen reserves and subsequent improvement of oxygenation.15 Boyce
et al18 demonstrated that the decrease in oxygen saturation during
apnea under general anesthesia is slower in head-up position than
in supine position. Dixon et al19 demonstrated that preoxygenation
in a 25-degree head-up position provides a longer safe apnea period
than in supine position in morbidly obese patients. In addition, for
anesthesia induction and secured airway in patients with obesity,
head-up positions such as ramp and table ramp position are recom-
mended, because these positions provide not only a good laryngeal
view with a laryngoscope and avoid silent regurgitation, but also a
longer safe apnea period.20 Ramp and table ramp positions are
head-elevated positions achieved either by placing multiple blan-
kets under the patient's upper body or by flexing the table at the
trunk-thigh hinge and raising the back section of the table
(Fig. 1).20 Furthermore, Koyama et al8 reported that preoxygenation
in the head-up position was more effective than in the supine po-
sition to prevent oxygen desaturation in morbidly obese patients
during ECT. Accordingly, to increase FRC and oxygen reserves,
sufficient preoxygenation with 100% oxygen in head-up position
is strongly recommended in morbidly obese patients.
Noninvasive Positive Pressure Ventilation
Noninvasive positive pressure ventilation (NPPV) is the appli-
cation of mechanical ventilation without invasive airway manage-
ment (tracheal intubation or tracheostomy), including continuous
positive airway pressure (CPAP), pressure support ventilation
(PSV), and noninvasive bilevel positive airway pressure (BiPAP).
Noninvasive positive pressure ventilation is currently the most
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Journal of ECT • Volume 36, Number 3, September 2020
commonly used noninvasive technique to support patients with
acute respiratory failure.21 Noninvasive positive pressure ventila-
tion has been reported to offer the same physiological effects as
invasive mechanical ventilation via tracheal intubation, such as re-
spiratory muscle unloading, increase in FRC, gas exchange im-
provement, and augmentation of alveolar ventilation.21 Regarding
the efficacy of NPPV on preoxygenation, compared with conven-
tional preoxygenation, preoxygenation with low-pressure CPAP
and low-pressure PSV resulted in better oxygenation and prevented
oxygen desaturation during anesthesia induction in morbidly obese
patients.22 This was achieved using tight-fitting face masks with
pressure support mode, PSV-Pro mode of an Aisys anesthesia care
station (GE Healthcare, Helsinki, Finland). El-Khatib et al23 re-
ported that preoxygenation with BiPAP before rapid sequence induc-
tion in morbidly obese patients significantly improved oxygenation
and promoted CO2 washout. The BiPAP therapy is provided with a
specific apparatus such as Philips Respironics V60 ventilator (Philips
Healthcare, Cleveland, OH) and CPAP mask (Fig. 2). Furthermore,
preoxygenation with NPPV using an anesthetic machine ensured bet-
ter oxygenation compared with conventional preoxygenation in mor-
bidly obese patients undergoing elective surgery.24 The underlying
mechanism of this oxygenation improvement is that the use of NPPV
and CPAP contributes to increased FRC, improving alveolar recruit-
ment, decreasing ventilation/perfusion mismatch, and decreasing the
alveolar-arterial oxygen gradient.25 However, patient's optimal coop-
eration is required for NPPV therapy, because fitting the CPAP mask
or face mask tightly on patient's face is necessary. Although clini-
cally indicated, most patients fail to use NPPV due to mask intoler-
ance.26 Therefore, preoxygenation with NPPV may not be adequate
in some mentally ill patients requiring ECT.
Apneic Oxygenation
Apneic oxygenation supplies oxygen to the alveoli, even while
the patient's lungs are not ventilated. Regarding the underlying
mechanism of apneic oxygenation, oxygen continues to move
from the alveoli to the blood at a rate of 250 mL/min and CO2
moves from the blood to the alveoli at approximately 20 mL/min
during apnea.27 The difference in the gas flow is due to the differ-
ence in gas solubility between oxygen and CO2, the different affin-
ity of hemoglobin for oxygen and CO2, and buffering of CO2 by
HCO3 both at the blood and tissue levels.28 This gas flow difference
is attributed to a subatmospheric pressure in the alveoli creating
gas movement from the pharynx to the alveoli, a phenomenon
known as apneic oxygenation.29 This phenomenon improves
FIGURE 2. CPAP mask with headband.
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Journal of ECT • Volume 36, Number 3, September 2020
oxygenation and prolongs the safe apnea period in patients with
obesity. Various techniques for supplying oxygen during apnea
have been described, including the use of nasopharyngeal airways,
standard nasal cannula prongs, high-flow nasal cannula (HFNC),
and modified tracheal tubes in individuals with obesity.30 Oxygen
insufflation from nasal cavity immediately after preoxygenation
significantly delayed the onset of desaturation in morbidly obese
patients during the subsequent apnea.31 This apneic oxygenation
technique by supplying oxygen via the nasal cavity during apnea
can be easily applied without any specific apparatus.
High-Flow Nasal Cannula Preoxygenation
The purpose of respiratory support is to maintain adequate
ventilation and oxygenation. Noninvasive positive pressure venti-
lation has been the primary choice for the support of diminished
respiratory function.21 However, it is not always applicable due
to patient's poor tolerance. High-flow nasal cannula (AIRVO 2;
Fisher & Paykel, Auckland, NewZealand; Fig. 3A) has recently
been introduced as an innovative respiratory support for critically
ill patients.32 In contrast to NPPV, HFNC does not require patient's
optimal tolerance. High-flow nasal oxygen represents a recent
breakthrough in the area of apneic oxygenation, enhancing both
oxygenation and CO2 clearance, compared with conventional
low-flow nasal oxygen.33 This apparatus is composed of an air/
oxygen blender, an active heated humidifier, a single heated circuit,
and a nasal cannula (Fig. 3B). At the air/oxygen blender, the inspi-
ratory fraction of oxygen (FiO2) can be adjusted from 0.21 to 1.0
in a flow of up to 60 L/min.32 High flow of adequately heated and
humidified gas is considered to have a number of advantages on
respiratory function, such as better CO2 washout in anatomical
dead space, providing positive end expiratory pressure, stable
fraction of inspired oxygen, and appropriate humidification
without discomfort.32
Increased FRC and denitrogenation are important factors for
preoxygenation, especially in patients with obesity.34 Riera et al35
reported that HFNC contributed to increased FRC regardless of the
body position, resulting in increased oxygen reserves. Furthermore,
HFNC washes out CO2, effectively.32 Accordingly, apnea time
during general anesthesia can be prolonged safely with HFNC
preoxygenetion.36 In addition, Ricottilli et al37 demonstrated that
HFNC preoxygenation during anesthesia induction increases and
maintains FRC as oxygen reserves, leading to prolonged safe ap-
nea period in individuals with obesity. Zhu et al38 reported that the
HFNC could serve as an alternative to mask ventilation in nonobese
patients during ECT. Further studies investigating the efficacy
FIGURE 3. A and B, Images represent the main body of HFNC (AIRVO 2; Fisher & Paykel, Auckland, NewZealand) and its specific nasal
cannula, respectively.
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Oxygen Desaturation in Obese Patients During ECT
of HFNC in obese patients during ECT are required to support
our contention.
To the best of our knowledge, there are no reports investigat-
ing the efficacy of preoxygenation with NPPVand apneic oxygen-
ation for ECT anesthesia in morbidly obese patients. However,
considering the diminished respiratory function of morbidly obese
patients, preoxygenation with these techniques, which increase FRC
and oxygen reserves, and promote denitrogenation and CO2 wash-
out, will be effective in morbidly obese patients during ECT. Fur-
thermore, the use of these techniques in head-up position will be
much more effective in these individuals.
AIRWAY AND RESPIRATORY MANAGEMENT
Oxygenation maintained with manual mask ventilation is a
conventional technique used during ECT. However, alternative air-
way devices such as a laryngoscope, tracheal tube, and supraglottic
airway devices (SGAs) should be prepared for ECT anesthesia for se-
curing the airways when mask ventilation fails. Regarding respiratory
management during ECT, the goal is generally hypocapnia induced
by hyperventilation that will ensure appropriate seizure duration.
Manual Mask Ventilation
Obesity is one of the major risk factors for difficult mask
ventilation.13 In addition, morbidly obese patients (BMI > 40 kg/m2)
have a significantly higher incidence of difficult mask ventilation.39
Koyama et al8 reported that difficult mask ventilation led to critical
oxygen desaturation in morbidly obese patients during ECT. Mor-
bidly obese patients are likely to reach critical oxygen desaturation
with hypercapnia during apnea due to reduced FRC, increased met-
abolic rate, and greater oxygen consumption.9–12 Accordingly, dif-
ficult mask ventilation easily leads to critical oxygen desaturation,
especially in morbidly obese patients, and it should, thus, be avoided.
Consequently, alternatives should be available, especially in these
patients during ECT.
Supraglottic Airway Devices
Various SGAs are currently available in clinical settings (Fig. 4).
Compared with a face mask, SGAs provide enhanced maintenance of
the airway patency and, at the same time, bypass the stress of tracheal
intubation. According to the Practice Guidelines for Management of
the Difficult Airway of the American Society of Anesthesiologists,
when facemask ventilation is inadequate, the use of SGA is rec-
ommended.40 Parmet et al41 reported that SGA provided rescue
ventilation successfully in cases of unanticipated difficult mask
ventilation after anesthesia induction without any perioperative
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Koyama et al
FIGURE 4. Examples of SGAs are shown. A–C, Images represent ProSeal laryngeal mask airway (PLMA; Teleflex, Morrisville, NC), i-gel
(Intersurgical Ltd, Workingham, England), and Aura-i (Ambu Ltd, St Ives, Cambridgeshire, United Kingdom), respectively.
complications. In difficult mask ventilation scenarios, SGAs have
been effective for rescue ventilation.42,43 Koyama et al8 reported
that mechanical ventilation with SGA was considerably effective
in morbidly obese patients with difficult mask ventilation during
ECT. Furthermore, Sinha et al44 demonstrated that mechanical
ventilation using SGA after anesthesia induction was more effec-
tive in increasing oxygen reserves and improving oxygenation
than conventional mask ventilation in morbidly obese patients un-
dergoing elective surgery.
Maintaining appropriate arterial CO2 tension is important in
ECT anesthesia, because hypocapnia immediately before electrical
current application is beneficial to ensure adequate seizure duration.45
Accordingly, hyperventilation immediately before electrical stimula-
tion is recommended by the American Psychiatric Association.46 In
a previous report from Nishihara et al,47 arterial CO2 tension was
found to be significantly lower in patients under mechanical ven-
tilation with SGA throughout the procedure than in patients under
conventional manual mask ventilation, and seizure duration was
significantly shorter in patients with face mask ventilation than
in patients with SGA ventilation. Furthermore, controlled ventila-
tion using SGA can enhance the effect of ECT treatment, com-
pared with uncontrolled ventilation using a conventional face
mask.48 Hypoxia and/or hypercapnia induced by inadequate ven-
tilation produced hypertension and tachycardia after seizure,49
which may lead to cardiovascular or cerebrovascular events, espe-
cially in morbidly obese patients.
The use of SGAs is one among the major solutions for diffi-
cult mask ventilation and oxygen desaturation in morbidly obese
individuals after anesthesia induction. In addition, hyperventilation
and appropriate adjustment of end-tidal CO2 can be easily achieved
with SGAs.47 Furthermore, SGAs are currently easily available and
their use is widely accepted in clinical settings. Thus, SGAs are
strongly recommended for airway management, especially in mor-
bidly obese patients during ECT.
Tracheal Intubation
Tracheal intubation is not necessary in most cases, because
inadvertent regurgitations are extremely rare even in individuals
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Journal of ECT • Volume 36, Number 3, September 2020
with obesity.50 Repeated tracheal intubation for short intervals
can cause airway complications such as sore throat, swelling, and
even bleeding secondary to airway trauma.50 In addition, because tra-
cheal intubation is commonly associated with greater hemodynamic
responses, this procedure may impose an increased risk of cardio-
vascular and cerebrovascular complications during and after ECT
treatment in individuals with obesity. Furthermore, Hutchens et al51
reported that ECT treatment with repeated tracheal intubation re-
sulted in critical airway complications. Thus, repeated tracheal in-
tubation for subsequent ECT sessions is not recommended.
However, in case of failure of ventilation with SGAs, physicians
should be prepared for tracheal intubation and surgical airway access
as emergency airway securing. Although controversial,39 obesity is
thought to be associated with difficult intubation.52 Thus, in addition
to conventional Macintosh laryngoscope, if available, channeled
or nonchanneled blade-type videolaryngoscope (Fig. 5) should
be prepared for emergency tracheal intubation, because these are
more effective for difficult tracheal intubation due to difficult
laryngoscopy.53–55 Unlike the Macintosh laryngoscope, these do
not require optimal alignment of the three anatomic axes—the
oral, pharyngeal, and tracheal axes—to see the glottis. Thus, these
scopes enable the operator to identify the glottic opening on the
monitor and to easily advance the tracheal tube into the trachea.
Furthermore, these can contribute to attenuation of hemodynamic
responses to tracheal intubation.56–58
MUSCLE RELAXANTS
The goal of providing muscle relaxants during ECT is to
reduce the risk of injury caused by convulsion and at the same
time to allow for prompt recovery of spontaneous breathing after
seizure termination.
Depolarizing or Nondepolarizing Neuromuscular
Blocking Agents?
Succinylcholine chloride (SCC), a depolarizing neuromus-
cular blocking agent, is commonly used as a muscle relaxant dur-
ing ECT because of its short period of action.46 Sufficient muscle
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Journal of ECT • Volume 36, Number 3, September 2020
FIGURE 5. A and B, Images represent nonchanneled blade-type, McGrath videolaryngoscope (Aircraft Medical Ltd, Edinburgh,
United Kingdom) and channeled blade type, Pentax AWS (Hoya, Tokyo, Japan), respectively.
relaxation to prevent injury during ECT can be achieved with 0.9
to 1.1 mg/kg SCC in most patients.59
During ECT, oxygen consumption and CO2 production are
increased not only due to seizure activity,60 but also due to fascic-
ulation induced by SCC.49,61 Tang et al62 demonstrated that SCC
induced significantly shorter period of safe apnea and longer recovery
period from saturation to 97% than rocuronium—a nondepolarizing
neuromuscular blocking agent—in morbidly obese patients. This
is due to increased muscle oxygen consumption induced by SCC-
related muscle fasciculation. In addition, nondepolarizing neuro-
muscular blocking agents have been actually used in ECT patients
who are contraindicated for SCC.63 Regarding the use of muscle
relaxants during ECT, rocuronium is an alternative to SCC because
sugammadex, which can rapidly reverse rocuronium-induced neu-
romuscular blocking, is currently available in clinical settings. In sit-
uations where sugammadex is available in sufficient quantity, the
use of rocuronium during ECT is possible.63 Kadoi et al64 demon-
strated that rocuronium-sugammadex may be used as an alterna-
tive to SCC for muscle relaxation during ECT and that 8 mg/kg
sugammadex showed equipotent recovery time from muscle re-
laxation to 1 mg/kg SCC during ECT. Current recommendations
suggest a gap time of 24 hours between sugammadex administra-
tion and readministration of rocuronium, because sugammadex is
completely eliminated within 24 hours after administration.65 Ac-
cordingly, to avoid the increase in oxygen consumption caused by
SCC-related muscle fasciculation, rocuronium could be an alter-
native to SCC during ECT.
CONCLUSIONS
We described the unique physiology of morbidly obese pa-
tients and some effective anesthetic techniques to prevent oxygen
desaturation in these patients during ECT. Hypoxic episodes in
morbidly obese patients during ECT are not uncommon, and thus
anesthetic management during ECT is challenging. Considering
the respiratory physiology of morbidly obese individuals, head-
up positioning of patients with obesity and use of apneic oxygen-
ation, NPPV, and HFNC during and after preoxygenation improve
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Oxygen Desaturation in Obese Patients During ECT
oxygenation and prolong the safe apnea period. Supraglottic airway
devices can be strongly recommended in morbidly obese patients to
avoid manual mask ventilation failure, improve oxygenation, and
prevent hypercapnia during ECT. Oxygen consumption caused by
SCC-related muscle fasciculation can be avoided with rocuronium,
the effect of which can be rapidly reversed by sugammadex.
REFERENCES
1. Carey M, Small H, Yoong SL, et al. Prevalence of comorbid depression
and obesity in general practice: a cross-sectional survey. Br J Gen Pract.
2014;64:e122–e127.
2. Faith MS, Butryn M, Wadden TA, et al. Evidence for prospective
associations among depression and obesity in population-based studies.
Obes Rev. 2011;12:e438–e453.
3. Mannan M, Mamun A, Doi S, et al. Prospective associations between
depression and obesity for adolescent males and females—a systematic
review and meta-analysis of longitudinal studies. PLoS One. 2016;
11:e0157240.
4. Hidese S, Asano S, Saito K, et al. Association of depression with body
mass index classification, metabolic disease, and lifestyle: a web-based
survey involving 11,876 Japanese people. J Psychiatr Res. 2018;
102:23–28.
5. World Health Organization (WHO). Available at: https://www.who.int/
westernpacific/health-topics/obesity-and-overweight. Accessed
September 6, 2019.
6. Sturm R. Increases in morbid obesity in the USA: 2000–2005. Public
Health. 2007;121:492–496.
7. Surve R, Bansal S, Sriganesh K, et al. Incidence and risk factors for oxygen
desaturation during recovery from modified electroconvulsive therapy:
a prospective observational study. J Anaesthesiol Clin Pharmacol. 2015;
31:99–103.
8. Koyama Y, Nishioka H, Ibaraki T, et al. Successful anesthetic management
of morbidly obese patients during electroconvulsive therapy with the
ProSeal laryngeal mask airway in a head-up position: a report of 2 cases.
J ECT. 2017;33:e30–e31.
www.ectjournal.com 165
Koyama et al
9. Rose DK, Cohen MM. The airway: problems and predictions in 18,500
patients. Can J Anaesth. 1994;41:372–383.
10. Huang KC, Kormas N, Steinbeck K, et al. Resting metabolic rate in
severely obese diabetic and nondiabetic subjects. Obes Res. 2004;
12:840–845.
11. Koenig SM. Pulmonary complications of obesity. Am J Med Sci. 2001;
321:249–279.
12. Rochester DF, Enson Y. Current concepts in the pathogenesis of the
obesity-hypoventilation syndrome. Mechanical and circulatory factors.
Am J Med. 1974;57:402–420.
13. El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009;
109:1870–1880.
14. Altermatt FR, Muñoz HR, Delfino AE, et al. Pre-oxygenation in the obese
patient: effects of position on tolerance to apnoea. Br J Anaesth. 2005;
95:706–709.
15. Katz S, Arish N, Rokach A, et al. The effect of body position on pulmonary
function: a systematic review. BMC Pulm Med. 2018;18:159.
16. Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe duration
of apnea in anesthetized humans. Anesth Analg. 1991;72:89–93.
17. Hakala K, Maasilta P, Sovijärvi AR. Upright body position and
weight loss improve respiratory mechanics and daytime oxygenation
in obese patients with obstructive sleep apnoea. Clin Physiol. 2000;
20:50–55.
18. Boyce JR, Ness T, Castroman P, et al. A preliminary study of the optimal
anesthesia positioning for the morbidly obese patient. Obes Surg. 2003;
13:4–9.
19. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in
the 25 degrees head-up position than in the supine position in severely
obese patients: a randomized controlled study. Anesthesiology. 2005;
102:1110–1115.
20. Rao SL, Kunselman AR, Schuler HG, et al. Laryngoscopy and
tracheal intubation in the head-elevated position in obese patients:
a randomized, controlled, equivalence trial. Anesth Analg. 2008;
107:1912–1918.
21. Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure:
which recipe for success? Eur Respir Rev. 2018;27:180029.
22. Harbut P, Gozdzik W, Stjernfält E, et al. Continuous positive airway
pressure/pressure support pre-oxygenation of morbidly obese patients.
Acta Anaesthesiol Scand. 2014;58:675–680.
23. El-Khatib MF, Kanazi G, Baraka AS. Noninvasive bilevel positive airway
pressure for preoxygenation of the critically ill morbidly obese patient.
Can J Anaesth. 2007;54:744–747.
24. Futier E, Constantin JM, Pelosi P, et al. Noninvasive ventilation and
alveolar recruitment maneuver improve respiratory function during and
after intubation of morbidly obese patients: a randomized controlled study.
Anesthesiology. 2011;114:1354–1363.
25. Girgis K, Hamed H, Khater Y, et al. A decremental PEEP trial identifies the
PEEP level that maintains oxygenation after lung recruitment. Respir Care.
2006;51:1132–1139.
26. Chacur FH, Vilella Felipe LM, Fernandes CG, et al. The total face
mask is more comfortable than the oronasal mask in noninvasive
ventilation but is not associated with improved outcome. Respiration.
2011;82:426–430.
27. Shah U, Wong J, Wong DT, et al. Preoxygenation and intraoperative
ventilation strategies in obese patients: a comprehensive review. Curr Opin
Anaesthesiol. 2016;29:109–118.
28. Weingart SD, Levitan RM. Preoxygenation and prevention of
desaturation during emergency airway management. Ann Emerg Med.
2012;59:165–175.
29. Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation in man.
Anesthesiology. 1959;20:789–798.
166 www.ectjournal.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 36, Number 3, September 2020
30. Moon TS, Tai K, Kim A, et al. Apneic oxygenation during prolonged
laryngoscopy in obese patients: a randomized, double-blinded,
controlled trial of nasal cannula oxygen administration. Obes Surg. 2019;
29:3992–3999.
31. Baraka AS, Taha SK, Siddik-Sayyid SM, et al. Supplementation of
pre-oxygenation in morbidly obese patients using nasopharyngeal oxygen
insufflation. Anaesthesia. 2007;62:769–773.
32. Nishimura M. High-flow nasal cannula oxygen therapy in adults.
J Intensive Care. 2015;3:15.
33. Lyons C, Callaghan M. Uses and mechanisms of apnoeic oxygenation:
a narrative review. Anaesthesia. 2019;74:497–507.
34. Damia G, Mascheroni D, Croci M, et al. Perioperative changes in
functional residual capacity in morbidly obese patients. Br J Anaesth. 1988;
60:574–578.
35. Riera J, Pérez P, Cortés J, et al. Effect of high-flow nasal cannula and body
position on end-expiratory lung volume: a cohort study using electrical
impedance tomography. Respir Care. 2013;58:589–596.
36. Patel A, Nouraei SA. Transnasal humidified rapid-insufflation
Ventilatory exchange (THRIVE): a physiological method of
increasing apnoea time in patients with difficult airways. Anaesthesia.
2015;70:323–329.
37. Ricottilli F, Ickx B, Van Obbergh L. High-flow nasal cannula
preoxygenation in obese patients undergoing general anesthesia:
a randomised controlled trial. Br J Anaesth. 2019;123:e443–e444
(Abstracts from the Difficult Airway Society meeting, Edinburgh,
November 28–30, 2018).
38. Zhu Y, Kang Y, Wei J, et al. Effect of high-flow nasal cannula versus
conventional facemask ventilation for patients undergoing modified
electroconvulsive therapy: a randomised controlled, noninferiority trial.
Eur J Anaesthesiol. 2019;36:309–310.
39. Moon TS, Fox PE, Somasundaram A, et al. The influence of morbid
obesity on difficult intubation and difficult mask ventilation. J Anesth.
2019;33:96–102.
40. Apfelbaum JL, Hagberg CA, Caplan RA, et alAmerican Society of
Anesthesiologists Task Force on Management of the Difficult Airway.
Practice guidelines for management of the difficult airway: an
updated report by the American Society of Anesthesiologists Task
Force on Management of the Difficult Airway. Anesthesiology. 2013;
118:251–270.
41. Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask
airway reliably provides rescue ventilation in cases of unanticipated
difficult tracheal intubation along with difficult mask ventilation. Anesth
Analg. 1998;87:661–665.
42. Wetsch WA, Schneider A, Schier R, et al. In a difficult access scenario,
supraglottic airway devices improve success and time to ventilation.
Eur J Emerg Med. 2015;22:374–376.
43. Oshika H, Koyama Y, Taguri M, et al. Supraglottic airway device versus a
channeled or non-channeled blade-type videolaryngoscope for accidental
extubation in the prone position: a randomized crossover manikin study.
Medicine (Baltimore). 2018;97:e11190.
44. Sinha A, Jayaraman L, Punhani D, et al. ProSeal laryngeal mask airway
improves oxygenation when used as a conduit prior to laryngoscope guided
intubation in bariatric patients. Indian J Anaesth. 2013;57:25–30.
45. Chater SN, Simpson KH. Effect of passive hyperventilation on seizure
duration in patients undergoing electroconvulsive therapy. Br J Anaesth.
1988;60:70–73.
46. Weiner RD, Coffey CE, Fochtmann LJ. The Practice of Electroconvulsive
Therapy: Recommendations for Treatment, Training and Privileging.
2nd ed. Washington, DC: American Psychiatric Association; 2001.
47. Nishihara F, Ohkawa M, Hiraoka H, et al. Benefits of the laryngeal mask
for airway management during electroconvulsive therapy. J ECT. 2003;
19:211–216.
© 2020 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 36, Number 3, September 2020
48. Haeck M, Gillmann B, Janouschek H, et al. Electroconvulsive therapy can
benefit from controlled hyperventilation using a laryngeal mask. Eur Arch
Psychiatry Clin Neurosci. 2011;261(suppl 2):S172–S176.
49. Saito S, Kadoi Y, Nihishara F, et al. End-tidal carbon dioxide monitoring
stabilized hemodynamic changes during ECT. J ECT. 2003;19:26–30.
50. Kadar AG, Ing CH, White PF, et al. Anesthesia for electroconvulsive
therapy in obese patients. Anesth Analg. 2002;94:360–361.
51. Hutchens M, Smith KR. A case of tracheal injury with intubation during
electroconvulsive therapy. J ECT. 2009;25:67–69.
52. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intubation in obese
patients: incidence, risk factors, and complications in the operating theatre
and in intensive care units. Br J Anaesth. 2015;114:297–306.
53. Asai T, Liu EH, Matsumoto S, et al. Use of the Pentax-AWS in 293 patients
with difficult airways. Anesthesiology. 2009;110:898–904.
54. Koyama Y, Inagawa G, Miyashita T, et al. Comparison of the airway scope,
gum elastic bougie and fibreoptic bronchoscope in simulated difficult
tracheal intubation: a manikin study. Anaesthesia. 2007;62:936–939.
55. Kleine-Brueggeney M, Greif R, Schoettker P, et al. Evaluation of six
videolaryngoscopes in 720 patients with a simulated difficult airway: a
multicentre randomized controlled trial. Br J Anaesth. 2016;116:670–679.
56. Koyama Y, Nishihama M, Inagawa G, et al. Comparison of haemodynamic
responses to tracheal intubation using the airway scope(®) and Macintosh
laryngoscope in normotensive and hypertensive patients. Anaesthesia.
2011;66:895–900.
57. Nishikawa K, Matsuoka H, Saito S. Tracheal intubation with the
PENTAX-AWS (airway scope) reduces changes of hemodynamic
© 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Oxygen Desaturation in Obese Patients During ECT
responses and bispectral index scores compared with the Macintosh
laryngoscope. J Neurosurg Anesthesiol. 2009;21:292–296.
58. Yokose M, Mihara T, Kuwahara S, et al. Effect of the McGRATH MAC®
video laryngoscope on hemodynamic response during tracheal intubation:
a retrospective study. PLoS One. 2016;11:e0155566.
59. Mirzakhani H, Guchelaar HJ, Welch CA, et al. Minimum effective doses of
succinylcholine and rocuronium during electroconvulsive therapy: a
prospective, randomized, crossover trial. Anesth Analg. 2016;123:587–596.
60. Szirmai I, Boldizśar F, Fischer J. Correlation between blood gases,
glycolytic enzymes and EEG during electroconvulsive treatment in
relaxation. Acta Psychiatr Scand. 1975;51:171–181.
61. Muldoon SM, Theye RA. The effects of succinylcholine and
d-tubocurarine on oxygen consumption. Anesthesiology. 1969;
31:437–442.
62. Tang L, Li S, Huang S, et al. Desaturation following rapid sequence
induction using succinylcholine vs. rocuronium in overweight patients.
Acta Anaesthesiol Scand. 2011;55:203–208.
63. Bryson EO, Aloysi AS, Farber KG, et al. Individualized anesthetic
management for patients undergoing electroconvulsive therapy: a review of
current practice. Anesth Analg. 2017;124:1943–1956.
64. Kadoi Y, Hoshi H, Nishida A, et al. Comparison of recovery times from
rocuronium-induced muscle relaxation after reversal with three different
doses of sugammadex and succinylcholine during electroconvulsive
therapy. J Anesth. 2011;25:855–859.
65. Brull SJ, Kopman AF. Current status of neuromuscular reversal
and monitoring: challenges and opportunities. Anesthesiology. 2017;
126:173–190.
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